One Hope United 2013 CQIR Annual Report - Cross Region

7/27/2019 One Hope United 2013 CQIR Annual Report - Cross Region

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CQIRANNUAL REPORT

2013CROSS-REGION

ANALYSIS

FLORIDA HUDELSON NORTHERN

REPORT PREPARED BY KIMBERLY D.CLARK

CQIRSYSTEMS ANALYST

PLEASE DIRECT INQUIRIES TO:[email protected]

Primary Office Location

Area of Service Impact

1

4

5

67

8

2

3

Illinois

Missouri

Report Snapshot

OHU served 10,454

clients and families

in FY13.

80% of Outcome

Goals were met.

Cross-regionally,

the Compliance &Quality rating on

Peer Record

Reviews was 86%.

Overall satisfaction

with OHU services

is an A.


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Table of Contents

LETTER FROM THE EDITORS ................................................................................................................ 2

CQIR TEAM & HIGHLIGHTS .................................................................................................................... 3

EXECUTIVE SUMMARY .......................................................................................................................... 5

CLIENTS SERVED ................................................................................................................................... 7

OUTCOME MANAGMENT ....................................................................................................................... 8

PEER RECORD REVIEWS .................................................................................................................... 10

CLIENT SATISFACTION ........................................................................................................................ 13

INCIDENT REPORTS ............................................................................................................................. 14

OFFICE SYSTEMS REVIEWS ............................................................................................................... 15

SUPERVISORY SYSTEMS REVIEWS ................................................................................................... 16

PRIORITY REVIEWS ............................................................................................................................. 17

EMPLOYEE RECOGNITION .................................................................................................................. 19

QUALITY IMPROVEMENT TEAMS ........................................................................................................ 21


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Letter from the Editors

October 19, 2013

To Our Readers:

This is our 13th year of providing the Continuous Quality Improvement and Research (CQIR) annual report on

the agencys 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.

In Fiscal Year 2013, the CQIR team has adopted a Risk Management orientation in the processes and

functions we facilitate. This shift was made at the request of staff so that we could ensure that we are spotting

and addressing small problems before they become larger problems. Therefore, this type of orientation is meant

to be proactive rather than reactive in order to alleviate risks and ideally prevent them before they occur. With

this orientation, the CQIR team has begun using a new Risk Management report during Quality Improvement

Teams (QITs). This type of approach requires participation at all levels; therefore, during this process, all staff

(from direct service staff to program and agency leadership) are looking at current CQIR data to identify areas

for improvement and develop action plans to meet and/or exceed best practice. Staff members have reported

that this approach is better for them as they are able to see the data from their programs more regularly and

develop solutions to areas of concern.

In the human services field, organizations are constantly being asked to, do more with less while at the same

time being asked to perform at higher levels than ever before. In these economic times many programs are

being scaled back or eliminated for not reaching outcomes and targets set by funders. Now more than ever,

One Hope United needs to look at each program, even those that consistently perform at high levels, and use

creativity, research, and innovation to become even better. Each and every program can improve upon

something. If One Hope United becomes stagnant, we will fall behind.

Ultimately, at the end of the day, this constant attention to data and program improvement is for the clients we

serve. By asking ourselves, what can we do even better we are investing our time and energy into makingsure that our clients become healthy and productive adults when they leave One Hope United. In the next year,

the CQIR team will spend time developing methods to learn what happens to our clients after leaving services

in order to see what sticks from our service and genuinely changes lives. This work will help us ensure that

One Hope United is here for our future clients.

We hope that you find this report informative and that you will let us know what you think and how we couldmake the report better in the future. Thank you for your support.

Kimberly D. ClarkCQIR Systems Analyst

Fotena A. Zirps, PhDExecutive Vice President


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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 theorganization in 14 core tasks (PQI Standards) that are aligned with internal OHU principles and external

accreditation standards.

Dr. Fotena Zirps Executive Vice PresidentTina McLeod Assistant to the EVP

Florida Region Hudelson Region Northern Region Research Team

Ruann BarrackSenior Vice President

Jeffrey HonakerCQIR Director

Katurah RobyCQIR Coordinator

Ron CulbertsonCQIR Coordinator

Linda WeissCQIR Medicaid

Coordinator

Ryan Counihan

CQIR Technician

Stan GrimesCQIR Coordinator

Elizabeth HopkinsCQIR Medicaid

Coordinator

Jackie SchedinCQIR Coordinator

Sarah TunningDirector of Research

Kimberly ClarkSystems Analyst

Special thanks to Katrina Brewsaugh of the CQIR team who left in FY13.

Information presented in the Cross-Regional annual report is organized by these CQIR Core Tasks:

Outcome Management Incident Reports Priority Reviews Peer Record Reviews Office Reviews Employee Recognition Client Satisfaction Supervisory Reviews Quality Improvement Teams

The CQIR Team achieved the following accomplishments in FY13. Accomplishments have beencategorized in line with the OHU promises of Innovation, Collaboration, Leadership, Results, and Hope.

