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Report Prepared by Kimberly D. Clark CQIR Systems Analyst Please direct inquiries to: [email protected] Report Snapshot Up 10.61%, Northern region served 5,607 clients in FY12. 83% of Northern Outcome Goals were met. About 83% of files reviewed in the Northern region met agency standards for Compliance & Quality and Child Welfare Measures. 5 out of 6 program categories scored an ‘A’ in overall client satisfaction. CQIR ANNUAL REPORT 2012 NORTHERN REGION ANALYSIS An Action-Oriented Retrospective
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Page 1: CQIR AnnualReport 2012 Northern

Report Prepared by Kimberly D. Clark CQIR Systems Analyst

� � �

Please direct inquiries to: [email protected]

Report Snapshot

� Up 10.61%,

Northern region

served 5,607

clients in FY12.

� 83% of Northern

Outcome Goals

were met.

� About 83% of files

reviewed in the

Northern region

met agency

standards for

Compliance &

Quality and Child

Welfare Measures.

� 5 out of 6 program

categories scored

an ‘A’ in overall

client satisfaction.

CQIR ANNUAL REPORT

2012 NORTHERN REGION

ANALYSIS

An Action-Oriented Retrospective

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Table of Contents � Letter from the Executive Vice President.......................................................................................... 3

� Continuous Quality Improvement and Research Team .................................................................... 4

� Executive Summary ........................................................................................................................ 5

� Story of Hope .................................................................................................................................. 9

� Clients Served ............................................................................................................................... 10

� Outcome Management .................................................................................................................. 11

� Peer Record Reviews .................................................................................................................... 12

� Client Satisfaction ......................................................................................................................... 17

� Incident Reports............................................................................................................................. 18

� Office & Supervisory Reviews ........................................................................................................ 19

� Priority Reviews ............................................................................................................................ 20

� Employee Recognition .................................................................................................................. 21

� Quality Improvement Teams ......................................................................................................... 22

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Letter from the Executive Vice President

August 17th , 2012 To Our Readers: This is our 12th year of providing the Continuous Quality Improvement and Research (CQIR) annual report on the agency’s outcomes and other quality improvement activities and results. The CQIR team takes great pride in preparing and presenting this report to you, our valued stakeholders. Over the years our funders have increased their requirements for accountability. We, at One Hope United, have been leaders in applying rigorous discipline to ensure that we understand the processes of our service and manage towards the results. One Hope United, as an agency, values results as a basic promise of how we do business. We strive to ever increase our ability to understand how we provide services, how to improve services and the relationship of services to short and long term positive changes in people’s lives. There has been a pressure in the broader human service field to inflate numbers and to make estimates of what a program or agency can accomplish. We will not follow that trend – we believe that every number should be supported by hard data and that we could describe to any constituent how the numbers are derived. While we know that our services touch many lives, we will take credit only for those accomplishments we can measure and calculate responsibly and ethically. This report would not be possible without the collaboration of our partners in the field. We thank them for participating in the disciplined tasks that allow for genuine quality improvement. With funding pressures in many programs, case numbers may rise and demands increase thus making time for activities such as data collection and peer record review challenging. But these activities of quality are part of the One Hope United culture. Through expert time management, supportive supervision and accountable leadership ensuring that all staff take part in the activities, we can assure those we serve the very best possible programs. An unknown author said, “Good, better, best; never let it rest till your good is better and your better is best.” That is a driving force on our One Hope United CQIR team. We will keep working with our partners in excellence to be certain that what we provide is the very best. In the past 8 years I have been blessed to have the leadership role for CQIR. This is an amazing team of employees – devoted to excellence. As I have said many times, we never forget that the numbers in our reports reflect the people we serve as well as our colleagues. They deserve the very best we can offer. As ever, thank you for your interest. We know you will find the report interesting and thought provoking. We look forward to your feedback and continued work together.

Fotena A. Zirps, PhD Executive Vice President

Corporate Office 111 E. Wacker Dr., Ste. 325 Chicago, Illinois 60601

t: 312.922.6733 f: 312.922.6736 www.onehopeunited.org

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Continuous Quality Improvement & Research Team To support direct service providers and ensure best practice quality of service throughout the agency, the Continuous Quality Improvement and Research (CQIR) team at One Hope United guides the organization in 14 core tasks (PQI Standards) that are aligned with internal OHU principles and external Council on Accreditation guidelines.

Dr. Fotena Zirps – Executive Vice President Tina McLeod – Assistant to the EVP

Florida Region Hudelson Region Northern Region Research Team

Ruann Barrack – Senior Vice President

Jeffrey Honaker CQI Director

Sarah Tuning

CQI Coordinator

Katurah Roby CQI Coordinator

Ron Culbertson CQI Coordinator

Linda Weiss CQI Medicaid Coordinator

Ryan Counihan CQI Technician

Stan Grimes

CQI Coordinator

Elizabeth Hopkins CQI Medicaid Coordinator

Jackie Schedin CQI Coordinator

Katrina Brewsaugh Director of Research

Kimberly Clark Systems Analyst

Special thanks to members of the CQIR team that left the team in FY12 including: Stephen Brehm, Rosalyn Thomas and Maria Weber.

