Summit County Children Services (SCCS)

SummitCountyChildren Services (SCCS)

Continuous Quality Improvement Plan

2009-2011

SummitCounty Children Services’ Mission

The mission of Summit County Children Services is to excel in the investigation of reports of child abuse and neglect and in the delivery of culturally sensitive, collaborative protective services that provide children with a safe, nurturing and permanent home.

SUMMITCOUNTYCHILDREN SERVICES VISION STATEMENT:

Because of our strong commitment to protect abused, neglected and dependent children and strengthen families, we will:

Seek to assure the safety of children
Investigate needs with expediency and excellence
Be vital and effective in our work
Intervene only where necessary and only to the proper degree
Believe that all children should grow up in their own family or another permanent home
Serve and communicate well internally and externally
Serve in teamwork with families, relatives and our partner agencies in the community
Invigorate a staff that is well trained, culturally competent, compassionate, focused on excellence and quality improvement
Be fiscally responsible

Commitment to Continuous Quality Improvement (CQI)

SCCS is committed to the ongoing evaluation of outcomes throughout the agency. Through the CQI process of monitoring and tracking, internal and external service providers are held accountable for the quality of services provided. CQI activities also monitor and track internal agency supportive and administrative services.

The CQI process provides ongoing information to promote quality services and systemic improvements. This monitoring is desirable for quality control and meets the Council on Accreditation (COA) standards.

SCCS monitors the quality of services according to the following “Four A’s of Quality”:

a) Appropriateness of Services: All services shall be suitable, as determined by a trainedprofessional.

The services shall address the child and family members’ needs and shall result in progress toward goal

attainment.

b) Acceptability of Services: A trained professional shall determine services to benecessary and to

adequately meet the child or family members’ needs. Services shall also be determined to be necessary

and to adequately meet the child or familymembers’ needs from the consumers’ perspective.

c) Availability of Services: Services shall be available to meet the needs of agency consumerswithin

specified time frames.

d) Accessibility of Services: Services shall be accessible to consumers in terms transportation,location,

handicap accessibility, etc. Appointment times shall also meet the needs of consumers.

Child safety, permanency and well being is monitored the following areas:

Compliance Measures:
Compliance with Ohio Department of Job and Family Services (ODJFS) regulations
Compliance with COA standards
Compliance with statutory requirements
Compliance with agency policies/procedures
System Performance & Quality Measures
Quality of services
Consumers’ perceptions of services
Levels of satisfaction
Service utilization
Quality of professional staff
Safety of the service environment
Fiscal and Human Resource utilization
Effectiveness & Impact of Service Measures:

Child safety
Placement stability
Recidivism
Length of stay
Consumer satisfaction

CQI Goals

Provide an ongoing process of evaluation to assess the match between agency services and consumer needs
Provide an ongoing process to continually improve SCCS’ service delivery system

CQI Components

Written CQI plan
Input from stakeholders [1]
Ongoing data collection/analysis
CQI committee to review and analyze data
Established reporting schedules to summarize/share CQI results
Executive Council[2] review of CQI results
Established feedback loops for CQI activities
Departmental work groups of staff/managers to process CQI results and develop action plans for improvement, as indicated
Monitoring of action plans and the effectiveness of systemic improvements

The CQI Plan and related proceduresare reviewed annually for continued applicability. Revisions are made as indicated. This comprehensive review promotes an optimum CQI process.

CQI Internal/External Monitoring Reviews and Activities

CQI activities are performed to measure the quality of services, identify patterns and trends and hold internal staff and external service providers accountable. Objective, non-involved, third party reviewers conduct all case reviews.

CQI reviews
Peer Reviews: Monthly review of randomly selected [3] open and recently closed cases. Trained caseworker staff review cases to assess the assigned social worker’s professionalism, decision-making, judgment, cultural sensitivity and ability to engage consumers in the service and treatment process. Also assessed is the clinical acceptability of services.
Service Quality and Utilization Reviews: Monthly review of randomly selected open cases. A third party manager evaluates the utilization of planned services, consumers’ ability to access services, service availability, service barriers and consumers’ satisfaction.
Semi-annual Administrative Reviews (SAR): ODJFS mandated semi-annual review of all open cases. A third party manager conducts the review to assess the appropriateness of the case plan and planned services. Also reviewed are the consumers’ utilization of services and their level of progress. At the end of the review, each guest is asked for feedback about the review and services.

