Continuous Quality Improvement Report
2010-2011
Quarterly Quality Indicator Report Summary:
- No client grievances or complaints were filed
- No allegations by clients of abuse/ neglect by staff
- Resignation of Karlene Harbour (Peoples Clinic) and Marsha Kott (Saturday receptionist). Cam Gild was contracted with to do the CSC Groups and to do counseling at Peoples Clinic, Ryan Smith was contracted with to do substance abuse groups. Jolene Lepein-Doan went from a Contractor to a full-time staff, and Stephanie Evans went from Hourly to Part-Time. Sally Gallagher (evening and Saturday receptionist) retired, and Amanda Polotowicz was hired as an Intake Specialist (new position).
- No Recipient Rights Allegations were filed.
- No Employee Grievances were filed.
- No Complaints were received from funding/ licensing agencies.
- No client deaths or other critical incidents.
- No compliance issues with external audits.
Utilization Review: Seventy five cases were reviewed. In 96% of cases, treatment was progressing well, and client benefit was noted in the file. Other cases noted ongoing and additional stressors as treatment progressed. Cases appear to be triaged well, case assignments being more efficient with department directors doing the initial screenings. In high risk cases, all appropriate interventions were followed.
Staff Satisfaction: All areas of the survey were rated as “satisfied” or above, with the exception of staff salary and career development. Suggestions were to allocate funds to help pay for staff licensure, adding optical coverage, and adding pay raises rather than bonuses.
Client Satisfaction:
Quarterly Client Satisfaction Surveys: 544 Surveys were given to existing clients, and 430 were returned. All established benchmarks were met on all surveys, which indicated that in at least 90% of the cases, treatment was progressing as expected, and clients were satisfied with their treatment. Since transportation continued to be a barrier to services, funds donated by the Port Huron Rotary were used to purchase bus tickets, which helped to alleviate this problem to a degree. Since busses do not run regularly to the outlying areas of the county, this continues to be an issue in a small amount of the cases.
Post Discharge Surveys: 515 total client surveys were sent one-month post-discharge, six months post-discharge and one year post-discharge. 143 surveys were returned (approximately 28%) and out of those, 90% reported continued ease of symptoms one year post discharge.
Board Committee Evaluation 2010//2011
Finance Committee: All nine Goals and Objectives established by this committee were met and are operational per each objective. The Finance Committee meets on a quarterly basis, or on a “needs to meet basis”, and met to review the annual audit. The goal of meeting or exceeding the 2010/2011 budget was met and exceeded. The Agency was able to produce approximately $23,000 over expenses.
As will be discussed later in this report, there were two fund raising events this past fiscal year, the Grand Marshal’s Bowling Cup Challenge in which $800.00 was raised and the Second Annual Best Dessert Contest was held and over $7,000 was raised.
Membership and Nominating Committee: All nine goals and Objectives established by this committee were met and are operational per each objective. The Board did not meet its goal of three new Board members; however, it remained status quo. The Membership and Nominating Committee meets only when a prospective candidate is secured for Board membership. Due to the new structure of the agency as dictated by the AOD, quite possibly there will be no new candidates for board membership until the reorganization is complete.
Executive and Legislative Committee: All five Goals and Objectives established by this committee were met and are operational per each objective. The Executive & Legislative Committee meets as necessary or at least once a year to review governance issues within the Board and to have oversight over the President’s performance review. This review was conduced in September of 2011 with the President receiving a positive evaluation. The President was offered a two-year contract commencing 10-1-11.
The AOD starting 10-1-11 is in the process of reorganizing all of the CSS agencies and governance of the agencies is one area that is going to change as the CSS/St. Clair board will eventually become an Advisory board and not a governing board. This process begins said date by could take a few years to come to fruition.
Program Services Committee: All seven Goals and Objectives established by this committee were met and are operational per each objective. An on-going program of education and review of Agency programs and services is in the process for the committee members. Upon completion of the education review, the committee members will make recommendations for service needs not met by either the community or the agency. They will them make a determination if action is needed by the Agency and if it meets the guidelines of the Agency Mission Statement. The Program Planning and Analysis Committee meet on an as-needed basis but at least twice a year to review the programs and services of Catholic Social Services and to make recommendations for services needed in the community and that meet the Mission of Catholic Social Services. One of the goals of further education for committee members was not completed and will be completed in the 2011/2012 fiscal year. When that is completed, the committee will meet with administrative staff to review current programs and services and to look for new opportunities for growth within the agency. All of this maybe for naught as the AOD is in the process of reorganization of all the CSS agencies and this evaluation will be conducted by the team selected from the AOD.
Fund Development Committee: All five Goals and Objectives established by this committee were met and are operational per each objective. The Grand Marshal’s Cup Challenge was held in March of 2011 and approximately $900 was raised and will be used for staff training. On August 22, 2011 we held our third Annual Dinner “Best Dessert Contest in St. Clair County” contest. Over two hundred people attended and over $7,600 was raised from this event. Plans are being made for the 2012 Grand Marshal’s Cup Challenge and for the Fourth Annual Dinner a fund raising dinner to be held on August 9, 2012. The Fund Development meets on a monthly basis to plan and coordinate these events.
Personnel and Human Resources Committee: All ten Goals and Objectives established by this committee were met and are operational per each objective. All Agency Policy and Procedure Manuals and Clinical Manuals were reviewed and approved by this committee and by the Board of Directors. The Personnel and Human resources Committee meets on an as-needed basis and meets annually to review the various agency manuals for updates and compliance. This goal was met in 2010/2011.
Staff Committee Evaluation:
Staff Social Committee: The committee proposed several events for the fiscal year 2010/2011. The staff Christmas holiday party at Chip and Teresa’s house and a tour of Greenfield Village was held. The other events Boss’s Day luncheon, Clerical Day luncheon, Social Worker’s Day luncheon, a Tiger ball game, and the Staff/Board Christmas luncheon took place with many of the staff participating in all the activities.
Staff Building Committee Issues Addressed: The committee set goals to complete the following items and they were completed:
-added new mulch to all the outside beds in the spring
-cleaned the outside trailer and re-organized it
-painted the roof and sealed the leak, as well as re-painted the trailer
-trimmed all the shrubbery twice during the course of the year
-the slate floor in the waiting room was cleaned and re-sealed
-all the windows are to be washed quarterly (this was part of the contract with Sweeney Cleaners)
Staff Personnel Committee: The Staff Personnel Committee and the Board of Directors Human Resources Committee met together to review Agency Policy and Procedure Manuals to make sure they met with current COA Standards and/or needed to be updated. There were no changes to any policies or procedures as they currently met COA standards and were applicable as written.
ADDENDUM-September 2011
In light of the proposed changes to the administration and governance of CSS/St.Clair by the AOD, that are scheduled to start 10-1-11 and may take a few years to implement, this report may in fact change due to the nature of these changes. Time will tell as to what and when things will change. As of this writing, there are many unanswered questions as to what services and programs we will continue to provide.