Information presented in the Northern region annual report is organized by these CQI Core Tasks: � Outcome Management � Peer Record Reviews � Client Satisfaction

� Incident Reports � Office Reviews � Supervisory Reviews

� Priority Reviews � Employee Recognition � Quality Improvement Teams

Within each section, the following program categories are reviewed for the Northern region: Child Development, Counseling, Family Preservation, Placement, Prevention, and Youth Services.

Northern Leadership Mark McHugh – Executive Director

David Fox – Associate Executive Director Beth Lakier – Associate Executive Director

Senior Vice Presidents

Josie Disterhoft � Laura Franz � Joyce Heneberry � Timothy Snowden

Directors of Programs

Christina Czech � Rosanne DeGregorio � Jill Novacek Karen Powell � John Zupancic

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Executive Summary This year, OHU programs in the Northern region served 5,607 children and families, a 10.61% increase from last year. The quality with which service delivery was documented and captured in peer record review in these programs overall was about 83% (approximately 7% below the desired 90% target). The efforts of OHU programs overall resulted in 83% of all outcome goals being met within the Northern region.

OUTCOME MANAGEMENT

PEER RECORD REVIEWS

Across all programs, 83% of outcome goals were met in FY12. Well-being was strongest (90%); permanency was more challenged (68%).

Out of 1,031 files reviewed in FY12, Northern region compliance & quality was ~83%. Service Delivery needs more attention in most programs.

CLIENT SATISFACTION

INCIDENT REPORTS

All programs except Placement scored in the ‘fine tuning’ range. Northern region Overall satisfaction score has remained above 4.50 (‘A’) for the past three years.

Client/Caregiver Property Incidents (+1300%) and Behavior Management incidents (+122.87%) have gone up the most this year. These increases are primarily due to Placement programs.

OFFICE

REVIEWS

SUPERVISORY REVIEWS

PRIORITY REVIEWS

In the Northern region, 96% of Office Reviews and 77% of Supervisory reviews were compliant.

There were 26 priority reviews conducted in FY12: 13 Level III, 2 Level II and 11 Case Consultations (Level I reviews).

EMPLOYEE RECOGNITION

QUALITY IMPROVEMENT TEAMS

There were 15 STAR awards and 6 GALAXY awards distributed this year in the Northern region.

In the Northern region, there was an average QIT attendance rate of 97.23%.

KEEPING AGENCY PROMISES � Hope

� The CQIR team welcomed Kimberly Clark, Jeffrey Honaker, Katurah Roby, and Linda Weiss as new members.

� CQIR led the hosting of the first annual Golf Tournament in the Florida region. CQIR played a role in increasing the fund raising activities in the Florida region.

� CQIR has been involved in providing data and information for bids and grants for future services.

� Collaboration

� All three regions completed the Quality 2 Practice (Q2P) for Family Preservation and Foster Care. This was the first Q2P that included all three regions in discussions regarding practice and improvement in services.

� CQIR has worked collaboratively with operations in the Florida region to start-up Mental Health Services.

� CQIR collaborated with the Independent Living Unit in Florida to create new and improved service documentation in the Florida region.

� Katrina Brewsaugh collaborated with two outside agencies for a presentation on Child Welfare outcomes at the American Evaluation Association’s annual conference.

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� Hudelson and Northern region staff continues to participate in the Medicaid Committee meetings co-facilitated by the CQIR Medicaid Coordinators from each region.

� Staff from Hudelson and Northern regions assisted each other in an audit to review FY11 Medicaid documentation.

� The Charleston Office Manager for Hudelson region offered and allowed the Administrative Assistant to enter PRR data saving valuable time for CQIR Coordinators. This is an example of collaboration and support of the Region’s Leadership of CQIR.

� The Hudelson region now has two CQIR Coordinators for the first time. The two Coordinators have diversity in their strengths and are able to collaborate and use these strengths to enhance the CQIR presence in the region.

� Stan Grimes and Elizabeth Hopkins from the Northern region and Ronald Culbertson and Linda Weiss from the Hudelson region received STAR Awards during FY12.

� CQIR facilitated a joint meeting of the Northern region MST program leadership to review outcomes and program opportunities for enhancement.

� CQIR organized a multi-disciplinary task force to review the Rebound program model and make recommendations for changes in the Northern region.

� The QIT attendance rate over all Regional Partners was 97.9%. � Attendance for Peer Record Reviewers was 96%.

� Innovation

� Katrina Brewsaugh received the Innovation Promise Award in FY12. � Dr. Ray Foster provided training, resources, and discussion around formulating an evidenced

based Case Management Model in all three regions. This opportunity was made possible by Dr. Fotena Zirps.

� Initial steps have been taken to move toward the use of electronic signatures on case notes in CMS. A pilot is expected to be implemented in FY 13 in the Hudelson region.

