PERFORMANCE IMPROVEMENT PLAN
Mastrofrancesco is dedicated to providing Person Centered Services and supports to individuals that have a developmental disability or a mental illness.
The purpose of the PIP (Performance Improvement Plan) is to identify areas of improvement within the service delivery of its programs to assure the ongoing provision of quality services and supports. Specifically, the organization will improve the effectiveness, efficiency and quality of services, and ensure performance improvement efforts are in line with the changing needs of the persons served and other stakeholders.
PERFORMANCE IMPROVEMENT COMMITTEE
The PIP Committee will meet at least annually, and shall be composed of supervisors and staff of Mastrofrancesco Inc. The committee shall also make an effort to have consumers and or their representatives on the committee. The Executive Director will establish priorities and promote participation of all staff.
The purpose of the committee will be to identify improvements to areas of the performance improvement system and manage the review of overall plan implementation and its impact on performance improvement and will make recommendations to the Executive Director. The quarterly performance improvement reports will be forwarded to the Board of Directors. The board of Directors will review and approve any corporate wide recommendations made by the committee.
Data and information reviewed and evaluated by the committee are described in the following pages of this plan and will include the core indicators as required by various funder agency contracts with Mastrofrancesco Inc.
PERFORMANCE IMPROVEMENT REPORT
The program coordinator, site managers, and supervisors are responsible for data collection. The quality assurance manager will organize the data and complete a Performance Improvement data report. The Executive Director will ensure a report is generated on a quarterly basis. The quarterly Performance improvement is forwarded to the Board of Directors, funders, management staff and members of the PIP Committee. The program coordinator/home managers will be responsible for sharing a summary of results to all staff, persons served, family members and guardians. The report will be published on the agency web site for review. Reports will be available to anyone requesting a copy of it.
Performance Improvement Report results are used to develop the agency’s strategic plan, to improve existing services, and to make program /service changes to meet the needs of stakeholders.
PERFORMANCE IMPROVEMENT INDICATORS
Mastrofrancesco, Inc. has developed performance improvement indicators to evaluate the effectiveness, efficiency and quality of its services, access to services and the satisfaction of all stakeholders. Indicators are based on standards put forth by the agency, its funders, CARF (The Rehabilitation Accreditation Commission), and JCAHO (Joint Commission on Accreditation of Healthcare Organizations), as well as input from the PIP committee.
The indicators are established to assure that all individuals served and their families, significant others, and the organizations that fund the services are aware of and are satisfied with the services provided and the results of such services. The Performance Improvement Indicators are reviewed and revised quarterly in accordance with the changing needs of the organization and persons served. The PIP Committee is responsible for soliciting feedback from those receiving results of indicators, for sharing feedback with the management staff, and for utilizing the feedback to amend performance improvement indicators and the PIP.
CONSUMER AND OTHER STAKEHOLDER INPUT AND SATISFACTION
CONSUMER SATISFACTION SURVEYS
Mastrofrancesco Inc. uses a consumer satisfaction survey system to collect data and analyze levels of satisfaction by consumers. The use of this data will provide a continuous quality improvement process with the opinion of the consumer being a vital ingredient. All consumers and consumer guardian/representatives are asked to complete the survey which is provided through the mail annually. The survey format, contents, and scoring system will match the funder agency requirements. The surveys will be due by April 21, 2010 and results are reported in the second quarter PIP report. The goal is to achieve 100% satisfaction for fiscal year 2009/2010.
PROFESSIONAL SATISFACTION SURVEYS
Mastrofrancesco uses a professional satisfaction survey system to collect data and analyze levels of satisfaction of contract liaisons, funding/referral supports coordinators, therapists and other professionals. All professionals are asked to complete the survey, which is provided through the mail annually. The goal is to achieve 100% satisfaction for fiscal year 2009/2010.
An exit satisfaction survey is sent by mail to all persons served and consumer guardian/representatives when an individual exits the organization or transfers to another site operated by Mastrofrancesco.
Results of all completed and returned surveys will be aggregated and included in quarterly indicator reports.
