Reports/Open Communication

Reports/Open CommunicationThe Director of Quality and Compliance is a direct link to the Quality Council (EMT) – report progress, findings, etc.

The role of the QI Department will be to support the Champions and Quality Improvement Teams. Champions will complete a quarterly report/update on the progress of the QI measure to QI Director and Quality Council.

Quality Initiatives Champion (s) will be assigned to each quality initiative.

Quality Improvement Teams will be created for each quality initiative – consisting of staff with the expertise, skills and knowledge needed. The Quality and Compliance Director is a support to all Quality Improvement Teams for support and guidance of quality initiatives.

VisionA bridge to a brighter future through lifelong learning

Core Values•Learning as a focus across all Glade Run’s programs as evidenced by:

•Discerning the strengths and cultures of families•Emotional and behavioral management to facilitate academic achievement

•Innovative learning opportunities for staff, children and families•Program excellence and positive impacts as evidenced by:

•Partnerships with families to understand their needs and achieve success at home and in the community•Data that indicates successful outcomes for individuals and families

•Improved academic performance•High satisfaction ratings

•A welcoming culture•Working with individuals and families in the most appropriate setting available

•Work environments that thrive on the seven commitments of sanctuary•Our Christian foundation

MissionLinking Faith and Service

QUALITY COUNCIL (EMT)

Program Excellence Through Lifelong Learning

Life Long Learning: Staff,families/individuals and other professionals gainknowledge and competence through training and skillattainment

EPT: Implements the strategic goals established by the EMT while ensuring program excellence and compliance

EMT: Oversees program excellence and strategic growth

EST: Provides support for the EMT and EPT to achieve program excellence and strategic growth

EMG consists of EMT, EPT, and EST. The implementation and leadership of the Continuous Quality Improvement initiatives is the responsibility of the EMG.

Goals and Action Steps to Achieve Outcome/Impact

Quality Initiatives Impact Statement; The end result of the Quality Initiative

Quality Initiative Measurement Tools

Quarterly Summary/Follow-up

Family Partnership: Families feel empowered in the decision making process and express a sense of connectedness to supportive networks

Academic Excellence:The learning environmentat St. Stephen’s LutheranAcademy reflects academic excellence and an Accountable, Safe and Kind environment

Individualization/Generalization: families/individuals learn and practice skillsthat will transfer to theirunique home and communitysettings

Evidence Based Practices: Program excellence is achieved with the training and utilization of evidence based practices

1. Training records will identify the completion of career track trainings.

2. Quarterly training effectiveness survey’s

2. New hire surveys initial and at first quarter

4. Google analytics will be used to evaluate utilization of web-based trainings.

5. Clinical case review evaluations/checklists

5. Skill evaluation checklists

5. Exit interviews/ Review and revise to include skill development

Retention rates

Parent survey

PAS audits reviews

1. Develop career tracks for all job classifications

2. Assess, prioritize and evaluate training needs for staff, individuals families and other professionals

3. Educate and train employees and supervisors regarding career tracks.

4. Design web-based trainings

5. Develop professional skill evaluation checklistsEstablishment of learning goals for employees

Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools.

Lifelong LearningChampion Nickole Pribozie

Staff, families/individuals and other professionals gain knowledge and competence through training and skill attainment

Measurement Tool Responsible Person Frequency

Review training records for career track completion

Nickole Pribozie Quarterly (Oct, Jan, April, July)

Training effectiveness surveys

Nickole Pribozie Quarterly (Oct, Jan, April, July)

Training Needs survey Nickole Pribozie Semi-Annually

Clinical Case Review evaluations

Program Managers/supervisors

90 days and Annually

Retention Rates Tina Lynch Semi-Annually (Sept, March)

Quarterly summary/follow upLife Long Learning

• 105 Training Assessment needs have been completed. This is a six Question survey to identify training needs by position. This data is currently being evaluated to help assist in the continued development of Career Tracks.

• 70 Training Evaluation surveys have been completed. The surveys are administered after new hire training and then again at the quarterly basis. The survey is an eight question survey that evaluates the employees skill confidence to job duties and an evaluation of the effectiveness of the trainer to deliver the material in a way that the employee is able to relate the training to skill development and job preparedness.

• Average score of 4.27 on the Question I feel the training provided me new knowledge or insight.

• Average score of 4.67 on the question “I feel confident that I have the knowledge and skills to be able to use what I learned in my work”

• Average score of 4.59 on the question “Overall, this training will help me do my job well.”