� CQIR Coordinators have increased the use of teleconferences and MegaMeeting in QITs enabling staff “visibility” during meetings and reducing travel time and expense.

� Leadership

� The CQIR team maintained implementation of the quality activities and processes during the loss and transition of several team members this past year.

� Members of the CQIR team were a part of Supervisory Training this past year provided by Bill Gillis and Dr. Fotena Zirps.

� Members of the CQIR team published a chapter entitled Child Welfare Information Systems in the Child Welfare League’s revised edition of the book “What Works in Child Welfare”.

� The updated and improved Supervisory Protocol was finalized for the Agency in FY12. � Florida region CQIR team members developed a partnership with the Social Work program at

Warner University to begin internship programs for Counseling and Case Management. � The Hudelson region Residential program received the second highest compliance rate (93%)

in the state on the most recent IPI Post Payment Review. The highest percentage was 94%. � CQIR helped facilitate a multi-agency COA peer reviewer training in which a number of

agency staff were certified to be COA reviewers. � Results

� Sarah Tunning received the Results Promise Award in FY12. � The CQIR Team in Florida completed a 100% file review (228 cases) in Tampa prior to

starting services. � The CQIR team completed two Program Evaluations in FY12, one in the Intact Family

Program (Northern) and the second in the Youth Diversion Program (Hudelson). � There was an increase in the percentage of programs reaching validity on the Client

Satisfaction Survey across the agency. � The CQIR team updated their performance outcomes to make them more related to impact.

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� On the Client Satisfaction Survey the scores for all Regional Partners were within the “fine tuning” range.

� All eligible Child Development Centers are now accredited by NAEYC. Congratulations to the Child Development Centers.

� CQIR surveyed staff at all local QITs to determine their level of satisfaction with the QIT process. Results were very positive.

Glossary of Acronyms

� CQIR/T – Continuous Quality Improvement & Research Team � COA – Council on Accreditation � IPI – Infant-Parent Institute � IR – Incident Report � IS – Information Systems � PQI – Performance & Quality Improvement � PRR – Peer Record Review � QIT – Quality Improvement Team

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RISK MANAGEMENT TOPICS FOR FY13 QITS In reviewing each area assessed in this report, the following actions are recommended in FY13 based on outcomes, reviews, and incidents in FY12.

Area Reviewed Recommended Actions

Outcome Management � Most outcome goals (83%) were met in FY12. Permanency (68%) most affected the total percent of goals met. This child welfare measure has been a challenge for Northern for the previous three years as well, which may indicate the need to set a more achievable target. It is recommended that the Placement programs, in particular, identify risk factors that can be evaluated that most affect permanency.

� Furthermore, the Safety measure declined in 2012 by 20 percentage points (from 100% in FY 11 to 80% in FY12). The Adolescents with Sexual Behavior Problems program and Foster Care programs most affected this measure, missing their established targets by 2% and 0.1% respectively. It is recommended that programs identify risk factors that can be evaluated that most affect Safety.

Peer Record Reviews � To close the 1% to 10% gap between actual and target performance with regard to Compliance & Quality and Child Welfare Measures the specific items noted throughout the year via quarterly reports should be monitored.

� In addition, the items highlighted in this annual report, especially Assessment, Treatment Planning and Service Delivery should be tracked more closely this year.

Client Satisfaction � Overall Client Satisfaction for the Northern region is 4.60 (‘A’), which is in the Fine Tuning range.

Incident Reports � Client/Caregiver Property and Behavior Management incidents have gone up the most this year primarily in Placement programs.

� Wherever possible, new interventions to prevent restraints should be developed.

� In particular, lessons learned from priority reviews should serve as a guide.

Office Reviews � Over 95% of all Office Systems reviews in the Northern region were compliant.

Supervisory Reviews � Supervisory Reviews achieved 77% compliance (down 4% since last year). The main items to focus on are: ‘Annual performance reviews completed within 30 days’ and ‘Documentation that team meetings occur two times per month with classroom teachers’ for Child Development centers.

Priority Reviews � Overall, number of priority reviews conducted in FY12 increased primarily due to more Level 1 reviews being conducted. Level 1 reviews, or ‘case consultations’, are preventative in nature.

� Case Consultations should continue to be utilized to improve outcomes and mitigate risk for complex or challenging cases.

� Lessons learned should continue to be captured and shared.

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Story of Hope Stories of Hope share the experiences of One Hope United staff who are protecting children and strengthening families as well as the real-life stories of

empowerment based on our clients. Often, names are changed in stories to protect clients facing extremely difficult situations and roadblocks in their lives. In these stories our agency illustrates how we serve our mission on a day to day basis and work towards our vision of a safe and nurturing home for every child. – Northern region is pleased to share the following ‘Story of Hope’.

