Quality Assurance Procedures

The Program is evaluated annually by an outside independent contractor in compliance with the Continuous Quality Improvement Plan approved by the Board of Directors as follows. The Program also does an internal review of the Children’s Program on a Quarterly Basis using CAFAS, which provides an overview of each child’s progress over a spectrum of behavioral and emotional areas.

Eagle Rock Boys Ranch, Inc. Performance Improvement/ Quality Assurance Committee, hereinafter referred to as the PI/QAC through the established planning process which includes participation by consumers, advocates and service providers has developed a systematic plan of action for CQIP for Eagle Rock Boys Ranch, Inc. service providers.
The plan is designed to:

1. Identify and assess process and outcomes,
2. To correct and follow-up on problems, and
3. To improve the services offered by Eagle Rock Boys Ranch, Inc. for youth in compliance with certifying agencies and Board Policy.

The PI/QAC seeks to ensure that effective high-quality and clinically appropriate treatment is provided for all persons identified as appropriate for treatment. Eagle Rock provides two types of residential care for boy’s ages 9-20. Boys age 9-17 who are deemed to be moderately troubled or pre-delinquent benefit from a home-like setting in which they engage in a structured lifestyle while learning to overcome behavioral shortcomings. Boys age 17 and up live in a semi-supervised apartment setting and are taught basic skills needed to transition into a productive adult life. Boys with these identified issues will be offered treatment services that will promote the individual’s quality of life, human worth, and dignity. The treatment options will be characterized by the following principles and values:
PRINCIPLES

1. Treatment will adhere to a high standard of quality.
2. An eclectic approach is an effective form of treatment for the diverse needs of youth.
3. Understanding each child in need of residential treatment and behavior rehabilitation is unique; therefore services will be accessible, flexible, individualized, and targeted toward improving the quality of their lives.
4. Services will be timely, affordable and of sufficient intensity and duration to be effective.
5. Services will be provided in a safe, structured, and treatment oriented environment.

VALUES

QUALITY:

We believe it is important to do a good job at what we do. Doing something right does not always mean we have to be bigger or better or more recognized. We take pride in providing a quality home where boys can grow and succeed.

MISSION DRIVEN:

Everything we do must be directed at reaching our stated mission. We will not allow our program to be money driven by modifying our mission just because there is money in another direction. We will not change our program due to political or public relation needs.

CHILDREN FIRST:

In every decision we will first ask: “Will this help us provide more opportunity for the children we seek to help?” We will not allow political or financial issues to drive our decision making process.

INTEGRITY:

Integrity will infiltrate every aspect of our ministry including how we treat our children, our staff, our supporters, and anyone touched by Eagle Rock.

STEWARDSHIP:

We will be good stewards of everything we’re given whether it is in abundance or frugality. We will be good stewards of our money, our time, and our facilities.

EXTRA MILE:

We will go the extra mile with our children even when they may not deserve it. We will seek to issue mercy in the same measure as Christ gives mercy to us. The only limits to our mercy toward children will be when mercy is detrimental to the development of good character. This means we will never take the “easy way out” when dealing with troubled boys.

FRONT LINE FIRST:

The people who have the most day to day influence on our boys are the people who work directly with them day in and day out. We will place high value and high priority on theses individuals. We see the importance of having quality people in these positions. We will not treat these individuals as lesser employees. We will not be “top heavy” in our staffing or our allocation of salaries.

RELATIONSHIPS:

This is the single most important thing we give our children. Our children are not objects of our plans and programs. They are real human beings created by God in His image. We will not “run” children through a “program” as if they are our products.

OPENNESS:

We have nothing to hide.

1. The goals/objectives of the PI/QAC is to improve selected key functions and processes related to outcome and direct care, while continuing to address problem identification and resolution. Specifically:
   
2. To focus on opportunities to improve direct services and direct care.
3. To address problems identified that affect consumer outcomes including:
• Tracking each service entity of Eagle Rock Boys Ranch, Inc. over time to assure sustained improvements.
• Improving services by utilizing feedback from consumers, their families and other organizations.
• Develop an internal system of information management by the implementation of integrated computer software programs that will include a consistent method of managing consumer outcomes.
• Identifying key functions and processes that are to be measured that will determine whether established standards of quality are being met or exceeded.
• Coordinating an annual quality review of each program.
• Facilitating the development of actions and recommendations of problems identified to ensure improved care.
• Conducting peer reviews designed to evaluate quality and appropriateness of services provided.
• Identifying and examining “best practices” over time and utilizing the information to improve services and outcomes.
4. Provide important information regarding quality of care issues and performance improvement to the management of Eagle Rock Boys Ranch, Inc.
5. Provide education/training to Eagle Rock Boys Ranch, Inc. service providers to increase staff competence and skills.
6. Promote consistent communication and collaboration between the programs of Eagle Rock Boys Ranch, Inc. and consumers, advocates, and other service providers.
7. To disseminate information and obtain follow-up actions from appropriate individuals, groups and all levels of staffing.