Innovation The CQIR team has been utilizing Survey Monkey technology to enter Incident Reports, Office

Reviews, and Supervisory Reviews which has made the data entry process more efficient. A pilot

for utilizing Survey Monkey for Peer Record Reviews is planned for FY14 using Tablet

technology.

The CQIR team has taken a Risk Management focus which included a pilot and a full

implementation of the OHU Risk Management Report in Local, Service, and Regional Quality

Improvement Teams.

Under the direction of Fotena Zirps, PhD. and Sarah Tunning; Ruann Barack, Jeffrey Honakerand Kimberly Clark are members of Team Data which is looking at the current and future dataneeds of the organization in alignment with the agencys strategic plan. In addition, there are


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many members from Operations (including the Team Excellence Outcomes committee) and ITthat are collaborating on this project.

Peer Record Review Training has been developed and placed on the Essential LearningWebsite.

Collaboration Stan Grimes, Jackie Schedin, and Elizabeth Hopkins have all participated as volunteers with the

Council on Accreditation to re-accredit 3 organizations.

In collaboration with the Department of Children and Family Services, all Illinois OHU CQIR staffhave access to SACWIS which will assist with electronic review of case files.

The CQIR team participated in a WorkSmart training facilitated by Larry Kujovich from ExecutivePartners.

Jackie Schedin was a presenter at a CANS training in collaboration with the Casey Foundation.

Linda Weiss and Elizabeth Hopkins continued to collaborate to ensure consistency acrossRegions with the Medicaid Rule Changes. This included monthly meetings with program leadersto ensure all involved participated in the process of change.

Jackie Schedin and Ron Culbertson collaborated with operations in the Northern and HudelsonRegions in revising the Intact Operating Procedures for the Agency Operating Manual basedupon Rule changes. The group also collaborated in the revision of the Intact Quality Review Tool.

Linda Weiss worked with operations in the revision of the SASS Model for service delivery toachieve a team approach to provide more efficient and effective service delivery.

Ron Culbertson provided technical assistance with Missouri Leadership to assist the Missourioffice in maintaining their Licensing as a Child Placement Agency.

Leadership

Linda Weiss from Hudelson and Elizabeth Hopkins from Northern have led the process ofimplementing the new Medicaid Rule to ensure all Medicaid programs are in compliance. Theyhave also consolidated forms to one Mental Health Assessment and two Individualized TreatmentPlans so that there is more consistency amongst the Northern and Hudelson regions.

Stan Grimes, Jeffrey Honaker, and Kimberly Clark are participants in the 2013 LeadershipAcademy facilitated by CEO Bill Gillis and Executive Vice President Fotena Zirps PhD.

Ruann Barack was awarded the Promise Award for Leadership.

Jackie Schedin was awarded a STAR Award for exemplary service during the 4 th quarter of FY13.

Results

The CQIR team in Florida has launched a weekly data reporting process that takes a proactivestance in addressing programmatic concerns.

The Medicaid Team in Hudelson achieved a 97% rating and Northern achieved a 94% rating (a19 point increase) on their Post Payment Reviews for FY13 services.

The CQIR team participated in a CQI Capacity Assessment administered by the Department ofChildren and Family Services and received a 19 out of 20 rating. The assessment focused onFoster Care Programs in Illinois.

Members of the CQIR team completed a Program Evaluation of the Circle of Hope program inSpringfield, MO.

Members of the CQIR Team completed a 100% file review of the Tampa program.

Hope

Katurah Roby joined the CQIR team in Tampa, FL.

Sarah Tunning has taken on the Director of Research role for the Federation.


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Executive Summary

This year OHU programs cross-regionally served 10,454 clients and families. OHU sets high standardsfor service to clients with a target for Compliance & Quality to be at or above 90% in each program. The

Compliance & Quality of service record documentation overall was 86%. The efforts of OHU programs

resulted in 80% of all outcome goals being met across the regions, with the Florida and Hudelson

Regions meeting or exceeding the target of 90% goal achievement.

OUTCOME MANAGEMENT PEER RECORD REVIEWS

Across all programs, 80% of Outcome goals weremet in FY13.

Out of 1,680 files reviewed in FY13, the Cross-regional Compliance & Quality rating was 86% onservice documentation.

CLIENT SATISFACTION INCIDENT REPORTS

Cross-regionally the overall satisfaction score hasremained above 4.50 (A) for the past three years.

Cross-regionally, the number of incident typesdecreased by 4%. Incidents involvingClient/Caregiver Property (-92%), Educationincidents (-37%), and Sexually ProblematicBehaviors (-26%) had the largest decreases fromFY12 to FY13.

OFFICEREVIEWS

SUPERVISORYREVIEWS

PRIORITY REVIEWS

Cross-regionally, 93% of Office Reviews and 84%of Supervisory reviews were compliant.

