PERFORMANCE AND QUALITY IMPROVEMENT
Quarterly Report
August 2017
INTRODUCTION
Welcome to MHCO’s PQI Quarterly Report! This report is for all stakeholders including residents, personnel, community members, board members, donors, and any individual interested in the great work that we do. PQI – Performance and Quality Improvement – is an integral part of MHCO. We are open and willing for new opportunities to grow. We hope this report demonstrates our commitment to the residents we serve, our transparency for when things don’t go as well as planned, and desire to receive feedback from others. If you have ideas on how this document can be improved, please let us know!
We seek to learn from our experiences and grow. As you read through this report, when you see progress that is not up to our expectations, there will always be a plan for how to address the challenge. Being able to take ownership of our shortcomings and work to improve them is an underlying philosophy of our organization.
Our outputs are simple numeric measurements of productivity. The outputs do not necessarily mean that the residents are achieving desired outcomes, but do mean that personnel provided a certain number of services to a certain number of people. You will notice that we use a simple icon system for our outputs:
A yellow sticky note means that still have work to do to meet reach the target.
A green arrow hitting the bullseye means we are at target or above.
Resident outcomes show sustainable change that demonstrates the interventions provided by MHCO work. Outcomes are measured over time. We are currently developing methods of tracking outcomes to identify any trends and determine ways to improve.Over the course of residency, it is our intention to increase life skills appropriate to each resident’s development.
Additionally, resident records are reviewed quarterly to ensure that the records contain all required information to provide service. The record review is an opportunity to assess the quality of service delivery and ensure that confidential information remains confidential. The target for MHCO is 80% compliance for Direct Care and the Independent Living Program. Resident satisfaction is another very important to MHCO mission achievement and methods are being developed to determine satisfaction outcomes.
OUTPUTS
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DIRECT CARE
Direct Care / Apr / May / June / Q1 2017 / Q2 2017 / Q2 2016Residents Served (total) / 41.0 / 43.0 / 39.0 / 49.0 / 41.0 / 53.3
Admissions (total) / 0.0 / 2.0 / 2.0 / 8.0 / 4.0 / 2.0
Discharges (total) / 0.0 / 0.0 / 6.0 (ILP) / 11.0 / 6.0 / 8.0
Referrals (total) / 2.0 / 3.0 / 3.0 / 5.0 / 8.0 / 7.0
Length of stay (avg) / 1026.3 / 1013.8 / 1130.1 / 971.7 / 1056.7 / nd
Deferrals (total) / 0.0 / 0.0 / 0.0 / 1.0 / 0.0 / 1.0
Ethnicity and Gender / Apr / May / June / Q1 2017 (%) / Q2 2017 (%) / Q2 2016 (%) / Deferred / Discharged
African-American (total) / 15.0 / 15.0 / 17.0 / 28.6% / 38.3% / 46.3% / 0.0 / 1.0
Caucasian (total) / 18.0 / 20.0 / 14.0 / 39.4% / 42.2% / 42.6% / 0.0 / 5.0
Hispanic (total) / 0.0 / 0.0 / 0.0 / 0.0% / 0.0% / 0.0% / 0.0 / 0.0
Multi-Racial (total) / 8.0 / 8.0 / 8.0 / 26.5% / 19.5% / 11.3% / 0.0 / 0.0
Male (total) / 22.0 / 23.0 / 24.0 / 55.1% / 56.1% / 66.8% / 0.0 / 4.0
Female (total) / 19.0 / 20.0 / 18.0 / 40.8% / 46.3% / 33.2% / 0.0 / 2.0
Custody / Apr / May / June / Q1 2017 (%) / Q2 2017 (%) / Q2 2016 (%)
