YOUTH CONSULTATION SERVICE

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Site Specific Policy & Procedure Manual

DOCUMENT #: A-14Procedure Date: 7/20/10

Rev.: 8.21.12

TITLE: Quality Improvement at Youth Consultation Service

I. PURPOSE: Youth Consultation Service Central Continuous Quality Improvement

II. INTRODUCTION: The YCS Continuous Quality Improvement Program establishes a permanent structure and ongoing process for measuring and improving the quality of all YCS programs.

All CCQI recommendations are data based; as are the follow-up evaluations that determine whether the implementation of recommendations have had a favorable impact on the quality of service. The PDCA improvement model guides the program. It is a simple, practical, and widely endorsed model to do process improvement:

Plan: Identify and select the problem, analyze the problem, generate potential solutions, plan the solution.

Do: Implement the solution

Check: Evaluate the solution

Act: Refine/act on what is learned

III. PROCEDURES / IV STAFF RESPONSIBLE
V. REPORTING & DOCUMENTATION
The core of the program is the Central CQI Steering Committee [CCQI], which is composed of top administrators [President, Chief Operating Officer, and Vice Presidents], and representatives of key service delivery and support programs. This membership allows for communication from and to the top YCS leadership. The committee meets six times each year to: [a] review data generated through established workgroups and other reporting vehicles, and [b] make recommendations that will improve services delivered to YCS clients. Minutes are recorded, distributed, and reviewed at every meeting.
There are five permanent workgroups that report to the CCQI Steering Committee:
[1] Behavior Management; [2] Program and Service Improvement; [3] Client Involvement and Satisfaction; [4] Human Resources; [5] Medical Quality Improvement. These workgroups collect, review and summarize data in their critical areas and make recommendations to the Steering Committee. Additional workgroups can and have been established when the need arises.
The CCQI program is responsive to the requirements of external accreditation organizations (e.g., Joint Commission) and YCS funding sources (e.g., New Jersey DOHSS, and New Jersey DHS). As a result, data that are regularly tracked and reviewed include: use of physical controls [frequency and injuries]; medication administration [incorrect doses and medication errors]; client and parent satisfaction; incidents, injuries, and client grievances; client outcome indicators [including discharge follow-up data]; staff training and turnover; medical and nursing indicators; education indicators; clinical site audit findings; medical site audit findings; environment of care monitoring. / Director of Research
President, Chief Operating Officer, and Vice Presidents
Representatives of key service delivery and support programs including Medical, Clinical, Human Resources, Treatment Homes, Operations, and Research Departments
Director of Research
Meeting Agenda, Meeting Minutes, Data, Descriptions, Charts and Graphs
  1. ATTACHMENTS:

A-14.1Policy and Procedure for Monthly Quality Improvement Team Meetings

A-14.1AQI Team Calendar

A-14.1BYCS Program Specific QI Plan

A-14.2CProgram Specific QI Plan Directions

VII. Regulatory Reference: 10:44A-2.2(b)14
Continuous Quality Improvement [CQI] At YCS

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