� � � Stephanie, 25, had a traumatic childhood. She was in and out of foster homes, and even was adopted and then returned to foster care. Stephanie had a baby boy, Shawn, when she was 21 and unmarried. Due to Stephanie’s cognitive limitations, Shawn's father was taking care of him. However, when Shawn was 2 years old, the child's father, who is on medication for mental health issues, called Stephanie, said he was frustrated with the boy and threatened to physically harm him. Stephanie called the Department of Children and Family Services for help, and Shawn was placed in foster care. Stephanie then began a three-year journey to get Shawn back. She partook in services, including parent coaching with supervised visitations twice a week. Stephanie was receptive to feedback and worked hard to learn how to best care for her son. Stephanie's caseworkers noticed that Stephanie began putting her child first, even discussing giving up her dog due to Shawn’s asthma. In June, after much support and a variety of services, Shawn moved back in with his mother. "It's amazing, especially considering what she's overcome in her own life, that she is now able to be parenting her own child," Stephanie's caseworker said.

“In these stories our agency illustrates

how we serve our mission on a day to

day basis …”

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Clients Served

In fiscal year 2012, One Hope United served 5,607 clients in the Northern region. This is a 10.57% increase from FY11. Five of the six program categories experienced an increase in the number of clients served. Placement is the only program that experienced a percentage decrease (-10.29%). The largest increase occurred in Family Preservation (82.03%). Counseling served more clients by approximately 21% and Prevention and Youth Services served about 14% more clients compared to FY11. Child Development grew by about 4.5% from FY11 due to the opening of a new center in Aurora in FY12.

# of Northern Region Clients Served by Fiscal Year

Program Category FY12 FY11 FY10

Child Development 2137 2045 1729

Counseling 1136 938 1028

Family Preservation 466 256 293

Placement 830 923 935

Prevention 800 7001 2844

Youth Services 238 207 222

TOTAL: 5,607 5,069 7,051

The main influences contributing to the increase in clients served occurred in Family Preservation and Counseling.

� In Family Preservation, the opening of the Differential Response (DR) program contributed to the increase. This also accounts for the decrease seen in the Placement program since many of these clients were deflected from Placement due to early intervention from DR.

� In Counseling, the Adolescents with Sexual Behavior Problems program saw an increase in clients served. Counseling leadership also reports many clients were referred for services that were not appropriate for services, resulting in those cases being opened and closed quickly.

Clients Served: Northern

39%

20%8%

15%

14%4%

Child Development Counseling Family Preservation Placement Prevention Youth Services

Most services were provided in the areas of Child Development, representing 39% of clients served. Counseling (20%) serves the second largest population of clients in the Northern region.

1 In FY11 the Prevention client’s served number was originally reported at 1,135. Due to turnover and lack of documentation

this number could not be confirmed. Therefore, the number was changed to 700 which was confirmed in documentation.

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Outcome Management An outcome or accomplishment can be defined as the result of efforts or outputs (interventions by an individual or team) within an agency that have value to the goals of the agency. Outcome goals are important to establish because they provide purpose for the work with children and families and should tie either directly or indirectly to the mission of the agency. Additionally, outcome goals create a culture of accountability and also provide an evaluation of Child Welfare Measures (referring to a client’s safety, permanency and well-being). CQIR monitors contract and agency outcome goals established by federal standards and OHU values. PROGRAM PERFORMANCE

% of Northern Program Goals Met by Fiscal Year

FY2012 FY2011 FY2010

Overall Total 83% 83% 81%

Safety 80% 100% 82%

Permanency 68% 74% 63%

Well-Being 90% 84% 89%

As a region, 83% of all established goals have been met. Well-being improved the most from last year, increasing 6 percentage points from 2011. Both Safety and Permanency declined from 2011. PERMANENCY ACHIEVEMENT

Specialized Foster Care Permanency Outcomes

Region Starting Caseload

Total Permanencies (measured by

points)

FY12 Permanency

Rate FY12 Goal

Northern 22 10.0 45.5% 20%

Specialized Foster Care Actual Children

Region Adoption Return Home

Guardianship Other Total

Northern 2 2 2 0 6

Illinois Traditional & Relative Foster Care Permanency Outcomes

Region Starting Caseload

Total Permanencies (measured by

points)

FY12 Permanency

Rate FY12 Goal

NR Downstate 215 151.5 70.5% 33%

NR Cook 170 66.5 39.1% 29%

Illinois Traditional & Relative Foster Care Actual Children

Region Adoption Return Home

Guardianship Other Total

NR Downstate 64 43 14 0 121

Cook County Contract 18 15 17 1 51

“CQIR monitors contract and agency

outcome goals established by federal

standards and OHU values.”

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Peer Record Reviews A Peer Record Review is the process by which CQIR internally examines records in depth for timely completion of required activities (a Compliance Review) and for quality of services (a Quality Review). COA standards require OHU to randomly select a sample of records to review for all programs. CQI Coordinators conduct file reviews for each program every quarter and the results are communicated via a report for each review date, as well as a quarterly report that rolls up all programs in a particular program category. For the annual report, peer reviews are looked at for the fiscal year beginning July 1st, 2011 through June 30th, 2012. The program categories reviewed for the Northern Region in this report are: Child Development, Counseling, Family Preservation, Placement, Prevention, and Youth Services.