There were 22 priority reviews conducted in FY13:8 Level III, 4 Level IIand 10 Case Consultations.

EMPLOYEE RECOGNITION QUALITY IMPROVEMENT TEAMS

There were 64 STAR awards and 12 GALAXYawards distributed this year.

There was an average QIT attendance rate of 96%across all regions.


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In reviewing each area assessed in this report, the following actions are recommended in FY14 based on

outcomes, reviews, and incidents in FY13. More specific recommendations by Program Category and

Program can be found in each Regions Annual Report.

Area Reviewed Risk Management Topics for FY14 QITs:Recommended Areas to Develop Action Plans

Outcome Management

Hudelson achieved 91% of its outcome goals. As a region, Florida, achieved 90% of its outcome goals. In assessing

each Circuit, individually, Circuits 9 and 10 achieved 80% of theiroutcome goals and Circuit 13 achieved 50% of their outcome goals.

Northern achieved 73% of its outcome goals. Cross-Regionally, Counseling, Placement, and Youth Services

programs are below the 90% target of outcome goal achievement.Counseling and Youth Services should focus on Permanency and Well-Being outcomes. Placement needs to focus on Safety, Permanency,and Well-Being outcomes.

Peer Record Reviews To close the 4% gap between actual and target performance with

regards to Compliance & Quality on service documentation the specificitems noted throughout the year via the Risk Management Reportsshould be monitored.

Client Satisfaction Overall Client Satisfaction for the agency across regions is 4.65 (A),

which is in the Fine Tuning range.

Incident Reports Client/Caregiver property incidents had the largest decrease down by

over 90% from FY12 to FY13. Medical/Psychiatric incidents had the largest increase this year.

Office Reviews Ninety-three percent (93%) of all office reviews across the agency were

compliant.

Supervisory Reviews

Supervisory Reviews achieved 84% compliance (down 2% since last

year). The main items to focus on are:Child Development Centers:

1) Annual performance reviews completed within 30 days for ChildDevelopment Centers.

2) Supervision occurs monthly (Management Team Meetings and/orIndividual) at Child Development Centers.

Counseling, Family Preservation, Placement, Prevention, and YouthServices programs:

1) The supervisor completes annual staff performance reviews withinthe month they are due.

2) Individual supervision occurs.

Priority Reviews

Four out of eight Level 3 Reviews were due to suicide attempts and

there was an additional Level 3 Review was conducted due to a suicideof a former client.

Lessons learned should continue to be captured and shared. Case consultations should continue to be utilized to improve outcomes

and mitigate risk for complex or challenging cases.


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Clients Served

In fiscal year 2013, One Hope United served 10,454 clients and families a decrease of 1.55% from

FY12.

# of Clients Served by Fiscal Year

FY13 FY12 FY11

Child Development 2,180 2,137 2,045Counseling 1,222 1,335 1,301

Family Preservation 1,634 1,433 1,360Placement 3,080 2,666 2,920Prevention 1,340 1,335 1,2351

Youth Services 998 1,040 1,040FL Circuit 13 N/A 673 N/A

TOTAL 10,454 10,619 9,964

The majority of services across the agency were provided in the areas of Child Development and

Placement representing 50% of clients served.

Placement (+15.6%) and Family Preservation (+12.5%) both increased the number of clients they served

compared to FY12. These increases can be attributed to the addition of services in Circuit 13 in Floridathat were in full implementation during FY13 (in FY12 services were only provided for half of the year).

Both Hudelson and Northern experienced decreases in the number of clients served in Placement and

Family Preservation services due to a decrease in Foster Care referrals from DCFS and the closing of

the Differential Response and Circle of Hope programs.

1Due to lack of available documentation, the number reported for Prevention clients served was reduced from the number

reported in the FY11 Annual Report.2

This number was derived from lead agency reports and FSFN. The process for tracking clients by Program Category was notestablished in C13 during FY12.

21%

12%

16%

29%

13%9%

Clients Served: Cross-Region

Child Development Counseling Family Preservation Placement Prevention Youth Services


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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 havevalue 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 clients safety, permanency and well-being). CQIR monitors contract

and agency outcome goals established by federal and state standards and OHU values.

Percentage of Outcome Goal Achievement: By Region

Florida Hudelson Northern Cross-Region

OVERALL TOTAL 90% 91% 73% 80%

Safety 100% 100% 90% 95%

Permanency 86% 84% 55% 72%

Well-Being 100% 92% 76% 82%

Cross-regionally 80% of outcome goals were met during FY13. The Florida and Hudelson Regions met

or exceeded the agencys target of 90% outcome goal achievement.

One Hope United holds itself to a number of outcome goals depending on the Program Category. Below

is the outcome goal achievement by Child Welfare Measures by Program Category for FY13. For furtheroutcome achievement information please see the individual Regional Annual Reports.

