FATHER MALONEY’S BOYS AND GIRLS HAVEN

Performance and Quality Improvement Plan

I. Introduction

A. PQI Philosophy

The mission of Boys and Girls Haven is to shelter, heal and teach struggling young people to become productive and healthy members of our community. We continuously strive to fulfill our mission and provide the highest quality of care to our clients, their families and our community. We accomplish this, in part, through the implementation of a Performance and Quality Improvement (PQI) plan. This plan:

  • Promotes excellence and mission-driven action throughout the agency
  • Involves clients, staff members, stakeholders and other relevant parties in the PQI process
  • Utilizes data to assess the performance of individual programs, departments and the agency as a whole
  • Encourages continuous improvement across all services and programs offered by Boys and Girls Haven
  • Supports the strategic priorities, goals and objectives of the agency.

B. PQI Structure

Teams and Committees

Teams and committees play an integral role in the implementation of our PQI plan. Descriptions of these teams and committees are provided below:

  • All Staff: “All staff” meetings are held at least six times per year. These meetings include all employees and are facilitated by the CEO. Directors provide reports relevant to their departments. During these meetings, PQI information is provided to the employees. The employees also have the opportunity to share information and provide feedback to agency leaders.
  • Program Teams: Program teams are comprised of staff members of agency programs. Program teams are led by Program Supervisors and Program Managers. These teams oversee efforts to improveservice delivery within their respective programs. Each program team helpsidentify opportunities to enhance the overall quality of services for our consumers. Program teams communicate PQI information to their supervisors or managers, who then share that information with others in the agency. Program teams meet at least twice per month.
  • Risk Management Team: The Risk Management Team is comprised of the CEO, Directors, Associate Directors, Program Managers, Program Supervisors, the Training/Recreation Supervisor, the Referral/Intake Coordinator and the Maintenance Supervisor. The Director of Programs & Operations is responsible for leading the Risk Management Team. This team is responsible for quarterly reviewsof issues related to risk management. This team, or portions thereof, meet with greater frequency as needed to review safety concerns and risks as they arise.
  • Case Record Review Team: A peer review team comprised of managers, supervisors, therapists, case managers, the Training Supervisor and Associate Director of Programs reviews client records on a quarterly basis. The Associate Director of Programs leads the case record review team. Client records are randomly chosen each quarter for review by the team. The number of records that are reviewed is based on a percentage of the total number of clients served per year, in accordance with COA standards. See Appendix A for a description of the agency’s case record review process.
  • Leadership Team: This team is comprised of the CEO, Director of Programs and Operations, Director of Development, Director of Finance, Director of Human Resources, Associate Director of Programs, Program Managers, Referral/Intake Coordinator and the Training Supervisor. This team reviews information that is important to the daily operation of the agency, and makes plans to disseminate information and implement necessary changes. This team also reviews PQI information and assists with the implementation of performance improvement plans. Leadership Team meetings take place monthly.
  • PQI Committee: The PQI Committee bears primary responsibility for implementing the agency’s PQI plan. It is chaired by the CEO or the Director of Programs and Operations. The PQI Committee includes Directors, Associate Directors, Program Supervisors, Program Managers, the Referral/Intake Coordinator and Training Supervisor. The Chair of the Board of Trustees may also choose to sit on this committee. This committee meets quarterly to review a wide range of data related to the performance of individual programs and the organization as a whole. Committee members identify potential opportunities for improvement, and initiate Performance Improvement Plans (PIPs) accordingly. The committee also reviews existing PIPs to determine if the desired outcomes have been achieved.
  • Board Committees: Board Committees are comprised of members of the Board of Trustees, the CEO, one or more Directors and Associate Directorsand select staff members. Each committee is led by one Board member who has volunteered to lead that committee and has an interest in that particular aspect of the agency. The Board committees include: Executive Committee, Governance Committee, Program Committee, Finance Committee, HR Committee, and PR/Development Committee. Committees meet at least four times per year. PQI reports are presented at committee meetings. Board members share feedback related to PQI that can be communicated to other teams and committees. Each Board committee also reports on relevant PQI activities to the full Board of Trustees.
  • Board of Trustees: The CEO reports on at least a quarterly basis to the Board of Trustees on the progress of the Performance and Quality Improvement Plan. During each meeting Board Committees report PQI information to the full Board to ensure that continuous quality improvement is a prime component of the Board’s activities. The Program Committee is primarily responsible for reviewing and reporting on program outcomes; however, all Board committees are involved in activities related to PQI. Any feedback from the board related to performance and quality improvement is documented and relayed by the CEO to the other teams and committees.