The CQIP of Eagle Rock Boys Ranch, Inc. must be approved and endorsed by Board of Directors Eagle Rock Boys Ranch, Inc. The PI/QAC is responsibility for the development and implementation of the CQIP. The elected Board member will serve as the chair of the PI/QAC and is responsible for the functions of the committee and to report activities to the Executive Director and Board of Directors on a quarterly basis. This Board member may utilize the expertise of external consultants in carrying out the responsibilities of this position.
The PI/QAC will be a standing committee of Eagle Rock Boys Ranch, Inc. Board of Directors. The Chair of the PI/QAC will be the elected by the Board of Directors for a two year term. The PI/QAC will utilize ad hoc committees to promote the mission, goal, and objectives of the PI/QAC.
The PI/QAC functions include reviewing, advising, training, and monitoring on processes and systems affecting the overall quality of Eagle Rock Boys Ranch, Inc. care delivery system. It is directly responsible to the Board of Directors in making recommendations for improvement and reporting on the implementation of policy.
THE PERFORMANCE IMPROVEMENT / QUALITY ASSSURANCE COMMITTEE (PI/QAC) WILL:

1. Identify key functions and processes to be measured to determine if established standards of quality care are met or exceeded by the program.
These will include the following:
1. The agency’s purpose and operating principles are clearly stated and understood by board and staff. They are in writing and regularly communicated to relevant users.
2. There is a rationale and methodology for the agency’s approach, programs, and services that connect the youth it serves to the agency’s purpose and expected outcomes.
3. The agency regularly solicits information from youth, opinion leaders, and other constituents regarding the appropriateness and quality of the agency’s programs, relevant community trends, and best practices.
4. A plan has been developed and approved in accordance with board governance policies and communicated to all staff. The plan describes what the agency’s goals are for the next year or more, how it expects to achieve those goals, and how it will know if it has been successful or not. The plan serves as the agency’s framework for decision-making and resource deployment. It contains the following elements:
1. A description of the agency’s purpose, priorities, and activities.
2. Measurable goals and performance objectives tied to a timeline.
3. Information gathered from the assessment of community trends, best practices, youth input, customer satisfaction, and internal capacity (for example, staff expertise, financial resources, physical space) that guided the creation of the plan.
4. A financial plan and annual budget, which address the sustainability needs of the agency, protects the agency’s assets, and directs the fundraising efforts of both the board and staff.
5. There is a process to routinely monitor and make mid-course adjustments to program and financial performance objectives. The board receives a full progress report at least annually.
6. On a regular basis, there is a risk audit conducted for all agency policies and facilities (for example, insurance, physical space, human resource, financial performance, and legal issues) to ensure that participants, staff, and the agency’s assets are adequately protected. The findings are reported to the board and management staff and action plans are implemented to make any necessary corrections.
7. Youth and their families have a role in setting the agency’s priorities and in the design, continuous improvement, and evaluation of the agency’s programs and services.
8. Youth participants are recruited, screened, and transitioned to other services within the agency or the community based on clearly written criteria that is understood by the appropriate staff and participants.
Staff and volunteers are:
1. Qualified and trained to perform their duties.
2. Well informed about their job performance expectations and their specific role in executing the agency’s purpose, rationale, and methodology.
3. Clear about the chain of command.
9. Facilities are safe and appropriate for the activity being offered and the program participants being served.
10. Communication policies and procedures are in place to ensure that internal and external audiences receive necessary and relevant information on a timely basis.
11. There are written policies to manage leadership transitions, unplanned events, and/or crises. These policies are understood by board, staff, and volunteers.
12. The agency actively seeks out collaborations and partnerships that meet a specified need and the agency is able to monitor the partnership’s performance and benefit on an on-going basis.
13. Organizational policies and procedures (for example, insurance, physical space, human resource, financial performance, and legal issues) are in writing, updated regularly in accordance with appropriate law, and understood and appropriately applied by board, staff, and volunteers.
14. Staff retention trends for all positions are regularly monitored by management staff and exit interviews are conducted with all departing employees.
15. Controls are in place to ensure that programs and services are effective and efficient. Agency operations, including programs and services, are regularly improved based on information gathered through monitoring processes and evaluation.
16. A comprehensive agency evaluation is conducted at least every three years.
17. Financial transactions are documented and summarized in accordance with legal policies and generally accepted accounting principles and ensure that the assets of the agency are protected.
18. Instances of non-compliance with organizational goals, policies, and procedures are identified on a timely basis and action plans are implemented to make the necessary changes.
19. Progress toward meeting each of these Youth Standards is documented, regularly updated, and monitored even after the Standard has been met.
2. Define performance improvement indicators necessary to measure the program's performance in achieving desired outcomes for recipients of service.
3. Develop appropriate reporting tools and mechanisms for recording, measuring, and communicating outcome data.
4. Report, investigate, review, and make recommendations to correct special incidents involving persons being served.
5. Develop surveys and other measurement tools designed to gain input from consumers, customers, and employees regarding issues impacting the quality of care and treatment.
6. Review the treatment (service) planning process to ensure the recipients of services were involved in the development of the plan and that their needs are being met.
7. Identify significant deficiencies and best practices as a result of audits, as conducted by independent, federal, state, and local accrediting and licensing bodies, in order to provide technical recommendations to the program's service providers.
8. Collect and review data gathered through the quality assurance process and other internal and external studies and reviews to aid in the maintenance of consistent adherence to Eagle Rock Boys Ranch, Inc., policy and procedures.
9. Schedule and implement peer reviews, external and internal audits, QA reviews of systems, documentation, and services related to the care-delivery system.
10. Provide and coordinate educational training programs related to continuous quality improvement for the purpose of raising the understanding of participants in the PI/QAC, and other Eagle Rock Boys Ranch, Inc. personnel.
11. Facilitate the development of recommendations and actions, including but not limited to changes in policies/procedures and standards, when trends or problems are identified.
12. Review Eagle Rock Boys Ranch, Inc., CQIP plan annually and recommend improvements to the Board of Directors.