# of Northern Region File Reviews by Quarter

PRR Review Tool Q1 Q2 Q3 Q4 TOTAL

Compliance* 0 0 0

Standard Compliance 97 100 94 100 391

Compliance & Quality 0 0 0 0

Child Development 30 31 94 88 243

Foster Care Licensing 19 16 19 18 72

Medicaid 9 13 18 11 51

Quality 0 0 0

Foster Care 16 17 16 13 62

Intact 6 8 7 5 26

Rebound 1 1 1 1 4

System of Care (SOC) 3 4 3 4 14

Standard Quality 40 42 42 44 168

TOTAL: 221 232 294 284 1,031

*Foster Care, Intact, Rebound, and SOC were reviewed with the standard Compliance tool, as well as their program-specific quality review tools. There are 9 tools utilized in the Northern region that assess Compliance & Quality and Child Welfare Measures (safety, well-being, permanency, and risk management). Results were combined across all tools to produce the following two graphs.

“COA standards require OHU to

randomly select a sample of records to

review for all programs.”

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The goal for each phase of client service is 90%, represented by the black dashed line on charts below.

Compliance & Quality - Overall: Northern Programs

74%

76%

78%

80%

82%

84%

86%

88%

90%

92%

Actual 89% 84% 83% 80% 90%

Cross-Region 88% 83% 84% 82% 88%

Target 90% 90% 90% 90% 90%

Intake Assessment Treatment Plan Service Delivery Closing

The Northern region programs achieved the Compliance & Quality target in the Closing measure and were within 1% of the target in the Intake measure. In all other Compliance & Quality measures they were within 6% to 10% of meeting targets in FY12.

Child Welfare Measures - Overall: Northern Programs

0%

20%

40%

60%

80%

100%

Actual 81% 84% 89% 81%

Cross-Region 84% 82% 91% 84%

Target 90% 90% 90% 90%

Well-Being Safety Risk Management Permanency

Northern region programs were within 1% of meeting the target in the Risk Management measure. In all other Child Welfare measures they were within 6% to 9% of meeting targets on file reviews in FY12.

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Compliance & Quality performance for the Northern region was analyzed by Program Category to produce the following graph.

Program Performance FY’12

Compliance & Quality: Northern Region

0%

20%

40%

60%

80%

100%

Child Development 95% 92% 90%

Counseling 85% 89% 86% 88% 90%

Family Preservation 92% 86% 82% 92% 79%

Placement 83% 74% 75% 69% 76%

Prevention 95% 91% 87% 88% 100%

Youth Services 91% 92% 85% 96% 98%

Target 90% 90% 90% 90% 90%

Intake AssessmentTreatment

Planning

Service

DeliveryClosing

The Northern region achieved 90% compliance on all Compliance & Quality in their Child Development Centers. This is the first time in three years that they achieved the 90% target in all three areas measured. Youth Services nearly achieved 90% on all 5 measures. Treatment Planning was within 5% of the desired target. Prevention programs achieved the 90% target in 3 out of 5 measures. Service Delivery and Treatment Planning were within 2%-3%, respectively.

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To improve performance in FY13, programs should focus on the areas missed most on reviews throughout the year. Below is a full-year item analysis for each review conducted in FY12 for Program Categories that did not reach the 90% target in most measures. The percentages indicate the percent of files in compliance while the numbers in parentheses at the end of each statement indicates the number missed out of the total for each review. Counseling

� Intake (85%): Are Release of Information Forms current…? (47/137) � Assessment (89%): Is a copy of the Updated Assessment Report in the file? (18/59) � Treatment Planning (86%): Is the current service/treatment/case plan signed and dated by the client

and parent/guardian? (34/133) � Service Delivery (88%): Are there Quarterly Progress Reports at least every 90 days? (7/18) Family Preservation

� Assessment (86%): o Was the Home Safety Checklist for Intact and Permanency Workers completed prior to a

major change of life circumstances? (4/11) � Treatment Planning (82%):

o Is there evidence that Child and Family Team Meetings were held on a quarter basis? (4/14) o Is there evidence that the assessment was updated to reflect changes in household

composition and case dynamics? (3/9) � Closing (79%):

o Does the record contain documentation of an aftercare plan…or a reason why one was not needed? (1/3)

o Was a Child/Family Team Meeting held for case closure? (1/1)

Placement

� Intake (83%): o Foster Parent Disaster Preparedness Plan? (37/71) o Foster Home Licensing Confidentiality Agreement? (23/44) o Are the Release of Information Forms current…? (38/88) o Are the Client’s Rights and Responsibilities in the record & signed by all parties? (43/104)

� Assessment (74%): o Does the diagnostic formulation support the diagnosis given? (7/8) o Is there a Children’s Global Assessment Scale? (7/8) o Was the CANS completed every three months (Residential)? (6/6) o Child Caregiver Matching Tool? (15/18)

� Treatment Planning (75%): o Is the current service/treatment/case plan signed and dated by the client and

parent/guardian? (38/98) o Was progress on the ITP reviewed with the client and guardian every 6 months…? (5/6)

� Service Delivery (69%): o Is there documentation of monthly contact between case manager and school? (31/40) o Did the initial Family Meeting occur within 48 hours of case assignment (with Supervisor

present)? (41/59) o Did the Case Manager meet weekly with the child in substitute care for the first month

following initial placement or change in placement? (35/60) o Were recommended services on ITP provided at the recommended frequency…? (7/8) o Is progress towards each goal and objective evaluated in the current quarter progress note?