• Five new trainings created by Glade Run have been added to Essential Learning (Residential 3800 regulations, Child Psychomarmacology, Sanctuary module 3 and 4, welcoming environment and HIPAA security.)

Quarterly summary/follow upLife Long Learning

Six career tracks have been developed

•Direct care – includes TSS, MHW’s, Teaching Assistants, Adventures staff•Therapist – MHP, BSC, Mobile therapists•Clinical Supervision•Leadership•Support Staff•Case Management

New Trainings developed

•Progress note training utilizing DAP format. (56 have attended)•BHRS Redesign•Sanctuary Modules•Alolescent and Autism•CAASP principles•Suicide Prevention

Orientation and Training Surveys

Training Survey’s

Q 1 Overall Score

Q2 Overall Score

I feel confident that I have the knowledge and skills to be able to use what I learned in my job

81 4.28% 76 4.38%

I feel the training provided me new knowledge and insight 81 4.63% 76 4.53%Overall, this training will help me do my job well 81 4.64% 76 4.47%

1st Q Agree Strongly Agree

2nd Q Agree Strongly Agree

Employee orientation has increased my excitement about working at Glade Run

4 25% 75% 8 12.5% 75%

I have a clear understanding of the history of Glade Run

4 25% 75% 8 37.50% 62.5%

I understand how the values of Glade Run impact the work that we do

4 25% 75% 8 12.5% 87.5%

I am familiar with the services provided by Glade Run

4 25% 75% 8 50% 50%

I have a basic understanding of the sanctuary model

4 25% 50% 8 37.5% 62.5%

I know where to learn more about any of the topics covered

4 50% 50% 8 37.5% 62.5%

I feel welcomed by Glade Run 4 100% 8 25% 75%

New Hire Campus Orientation Survey

Community New Hire Orientation survey

1st Q Agree Strongly Agree

2nd Q Agree Strongly Agree

Employee orientation has increased my excitement about working at Glade Run

3 33.33% 66.67% 2 100%

I have a clear understanding of the history of Glade Run

3 66.67% 33.33% 2 100%

I understand how the values of Glade Run impact the work that we do

3 33.33% 66.67% 2 100%

I am familiar with the services provided by Glade Run

3 66.67% 33.33% 2 50% 50%

I have a basic understanding of the sanctuary model

3 66.67% 33.33% 2 50% 50%

I know where to learn more about any of the topics covered

3 66.67% 33.33% 2 100%

I feel welcomed by Glade Run 3 50% 50% 2 100%

Family PartnershipChampion Leslie Walter

Grow the Glade Run Family network data base

Increase decision making and participation of families in agency events/activities

family partnership support will increase visibility and continue communicating their role in glade run culture

Family advisory counsel continues to grow and become involved in decision making and planning.

Families/Individuals feel empowered in the decision making process and express a sense of connectedness to supportive networks

Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools

Review the number and percentage of active participants in the Glade Run Family Network Database

Review family participation/voice in treatment plans, progress notes and ISPT and treatment plan signature pages

Training recordsReview advisory counsel minutes.

3, 6, 9 month aftercare calls

Family satisfaction surveys

Database communication form.

Measurement tool Person responsible Frequency

Advisory Counsel Minutes Leslie Walter Quarterly

Review Family Network database

Leslie Walter Quarterly

Family satisfaction Surveys TBD TBD

Review Treatment plans, progress notes, signature pages

Ruth Girton 10% records quarterly

3, 6, 9 month after care calls TBD Monthly, Quarterly summary

• To Date there are 147 families entered into the data base..– 97% would like to receive updates on family/community events– 76% would like to become more involved and share their voice and experience with us.– 78% would like information on how to connect with other families– 53% would like to be connected to spiritual and/or other supports within the community– 93% would like to receive the Glade Run newsletter, The Bridge.

• Parent satisfaction surveys are in final stages. The survey is complete just working out the process for administration, frequency and person responsible.

Quarterly summary/follow upFamily Partnership

Quarterly summary/follow upFamily Partnership/First Quarter

Family Partnership/2nd Quarter Update

• Advisory Counsel meeting quarterly and have added 5 new members.• Continue to bring sanctuary to meetings and to our families• Working on how to bring the families together. Several families did help on the family survey• Working with Training Department to develop and deliver the training. • Finalized Family Satisfaction Survey’s. Sent out approximately 2000, and have received back more than 10%,

good representation among all program areas. • Working with families to find out what trainings they would like to have. Identified behavior management and

parenting skills as first focus based on survey feedback. • Changed the way we do medication sheets for therapeutic leaves based on feedback from a family member

through the survey.• Utilization of e-blast to share stores, events, themes, resources etc.

• Still working on how to show family engagement with the agency. There has been a recent culture change to include families in events such as Marthen’s and Reiber’s cottage families events, positive parenting in Beaver Falls and the Jeremiah Village community information sharing meetings.

Quarterly summary/follow upFamily Partnership

Strongly Disagree

Disagree Neutral AgreeStrongly Agree

Rating Average

Response Count

0 1 8 34 56 4.46 99990

Strongly Disagree


Rating Average

Response Count

0 4 6 36 53 4.39 99990

Strongly Disagree


Rating Average

Response Count

0 3 10 42 44 4.28 99990

Strongly Disagree


Rating Average

Response Count

0 0 5 31 62 4.58 98981

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Family Satisfaction Survey

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2. I am asked for my input about the strengths and needs of my family.

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3. I helped to create the current goals.

4. Glade Run staff are friendly and polite.

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1. I feel Glade Run staff are welcoming.

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Answer Options

Strongly Disagree


Rating Average

Response Count

0 8 12 29 49 4.21 98981

Strongly Disagree


Rating Average

Response Count

2 4 17 37 38 4.07 98981

Strongly Disagree


Rating Average

Response Count

0 1 14 33 50 4.35 98981

Strongly Disagree


Rating Average

Response Count

0 1 5 37 55 4.49 98981

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7. Glade Run staff show concern for my family's improvement.

5. I receive updates on progress towards goals.

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8. I have a voice regarding decisions involving care, treatment and services.

6. I receive information about the services available at Glade Run.

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Strongly Disagree


Rating Average

Response Count

0 2 16 43 37 4.17 98981

Strongly Disagree


Rating Average

Response Count

0 6 22 35 35 4.01 98981

Strongly Disagree


Rating Average

Response Count

1 10 27 27 33 3.83 98981

Answer Options

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9. My needs are being addressed.

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11. Glade Run staff are helping/have helped me build a supportive network in my community (family, friends, resources, etc.).

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10. I receive information on resources/events that are relevant and beneficial to me.

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Family Satisfaction Survey - Sanctuary

Strongly Disagree


Rating Average

Response Count

0 2 7 38 52 4.41 99990

Strongly Disagree


Rating Average

Response Count

0 1 8 34 56 4.46 99990

Strongly Disagree


Rating Average

Response Count

1 0 6 33 59 4.51 99990

Strongly Disagree


Rating Average

Response Count

0 1 2 27 69 4.66 99990

Strongly Disagree


Rating Average

Response Count

0 0 5 31 62 4.58 98981skipped question

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Family Satisfaction Survey

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3. I can openly communicate without feeling judged.

4. I am treated with respect.

1. My rights and responsibilities were explained to me and I know how to find this information, when needed.

5. Glade Run staff are friendly and polite.

Answer Options

answered question

2. I feel Glade Run staff are welcoming.

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Strongly Disagree


Rating Average

Response Count

1 8 9 24 56 4.29 98981

Strongly Disagree


Rating Average

Response Count

0 8 12 29 49 4.21 98981

Strongly Disagree


Rating Average

Response Count

0 1 14 33 50 4.35 98981

Strongly Disagree


Rating Average

Response Count

0 1 5 37 55 4.49 98981

Strongly Disagree


Rating Average

Response Count

0 2 20 26 50 4.27 98981skipped question

10. The program is helping my family.

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8. Glade Run staff show concern for my family's improvement.

7. I receive updates on progress towards goals.

9. I have a voice regarding decisions involving care, treatment and services.

Answer Options

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6. Glade Run staff routinely communicate with me.

Strongly Disagree


Rating Average

Response Count

0 0 19 29 50 4.32 98981

Strongly Disagree


Rating Average

Response Count

0 2 16 43 37 4.17 98981

11. Glade Run staff promote safety for all.

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12. My needs are being addressed.

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Academic AchievementChampion Amy Williams

The learning environment at St. Stephens’ Lutheran Academy reflects academic excellence and an Accountable, Safe and Kind environment

85% attendance Rate

Grades will improve school wide

Major incidents will decrease (Acts of violence, self injurious behavior, awol, restraint, police involvement, psychiatric hospitalization)

Students will demonstrate increased proficiency in reading comprehension and math

Implement the CBITS

Classroom Engagement

Attendance Records

School wide grade reports

Positive Behavior Support Assessment; Incident Report review; ASK points

Aims-WEB reports

CBITS evaluation tools

Walk through observation/evaluation cards

Goal Attainment Scale Leadership groups

Teacher and teacher Aid staff retention

Staff, student, parent, school district surveys

Goals and Action steps to Achieve Outcome/Impact Quality Initiative Measurement Tools

Education

Measurement Tool Person Responsible Frequency

Attendance Records Jayme Glover 9 week intervals and end of school year

School wide grades Jayme Glover 9 week interval and end of school year

PBIS Keenon McGaughey Semi-annually

Walk thru engagement cards

Amy Williams, Keenon,McGaughey Ruth Girton, Beth Hines

10 per month

Student, family surveys TBD TBD

ASK points Jayme Glover Semi-annually

Incident report review Jayme Glover Quarterly

Quarterly summary/follow up

•Education observation/evaluation cards

Observed to a high degree

Observed to be effective and appropriate

Observed Needs further development

Not observed Needs improvement

StudentEngagement

11/46 24% 19/46 41% 16/46 35% 0

Staff Engagement

5/46 11% 23/46 50% 16/46 35% 0

Classroom engagement

9/46 20% 12/46 26% 12/46 26% 0

APoss.

A% A S

Poss.S

% S KPoss.

K% K

Total ASK Points

Total ASK Points

Possible

Percentage ASK Point Earned

35658 38591 90.73% 37457 38597 96.84% 36517 38610 95.08% 109632 115798 94.31%

6362 7010 90.12% 6733 7011 96.03% 6554 7012 97.79% 19649 21033 94.19%

11419 12176 93.30% 11991 12189 100.00% 11769 12189 99.24% 35179 36554 95.25%

17877 19405 92.12% 18733 19397 96.57% 18194 19409 93.74% 54804 58211 94.49%

Individualization/GeneralizationChampion Beth Hines

Families/individuals learn and practice skills that will transfer to their unique home and community settings.

Strength Needs and Cultural Discovery Treatment Plan Reviews

Goal Attainment Scale

Parent/client surveys

3, 6 and 9 month after care surveys

Treatment plan reviews

Progress Notes review

100% of Treatment plans will identify family strengths and prioritized needs

100% of Treatment plans will develop goals and interventions to include natural and informal supports

Progress note format training

Progress notes reflect evidence of skill transfer through teaching, modeling, evaluation and/or monitoring

Goals and Action steps to Achieve Outcome/Impact Quality Initiative Mesurement Tools

Quarterly summary/follow upIndividualization/Generalizaion

– 1, 3, 6, 9 month after care calls were centralized and created using survey monkey.• There have been 111 aftercare calls attempted for the RTF and 553 for the community

programs• surveys were successfully completed for the community programs

30 Day Surveys: (84 Surveys Community)• 88% of clients were still living in the home they discharged to • 75% in school or vocational training• 95% had not experienced a significant crisis requiring hospitalization• 85% reported the program being helpful• 76% using skills they learned in the program.

– 6 month Surveys (64 surveys Community)– 89% still living in the home they discharged to – 83% in school or vocational training– 89% had not experienced a significant crisis requiring hospitalization– 76% reported using skills they learned in the program– 79% reported program being helpful

RTF had a total of 51 total surveys answered

RTF (30 Day survey, 11 responses86% still in less restrictive placement62% made it to first aftercare appointment71% following aftercare plan35% felt they were doing better since discharge29% doing the same36% doing worse

RTF (60 Day survey, 12 responses)79% still in less restrictive placement80% following aftercare plan33% doing better33% doing the same33% doing worse

RTF (90 Day survey 1776% in less restrictive placement71% following aftercare plan41% doing better17% doing the same41% doing worse

RTF (180 day Survey 12 completed92% in less Restrictive75% still following aftercare plan33% reported doing better than at discharge16% doing the same50% doing worse

Response Count

76760

Response Percent

Response Count

100.0% 76760

Response Percent

Response Count

14.5% 1185.5% 65

760

Response Percent

Response Count

58.1% 250.0% 037.2% 164.7% 2

4333

6 Months

2. Date

No Contact Information (consumer's phone number is

30 Days

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Client Re-Admitted to Program/Treatment

Answer Options

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No Response (consumer did not return call or answer

1. Consumer's Name

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3. Type of Interview

Date of call:

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Community Post Discharge Survey

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Consumer Refused to Answer Questions

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4. If survey cannot be completed, indicate why.

Response Percent

Response Count

13.2% 1022.4% 1719.7% 156.6% 56.6% 52.6% 217.1% 132.6% 29.2% 7

760

Response Percent

Response Count

88.0% 2212.0% 3

2551

Response Percent

Response Count

8.3% 291.7% 22

2452

Response Percent

Response Count

4.0% 196.0% 24

2551

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BHRS- Beaver

7. Have you been arrested since discharge?

No

Answer Options

Family Based - Butler

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BCM - ButlerBCM - Beaver

Yes

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8. Have you experienced a crisis that resulted in a psychiatric hopsitalization?

Family Based - Beaver

No

Answer Options

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BHRS - Pittsburgh

Yes

Answer Options

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6. Are you currently living in the same home as when you were discharged?

No

Family Focused Solution Based

BHRS - Butler

Answer Options

5. Program:

Yes

Family Preservation-Reunification

Response Percent

Response Count

0.0% 0100.0% 25

2551

Response Percent

Response Count

60.0% 1516.0% 424.0% 6

2551

Response Percent

Response Count

0.0% 0100.0% 25

2551

Response Percent

Response Count

8.0% 220.0% 572.0% 18

2551

Response Percent

Response Count

88.0% 2212.0% 3

2551

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10. Are you currently taking your prescribed medication?

Yes

No

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11. Are you currently involved with or receiving services from CYF (Children, Youth, and Families)?

Yes

N/A (No medications prescribed)

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Yes

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No

12. Are you currently employed?

Answer Options

No

13. Are you currently attending school, college, or a vocational program?

Yes

N/A (Consumer is a child)

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9. Have you been voluntarily hospitalized?

Yes

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No

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No

Evidence Based PracticesChampion Beth Hines

Program excellence is achieved with the training and utilization of evidence based practices

Goals and Action steps to Achieve Outcome/Impact Measurement Tools

Research and obtain information on the following Evidence Based Practices (CBITS, DBT, CBT, TF-CBITS, PCIT, ABA, ART, SFT, PBIS) Academic curriculum,

Identify and develop who will become trained trainers in the above mentioned modalities

Train employees in the above mentioned modalities

Develop clinical coaching supervision model to ensure fidelity of the modalities

Measurement tools associated with each modality if indicated/available: Child PTSD scale (CPSS); Pediatric Symptom Checklist (PSC) CAFAS reports

Training records

Review supervision records


Evidence Based PracticesChampion Beth Hines

Program excellence is achieved with the training and utilization of evidence based practices

Goals and Action steps to Achieve Outcome/Impact Measurement Tools

Quarterly Summary/Follow up

Research and obtain information on the following Evidenced Based Practices:

•Cognitive Behavioral Therapy (CBT)

•Dialectical Behavior Therapy (DBT)

•Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

•Cognitive Behavioral Intervention for Trauma in Schools (CBITS)

•Parent-Child Interaction Therapy (PCIT)

•Safe and Civil Schools Positive Behavioral Interventions and Supports Model (PBIS)

Identify and develop who will become trained trainers in the above mentioned modalities

Train employees in the above mentioned modalities

Develop clinical coaching supervision model to ensure fidelity to the modalities

Measurement tools associated with each modality if indicated/available:

Suicide Attempt Self Injury Interview (SASII); Nonsuicidal self-injury (NSSI)

Child Behavior checklists; child depression inventory; Weekly Behavior report; Parent Emotional Reaction Questionnaire ; Parenting Practices Questionaire (PPQ); Parent Support Questionnaire (PSQ)

Child PTSD symptom Scale (CPSS); Pediatric Symptom Checklist (PSC);

Dyadic Parent-Child Interaction Coding System (DPIS); Parenting Scale (PS); Eyberg Child Behavior Inventory (ECBI); Child Behavior Checklist;

Home Situations Questionnaire—Modified (HSQM); Parenting Stress Index (PSI); Parent Locus of Control Scale (PLOC); Parent Sense of Competence Scale (PSOC);

An Academic Index Kentucky Core Content Tests; California Standards Test in Mathematics; Positive Behavior Support (PBS) Assessment—Staff survey; Teacher Surveys

Training Records

Review Supervision records

3, 6, 9 month aftercare calls

Treatment retention

Reports/Open Communication

Documents

Transcript of Reports/Open Communication