Percentage of Outcome Goal Achievement: Program Category

ChildDevelopment

% Achieved Counseling%

AchievedFamily

Preservation% Achieved

Safety100%(1/1)

Safety100%(4/4)

Safety100%(4/4)

Well-Being100%(4/4)

Permanency89%(8/9)

Permanency100%(3/3)

TOTAL100%(5/5)

Well-Being58%

(7/12)Well-Being

67%(2/3)

TOTAL76%

(19/25) TOTAL90%

(9/10)

Placement%

AchievedPrevention

%Achieved

Youth Services % Achieved

Safety86%(6/7)

Safety100%(3/3)

Safety100%(2/2)

Permanency60%

(15/25)Permanency

100%(2/2)

Permanency71%(5/7)

Well-Being64%

(7/11)Well-Being

100%(32/32)

Well-Being71%

(10/14)

TOTAL65%

(28/43)TOTAL

100%

(37/37)TOTAL

74%

(17/23)

CQIR monitors contract and agency

outcome goals established by federal

and state standards and OHU values.


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CQIRPERFORMANCE

CQIR Outcome Goals Target FY13 FY12 FY11 FY10Exit Interviews are conducted after Record

Reviews.

90% 98.7% 99.4% 96.4% 98.4%

CQIR coordinators conduct SupervisoryReviews each year.

100% 90% 100% 100% 100%

CQIR coordinators conduct Office Reviewseach year.

100% 93% 100% 100% 100%

CQIR Reports will be distributed on time. 90% 94% 75% 100% 54%CQI Coordinators attend local QIT meetings. 90% 100% 100% 100% 100%Overall regional compliance & quality will be3% higher than the previous fiscal year.

87% 86% 84% N/A N/A

Overall regional percent for outcomes reachingestablished targets will improve by 3%compared to the previous fiscal year.

89% 80% 86% N/A N/A

CQIR established 7 outcome goals for FY13. The first five outcome goals are process outcomes while

the last two goals are performance outcomes. The last two were new goals for FY12. Out of six CQIR

Outcome Goals, 43% (n = 3) exceeded the target and 57% (n = 4) were within 10% of the target.


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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 Risk Management reports that

show individual program results and results by

program category. For the annual report, peer reviews are looked at for the fiscal year beginning July 1st,

2012 through June 30th, 2013. The program categories reviewed cross-regionally in this report are: Child

Development, Counseling, Family Preservation, Placement, Prevention, and Youth Services.

# of File Reviews by Quarter

Program Category Q1 Q2 Q3 Q4 TOTALChild Development 95 97 91 89 372

Counseling 54 54 59 57 224

Family Preservation 56 39 48 60 203Placement 152 144 152 130 578Prevention 37 37 37 35 146

Youth Services 36 38 40 43 157TOTAL 430 409 427 414 1,680

In FY13, 1,680 files were reviewed across all six program categories.

There are 14 tools utilized in the Northern & Hudelson Regions and 3 tools in the Florida Region that

assess Compliance & Quality There are some tools that are used that assess only compliance and then

others tool that assess quality (Ex. Hudelson and Northern Foster Care utilizes a Standard Compliance

Tool and then a Foster Care Quality Tool). There are other programs that use one tool that assess both

Compliance and Quality (Ex. Child Development in Northern and Out of Home Services in Florida).

Results werecombined across all tools to produce the following graph which looks at how each Region

performed as well as how the agency performed as a whole.

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 services is 90%, represented by the black dashed line on the chart

below. The purple solid line represents how each phase of client services scored cross-regionally.

In FY13, across all Regions and Programs, overall Compliance & Quality rating on service

documentation was at 86% - this was an increase of 2% from FY12. The Hudelson Regions overall

Compliance & Quality rating was 93% - a 1% increase from FY12. The Northern Region achieved an

88% rating - a 5% increase from FY12, and the Florida Region achieved a 76% rating - a 2% decreasefrom FY12.Compliance & Quality performance for all Regions was also analyzed by program category to produce

the following graph.

Intake AssessmentTreatment

PlanServiceDelivery

Closing Overall

Florida 73% 78% 79% 75% 38% 76%

Hudelson 96% 94% 92% 92% 85% 93%

Northern 94% 86% 84% 85% 91% 88%

Cross-Region 90% 85% 84% 84% 83% 86%

Target 90% 90% 90% 90% 90% 90%

0%

20%

40%

60%

80%

100%

Compliance & Quality - Overall: Cross-Region

Child

DevelopmentCounseling

Family

PreservationPlacement Prevention

Youth

Services

Program Category 96% 90% 85% 79% 97% 93%

Target 90% 90% 90% 90% 90% 90%

0%

20%

40%

60%

80%

100%

Overall Compliance & Quality - Across All Program Categories


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Child Development Centers, Counseling, Prevention, and Youth Services are all meeting or exceedingthe agencys 90% target for Compliance & Quality on service documentation across all areas measured.Family Preservation programs are within 5% of the target. Placement programs are within 11% of thetarget. Each program category is analyzed more closely in each Regions Annual Report.