Parents / 33.0 / 33.0 / 35.0 / 77.6% / 82.2% / 63.2%
Self / 5.0 / 5.0 / 0.0 / 10.8% / 8.0% / 27.6%
DSS / 3.0 / 5.0 / 4.0 / 4.1% / 9.8% / 9.4%
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Direct Care / Apr / May / June / Q1 2017 (%) / Q2 2017 (%)Residents in School (total) / 41.0 / 42.0 / 39.0 / 82.2% / 99.0%
Absences (total) / 55.0 / 30.0 / nd / 35.3 (avg) / 42.5 (avg)
Residents in Tutoring (total) / 36.0 / 39.0 / 40.0 / 88.6% / 94.3%
Residents with IEP (total) / 8.0 / 8.0 / 8.0 / 22.3% / 19.7%
Report Cards / 2nd 9 weeks / 3rd 9 weeks / 4th 9 weeks
Honor Roll (% of residents in school) / 22.3% / 19.7% / 27.1%
Honorable Mention (% of residents in school) / 19.9% / 34.5% / 27.1%
GPA Increase 5+ Points (% of residents in school) / 9.9% / 19.7% / 19.7%
Maintained 90+ GPA (% of residents in school) / 7.4% / 2.5% / 0.0%
Campus GPA (avg) / 79.0 / 79.5 / 81.0
Report Cards (% of residents in school) / Q1 2017 / Q2 2017
Passing all Subjects / 58.6% / 69.7%
Failing 1 Subject / 22.3% / 5.7%
Failing 2 Subjects / 10.7% / 3.2%
Failing 3 Subjects / 4.2% / 0.7%
Failing all Subjects / 2.5% / 1.7%
Residents with IEP / 23.1% / 19.7%
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Direct Care / Apr / May / June / Q1 2017 / Q2 2017 / Q2 2016Medical Illnesses (total illnesses) / 22.0 / 39.0 / 14.0 / 16.0 (avg) / 25.0 (avg) / 10.3 (avg)
Medical Appointments (total appointments) / 26.0 / 31.0 / 19.0 / 28.6 (avg) / 25.3 (avg) / 20.7 (avg)
Medication Administration Record Controlled (% signed off daily) / 100.0% / 100.0% / 100.0% / 100.0% / 100.0% / 100.0%
Medication Administration Record Non-Controlled (% signed off daily) / 100.0% / 100.0% / 100.0% / 96.7% / 100.0% / 100.0%
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Other Activities / Apr / May / June / Q1 2017 / Q2 2017 / Q2 2016CFT Meetings (total meetings) / 4.0 / 5.0 / 4.0 / 5.0 / 8.0 / nd
Cottage Moves (total residents) / 7.0 / 5.0 / 0.0 / 5.0 / 12.0 / 4.0
Wellness Participation (total residents) / 289.0 / 294.0 / 419.0 / 283.3 (avg) / 334.0 (avg) / nd
Animal Assisted Therapy (total residents) / 0.0 / 9.0 / 0.0 / 16.7 (avg) / 3.0 (avg) / nd
Church Service Attendance (total residents) / 108.0 / 120.0 / 94.0 / 125.7 (avg) / 107.3 (avg) / 108.7 (avg)
Eligible for Employment (total residents) / 11.0 / 11.0 / 10.0 / 11.7 (avg) / 10.6 (avg) / 9 (avg)
Employed (total residents) / 6.0 / 8,0 / 4.0 / 6.7 (avg) / 6.0 (avg) / 4.3 (avg)
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INDEPENDENT LIVING PROGRAM
Independent Living Program / Apr / May / June / Q1 2017 / Q2 2017 / Q2 2016Residents Served (total) / 15.0 / 16.0 / 22.0 / 18.0 (avg) / 17.7 (avg) / 16.0 (avg)
Admissions (total residents) / 1.0 / 1.0 / 6.0 / 2.0 / 8.0 / 2.0
Discharges (total residents) / 0.0 / 0.0 / 1.0 (by choice) / 5.0 / 1.0 / 0.0
Referrals (total residents) / 4.0 / 0.0 / 1.0 / 9.0 / 5.0 / 7.0
Length of stay (avg days) / 1390.4 / 1267.8 / 1340.9 / 1370.7 / 1333.0 / 2013.8
Deferrals (total residents) / 1.0 (HLC) / 0.0 / 0.0 / 2.0 / 1.0 / 0.0
African-American / 8.0 / 9.0 / 10.0 / 44.4% / 50.8% / 31.3% / 0.0 / 1.0
Caucasian / 5.0 / 5.0 / 9.0 / 33.3% / 35.6% / 50.0% / 1.0 / 0.0
Hispanic / 0.0 / 0.0 / 0.0 / 0.0% / 0.0% / 0.0% / 0.0 / 0.0
Multi-Racial / 2.0 / 2.0 / 2.0 / 9.4% / 11.3% / 18.8% / 0.0 / 0.0
Male / 7.0 / 7.0 / 11.0 / 44.4% / 46.9% / 45.6% / 0.0 / 0.0
Female / 8.0 / 9.0 / 10.0 / 55.6% / 50.8% / 29.4% / 1.0 / 1.0
