Continuous Quality Improvement Report
2008-2009
Quarterly Quality Indicator Report Summary:
- No client grievances or complaints were filed
- No allegations by clients of abuse/ neglect by staff
- One temporary person hired to help out with billing, and one contractual CYS staff was hired. One CCS staff retired, and hours were increased by two CCS part time staff to fill those hours. The Substance Abuse secretary resigned, and was replaced with a full time person.
- 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: Eighty-four cases were reviewed. In 92% of cases, treatment was progressing well, and client benefit was noted in the file. Other cases noted ongoing and additional stressors as treatment progressed. Economic issues appear to trigger additional issues than the client originally presented for treatment. Clinically, it appears that clinicians are being more efficient with tying the progress notes to the treatment plan. 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.
Client Satisfaction: This will be completed for the 2009-2010 report in the fall, 2010
Quarterly Client Satisfaction Surveys: Surveys were conducted each quarter, and the benchmark of 90% satisfaction in all areas was met. Barriers to service that were identified were transportation, therefore bus passes were donated by the local Rotary Club, and were handed out and monitored by each therapist.
Post Discharge Surveys: Client surveys were sent one-month post-discharge, six months post-discharge and one year post-discharge. Approximately 11% of the sent surveys were returned, and out of those, 91% reported continued ease of symptoms one year post discharge.
Staff Satisfaction: This will be completed for the November 2010 report.
Board Committee Evaluation:
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 2008/2009 budget was met and exceeded. The Agency was able to produce approximately $16,000 over expenses.
During the year, the staff voted to eliminate President’s Day and the two “holidays” traditionally given by the Board of Directors at Christmas time. They also voted to reduce that agencies contribution to the pension fund from 9 % to 7 % starting April 1, 2009. The staff also agreed to reduce their mileage reimbursement from .55 per mile to .30 per mile as a way of saving the Agency money. The Finance Committee reviewed these projected savings and agreed to them and recommended them to the Board of Directors.
During this fiscal year, the Agency was able to secure grant funds and a new
Staff lounge was updated with new cabinets and new flooring.
Membership and Nominating Committee: All nine goals and Objectives established by this committee were met and are operational per each objective. The Board was able to meet its goal of three new Board members (actually four new members joined; however six members (Franklin Bennett, Jr., John Cummings, Robin Cloetens, Maureen Duncan, Ann Marie Grabar, & Lynn Slaman resigned) leaving a net increase of two. The Membership and Nominating Committee meets only when a prospective candidate is secured for Board membership.
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 2009 with the President receiving a positive evaluation. Previously, the President was offered a two-year contract in 2008, which ends ending in September 2010.
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 2008/2009 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.
One of the strategic plans identified is to build better relationships with the clergy in the county, including catholic and non-catholic. Fr. Joe Gagnon came up with a plan to do this and the Board will act on it at the beginning of the fiscal year.
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 2009 and approximately $1,300 was raised and will be used for staff training. On August 22, 2009 we held our first Annual Dinner with the inauguration of the “Best Dessert Contest in St. Clair County” contest. Over two hundred people attended and over $8,600 was raised from this event. Plans are being made for the 2010 Grand Marshal’s Cup Challenge and for the Second Annual Dinner a fund raising dinner to be held on August 19, 2010. 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 2008/2009.
Staff Committee Evaluation:
Staff Social Committee: The committee proposed five events for the fiscal year 2008-2009. One of the events previously suggested, the staff Christmas holiday party, was not held. The other events Boss’s Day luncheon, Clerical Day luncheon, Social Worker’s Day luncheon, 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:
-changed from a cleaning person to a cleaning company Sweeney Cleaning Company
-we changed the base blocks (and painted them) for the ramp to the trailer
-changed the electrical outlets in two restrooms and the outlet by the drinking fountain to GFI outlets
-added new mulch to all the outside beds in the spring
-cleaned the outside trailer and re-organized it
-trimmed all the shrubbery twice during the course of the year
-has an on-site inspection from Michigan Catholic Conference regarding our building (there were several requests from them for updates (GFI outlets) and they have been completed)
-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)
-new furniture was installed in the lobby; it was repainted a different color to match the furniture; we also purchased new floor mats to compliment the lobby as well as to replace the worn out old mats
-a new copy machine will be in place in November.
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.