(5/7) o Has a current written visiting plan in the 497 been developed for all siblings in substitute care?

(3/3) � Closing (76%): Does the record contain documentation of an aftercare plan completed with and

signed by the client or a reason why an aftercare plan was not needed? (2/7)

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During fiscal year 2012 there were 89 case managers, therapists and supervisors who assisted in reviewing 1,031 files as a part of the CQI peer record review process. These champions of quality serve as an integral part of the continual process of assessing the quality of our files, providing feedback on how to improve, and ensuring that plans of correction are being completed on time.

Northern – Cook Northern – Downstate Paula Williams

Brittany Humphrey Deborah Holmes Thomas

Jane Lough Kahdijah Hakeem Artrice Brewer Tashay Jenkins Lisa Gregory Mary Mann Ana Fajardo Cindy Rotman Shirica Flowers Jennifer Keith

Delores Moment Chris Bisplinghoff Jennifer Woods Delores Moment Heather Rutenber Terri Cummings Brandy Kukurba Emily Husseini Kathie Easley Noell Juola Sarah Martin Beth Ericksen Terry Kean Laura Oddi Kelly McGee Sara Newhard Denny Clouse Amy Kline

Carleen Otto Jim Ogle

Karen Powell Samella Taylor Devin Dittrich

Kiwauna Conwell Cindy Peterson Niki Kuforiji

Ramona Dixon Lavoris Childress

Leroy Willis Kareen Nunnally Tiffany Trewartha Connie Acevedo

Lois Aliotta Brenda Gossett Marybeth Milkotic

Beth Tuthill Amy Hirsch Teresa Green

Margaret Vergamini

Keith Wheeler Arletta Jones Wendy Embry Ronald Smith

Freya Gorenstein Allan Weiner

Shirley Hawkins Linsay Heimberg Denise Herron Kristin Patten Danielle Sines Michael Williams

Kyle King Erika Erdakos

Franciene Williams Adrienne Patterson-Green

Michelle Lonzo Pixie Davis Walter Shaw Nancy Harris

Liza Simon-Roper Brian McGannon Jill Bulakowski Tammy Ambre John Hawley

Julius Benjamin Dennis Delgado Tiffany Trewartha

Amy Hirsch Denise Downing

Cheryl Davis-Malone Brigette Davis

Marybeth Milkotic Sue Laschinski Connie Acevedo

Cheryl Davis-Malone Brenda Gossett

Total Reviewers: 89

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Client Satisfaction CQIR conducts an annual Client Satisfaction Survey to monitor OHU clients’ impressions of the services we provide. After all surveys have been received, region and program reports are compiled to provide stakeholders with a Consumer Report Card that compares their program to the programs in their program category (example: Counseling Programs) and to regions as a whole (example: Federation). Please contact Katrina Brewsaugh, Director of Research for One Hope United, for a report card on any program or region.

Overall OHU Client Satisfaction: Northern Region

3.60

3.80

4.00

4.20

4.40

4.60

4.80

5.00

Child

Development

Counseling Family

Preservation

Placement Prevention Youth Services

Child

Development Counseling Family

Preservation Placement Prevention Youth

Services

� FY12 4.70 (N=597)

4.54 (N=351)

4.63 (N=131)

4.34 (N=345)

4.83 (N=169)

4.68 (N=97)

� FY11 4.74 (N=547)

4.63 (N=351)

4.78 (N=137)

4.29 (N=334)

4.89 (N=165)

4.79 (N=86)

� FY10 4.62 (N=551)

4.66 (N=324)

4.81 (N=109)

4.20 (N=306)

4.86 (N=157)

4.84 (N=85)

Across region and fiscal year, all programs except Placement have scored in the ‘fine tuning’ range. Five program categories saw a decrease in “Overall satisfaction with OHU”; however none of these changes were significant. Although Placement has scored in the ‘needs improvement’ range for three years, their score has been increasing each year since FY10. For the past three years, OHU clients have scored the Prevention program higher than the other program categories.

2012 2011 2010 4.60

(N=1,690) 4.64

(N=1,620) 4.59

(N=1,532)

In the Northern region, overall client satisfaction with OHU has remained above 4.50 (‘A’) for the past three years. Number of surveys returned increased 4.32% from 2011.

“Client Satisfaction Surveys monitor

clients’ impressions of the services OHU

provides.”