During fiscal year 2013 there were 157 case managers, therapists, supervisors, and directors whoassisted in reviewing 1,680 files as a part of the CQI peer record review process. These champions ofquality serve as an integral part of the continual process of assessing the quality of our files, providingfeedback on how to improve, and ensuring that plans of correction are being completed on time.

Peer Record ReviewersFlorida Hudelson Northern

Lauren PrekopMelanie RiveraMaryAnn MillerDhaima ChinElliot Vegas

Brandy DavisApril CampbellShawna Sweetman

Natheena SotoMiguelina Jorge

Carmen LottCarissa Arena

Emily GustafsonEbonie Hopkins

Laurie SternYolanda WalkerVanessa HydenBernadine WestBarbara Hester

Monica SandersDarby BarwickVeronica BellAndre Davis

Becka KampmanMuriah Davis Deuth

Ayana AlexanderDanielle Day

Robin SherwoodAshley VaughnJeannine Powell

Pam EvansCandace Fraser

Anna BeyeaJustin WilkinsNyla WilliamsLaurie Vincent

Amy ClarkeKristy Swift

Anne Marie JohnsonMyra Singleton

Renante DemezierStacey Singleton

Emily BlackburnStephanie Bowdler

Kendra SchulerMindy Miller

Jayme Godoyo

Jim WebsterTawnya HacklerDeb PackmanDawn WhiteNikki Quandt

Brionne RhodesHoward Coon

Colleen LareauBrigette Spelbring

Lisa RankinChanta Love

Jennifer WetzelSophia Ruffin

LaNette Heselton

Heather KellyJoy Loyd

Jen MaleeJoe Berry

Michelle TroyerPenny Hanks

Kristy HardwickRachel GubbinsDarren Dunahee

Lauren Kessler-SchottMelissa Webster

Becca SmithKara Lowry

Christy BrownHolly CottonKatie Klass

Afthan ReentsJennifer Shook

Kristi ZettlerTyler Moor

Becky NewcomerShannon StokesAmy Overmyer

Jennifer WoodsJennifer Riha

Jennifer HedrichMargaret Vergamini

Terri Cummings

Brian McConvilleBrandy KukurbaBessie Whitehurst-Smith

Bobbie WeinerSue Olson

Keith WheelerCindy Rotman

Mary MannShirica FlowersJennifer KeithSarah MartinNoell Juola

Kahdijah HakeemKatie JacksonDenny ClouseLisa WiemhoffLorena Duran

Jim OgleCarleen Otto

Cindy PetersonDennis Delgado

Beth TuthillJoi LaMon

June GalinskiKaren Felix

Samella TaylorDevin Dittrich

Karen PowellTerry KeanJane Lough

Beth EricksenDana Torres

Brenda GossettAnn OMalley

Cindy PaladinoRon Smith

Danielle Sines

George HusickShantina Griffin

Deborah Holmes-ThomasAndrea Gray-Strutzenberg

Freya Gorenstein

Brian McGannonShirley HawkinsCortney Rhadigan

Kristin PattenDenise HerronJennifer ForbesDiana Guzman

Carolina RodriguezJulius BenjaminAndrew HamlynLatrina PresleyMegan SullivanCecilia Rivas

Lakiethia Butler

Adrienne Patterson-GreenMarlice WaddyFelicia Foster

Liza Simon-RoperJoanna ZakhemJill BulakowskiTammy AmbreBrenda Gossett

Amy CollinsBrigette Davis

Lois AliottaMindy Kwoh

42 42 73

Total Reviewers: 157

Thank you for your time, efforts, and commitment to quality service delivery.


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Client Satisfaction

CQIR conducts an annual Client Satisfaction Survey to monitor OHU clients impressions of the services

provided. 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 and to

regions as a whole. Please contact Sarah

Tunning, Director of Research for One Hope

United, for a report card on any program or region.

ChildDevelopment Counseling

FamilyPreservation Placement Prevention

YouthServices

CaseManagement

Florida

FY13

4.81(N=619)

4.68(N=381)

4.70(N=276)

4.26(N=426)

4.88(N=328)

4.73(N=202)

4.57(N=622)

FY12

4.70(N=597)

4.55(N=368)

4.67(N=250)

4.26(N=410)

4.83(N=356)

4.75(N=209)

4.61(N=785)

FY11

4.74(N=547)

4.65(N=395)

4.78(N=239)

4.28(N=411)

4.85(N=358)

4.77(N=295)

4.59(N=435)

Cross-regionally, all program service areas scored in the fine tuning (A) range, with the exception ofPlacement. Overall satisfaction with OHU increased in FY13 in Child Development, Counseling, FamilyPreservation, and Prevention. Youth Services and Case Management (which includes FamilyPreservation and Placement cases in Florida) decreased slightly in FY13; however both remain in thefine tuning (A) range. Placement remains unchanged from FY12 and continues to score in the needsimprovement (B) range.