Completeness of Records & Documentation Review: Monthly review of randomly selected cases conducted by records department staff. The reviewexamines the presence or absence of required documentation in the hard copy case record and agency electronic client database.
Quality Improvement Reviews of Compliance: Monthly case review of randomly selected cases by a third party manager to assess service quality and compliance with ODJFS mandates. The review examines the hard copy case record and the Agency KIDS 2100 database.
Safety Reviews

Incident Reports & Major and Unusual Incidents (MUI)

Maintenance Quarterly Checklists/Logs

Health & Safety Committee Reports

Annual Occupational Safety and Health Administration (OSHA) Report

SummitCounty Child Fatality Review (CFRB) Board Report(s) [4]

Human Resource Reviews

Staff vacancy/turnover

Salaries/benefits

Staff recruitment/retention

Annual Performance Evaluation compliance

Compliance with annual review of personnel files

Review of Employee/Consumer Complaints, Grievances, and Appeals

Client’s Rights Officer’sReport

Employee grievances, arbitrations, and appeals

Litigation/Civil Rights Complaints

Review of Resource Allocation & Use

Placement resources/expenditures

Facility utilization

Fiscal resources

Review of Compliance Related Reports

Statutory/Regulatory Compliance

ODJFS Special Reviews

ODJFS Child Protection Oversight Evaluation (CPOE)

PCSA Foster Care Review

COA Pre-Site & Onsite Reaccreditation

COA Maintenance of Accreditation

Fiscal Audits

Other CQI Activities include:

Special Multi-Disciplinary Reviews: Review requested by the Executive Director; may involve a single or identified group of cases. The review will be conducted by a panel, with specific disciplines of expertise, appointed for the specific purpose of the requested review. The review panel submits a report to the Executive Director. The CQI Committee may review the report.
Special Case Reviews: Review requested by the Executive Director; may involve a single or identified group of cases. One person or a small group of professionals conducts this review. A summary of the review is submitted to the Executive Director. The CQI Committee mayreview the report.
Stakeholder Surveys, Focus Groups, and Interviews

Stakeholder satisfaction

Stakeholder perceptions/feelings

Stakeholder expectations

Stakeholder input

KIDS 2100/SACWIS Data Analysis

Consumer demographic profile & descriptive statistics [5]

Service volume

Consumer needs

Services planned & provided

Services and case activity

Timeliness of service delivery

Qualitative & Quantitative Research

Long and short-term plan measures

Collaborative research with universities/institutes

Review of narrative data contained within Case Documentation

Review of scholarly literature

Review of secondary source

CQI Structure and Process

SCCS’ Division of Organizational Research & Evaluation (ORE) coordinates CQI activities, conducts research, and prepares CQI reports. The Agency’s Director of ORE and Clients Rights Officerserves as the permanent Chairs of the CQI Committee.

CQI Committee

The Agency’s CQI Committee represents a cross-section of agency staff with social work, research, and administrative backgrounds. Committee members serve as liaisons to all agency departments to facilitate the CQI process of feedback, evaluation and system improvement. The Executive Director appoints members for two-year terms, which may be renewed.

The Committee meets monthly to review and discuss QI activities and findings. Data and reports from throughout the agency are reviewed at least quarterly according to the following categories:

Service Related

Four A’s of QualityStakeholders satisfactionCompliance with standards Service Utilization

Caseload size and activityService volume

Consumer demographics Child placement

Human Resources

Staff vacancy/turnover/retentionPersonnel file compliance

Staff training Salaries/Benefits

Staff recruitmentLabor/Management relations

Risk Management

Regulatory compliance

Safety and Security (facilities, safety drills, security reports)

Incident reports, major and unusual incidents, medication dispensing (monthly)

Limits to freedom (child restraints and seclusions)

Foster Care Rule Violations

Lapsed Foster Care licenses

Litigation/Civil Rights complaints

Consumer/employee grievances, arbitrations, and appeals

Audit Reports

Insurance/liability

Miscellaneous

Review of long and short-term agency plans/goal attainment.

Literature reviews are ongoing and occur as needed.

Additional QI reviews are conducted, as indicated or requested

Reports

Quarterly and annual CQI reports of activities, findings and results are submitted to the Agency’s Executive Council for review. CQI findings and results are reported to stakeholders on an ongoing basis via quarterly reports provided to the Board of Trustees, internal and external newsletters, annual reports, and the Agency website and electronic e-mail. Copies of CQI reports are available upon request.

Quarterly Reports

CQI Committee reviews and findings are reported quarterly by the CQI Chair. Action plans for improvement are also identified and tracked.

Quarterly reports are also completed to monitor and track the quality, volume and trends in service delivery over time. These reports are submitted to agency administrators and the Board of Trustees and include, at a minimum the following:

Consumer demographics

Service volume and categories of services

Service utilization

Annual Reports

CQI reviews, activities and findings are reported annually.