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Independent Living Program / Apr / May / June / Q1 2017 / Q2 2017 / Q2 2016College (%) / 66.7% / 62.5% / 68.2% / 50.0% / 66.1% / nd
GED (%) / 6.7% / 6.3% / 9.0% / 5.5% / 7.3% / nd
Eligible for Employment (total) / 14.0 / 16.0 / 15.0 / 16.3 (avg) / 15.0 (avg) / 10.0 (avg)
Employed (total) / 14.0 / 11.0 / 8.0 / 62.8% / 62.1% / 85.6%
Independent Living Program / Apr / May / June / Q1 2017 / Q2 2017 / Q2 2016
Workshops (total residents) / 1.0 / 1.0 / 2.0 / 2.0 / 4.0 / 2.0
Workshops attendance (% residents) / 66.7% / 68.8% / 40.9% / 57.5% / 58.8% / 91.7%
Survival Skills Lab attendance (% residents) / nd / nd / 45.5% / nd / 45.5% / nd
Transports given (total transports) / 142.0 / 104.0 / 118.0 / 144.0 (avg) / 121.3 (avg) / nd
Residents with own car (total residents) / 8.0 / 9.0 / 9.0 / 8.0 (avg) / 8.7 (avg) / nd
Wheels4Hope applications (total applications / 1.0 / 1.0 / 0.0 / 1.0 (avg) / 0.7 (avg) / nd
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COUNCIL ON ACCREDITATION SURVEY RESULTS
A total of 176 stakeholders completed surveys for the Council on Accreditation (COA) self-study. In most cases, our average scores rated higher than the COA average for all other agencies. Also in most cases, our average score this year rated higher than our average scores in 2013. Highlights from the surveys and aggregate scores are included below.
The Board of Directors answered the Governance Survey with the overall average score for all questions being 4.772 out of 5, 4.066% higher than the COA overall average and 9.388% higher than our average score in 2013. The highest rated questions (4.923) pertained to board involvement in developing and approving policies, reviewing fiscal financial reports, approving the annual budget, and accepting the annual audit. The lowest rated question (4.500) pertained to the board establishing resource development targets and goals.
Individuals involved in board committees that were not members of the Board of Directors answered the Advisory Board Survey with the overall average score for all questions being 4.752 out of 5, 6.630% higher than the COA overall average. The highest rated questions (4.909) pertained to the advisory board is active in carrying out assigned responsibilities on behalf of MHCO and that the reputation of MHCO is favorable in the community. The lowest rated question (4.455) pertained to the advisory board received orientation that addressed responsibilities and roles.
Community members answered the Community Survey with the overall average score for all questions being 4.808 out of 5, 8.820% higher than the COA overall average and 11.481% higher than our average score in 2013. The highest rated question (4.950) pertained to MHCO respecting confidentiality of residents. The lowest rated question (4.618) pertained to services being conveniently located and accessible to public transportation.
Current residents over the age of five answered the Consumer Survey with the overall average score for all questions being 4.290 out of 5, 3.726% lower than the COA overall average and 3.623% lower than our average score in 2013. The highest rated questions (4.500) pertained to feeling safe while at MHCO and on its property and overall satisfaction with services received. The lowest rated question (4.000) pertained to being treated with respect and courtesy by MHCO employees. Two out of the five questions scored below the COA average were higher than the 2013 MHCO average scores.