2013 2012 20114.65

(N=2,854)4.61

(N=2,975)4.65

(N=2,680)

Cross-Regionally, overall client satisfaction with OHU has remained above 4.50 (A) for the past threeyears. This year, there were 2,854 surveys returned, a 4% decrease from the 2,975 surveys collected in

2012.

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

Case

ManagementFlorida

Overall OHU Client Satisfaction: CrossRegion

Client Satisfaction Surveys monitor

clients impressions of the services OHU

provides.


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Incident Reports

An incident is any occurrence that may have

the potential for increased risk for our clientsand 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 circuit over three fiscal years.

Across all Regions, there was a 4% decrease in the number of incident types in FY13 compared to

FY12. The Northern Region had the largest decrease in incident types (-11.8%) followed by Hudelson

(-3.7%). The Florida Region had a 25% increase in incident types, which is primarily attributed to the

addition of services in Circuit 13.

There were three incident types that increased and those were Medical/Psychiatric Incidents (+20%),

incidents classified as Other (+4%), and Behavioral Issues (+3%).

All other incident categories saw a decrease. The most significant decreases were in Client Caregiver

Property (-92%), Education (-37%), Sexually Problematic Behaviors (-26%), Deaths (-24%), andBehavior Management (-21%).

It is important to note that the number of Behavior Management incidents (incidents involving a restraint)

in the Northern CARE Day Treatment (DTx) and Northern and Hudelson Residential (RTx) programs

decreased for the first time since FY10. In FY12, 24% of all incidents involved a restraint. In FY13, out of

the 3,534 incidents, 19% involved a restraint, a 5% decrease.

0400800

120016002000

Incidents by Type: Cross Region

FY13 FY12 FY11

Incident reports track situations that may

have the potential for increased risk for our

clients and the liability of our agency.


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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 clientconfidentiality and safety and risk management. CQIR coordinators conduct OHU office systems reviews

annually.

Twenty-eight Office Systems Reviews were conducted across all 3 regions (4 in Florida, 7 in Hudelson,

and 17 in Northern). Cross-regionally, 93% of all office systems reviews were compliant a 4% decreasefrom FY12.

89%94% 94% 93%

0%

20%

40%

60%

80%

100%


Office Systems Compliance: Cross-Regionally


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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 ofsupervision tasks. Although there are several items addressed, there is a concentration on the frequency

of supervision and quality documentation of supervisory activities.

Ninety-four Supervisory Systems Reviews were completed across all three regions (15 in Florida, 22 in

Hudelson, and 57 in Northern). Cross-regionally, supervisors were 84% compliant, 6% below theagencys 90% target, with items measured a 2% decrease from FY12. Hudelson is exceeding the

agencys 90% target (represented by the black dashed line).

78%

97%

79% 84%

0%

20%

40%

60%

80%

100%


Supervisory Systems Compliance: Cross-Regionally


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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 providedto 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 is 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, suicide attempt, or felony.

# Priority Reviews in FY13

Program CategoryCase

ConsultationsLevel 2 Level 3 TOTAL

Child Development 0 0 0 0

Counseling 1 0 2 3

Family Preservation 2 0 1 3

Placement 7 4 2 12

Prevention 0 0 2 2

Youth Services 0 0 2 2

TOTAL 10 4 8(see footnote)

22(unduplicated)

There were 22 priority reviews conducted in FY13 (down 17 from FY12): 16 in the Northern Region(down 11 from FY12), 3 in the Hudelson Region (down 1 from FY12) and 3 in the Florida Region (down 5

from 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. Cross-regionally 8 less Case Consultations were

conducted in FY13 compared to FY12.

There were four Level 2 Priority Reviews in FY13 (down 2 from FY12). One review was conducted due to

the medical neglect of a youth in placement by their caregiver, which resulted in a permanent injury, one

was due to the abduction of a child from Foster Care, one was due to inappropriate behavior between 2clients, and one was at the request of program leadership.

There were eight Level 3 Priority reviews in FY13, down 7 from FY12 (one review was for a client that

was enrolled in 2 OHU programs). Four reviews were due to suicide attempts made by clients, three

were due to deaths of clients while in OHU services, and one was due to the suicide of a former OHU

client.

3

One Level 3 review that took place in Counseling and Prevention involved a client that was enrolled in both Intact FamilyCounseling and the Wings CPS program in the Northern Region. In the total column this review was only counted once.


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Below are some highlights of lessons learned throughout the year:

When a family OHU is serving experiences a death or significant change, such as moving, it

would be in the families best interest for OHU to provide aftercare services (up to 3 months) tohelp the family cope, even if the funder (such as DCFS) has closed the case. This would be agood practice for all OHU services.