This data will be obtained by tracking the total number of activities in the community each quarter, and breaking them down into number of group activities and number of consumer chosen activities. Group activities are defined as those in which the majority of consumers participate. Consumer chosen activities are individual or small number of consumers choosing to go out on a particular activity. The source for the data to be obtained will be recorded on specific community integration worksheets, which will be stationed at the individual program sites including community living support locations. Staff at the individual programs will chart the data on the worksheets and they will be submitted to the committee on a quarterly basis. Data will be reported quarterly in the Performance Improvement Indicator Report.
CONSUMER ACHIEVEMENT OF PERSONAL GOALS
The data for this objective will be taken from the following question on satisfaction surveys, which asks consumers to rate: “This program is helping to achieve my goals”. Those who rate a 3 (Agree) or 4 (Strongly Agree) will be considered achieving personal goals/objectives. The goal for FY 09/10 is to achieve 100% satisfaction in this area.
This data will be used to evaluate staff turnover within the corporation. The data will be obtained by calculating the percentage of staff working in each program for 12 months, twelve months (or more) and 24 months (or more).
ACCESS TO SERVICE
This data will be used to evaluate the length of time that it takes the corporation to actually provide services to a consumer once they are referred to us by an agency. The data will be obtained by calculating the average number of days from referral to the date services actually begin, with a goal of less than 30 days.
STAFF ORIENTATION AND TRAINING FOR CARE GIVERS
The Quality Insurance Manager, and the program coordinator or house managers are responsible for monitoring and ensuring that the direct care staff receives proper training required by Mastrofrancesco Inc. and the respective funding source. Information regarding the number of staff and how many require training will be submitted to the contracting agency with quarterly outcomes information data. At a minimum, direct care staff will complete the initial Toolbox training or the initial Direct Care Staff training that is required by the state regulatory agency, before any assigned tasks are performed. This will include CPR and First Aide training; complete the Toolbox training plan and/or Group Home Training Curriculum (dependent on funding source) and the Mastrofrancesco employee orientation checklist, before the employee works alone or as a lead worker on a shift, within 90 days; maintain certification in first aid and CPR, and receive annual training in safety policies and procedures, infection control, blood borne pathogens, recipient rights, and medication administration. Additional training needs will be ongoing and are site/consumer dependent.
STAFF TRAINING INDICATORS
Mastrofrancesco AFC Inc. feels that staff training is a critical component in the provision of safe, quality services to consumers. This training indicator will be a system to track and monitor staff training, and to ensure that staff attend all required trainings within the appropriate timeframe.
Staff Training data is reported quarterly. It is calculated by dividing the number of
staff on the payroll on the last day of the reporting quarter who have been
employed for the designated amount of time (see categories below) and are
trained in accordance with contract requirements, divided by the total number of
staff on the payroll on the last day of the reporting quarter who have been
employed for the designated amount of time.
Include all direct care staff working in the specific provider setting including
supervisors who have regular direct contact with consumers.
Two Staff Training categories are required:
1. Percentage of employees working less than 12 months (initial training)
2. Percentage of staff working more than 12 months (refresher training)
The goal for fiscal year 09/10 in staff training will be 100%.
CREDENTIALING AND COMPETENCY ASSESSMENTS
The credentialing and performance process, which applies to all staff, begins with a position description. The position description identifies educational requirements as well as experience and/or the certification/licensing requirements. In certain circumstances and classifications, candidates can attain certification/licensing after employment. In such event, Mastrofrancesco ensures that the candidate obtains certification/licensing requirements within a specified timeframe.
A thorough background check is completed on each new hire by his/her immediate supervisor and includes previous employment and professional references, a recipient rights screening through the local Office of Recipient Rights, a State criminal background check and residency affirmation, and a motor vehicle department record check (all staff responsible for transporting persons served). All background checks comply with the Federal Fair Credit Reporting Act. Background checks are monitored through the internal reviews of personnel records.
All employees are evaluated at six months from date of hire and annually on their anniversary date. Competency assessments are the tools used to evaluate staff and are based on job descriptions.