Current residents under the age of five answered the Youth and Child: Residential/Group Survey. Because only three surveys were completed and one question was left unanswered by all individuals, an overall average score could not be calculated and compared to the COA average. The highest rated questions (5.000) pertained to employees helping the resident to see his or her family and inclusion of a good school program. The lowest rated questions (3.333) pertained to employees listen to him or her and liking being at MHCO overall.
Non-management personnel answered the Personnel Survey with the overall average score for all questions being 4.379 out of 5, 7.705% higher than the COA overall average and 5.800% lower than our average score in 2013. The highest rated question (4.710) pertained to the employee receiving annual performance evaluations. The lowest rated question (3.935) pertained to MHCO implementing changes based on feedback received from personnel. The only question scored below the COA average was higher than the 2013 MHCO average score.
Management personnel answered the Supervisors and Managers Survey with the overall average score for all questions being 4.329 out of 5, 0.271% lower than the COA overall average and 8.501% higher than our average score in 2013. The highest rated questions (4.714) pertained to the manager receiving annual performance evaluations and awareness of the confidentiality policy and procedure. The lowest rated questions (4.000) pertained to MHCO services being well coordinated and monitoring contractors who provide services to consumers. Nine out of the eleven questions scored below the COA average were higher than the 2013 MHCO average scores.
Governance SurveyNumber of Surveys Sent / 15 / Overall Average / 4.772 / 4.066%
Number of Surveys Received / 13 / COA Overall Average / 4.578
Q# / Text / MHCO Average / COA Average / Variance / 2013 Average
Q1 / As a member of the Governing Body, we effectively conduct/participate in long term planning. / 4.769 / 4.602 / 3.627% / 4.36
Q2 / As the Governing Body, we effectively develop and approve policies. / 4.923 / 4.613 / 6.720% / 4.36
Q3 / As the Governing Body, we establish resource development targets and goals. / 4.500 / 4.439 / 1.363% / 4.27
Q4 / We regularly review fiscal financial reports. / 4.923 / 4.861 / 1.270% / 4.45
Q5 / We approve the organization’s annual budget. / 4.923 / 4.825 / 2.029% / 4.55
Q6 / As the Governing Body, we review and formally accept the annual audit. / 4.923 / 4.785 / 2.879% / 4.55
Q7 / As a member of the Governing Body, I review and provide input regarding the organization’s quality improvement activities initiatives. / 4.769 / 4.400 / 8.397% / 4.27
Q8 / As members of the Governing Body, we receive information on the organization’s program outcomes and outcomes for persons served. / 4.769 / 4.608 / 3.492% / 4.09
Q9 / The organization’s Governing Body and the CEO or Executive Director have an effective working relationship. / 4.846 / 4.804 / 0.880% / 4.55
Q10 / At least annually, as members of the Governing Body, we assess areas of risk to the organization. / 4.692 / 4.492 / 4.471% / 4.27
Q11 / We receive quarterly reports of immediate and ongoing risk within the organization. / 4.692 / 4.321 / 8.599% / 4.36
Q12 / The organization collaborates with the community regarding issues of mutual concern. / 4.615 / 4.544 / 1.570% / 4.09
Q13 / I received an orientation as to my Governing Body responsibilities. / 4.846 / 4.566 / 6.144% / 4.36
Q14 / The organization’s Governing Body is representative of the community it serves. / 4.615 / 4.231 / 9.08613% / 4.00
Q# / Text / Yes / No
Q15 / To your knowledge, within the last four years, has the organization had any allegations or findings of professional misconduct? / 2 / 11
Q16 / Within the last four years, has the organization had any allegations or findings of financial malfeasance? / 0 / 13