It is important for external reviewers to be able to read case notes and be aware of familialrelationships when there are multiple family members involved with families being served.

Ensure consents are correctly completed accurately, correctly, and for appropriate contacts.

There needs to be clarification on the requirements of incident reporting for emergency medicaltreatment. In cases of medical neglect, it is important that supervisors have an ongoingdiscussion with case managers to address any medical concerns during monthly supervision.

Collateral contacts with service providers are vital in monitoring client progress and following up ifconcerns are identified.

Medical neglect cases warrant an increased level of vigilance to make certain that medical needs

are addressed. We make assumptions that licensed providers, in this case, child care, are consistently meeting

licensing requirements. When visiting such providers, we should focus our attention on seeingwhere the child sleeps, feeding log, etc. Possibly enlist the assistance of lead agencies in thiseffort for extra oversight.

Possibly interviewing a new child care provider prior to placing the child in the service anddetermine the quality and licensing compliance.

When there is a significant safety issue or history of abduction with a natural parent, that caseneeds to be staffed immediately with the Director of Programs to devise a plan for visitation andservices with the supervisor moving forward.

Based on the dynamics of the case, the location of the visits needs to be assessed to identifysafety concerns.

Case aids need to be updated on the history and dynamics of each case in which they aresupervising parent-child visits.

Transportation requests need to be signed by the case manager as well as the supervisor toensure the case aid has all the important case information needed for safety and securityreasons.

The history of the case needs to be shared with everyone involved in the case. Transitional programming for clients who have finished high school would provide increased

structure and might help prevent boredom and some acting out behavior. Good communication on shared cases between programs is essential and aides in ongoing

assessment and treatment planning. This was done effectively on this case. The importance of having the proper training and completion of an Eco-map to understand the

family, strengths and resources. For non-traditional families that we work with, we need to look for non-traditional ways to engage

them.

The review was a reminder to obtain consents within the agency for different programs that havethe same client in order to communicate with each other.

Continue to try to engage client even though they may be resistant.

Additional information can be found by contacting a member of the CQIR team.


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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 64 Star awards and 12 Galaxy awards distributed

in the agency this year.

In FY13 we were proud to recognize these employees with a STAR Award.

Quarter 1

Myra Singleton Program Specialist(Tampa, FL)

Amanda Boley Family Support Specialist(Tampa, FL)

Stacey Singleton Permanency Specialist(Tampa, FL)

Christina Doty Office Manager (Tampa,FL)

Melissa Gabriel Office Manager (Tampa,FL)

Shawn Lux Youth Care Worker I(Centralia, IL)

Stacey Garner Lead Youth Care Worker(Centralia, IL)

Gregory Phoenix Residential Specialist(Centralia, IL)

Kayla Dunahee Residential Specialist(Centralia, IL)

Shannon Stokes Director of Programs(Jefferson City, MO)

Patty Diaz Eligibility Specialist (Aurora, IL) Andrew Rozanski Youth Care Worker

(Lake Villa, IL) Delores Momen Case Manager

(Kankakee, IL) Blanca Figueroa Payroll Manager (Lake

Villa, IL) Ginny Kowalski Office Manager

(Waukegan, IL/Busy Bee) Amy Hirsh Child Development Director

(Wilmette, IL) Susan Spjuth Child Development

Specialist (Des Plaines, IL

Quarter 2

Amanda Birge Case Manager(Sebring/Wauchula, FL)

Daniel Cook Life Coach

(Sebring/Wauchula, FL)

Rebecca Kampan Case Manager(Sebring/Wauchula, FL)

Bobbie Colvin Family Support Worker

(Sebring/Wauchula, FL) Beverly Mitchell Case Manager (Orlando,

FL) Dhaima Chin Family Case Manager

(Orlando, FL) Vanessa Hayden-Johnson Family Case

Manager (Orlando, FL) Lucie Memorie Case Manager (Orlando,

FL) Alan Blackmon-Case Manager (Orlando, FL) Brandy Davis Family Case Manager

(Orlando, FL)

Lauren Prekop Case Manager (Orlando,FL) Lauren Loffert Case Manager (Orlando,

FL) April Campbell Family Case Manager

(Orlando, FL) Fiona Simmons Records Management

Specialist (Orlando, FL) Ebonie Hopkins Supervisor (Orlando, FL) Yolanda Walker Supervisor (Orlando, FL) Laurie Stern Supervisory (Orlando, FL) Ferdinand Medina Family Support Worker

(Orlando, FL) Jennifer Carmin Case Manager (Orlando,FL)

Emily Gustafson Case Manager (Orlando,FL)

Jolene Palazzo Business Manager(Orlando, FL)