EMPLOYEE AND CONSUMER SAFETY
Mastrofrancesco maintains a Risk Management process that provides continuity and a centralized mechanism for reporting and tracking significant events that include ongoing agency functions. This process monitors the ongoing operations of the agency, including areas of risk, identified problems and managed objectives to reduce, minimize or eliminate problems. This written process organizes agency resources to meet potential and cited problem areas. The Agency’s Risk Management process provides a structured vehicle to expand and maintain quality services plus promote a safe work environment that leads to the well being of persons served, visitors, employees, and volunteers. This process seeks to:
- · Maximize agency resources through education and prevention methods to reduce loss of employee time due to injury, equipment repair, and other resources.
- · Maintain a Performance Improvement Model that includes input from agency staff, persons served, visitors, guardians, parent monitoring and advocacy groups. The agency receives ongoing consultation services as appropriate from local and state governmental agencies, independent consultants, and national standards (i.e. CARF Accreditation) that provide direction and guidance to agency operations.
- · Emphasize the goals of communication, planning, prevention, and education of all employees and persons served so that losses are eliminated or minimized. The agency takes an active role in investigating and providing written recommendations to correctly identify operational problems or concerns.
The goal for fiscal year 2009/2010 is to continue to improve the risk process and provide necessary agency information to administrative staff to reduce our risk exposure. The objective will be monitored semi-annually through a report that provides leadership with a tool to implement changes based in data and trends.
Each licensed site tabulates Individual E Score data and completes a report that aggregates data pertaining to the Risk of Resistance and Response to Instruction categories of E Score development. The internal quarterly management audit is used to ensure each licensed site has a current E Score.
The goal for fiscal year 2009/2010 is for all licensed homes to have annual E Scores and they are updated within fifteen days of occupancy changes with 100% compliance.
Fire and Emergency Procedure Drills:
All service sites shall conduct fire evacuation drills a minimum of one per shift per quarter.
All sites shall conduct other relevant drills, including tornado, missing person, bomb threat and vehicle drills, power failure, threat of violence, and medical emergencies a minimum of one per shift annually.
Administrative only sites will complete a fire evacuation drill, severe weather, and power failure drills annually.
All drills will be reviewed by the program coordinator/program manager and/or safety committee. Corrective action will be noted as necessary and followed-up on subsequent drills.
The internal quarterly management audit will be used to monitor conformance to the agency drill schedule.
External Safety Audits:
All service sites, and vehicles owned, rented or leased by Mastrofrancesco, Inc. shall have annual inspections, including heating and cooling, fire alarm systems, fire extinguishers, and an annual safety inspection on the vehicles. The insurance carrier or a contractor will conduct a safety audit at least once every three years. Corrective action plans will be implemented within a reasonable amount of time.
Internal Safety Audits:
The site manager or assigned staff shall conduct monthly and quarterly safety checks at each service site, including administrative only locations. Corrective action will be completed within 30 days.
All licensed sites will operate within the licensure rules and regulations. Upon receipt of licensing consultant reports, the Program Manager and/or area supervisor will complete a plan of correction and submit it to the Executive Director for signature. The plan is then sent to the licensing consultant for approval.
INFECTION CONTROL/COMMUNICABLE DISEASE
All cases of communicable diseases will be tracked and forwarded to the funder as required.
The Program managers will insure employee training records and in-service sessions include documentation that staff and persons served are receiving ongoing training in infection control procedures and universal precautions.
INCIDENT REPORT DATA AND ANALYSIS:
Incident reports and consumer grievances will be tracked by the individual program on a semi-annual basis for trends. An analysis of the data will be completed, along with a corrective action plan as needed in order to decrease the number of incidents in each respective category. Included in this will be all incidents of abuse, neglect, sexual harassment, exploitation, deaths, injuries/accidents, aggressive behaviors, unauthorized leaves of absence, etc.
CHARACTERISTICS AND DEMOGRAPHICS ANNUAL REPORT
Periodically throughout the fiscal year 09/10, Program Managers will collect the characteristics of consumers served and submit them to the quality manager. Annually, a demographics report will be included in the annual quality improvement report.