TARRY HOUSE, INC.
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Subject:
Performance Improvement |
Procedure Number: M.L.
14 |
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Site: All |
Developed: |
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Issued By: Executive
Director |
Effective: |
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Approved By: The
Board of Trustees |
Revised: |
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Reference Policy: M.L.02; M.L.10; B.P.01; H.R. 1,2,3
& 4; C.P. 4 & 5; H.S. 1 & 13; R.P. 1,6 & 18. |
Reviewed: |
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Standards Reference: |
CARF: Section 1 - C ODMH: 5122-30-22 |
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Purpose
The mission of Tarry House, Inc.
is to provide quality consumer-driven and family-supported residential recovery
services to assist persons with severe mental illness to maximize their
independence. To that end, it is the
policy of Tarry House to continually improve both (a) the quality of the
services offered and provided and (b) the business and financial framework that
will support the services offered and provided.
Performance improvement can be
conceptualized as a continuous cycle of asking questions, gathering data to
answer the questions, analyzing the data, and using the results to improve
services and ask more questions. The
purpose of the Tarry House Performance Improvement Policy is to establish a
framework for the following:
a) Strive to ensure that activities reflect best
practices,
b) Assessing the effectiveness and efficiency of
all activities, and
c) Gathering feedback from those served and other
stakeholders regarding their satisfaction with services.
It will include guidelines for collecting
and analyzing data, reporting information, and implementing change and will
consider the following areas:
1)
Clinical programs and services
2)
Business function
3)
Governance
4)
Human Resources
5)
Health and safety
Procedure
Training regarding performance improvement,
outcomes management, statistics, and research design is conducted or scheduled
by the Executive Director, Clinical Director, or designee.
1) Clinical programs
and services
A) Outcomes
Management
The outcomes management plan
applies to each Tarry House program maintaining or seeking accreditation, and
performance goals will be established based on the program’s history, targets
derived from best practices, or perceived trends.
After the establishment of goals,
appropriate measures will be selected and data will be collected to answer
questions regarding effectiveness, efficiency, service access, and customer and
stakeholder satisfaction. The plan will
also specify to whom the indicator will be applied, the primary sources for
data collection, and extenuating/influencing factors.
When a service that is offered or
provided to the persons served is being considered, data will be collected at
the beginning of services, at appropriate intervals during services, at the end
of services, and point(s) in time following services as appropriate and when
applicable. A schedule of outcomes
management activity can be found in the annual Performance Improvement
Plan.
B) Records Review
Performance improvement includes
regular review of randomly selected open and closed records. The review will be completed by a trained
consultant, volunteer, or staff member who is/was not primarily responsible for
producing the record.
C) Client Rights
& Grievance Reports
All written and verbal grievances
are reviewed by a Client Rights Advocate.
The Client Rights Advocate makes Tarry House management aware of any
problems, issues, or trends. The
grievances are summarized annually and presented to the Tarry House management
and to the
D) Critical Incident
Summary
Critical incidents are discussed
as needed during the Administrative Staff Meetings and action is taken when necessary. The incidents are summarized annually and
presented to Tarry House management for consideration in the Performance
Improvement Plan.
2) Business function
Financial reports are prepared
monthly for the Board of Trustees and financial statements are reviewed at
least six times per year. An independent
audit will completed annually by a certified accounting firm.
Areas of potential financial risk
are identified through inspection and consideration of all reports generated by
the agency, including but not limited to safety drills, accessibility
information, grievances, and technology recommendations. In addition, all Tarry House Policy and
Procedures are reviewed annually, as are all of the insurance policies.
Corporate Compliance Review
The Performance Improvement Report
and Action Plan will also include a review of any substantiated reports via the
Corporate Compliance Program. Details
regarding this system can be found in the Corporate Compliance Policy and
Procedure. The Corporate Compliance Officer
will meet at least one time annually with the Executive Director and Board
President and any other Board Member who wishes to attend, to review activity if
any, within the Corporate Compliance Program.
Any recommendations made during this meeting and/or anytime a corporate
compliance review is conducted, will be followed up with goals, objectives and
action steps placed into the Tarry House Strategic Plan.
3) Governance
Each member of the Board of
Trustees is provided with a copy of the by-laws and is expected to be familiar
with them. Members of the Board of
Trustees are expected to participate in the organization’s strategic planning
process and assist in areas of performance improvement when appropriate. The Board of Trustees is subject to
corporate compliance review.
4) Human Resources
Decisions regarding the selection,
retention, and training of the staff are based on a review of the data gleaned
from annual performance evaluations and on contact with other agencies and the
5) Health and safety
Safety drills and self-inspections
are conducted at regular intervals, and the results inform training decisions
and physical plant modifications and/or improvements. In addition, critical incidents are
considered and consultation with medical professionals has been arranged.
Analysis and Reporting
Analysis of collected data will
occur on an ongoing basis or within a reasonable time following the specified
data collection timeframe. A yearly
summary, found in the Tarry House Management Report, will be generated that
presents the data, provides analysis, and sets goals. The report will also:
The report will be shared as
appropriate and available to staff members, persons served, the Board of
Trustees, other stakeholders such as funding agents and referral agencies, and
surveyors.
Improvement
The information will be integrated
into clinical services, training for the staff and Board of Trustees, strategic
planning, and/or business practices to improve the organization’s performance. Finally, the information will be used to
review the implementation of the mission and goals of the organization.
Confidentiality
Some performance improvement
activities are confidential. No involved
staff member will voluntarily reveal discussions concerning peer review
activities outside the designated forums.
Results of performance improvement
efforts are available for review by authorized personnel, persons served, and
others as appropriate.
Responsibility
The responsibility of data
collection will vary depending on the type of data being collected. Analysis responsibilities will be shared by
various staff members.
Compilation of the final report,
general coordination of the Quality Improvement efforts and implementation of
the plan will be of the Quality Improvement Coordinator.
The information gathered and
reported will be used to improve the organization’s functioning and the quality
of the services provided.
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Executive Director Date