Personnel Involved in PQI Activities

The following chart lists individuals who are involved in carrying out the agencies PQI plan. Their roles and training necessary to carry out PQI activities are also identified:

Title / PQI Roles / Training
Board members / Members of the Board of Trustees participate in meetings of the full Board as well as Board committee meetings. They review PQI information, offer feedback, and assist in identifying areas where performance/quality improvement is needed. / Members of the Board receive a general orientation as well as orientation specific to the committees in which they will participate. During these orientations, their role in reviewing and disseminating PQI information is discussed.
CEO / The CEO is responsible for facilitating all-staff meetings and meetings of the Board of Trustees. The CEO also participates in Board committee meetings, Leadership Team meetings, Risk Management Team meetings and PQI Committee meetings. / The CEO participates in trainings related to the PQI process through the Kentucky Children’s Alliance, the Center for Nonprofit Excellence and other non-profit organizations. In addition, the CEO engages in in webinars and self-paced trainings offered by COA.
Directors / Directors are responsible for leading the PQI Committee, Risk Management Team and Leadership Team. Directors also facilitate Board committee meetings and participate in all-staff meetings. / Directors participate in trainings related to PQI through COA, as well as internal trainings offered by the agency’s Director of Programs & Operations. Directors also receive training that is relevant to their particular program areas. This includes training on the electronic medical records system, Microsoft Excel, data collection, data analysis, basic statistics and implementation of performance improvement plans. PQI trainings are provided by the agency upon hire and on an annual basis.
Associate Directors / Associate Directors lead the Case Record Review Team. Associate Directors are also responsible for attending PQI Committee meetings, Risk Management Team meetings and Board committee meetings. Associate Directors also participate in all-staff and Leadership Team meetings. / Associate Directors participate in trainings related to PQI through COA, as well as internal trainings facilitated by the Director of Programs & Operations. Associate Directors receive training that is relevant to their particular program areas. Training topics include the electronic medical records system, Microsoft Excel, data collection, data analysis, basic statistics and implementation of performance improvement plans. PQI trainings are provided by the agency upon hire and on an annual basis.
Program Managers / Program Managers are responsible for participating in all-staff meetings, Leadership Team meetings, Risk Management Team meetings, case record reviews, and PQI Committee meetings. Program Managers also work with the Program Supervisors to lead program team meetings. / PQI trainings are provided by the agency upon hire and on an annual basis. Program Managers receive PQI training facilitated by the Director of Programs & Operations, and may also participate in webinars and self-paced trainings offered by COA. They receive training relevant to their particular program areas. This includes training on the electronic medical records system, Microsoft Excel, data collection, data analysis and implementation of performance improvement plans.
Program Supervisors / Program Supervisors are responsible for participating in all-staff meetings, Leadership Team meetings, Risk Management Team meetings, case record reviews, and PQI Committee meetings. Program Supervisors also work with the Program Managers to lead program team meetings. / PQI trainings are provided by the agency upon hire and on an annual basis. Managers receive PQI training facilitated by the Director of Programs & Operations, and may also participate in webinars and self-paced trainings offered by COA. They receive training relevant to their particular program areas. This includes training on the electronic medical records system, Microsoft Excel, data collection and performance improvement plans.
Support Personnel / Support Personnel are responsible for participating in all-staff meetings, Leadership Team meetings, Risk Management Team meetings, case record reviews, and PQI Committee meetings. They also assist with gathering survey data and other information relevant to PQI. / PQI trainings are provided by the agency upon hire and on an annual basis. Support personnel receive PQI training facilitated by the Director of Programs & Operations, and may also participate in webinars and self-paced trainings offered by COA. They receive training relevant to their particular program areas. This includes training on the Electronic medical records system, Microsoft Excel, data collection and data analysis.
Staff members / Staff members participate in all-staff meetings as well as program team meetings. Select staff members participate in case record reviews and Risk Management Team meetings. / PQI trainings are provided by the agency upon hire and on an annual basis. Ongoing information regarding the PQI process is provided during program team meetings and all-staff meetings.
Foster parents / Foster parents participate in program meetings, trainings and events as members of the therapeutic foster care team. They provide direct feedback to staff members and complete stakeholder surveys. / PQI information is shared with foster parents during the initial certification process. It is also reviewed on an annual basis. Staff members explain how feedback from foster parents contributes to the PQI process.
Volunteers / Volunteers participate in program meetings and agency events when appropriate. Volunteers may also participate in team and committee meetings. Volunteers are apprised of PQI activities and are asked to complete stakeholder surveys. / The agency communicates PQI information through various means, including newsletters, annual reports, social media and the agency’s website. Volunteers are informed of the PQI plan during the orientation process. Volunteers are also encouraged to complete stakeholder surveys.
Stakeholders / The agency seeks feedback and input from stakeholders during every step of the PQI process. There is a continuous flow of information from stakeholders to the agency, and from the agency to stakeholders. Stakeholder feedback plays a crucial role in identifying opportunities for performance and quality improvement. / The agency communicates PQI information through various means, including newsletters, annual reports, social media and the agency’s website. Solicitations for survey responses include information about how those responses will be used (e.g. to support the PQI activities).