Page 18: CQIR AnnualReport 2012 Northern

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Incident Reports An unusual incident is any occurrence that may have the potential for increased risk for our clients and the liability of our agency. Reportable incidents also include situations that raise risk to staff or agency property, such as a theft or natural disaster. CQIR provides monthly reports on incident trends and correlations. Annually, this report rolls up data for the fiscal year and presents incident trends by region and program category.

Incident Types by Year: Northern Region Programs

10153

4199 11

8

48119

121

575

723

28

206

12131

32 78 124

48147

79

258

575

2

308

8117

21 61 94 53124

71 82

409

7

245

0

200

400

600

800

Death

Abuse & Neglect

Sexually Problemati...

Injury

Medical/Psychiatric

Education

Hospitalization

Criminal Act

Behavior Management

Behavioral Issues

Client/Caregiver Pro...

Other

FY12 FY11 FY10

Incidents classified as “Other” (-33.12%), Hospitalizations (-19.05%), Deaths (-16.67%), and Medical/Psychiatric incidents (-4.84%) all decreased in FY12 from FY11. Education incidents had no change. All other incident categories saw an increase. The most significant increases were in Client/Caregiver Property Incidents (+1300%) and in Behavior Management incidents (+122.87%). Client/Caregiver Property incidents increased from two in FY11 to twenty-eight in FY12. This increase was seen mostly in the Residential program. Additionally, Behavior Management Incidents have been increasing over the past 3 years, primarily due to the Residential Treatment program. In FY12 these incidents increased approximately 122.87% from FY11. The number of incidents that include a restraint has been rising over the past three years. Of the 1,673 incident reports in FY12, 34% included a restraint. In FY11, 20% of incident reports included a restraint; and in FY10, 8% of incident reports included a restraint. Although the residential program saw an increase in the number of clients served in FY12 compared to FY11; the increase was minimal compared to the increase in FY11 from FY10. Therefore, the increase in Behavior Management incidents is unlikely to have been caused solely by the number of clients served. In FY13, it is recommended that the Residential program implement measures intended to prevent restraints.

“Incident reports track situations that may

have the potential for increased risk for our

clients and the liability of our agency.”

Page 19: CQIR AnnualReport 2012 Northern

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Office Systems Reviews The Office Systems Review is a process to determine if an office is meeting agency standards. This includes professional appearance, staff response to answering telephone calls, maintaining client confidentiality and safety and risk management. CQIR coordinators review OHU office systems annually.

Office Systems Compliance: Northern

96%

3%

1%

Compliant Not Compliant Partially Compliant

Seventeen Office Systems Reviews were completed in the Northern Region: 96% of all office systems reviews were compliant, a 1% increase from last fiscal year.

Supervisory Systems Reviews On an annual basis CQIR conducts an assessment of supervision provided by each direct service supervisor in the organization. The review uses a standardized form and involves a check of a number of supervision tasks. Although there are several items addressed, there is a concentration on the frequency of supervision and quality of documentation of supervisory activities.

Supervisory Systems Compliance: Northern

77%

23%0%

Compliant Not Compliant Partially Compliant

Sixty Supervisory Systems Reviews were completed in the Northern Region. Supervisors were 77% compliant with items measured.

Page 20: CQIR AnnualReport 2012 Northern

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“Priority review is a process that

examines the quality of services provided

to a client or family.”

Priority Reviews A priority review is a process that examines the quality of services provided to a client or family and compliance with program policies and procedures. There are three levels of priority reviews: The Level 1 Priority Review – also called a case consultation – is voluntary and can be conducted on any case upon the request of the supervisor. The Level 2 Priority Review are conducted in the event of a serious injury to a client or a crime. Level 3 Priority Reviews are held when there is a client death or felony.

Program Category Level 3 Level 2 Case Consultations

TOTAL

Child Development 0 2 0 2

Counseling 2 0 2 4

Family Preservation 4 0 1 5

Placement 7 0 5 12

Prevention 0 0 3 3

Youth Services 0 0 0 0

TOTAL: 13 2 11 26

There were 26 priority reviews conducted in FY12 (up 9 from FY11). The increase in Priority Reviews in the Northern region can be attributed to the Case Consultations that were conducted in FY12. Case Consultations are preventative in nature and are meant to be used as a method to share thoughts and ideas about a case that may be challenging. Northern did not conduct any Case Consultations in FY11 and in FY12 they conducted 11. There were two Level 2 Priority Reviews conducted (down 2 from FY11). One Level 2 review was due to TB exposure at a Child Development Center and one was due to allegations of inappropriate behavior by a client. There were thirteen Level 3 Priority Reviews conduced in FY12, which is the same number that was conducted in FY11. Four of the Level 3 reviews were due to the death of natural parents, three were due to the death of current clients, two were due to suicide attempts, two were due to suspected abuse by a parent/caregiver, one was due to a death of a former client, and one was due to an injury of a client. None of the deaths were found to be related to OHU’s service provision. Below are some highlights of lessons learned throughout the year:

• As service providers, we have to understand at times we have a limit of our influence on client’s behaviors and choices.