Q17 / Has the organization failed to comply with laws and regulations governing equal opportunity and workforce administration? / 0 / 13
Q18 / Has the organization had any investigations by a regulatory or other monitoring body which identified significant problems at the organization? / 0 / 13
Advisory Board Survey
Number of Surveys Sent / 17 / Overall Average / 4.752 / 6.630%
Number of Surveys Received / 11 / COA Overall Average / 4.437
Q# / Text / MHCO Average / COA Average / Variance
Q1 / The organization’s Advisory Board is sufficiently active in carrying out its assigned responsibilities on behalf of the organization. / 4.909 / 4.454 / 10.230%
Q2 / The role of the organization’s Advisory Board is well defined. / 4.818 / 4.356 / 10.607%
Q3 / As a member of the Advisory Board, we receive information such as management or quality improvement reports that supports our designated role on behalf of the organization. / 4.818 / 4.388 / 9.794%
Q4 / The work of the organization’s Advisory Board extends the capability of the organization. / 4.727 / 4.424 / 6.856%
Q5 / Upon joining the organization’s Advisory Board, I received and orientation that addressed Advisory Board membership responsibilities and roles. / 4.455 / 4.216 / 5.663%
Q6 / Advisory Board members have unique knowledge and skills which complement the knowledge and skills of the organization. / 4.636 / 4.586 / 1.096%
Q7 / The Advisory Board’s recommendations to the organization contribute to organizational effectiveness. / 4.818 / 4.417 / 9.075%
Q8 / As a member of the Advisory Board, I feel my participation contributes to quality of care and/or organizational capacity improvements. / 4.636 / 4.374 / 6.007%
Q9 / The organization’s reputation with the community is favorable. / 4.909 / 4.644 / 5.699%
Q10 / The organization collaborates with the community regarding issues of mutual concern. / 4.818 / 4.594 / 4.874%
Q11 / The organization’s Advisory Board is representative of the community it serves and/or the needs of persons served. / 4.727 / 4.354 / 8.580%
Q# / Text / Yes / No
Q12 / To your knowledge, within the last four years, has the organization had any allegations or findings of professional misconduct? / 0 / 11
Q13 / Within the last four years, has the organization had any allegations or findings of financial malfeasance? / 0 / 11
Q14 / Has the organization failed to comply with laws and regulations governing equal opportunity and workforce administration? / 0 / 11
Q15 / Has the organization had any investigations by a regulatory or other monitoring body which identified significant problems at the organization? / 0 / 11
Community Survey
Number of Surveys Sent / 262 / Overall Average / 4.808 / 8.820%
Number of Surveys Received / 84 / COA Overall Average / 4.384
Q# / Text / MHCO Average / COA Average / Variance / 2013 Average
Q1 / The organization’s facilities are clean and well-maintained. / 4.928 / 4.462 / 10.445% / 4.52
Q2 / The organization’s services are accessible to persons with disabilities. / 4.759 / 4.420 / 7.662% / 4.30
Q3 / The organization’s services are conveniently located and accessible to public transportation. / 4.618 / 4.268 / 8.201% / 3.94
Q4 / The organization does not discriminate in the provision of its services. / 4.939 / 4.619 / 6.926% / 4.61
Q5 / Information about the organization’s services and eligibility criteria are made available to the community. / 4.800 / 4.414 / 8.746% / 4.36
Q6 / The organization provides culturally sensitive services. / 4.709 / 4.405 / 6.894% / 3.97
Q7 / The organization respects the confidentiality of the persons it serves. / 4.950 / 4.618 / 7.182% / 4.64
Q8 / The organization is known for its integrity and ethical practices. / 4.926 / 4.441 / 10.909% / 4.73
Q9 / The organization conducts a public education program to make its presence known to the community. / 4.636 / 4.147 / 11.803% / 4.00