Flow of PQI Information

There is continuous circulation of information throughout all levels of the organization.

See the chartentitled “Boys and Girls Haven: Flow of PQI Information” for a visual representation of how information flows between the teams, committees and stakeholders involved in the PQI process.

C. Stakeholders

Key stakeholders

Boys and Girls Haven engages the following stakeholders in its PQI process:

  • Referral sources (e.g. DCBS, DJJ)
  • Judges/Court personnel
  • Schools
  • Clients
  • Staff members
  • Foster parents
  • Volunteers
  • Board members
  • Donors
  • Consultants
  • Contractors
  • Vendors
  • Community partners
  • Political figures
  • Governmental organizations
  • Private foundations
  • Neighbors

Involving stakeholders in PQI

Boys and Girls Haven involves our stakeholders and consumers in our Performance and Quality Improvement Process through surveys to clients, Board members, parents/guardians, referral sources, staff, community partners and volunteers. Surveys are distributed at least annually to most stakeholders. Staff members participate in an annual employee survey. Client surveys are distributed quarterly.

Stakeholder surveys are sent out with self-addressed stamped envelopes to encourage a higher rate of return. When possible, surveys are distributed and collected via electronic means (e.g. e-mail, Survey software).

Collected data is analyzed and used in conjunction with other external surveys used by licensing and regulating agencies (e.g. COA), to improve our overall quality and delivery of services to our consumers and community. Survey results are presented during PQI committee meetings and are used to develop performance improvement plans. Survey results, when appropriate, are shared with staff at every level of the organization.

Boys and Girls Haven personnel receive regular feedback from stakeholders as they carry out their job duties. This feedback is used to identify opportunities to improve quality. Informal feedback can be shared with any staff member and then communicated to the various teams and committees that are involved in the PQI process.

II. Measures and Outcomes

A. Long-term Strategic Goals and Objectives

Strategic Planning

The strategic plan is revised every four years and is reviewed yearly by the Leadership Team and Board of Trustees. The strategic plan is updated regularly to take into account current trends, needs and opportunities. The strategic plan includes the following:

  • Clarification of mission, values and mandates.
  • Goals and objectives that flow from our mission and mandated responsibilities.
  • An assessment of our strengths and weaknesses.
  • An assessment of our human resource needs.
  • Identification and formulation of strategies for meeting our identified goals.
  • An assessment of our community, to include:
  • Services offered by other providers.
  • Gaps in our array of services
  • Accessibility issues.
  • A demographic profile of our community and consumers which includes:
  • Annual household income.
  • Gender
  • Age
  • Racial/ethnic composition
  • Religious affiliation
  • Language of choice

The most recent update to the Boys and Girls Haven strategic plan was completed in August 2012. The agency’s current strategic goals and objectives are listed below:

Goal 1: / We will develop a comprehensive plan to address shortfalls in program funding
1.1 / We will implement a strategy to identify and cultivate sustainable program prospects that address a core funding gap.
1.2 / We will implement a strategy to identify and cultivate an additional $780,000 and expand private funding (i.e., a Wills and Trusts program).
1.3 / We will create overall plan and specific marketing plans for various special events.
1.4 / We will implement a capital campaign.
Goal 2: / We will build community awareness and the visibility of Boys and Girls Haven’s services across the social service spectrum and community.
2.1 / We will work to increase and expand local and statewide visibility.
2.2 / We will engage community members by creating an Advisory Board.
2.3 / We will create and engage a Speaker’s Bureau to promote BGH.
2.4 / We will expand the Communications and Development Office staff to help promote BGH.
Goal 3: / We will develop a plan of action to meet our census goals.
3.1 / We will develop new partnerships and strengthen existing partnerships with referral sources.
3.2 / We will secure alternate funding sources
3.3 / We will adapt current programs and develop new programs to meet the needs of our referral sources
3.4 / We will assess the feasibility of expanding current facilities and/or building new facilities in order to meet programmatic needs
Goal 4: / We will develop and implement a comprehensive plan for recruitment and staff development.
4.1 / We will develop and implement a workforce development plan to maximize output
4.2 / We will develop a Compensation & Recognition philosophy & structure.
4.3 / We will develop a succession plan for key employees.
4.4 / We will develop HR metrics (to include baseline).
4.5 / We will develop a plan to coordinate & recruit volunteers.
4.6 / We will develop a recruitment plan that uses diversified recruitment methods to attract & retain successful employees
Goal 5: / We will monitor our operating plan and budget to achieve positive programmatic results, as well as financial accountability and programmatic sustainability.
5.1 / We will implement a process for timely oversight of program financial performance.
5.2 / We will implement a Continuous Quality Improvement Strategy.
5.3 / We will implement a Critical Success/Risk Factor Report.

Our PQI plan is aligned with our strategic plan. By engaging in activities that promote continuous performance and quality improvement, we accomplish the goals and objectives established in the strategic plan. The PQI process also informs future revisions of that plan.