At a minimum the following are included:

Consumer demographics and trends

Service trends and volume

Summary of Service Related reviews and findings

Summary of Human Resources reviews and findings

Summary of Risk Management reviews and findings

Summary of all miscellaneous reviews and findings

Agency compliance with regulatory standards

Stakeholder/consumer satisfaction

Staff recruitment and retention

Agency’s long and short term plan goal attainment

CQI results and systemic improvements

Effectiveness of the CQI policies, procedures and processes

An annual Risk Management Report is completed and submitted, at minimum, to the agency’s Executive Council and Board of Trustees. The reports include CQI findings related to:

Safety

Compliance with regulatory standards and audits

Insurance/liability

Labor/management

Consumer/ employee grievances, arbitrations

Litigation/Civil Rights complaints

Risks related to service delivery

Major and unusual incidents

Long-Term Planning

SCCS long-term planning assesses critical issues facing the agency, SummitCounty, and Child Welfare. Utilizing the CQI process, findings, and literature review, strategic planning occurs every three to four, resulting in the Agency’s written Strategic Plan. The strategic direction is identified through stakeholder input, data collection, qualitative and quantitative data analysis.

The Agency’s Strategic Plan is implemented through the annual Operational Plan, which defines annual priorities.

Short-Term Planning

The Agency’s Short-term Planning involves two documents: 1) Agency Service Outcome Plan; 2) Operational Plan.

The Agency’s Service Outcome Plan establishes general and service specific outcome measures for a three-year period. The plan is approved by the agency Board of Trustees and reviewed annually for continued applicability.

The Operational Plan defines annual priorities of the Strategic Plan. Progress is reported quarterly.

Agency Outcome Measurements

Service outcomes for the Agency are measured annually as defined in the Service Outcome Plan.

Consumer and Stakeholder Input

SCCS conducts a Consumer Satisfaction Survey [6] at the end of each SAR and a broad stakeholder survey at least once every five years. The following forms of stakeholder input are utilized:

Consumer/stakeholder surveys [7]
Consumer comments and perspectives identified through the Utilization Reviews
Focus Groups [8]
Community Forums
Special Studies and/or interviews, as deemed appropriate
Board of Trustees meetings
Public comment at Board of Trustees meetings
Review of complaints, grievances, and appeals

Identification of Patterns and Trends

CQI activities and findings are analyzed to identify trends or patterns. A pattern is any identified result that continuously emerges for at least two consecutive quarters. A trend is any identified result that continuously emerges for three or more quarters.

Feedback Mechanisms

CQI Reports

CQI activities and findings are reported quarterly, summarized annually, and shared with the agency’s Executive Council. CQI findings are also shared with stakeholders on an ongoing basis via quarterly reports to the Board of Trustees, internal and external newsletters, and the Agency website and electronic e-mail.

Feedback to Individuals

CQI findings related to specific individuals or service areas are reported to those directly involved. Findings are shared with appropriate individuals to facilitate growth in knowledge and improvements to the service/ administrative system.

Confidentiality

CQI reports contain only aggregate data. No person or identifying information shall be revealed in a public report. CQI forms (hard copy) shall be maintained in secured files and electronic data shall be maintained in accordance with agency MIS policy. Only authorized agency personnel shall access QI data as necessary to conduct research, analyze data and produce aggregate reports.

Information Management

SCCS maintains the KIDS 2100 database to house consumers’ information. ORE utilizes the database to prepare numerous CQI reports. The MIS Division Director authorizes KIDS 2100 data access to select ORE staff.

Action Plans

Based upon CQI findings, the Agency takes systemic corrective actions. The Executive Director is responsible for systemic improvements and assigns tasks and responsibilities to appropriate staff. Individual corrective actions, such as those for an individual case, are the responsibility of the involved staff/supervisor. As part of the CQI process, Division/Department staff shall respond to findings and participate in activities designed to improve and strengthen the agency’s service system. The CQI Committee monitors corrective actions.

Random Sampling Size Chart

Population Size / Sample Size
100 – 199 / 100
200 / 110
250 / 124
500 / 165
750 / 185
1,000 / 198
1,250 / 206
1,500 / 211
2,000 / 219
3,500 / 230
5000+ / 250

Services with an annual consumer population less than 100 will have all (100%) files reviewed:

When the population size falls between two population-size numbers listed above, the sample size is calculated using the higher and lower numbers to arrive at the appropriate sample size.