Q10 / The organization works with other community organizations to advocate on behalf of the people it serves. / 4.835 / 4.480 / 7.939% / 4.55
Q11 / The organization promptly screens applicants and persons referred for its services. / 4.767 / 4.332 / 10.056% / 4.21
Q12 / Waiting periods for services are reasonable. / 4.686 / 4.139 / 13.207% / 3.67
Q13 / Fees are reasonable and fair. / 4.762 / 4.262 / 11.736% / 3.09
Q14 / The organization is fiscally responsible. / 4.896 / 4.351 / 12.525% / 4.61
Q15 / The organization’s reputation within the community is favorable. / 4.938 / 4.407 / 12.046% / 4.70
Q16 / Personnel are qualified and competent in the performance of their jobs. / 4.740 / 4.374 / 8.371% / 4.48
Q17 / The organization is in compliance with all applicable laws and regulations. / 4.844 / 4.385 / 10.473% / 3.97
Consumer Survey
Number of Surveys Sent / 37 / Overall Average / 4.290 / -3.726%
Number of Surveys Received / 19 / COA Overall Average / 4.450
Q# / Text / MHCO Average / COA Average / Variance / 2013 Average
Q1 / I was given written information about my rights and responsibilities as a consumer or client. / 4.438 / 4.429 / 0.184% / 3.89
Q2 / The people who work at the organization treat me with respect and courtesy. / 4.000 / 4.518 / -11.456% / 4.14
Q3 / The staff is respectful of my confidentiality and privacy. / 4.167 / 4.533 / -8.072% / 4.20
Q4 / The organization’s services are available at times that are good for me. / 4.188 / 4.383 / -4.459% / 4.18
Q5 / The organization’s building and offices are clean. / 4.056 / 4.428 / -8.412% / 4.36
Q6 / I feel safe while at the organization and on its property. / 4.500 / 4.483 / 0.378% / 4.18
Q7 / I help plan my services and set my goals. / 4.471 / 4.408 / 1.426% / 4.07
Q8 / If I needed help or services again I would come back to the organization. / 4.294 / 4.402 / -2.462% / 4.02
Q9 / Overall, I am satisfied with the services that I am receiving. / 4.500 / 4.467 / 0.742% / 4.25
Youth and Child: Residential/Group Survey
Number of Surveys Sent / 5 / Overall Average
Number of Surveys Received / 3 / COA Overall Average / 4.002
Q# / Text / MHCO Average / COA Average / Variance
Q1 / I feel comfortable here. / 3.667 / 3.850 / -4.768%
Q2 / Adults who work here listen to me. / 3.333 / 3.768 / -11.533%
Q3 / Adults here treat me with respect. / 4.667 / 4.045 / 15.361%
Q4 / The adults who work here are fair to everyone. / 3.667 / 3.792 / -3.310%
Q5 / I know who I can ask for help here. / 4.667 / 4.367 / 6.856%
Q6 / My privacy is respected here. / 3.667 / 4.015 / -8.681%
Q7 / I get enough to eat and drink. / 4.667 / 4.369 / 6.808%
Q8 / The rooms and buildings here are clean. / 4.667 / 4.050 / 15.230%
Q9 / I feel safe while living here. / 4.333 / 4.147 / 4.488%
Q10 / I am included in the planning of the services that I receive. / 3.500 / 4.153 / -15.729%
Q11 / I receive services here that help me. / 4.000 / 4.216 / -5.122%
Q12 / I have a say in the kind of services I receive here. / 3.856
Q13 / While living here, I am receiving the services I need. / 4.333 / 4.225 / 2.574%
Q14 / The adults who work here help me see my family. / 5.000 / 4.096 / 22.065%
Q15 / There is enough for me to do here when I am not in school. / 4.667 / 3.747 / 24.540%
Q16 / Adults here ask my opinion about things. / 3.667 / 3.595 / 2.001%
Q17 / There is a good school program here. / 5.000 / 4.049 / 23.473%
Q18 / Services I receive are helping me make positive changes. / 3.500 / 4.189 / -16.445%
Q19 / Overall, I like being here. / 3.333 / 3.516 / -5.185%
Personnel Survey
Number of Surveys Sent / 46 / Overall Average / 4.379 / 7.705%
Number of Surveys Received / 32 / COA Overall Average / 4.042 / 4.125
Q# / Text / MHCO Average / COA Average / Variance / 2013 Average
Q1 / My job responsibilities are clearly outlined in my job description. / 4.469 / 4.118 / 8.517% / 4.21
Q2 / I received an orientation within the first three months of beginning work with the organization. / 4.500 / 4.354 / 3.361% / 4.41