Jessica Perry Therapist (Centralia, IL) Brooke Lopez Administrative Assistant

(Centralia, IL) Guy Janic Maintenance (Centralia, IL) Nicole Apolo Donor Database

Administrator/Accountant I (Lake Villa, IL)


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Quarter 3

Mileidy Daniel Case Manager (Orlando,FL)

Therese Hartwell Family Case Manager(Orlando, FL)

Shawna Lambert Supervisor (Sebring, FL) Claudia Gonzalez Adoption Specialist

(Tampa, FL) Ana Cruz Case Manger I (Wauchula, FL) Lindsay Bass Case Manager (Wauchula,

FL) Robin Sherwood Lead Case Manager

(Wachula, FL) Nancy Baker-Guerin Case Manager I

(Wachula, FL)

Jim Webster Coordinator (Centralia, IL) Brenda Perry Family Support Specialist(Olney, IL)

Josh Smith Youth Care Worker (Centralia,IL)

Jayme Godoyo Fund Development Officer(Centralia, IL)

Tina Schrage Youth Care Worker(Centralia, IL)

Yudelca Romano Counselor/Therapist(Gurnee, IL)

Bonita Porter Therapist (Chicago, IL) Francine Williams Case Manager

(Chicago, IL)

Quarter 4

Courtney Hall Family Case Manager(Sebring, FL)

Natheena Soto Family Case Manager(Orlando, FL)

Cindy Smith Youth Care Worker (Centralia,IL)

Gabriel King Lead Youth Care Worker

(Centralia, IL) Jackie Schedin CQIR Coordinator(Chicago, IL)

Devin Gazelle Supervisor (Joliet, IL)

The following teams were presented with a GALAXY Award this year.

Quarter 1 Quarter 3

Residential Specialist Team (Centralia, IL) OHU Licensing Team (Orlando, FL) Baker Home (Centralia, IL) Intact Family Services (Hudelson, IL) CARE Day Treatment (Lake Villa, IL) Family Support Services and Visitation Team Des Plaines Child Development Center (Des (Collinsville, IL)

Plaines, IL) Gibb Home (Centralia, IL) Kenwood Support Staff (Chicago, IL)

Quarter 2

OHU Licensing Team (Orlando, FL) Quarter 4

Bridgeport II Child Development Center(Chicago, IL)

Team Excellence Evidenced Based Practice

Committee (Federation)


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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 onimproving the quality of service at the local level using data, effective problem solving and action

planning.

Cross-regionally there was an overall attendance rate of 96% in FY13. All Regions exceeded the 90%

target. The graph above shows individual attendance rates by region.

At the Federation level, the following ASO teams were assembled this year.

Service Team Name

CQIR Partners in Excellence

Executive Leadership

Team (ELT)Visionaries

Finance #s R Us

Fund Development Raise of Hope

Human Resources Team Excel

Facilities Facilities

94%

98%

96%

91%

80%

85%

90%

95%

100%

Florida Hudelson Northern Federation

QIT Attendance: Cross-Region

Region

Target


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The following local, service center and regional Quality Improvement Teams were assembled three

times this year.

Florida Hudelson Northern

Local

Sassy SoldiersStellar Seven

Elite 6Advocates

Unit 206 The A TeamTeam Terrific

Mighty HelpersEveryday HeroesUnit 853 The A Team

Best & BrightestTeam FocusPerfect StarsOHU Angels

Rescue RangersExcellence TrackersQ2 Quality QueensImprovement Seekers

Quality AvengersMighty Women of Quality

Givers of HopeNoble Intenders

Casenote QueensGibb Baker HeroesWilson Hick Heroes

BlissRG and the Sunshine BandBehavior Busters

Big 10Win3

The SupportersYouth Empowerment Program

Clinical HeroesSuper Glue Sticks

Youth Encouragers andStabilizers

Chain LinksNight Owls

Wonder WomenThe River Valley RespondersKFC Kenwood Foster Care

Whatever it TakesMST on The Prairie

Super CrewTop Performing Butterflies

OHU AdvocatesSocial Workers for Justice

The Guardian AngelsBridgeport II

Edgewater Educators

OHare CDCThe InspirationsThe Eclectics

The FacilitatorsCLC

Seeds of Change24-7 Crew

Team Extreme EBTThe Rainbow Team Teach

The 4 RunnersOld School Rebounders

CheersConnect 6

Team Unity All StarsEducaneers

The Show Must Go OnWilmette/Glenview CDC

Eternal OptimistsThe Pilots

The B.R.A.T.S.

Service

Center

C9 Super SupsC10 No WorriesC13 Quality Angels

Exceptional EightASAP

Missouri Service CenterLeaders of the Pack

EnergizersTo Infinity & Beyond

Mission MoversCARE Leadership

The WanderersPrevention Supervisors

Regional

Hopes Heroes Destination Excellence Community Transformers

One Hope United 2013 CQIR Annual Report - Cross Region

Documents