Standardized Reporting Categories for SCCS

Ethnicity/Race Categories

African-American
Caucasian
Latino
Asian
Bi-Racial
Native American
Other

Geographical Categories

SummitCounty (Ohio) Region / Zip Codes within the Region / Cities/Villages/Townships (Neighborhoods) within the Region
Akron / 44240, 44250, 44260, 44281, 44301, 44304, 44305, 44306, 44308, 44311, 44312, 44632
Barberton / 44203, 44210, 44216, 44314, 44319, 44321, 44614, 44630, 44685, 44720
North Summit / 44056, 44062, 44067, 44087, 44202, 44221, 44223, 44224, 44236, 44262, 44264, 44278, 44286
West / 44302, 44303, 44307, 44313, 44320, 44333
Other / All Zip Codes Outside of those Listed Above / Areas Outside of those Listed Above
Placement Type / Custody or Case Type / Annual Household Income Categories
Own Home / Voluntary /No Custody / $0 - $15,000
Foster Home / Protective Supervision / $15,001 - $25,000
Kinship/Relative Home / Juvenile Rule 6 / $25,001 - $35,000
Residential Placement / Emergency Temporary Custody / $35,001 - $45,000
Secured Residential Placement / Temporary Custody / $45,001 & Upwards
Independent Living Arrangement / Planned Permanent Living Arrangement
Hospital / Permanent Custody
Adoptive Home
Free Home (Absence from Care)
Group Home
Other
Religious Affiliation
Person Considers Herself/Himself to be: /

Primary Language in the Home

Buddhist / English
Christian – Catholic / Spanish
Christian – Protestant / Other
Jehovah’s Witness
Seventh Day Adventist
Amish/Mennonite
Hindu
Jewish
Muslim
Other
None

Review or Activity

/ Primary Responsibility of: /

Reporting Schedule

Corrective Action Plans / Executive Director / As Needed
CQI Committee Meeting & Meeting Minutes / CQI Committee Chair (or Vice Chair) / Monthly
CQI Report & Update presented to the Board of Trustees / Executive Director / Quarterly & Annual Summary
Executive Council Review of CQI Findings / CQI Committee / Quarterly
Safety Committee Meeting & Meeting Minutes / Safety Committee / Monthly
Consumer Survey / OR&E / Annual
Focus Groups / OR&E / As Needed
Stakeholder Participation / OR&E / Ongoing in Various Methods
Annual Evaluation of the CQI Process (including assessment of corrective actions/systemic improvements) / OR&E Coordinates and the following review findings:
CQI Committee, Executive Council, Board of Trustees / Annual
Annual Plan Measures/Five Year Plan Measures / OR&E / Quarterly Measures & Annual Summary
Consumer Satisfaction (See Consumer Survey) / OR&E / Annual
Consumers' Complaints & Grievances Review / Ombudsman / Quarterly & Annual Summary
External Monitoring / OR&E / Annual
Outcome Measurements (Annual Service Plan Measures) / OR&E / Annual
Risk Management Safety Issues / Safety Committee / Quarterly & Annual Summary
Risk Management Safety Issues / OR&E Review of Referral for Assessment Data (Referrals on Open Cases) / Quarterly & Annual Summary
Risk Management Compliance, Legal Mandates, and Liability Issues / Legal Division / Quarterly & Annual Summary
Risk Management – Limits to Freedom of Choice (Behavior Management & Physical Restraint) / Paid Placement Supervisor / Quarterly & Annual Summary
Safety Reviews & Reporting / Safety Committee / Quarterly & Annual Summary
Risk Management & Reporting / OR&E Summarizes All Risk Management Monitoring Activities & Findings / Quarterly & Annual Summary
Risk Management Review: Request for Assessment on:Open Cases/
Screen-Outs / OR&E / Quarterly & Annual Summary
Child Fatality Review Board Report / OR&E Obtains the Report / Annual
Critical Case Reviews / Executive Director / As Needed
Staff Complaints & Grievances / Human Resources / Quarterly & Annual Summary
Long-Term Planning / Executive Director / Every 5 Years with Annual Monitoring
Short-Term Planning / OR&E / Annual
Child Well-Being Measures & Reporting / OR&E / Annual
Compliance Monitoring & Reporting / OR&E / Quarterly & Annual Summary
Agency & System Performance Monitoring / OR&E / Quarterly & Annual Summary
Impact of Services / OR&E / Quarterly & Annual Summary
CQI Reports (final) sent to Executive Council / CQI Committee / Quarterly & Annual Summary
CQI Reports (preliminary) sent to CQI Committee / OR&E / Monthly
Impact Monitoring & Reporting / OR&E / Quarterly & Annual Summary
Performance Monitoring & Reporting / OR&E / Quarterly & Annual Summary
KIDS 2100 Data Analysis / OR&E / Quarterly & Annual Summary
Review of Secondary Source Documents / OR&E / Annual
Special Studies / Executive Director / As Needed
Completeness of Records & Documentation Review / Records Department / Quarterly & Annual Summary
Multi-Disciplinary Review / Executive Director / As Needed
Peer Review / OR&E / Quarterly & Annual Summary
Semi-Annual Administrative Review / OR&E / Semi-Annual
Utilization Review / OR&E / Quarterly & Annual Summary
Impact of Services / OR&E / Semi-Annually & Annual Summary
Impact & Effectiveness of Services/General / OR&E / Semi-Annually & Annual Summary
Program Evaluation(s) / Executive Director / As Desirable

This Continuous Quality Improvement Plan has been reviewed and approved by: