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«Jasper Mountain QUALITY ASSURANCE POLICIES Excerpt of Agency Policies & Procedures Manual 2. Programs and Services Policies & Procedures I. QUALITY ...»

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Jasper Mountain


Excerpt of Agency Policies & Procedures Manual

2. Programs and Services Policies & Procedures


1. Mission

2. Systemic Quality Improvement Plan & Design

a. Staff & Board Involvement in Quality Improvement

b. Consumer Involvement in Quality Improvement

• Client Input

• Stakeholder Input

• Contractor Input c. Operationalizing the Quality Improvement Process

3. Employee Utilization a. Staff Development b. Personnel Retention

4. Strategic Planning Process a. Overview b. Long Term Planning Process c. Short Term (annual) Planning Process d. Data Collection (See also sections J & K, below)

• Consumer Input

• Staff Input

• Volunteer Input

• Outcome Data

• Follow Up Data

• Quarterly Review of Clinical Progress & Documentation e. Dissemination of Strategic Plan


1. Outcomes of Treatment

2. Outcomes of Measures

3. Follow Up


1. Case Documentation

2. Retention of Records

3. Quality of Treatment Plan

2. I. QUALITY ASSURANCE In a commitment to excellence, Jasper Mountain has established the following procedures to ensure quality care to all consumers. These procedure fall into several categories but all are initiated to insure quality, improve every aspect of service delivery and correct all deficiencies in every aspect of the Agency and its services. Quality assurance encompasses three primary headings: Systemic Quality Improvement, Strategic Planning Process, and Employment Utilization. While these areas have distinct aspects assisting in quality improvement, they also have fundamental overlap as well.

To accomplish the Agency's expansive mission, steps must be taken to improve the quality of the organization and its staff on a continual basis. The framework of this process will be outlined here. It is critical to mention that quality is not a black or white concept. Quality is an ever-expanding commitment to excellence and a concept with no finish line. It is clear that the moment a program asserts that their program has met the threshold for excellence and the Board, management and staff reduce their efforts to make further improvement, they have lost excellence. Neither is quality a concept that is associated with some but not all of an organization. Every individual, every team and committee, and every program must be reviewed and held up against the standard established by the mission of the organization. The move in the direction of excellence is a continual commitment to action, evaluation and redirection.

2. I. 1. Mission The mission of the Agency is to bring hope and healing to traumatized children and their families and to enhance the physical, emotional and spiritual health of its consumers and staff. This mission is unobtainable internally despite an organization of the highest standards of excellence. The Mission can only be accomplished with a community partnership, a family partnership and an organizational partnership.

Therefore each of these partnerships must be involved in systemic quality improvement. The overall organization must be not only open to input from clients and the community at large, it must seek such input and make maximum use of it.

Therefore the perspective of quality must be a shared perspective of all stakeholders.


2. I. 2. Systemic Quality Improvement Plan and Design The Systemic Quality Improvement process was established to support improved consumer outcomes by identifying continuing education and training opportunities for personnel and targeting areas in which improvement is needed by reviewing results, performance indicators, consumer feedback, and the overall plan for continuous improvement of performance.

The improvement process design must address key questions concerning the organization and its services: 1) Does the organization stay true to its mission with everything it does? 2) Is the organization consumer based taking advantage of consumer input? 3) Are services evaluated by performance and outcome data? and 4) Does the organization have a continuous and organized review process? Each of these issues addresses indicators of quality.

Quality improvement is not a top down concept. It is not the function of management to dictate excellence to anyone other than to management. Quality is all about the culture of an organization, a commitment from everyone. Therefore the process must be comprehensive and facilitate involvement. Jasper Mountain's quality improvement plan necessitates input from multiple perspectives. Input must be obtained that is critical, evaluative and expansive. The Agency's process shall include input in the

following forms:

Staff  Board evaluations of the organization  Management evaluations  Committee and team evaluations  Client evaluations  Stakeholder evaluations  Contractor evaluations 

2.I.2.a. Staff & Board Involvement in Quality Assurance

The Board of Directors evaluates the executive director on an annual basis as well as the management, the staff, the programs and the overall efficiency of the organization. The Board is charged with reviewing each of the Agency's programs on a rotational basis on a twenty-four month timetable.

The Management Team conducts routine reviews of all aspects of the Agency's services and overall functioning during biweekly meetings. The team provides the Board with emerging concerns and issues as well as data concerning specific aspects of all Agency services. The team obtains input from other Agency committees regarding all internal functions of the organization including services, access, utilization, consumer feedback, Agency strengths and weaknesses, outcome and follow up processes, barriers, and use of Agency resources including staff. The Management Team reviews all recommendations from other committees for adjustments and reports areas of focus to the Board of Directors. The team is also charged with obtaining staff input on a variety of issues which are passed on to the Board along with recommendations to improve the effectiveness and overall climate of the organization.

Staff and client input is specifically obtained within teams and committees which are

established with an organizational role. These committees and teams include:

Management Team: charged with supervision of overall operations of the 

Agency, such as:

• supervision of all employees;

• development and implementation of an annual budget;

• all personnel matters;

• insure access to services using Agency performance measures;

• reviews clinical outcomes in aggregate form from outcome and follow-up data;

• program development;

• risk management;

• reviewing behavior management and special treatment procedures policies annually;

• liaison with the Board and the community.

Leadership Teams: charged with implementation of program operations and 

other functions as delegated by the Management Team, such as:

• monitoring implementation of treatment objectives and methods;

• monitoring critical incidents and incident reports;

• collecting daily tracking information on individual children;

• monitoring the effectiveness and the morale of treatment staff;

• insuring an atmosphere of structure and safety for residents and staff.

Quality Assurance Committee: shall be composed of clinical staff, program  director, a staff trainer, a treatment team staff member, representative of an external Agency, Agency psychiatrist participation through input, Agency Consumer Consultant, and one or more consumers. Membership on the committee will be reviewed by the Management Team annually for adequate Agency-wide representation (including consumer representation) on the committee.

Representatives on the QA committee will serve on an annual basis. If a member decides to no longer sit on the committee, it will be the responsibility of the QA coordinator in conjunction the Management Team to find another appropriate representative to fulfill the position. The committee is to meet monthly and keep minutes and is authorized to implement and track the Agency quality assurance

plan and procedures, such as:

• monitoring the progress of each child through input from Agency psychiatrist;

monitoring quality of care to each child and family;

• monitoring and evaluating access to, and delivery of, children’s intensive mental • health treatment services;

monitoring Agency’s activities in providing culturally responsive services;

• identifying and resolving problems in access of delivery of services;

• tracking length of stay in each program, individually and collectively;

• reviewing concerns coming from all other teams and committees;

• monitoring the use of special treatment procedures on an aggregate and • individual basis;

reviewing grievances, incident reports and accidents;

• recommending adjustments based on client and staff input;

• considering research implementation, and any experimental practices in order to • insure that such practices have been approved by the Board and where necessary, the State regulatory Agency;

reviewing removal of children from the milieu for over two hours at one time or • five hours over five days;

reviewing any problems associated with administration or prescription of • medications with input from the Agency psychiatrist;

reviewing special treatment procedures to consider reductions in use, • appropriate use, and consideration of alternatives to improve the quality of care for residents;

reviewing all cases where a child is a significant danger to self or others;

• Safety Committee: charged with reviewing all aspects of Agency operations for 

safety for clients and staff, such as:

• developing an Agency safety policy;

• monitoring the implementation of the safety policy;

• monitoring of campus grounds for hazards and unsafe environmental conditions;

• reporting to the Management Team on a quarterly basis with recommendations and evaluating implementation of action steps;

• receiving concerns from any source within the Agency and making recommendations to the Management Team.

Clinical Team: charged with reviewing, planning and implementing treatment 

interventions with each of the programs, such as:

• monitoring the clinical treatment plans of all clients;

• developing transition plans and monitoring readiness of clients;

• reviewing and working with systems that interact with children and families;

• collecting pre and post data and outcome evaluation data;

• reviewing daily treatment data on clients including critical incidents.

Representatives of the clinical team are involved in all aspects of treatment including: admission decisions, the need for additional physical and mental status examinations, the appropriate level of care, treatment planning, termination of care.

The clinical team includes the clinical supervisor, residential director, executive director, agency psychiatrists, and the child and family therapists.

Support Services Team: charged with providing the means for all support  services to be efficiently provided for clients and staff including material needs such as food and clothing for residents, transportation, scheduling appointments for children, and other duties which support the treatment components of the

programs, including:

• insure the basic needs of each clients are unconditionally provided;

• maintain the children in appropriate and presentable clothing;

• plan and implement celebrations for children and list their personal interests;

• maintain a schedule of off-site appointments and transport when possible;

• maintain a menu plan with balanced, healthy and interesting meals.

Clinical Review Teams: charged with the development and evaluation of 

intensive treatment plans for clients and their families, such as:

• reviews data on each client;

• recommends adjustments in treatment plans;

• collects input from everyone involved in the child's life;

• reviews the treatment progress of each client;

• approves transition plans.

Administrative Support Team: charged with all office duties that enable 

programs to function smoothly, such as:

• reception and communication;

• office support;

• payroll and accounts payable and receivable;

• contracts, insurance, reporting;

• bookkeeping.

Multidisciplinary Teams: charged with specific educational duties as outlined by 

Oregon educational law, such as:

• insuring the educational needs of each client are met;

• developing individual educational plans and IFSPs;

• monitors the balance of treatment and academic goals;

• responsible for meeting state educational regulations.

Maintenance Team: charged with implementing and tracking the organizations 

preventative maintenance plan for all facilities, such as:

• completes and submits a monthly maintenance checklist;

• responsible for daily checks on critical functions within facilities;

• implements action steps coming from the safety committee;

• implements the Agency's policy and procedures on preventative maintenance.

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