Q3 / I have an up-to-date copy of, or can access the personnel handbook. / 4.667 / 4.350 / 7.271% / 4.38
Q4 / I am aware of the organization's grievance procedures and know how to make a complaint. / 4.656 / 4.072 / 14.340% / 4.45
Q5 / I am notified when positions that I may be qualified for become available within the organization. / 4.125 / 3.949 / 4.448% / 3.90
Q6 / I can access my personnel record. / 4.484 / 3.888 / 15.314% / 3.93
Q7 / I receive annual performance evaluations. / 4.710 / 4.183 / 12.596% / 4.21
Q8 / I receive regular supervision. / 4.375 / 4.160 / 5.168% / 4.28
Q9 / At least annually, employee satisfaction is assessed by the organization. / 4.226 / 3.853 / 9.674% / 4.28
Q10 / The organization implements changes based on the feedback received from personnel. / 3.935 / 3.469 / 13.455% / 3.59
Q11 / I participate in quality improvement activities within the organization. / 4.375 / 3.828 / 14.286% / 4.14
Q12 / I receive information on program outcomes that is useful to me in working with persons served. / 4.281 / 3.849 / 11.220% / 3.83
Q13 / I have participated in on the job activities that enhanced my knowledge and skills. / 4.469 / 4.230 / 5.635% / 4.31
Q14 / Case records of persons that I serve are readily available or accessible to me. / 4.037 / 4.280 / -5.676% / 3.83
Q# / Text / Yes / No
Q15 / Are you aware of the organization's harassment policy? / 31 / 1
Q16 / Are you aware of the organization's discrimination prohibition policy? / 32 / 0
Q17 / Are you aware of the organization's policy regarding prohibition of corporal and degrading punishment of consumers? / 22 / 3
Q18 / Are you aware of the organization's confidentiality policy? / 32 / 0
Supervisors and Managers Survey
Number of Surveys Sent / 14 / Overall Average / 4.329 / -0.271%
Number of Surveys Received / 14 / COA Overall Average / 4.340 / 3.961
Q# / Text / MHCO Average / COA Average / Variance / 2013 Average
Q1 / The organization has an effective quality improvement program. / 4.143 / 4.196 / -1.259% / 3.89
Q2 / I participate in the organization's quality improvement activities. / 4.571 / 4.276 / 6.911% / 4.22
Q3 / The organization regularly examines its internal access and service delivery processes. / 4.286 / 4.276 / 0.221% / 3.67
Q4 / The organization conducts quarterly reviews of accidents, incidents, and grievances. / 4.357 / 4.445 / -1.966% / 4.00
Q5 / Outcome data is used to improve services for consumers. / 4.143 / 4.286 / -3.331% / 3.44
Q6 / I am aware of the organization's conflict of interest policy. / 4.643 / 4.395 / 5.646% / 4.22
Q7 / The organization does not discriminate in hiring/promoting. / 4.357 / 4.516 / -3.524% / 4.33
Q8 / I receive an annual performance evaluation. / 4.714 / 4.423 / 6.589% / 3.89
Q9 / The organization is prepared to respond to natural disasters and other emergencies. / 4.429 / 4.276 / 3.580% / 4.11
Q10 / The finances of the program in which I work are managed by the organization with integrity and according to sound business practices. / 4.286 / 4.415 / -2.923% / 4.33
Q11 / The organization's services are well coordinated. / 4.000 / 4.144 / -3.476% / 4.00
Q12 / The organization facilitates timely and easy access for consumers. / 4.214 / 4.319 / -2.435% / 3.56
Q13 / Access to emergency and crisis intervention services is available to consumers. / 4.214 / 4.402 / -4.260% / 3.89
Q14 / I have time to conduct supervision with my staff. / 4.231 / 4.169 / 1.493% / 4.00
Q15 / The organization monitors its relationship with contractors who provide services to consumers. / 4.000 / 4.256 / -6.014% / 3.89
Q16 / The organization's governing body and the CEO Executive Director have an effective working partnership. / 4.286 / 4.288 / -0.055% / 3.56
Q17 / I am aware of the organization's confidentiality policy and procedures. / 4.714 / 4.707 / 0.147% / 4.33
IMPROVEMENT PLANS