• Collaboration with other service providers should occur to ensure service coordination.

• A system should be developed to identify and ‘red flag’ clients who might have a higher level of risk based on their history so that they can be checked on more intently in supervision.

A complete list of lessons learned from reviews can be found in the quarterly reports or by contacting a member of the CQIR team.

Page 21: CQIR AnnualReport 2012 Northern

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Employee Recognition Two methods of awarding staff excellence are supported by CQIR. The first is the STAR Award for individual excellence, and the second is the GALAXY Award for team excellence. The awards recognize staff that have gone above and beyond “normal” work duties, exhibited exemplary performance and done their job under circumstances that are “out of the ordinary.” There were 15 Star awards and 6 Galaxy awards distributed in the Northern region this year. In FY12 we were proud to recognize these Northern employees with a STAR Award. Quarter 1

� Mick Bockstruct – Senior Graphic Designer (Chicago, IL)

� Stephen Brehm – Systems Analyst (Chicago, IL)

� Wendy Embry – Case Manager (Kenwood, IL)

� Beth Lakier – Associate Executive Director (Chicago, IL)

� Reneva Lane – Case Manager (Kenwood, IL)

� Kristina Martinez – Executive Assistant (Chicago, IL)

Quarter 2

� Ginny Kowalski – Office Manager (Waukegan, IL)

� Violet Lopez – Family Educator (Lake Villa, IL)

Quarter 3

� Dolores Eberle – Receptionist (Gurnee, IL) � Stan Grimes – CQIR Coordinator (Lake Villa,

IL) � Maggie Lei – Teacher Assistant (Bridgeport

I, IL) � JoAnn Taitt – Teacher Assistant (Bridgeport

I, IL) Quarter 4

� Isaura Covarrubias - Secretary (Elgin, IL) � Elizabeth Hopkins – CQIR Medicaid

Coordinator (Lake Villa, IL) � Laura Rowan – Fund Development (Lake

Villa, IL) The following teams were presented with a GALAXY Award this year. Quarter 1

� Aurora Early Learning Center (Aurora, IL) � Communications Team (Chicago, IL) Quarter 2

� Des Plaines Child Development Center (Des Plaines, IL)

� O’Hare Child Development Center (Des Plaines, IL)

Quarter 3

� Differential Response Team (Kenwood, IL) � Outpatient Counseling Team (Gurnee, IL)

Page 22: CQIR AnnualReport 2012 Northern

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Quality Improvement Teams Everyone in the agency participates in at least one Quality Improvement Team (QIT). This allows each employee the power to implement improvement within their own QIT. The QIT is focused on improving the quality of service at the local level using data, effective problem solving and action planning. Across the agency, there was an overall attendance rate of 97.9% in FY12. The attendance rate in Northern was: 97.23%, well above the 90% target. The following local, service center and regional Quality Improvement Teams were assembled each quarter this year in the Northern region.

Local

The Eclectics The Facilitators

CLC Seeds of Change

24-7 Crew Friendship

Team Extreme The Rainbow – Team Teach

The 4 Runners Old School Rebounders

Cheers Connect 6

Team Unity All Stars Educaneers

The Show Must Go On Wilmette/Glenview CDC

Eternal Optimists Aurora CDC

Wonder Women Unifiers

Top Performers MST on the Prairie

The Emergency Response Team Bridgeport II Butterflies

KFC Social Workers for Justice

OHU Advocates OHU Des Plaines OHU O’Hare

Weeble Wobbles The Guardian Angels Edgewater Educators

Team Kit Treat Them and Street Them

Service Center

Prevention Supervisors The Wanderers

CARE Leadership Mission Movers

To Infinity & Beyond Northern Management

Regional Community Transformers

Page 23: CQIR AnnualReport 2012 Northern

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In FY12, CQIR conducted a survey of all Local QITs to determine levels of satisfaction with the meetings and the process. Cross-regionally, a total of 276 responses were received, making the survey valid at the strongest confidence levels. Below is a summary of the results for the Northern region and then aggregated across all regions.

All NR-CD NR

Organization of the QIT 4.6 4.3 4.6

Purpose of the QIT Meeting 4.5 4.2 4.4

Facilitation kept the meeting productive 4.6 3.5 4.6

Quality of data available 4.4 4.2 4.3

Action plan(s) developed 4.5 4.3 4.4

Value of today’s meeting to the program 4.4 4.4 4.2

Value of today’s meeting to the agency 4.4 4.3 4.1

Value of the QIT team generally 4.5 4.4 4.2

Overall results were positive with 5 out of the 8 categories scoring in the ‘fine tuning range’. The Northern region Child Development Centers (NR-CD) scored all categories in the ‘needs improvement’ range. The other programs in the Northern region scored 2 out of the 8 categories in the ‘fine tuning range’ and the remaining 6 categories in the ‘needs improvement’ range.