First Nations and Inuit Home and Community Care Policies Template Manual

Part 5: Quality

First Nations and Inuit Home and Community Care Program
Policies Template Manual
Community Logo

Part 5: Quality
Community Name

Policy: Quality Planning
Policy Number: 5.1

Approval:
Date:

Policy

The First Nations and Inuit Home and Community Care Program has a quality program that is used for strategic and operational planning of the Program. The quality program includes:

• Assigning a senior person to the role of quality leader (a role that may be shared with other programs in the community)
• Developing of a philosophy of continuous quality improvement
• Allocating resources to the development of the quality program
• Developing quality program goals, objectives, and scope that fit with the Program's mission and vision
• Reviewing the literature and research about other quality program models, benchmarks and best practices
• Education of staff

Policy Rationale

To ensure that processes are in place to monitor performance indicators and evaluate the efficiency and effectiveness of Program services and processes.

Policy Details

Assessing the level of consistency in quality across the Program's activities is very important to future strategic and operational planning. Quality information is used to plan future services and for appropriate budget development and resource allocation.

Resources are used efficiently and effectively to improve the quality of services delivered by the Program. Removing barriers allows improvement in the Program's performance.

Quality improvement activities of all aspects of the Program are coordinated with the monitoring of performance indicators. Relationships developed with other local service providers are important to address community needs and to coordinate care delivery. Advocating on behalf of clients for program development and identifying the potential of such development in other health and social services are effective ways to improve clients' quality of life.

Standards of practice are used as the minimum practice requirements for delivery of Program services, where appropriate. Training and development of staff is an integral component of the quality program.

Process Guidelines

Processes for quality planning should include, but not be limited to:

• Implementing a continuous quality improvement program
• Involving key stakeholders in the quality planning process
• Assessing high risk, high volume and potential problem situations regularly
• Providing all staff with an orientation and ongoing training and education about the quality program, and the role of all staff in achieving the quality goals
• Developing an annual quality improvement plan
• Maintaining relevant quality improvement resource materials
• Developing policies, processes and procedures for Program services to achieve quality objectives
• Evaluating the quality program regularly
• Involving clients and families in the evaluation of care and services
• Regularly reviewing and analyzing quality reports and trends by Program management
• Communicating results of reports and trends in quality to staff, clients, families, community leadership and authorities, as appropriate
• Involving staff in quality improvement initiatives
• Demonstrating a customer-focused behaviour and attitude by all Program staff
• Demonstrating the outcome of continuous quality improvements through implementation of new services and Program improvements
• Responding to Program development in a timely way
• Developing tools to assist with measurement of quality indicators

Performance Measurement Suggestions

Indicator: This information is to be developed by communities as they work with their Programs. For an example of the kind of measures that should be identified, refer to the Hiring Policy template.

Formula:

Related Standards

1.1 Community Needs Assessment
1.2 Development and Achievement of the Vision
2.1 Program Management
2.2 Risk Management
3.1 Services Delivery
3.3 Health Promotion, Disease Prevention and Protection Services
4.1 Health and Safety
4.4 Partnerships/Community Linkages
4.5 Emergency and Disaster Planning
5.1 Planning
5.5 Quality of Work Life
6.1 Information Needs
6.2 Data Collection and Reporting
6.5 Program Changes and Improvements

Some Suggested References

The First Nations and Inuit Home and Community Care Planning Resource Kit: All sections
Draft Liability Documents: May, section 2.2

Occupational Health and Safety Act
CCHSA AIM Standards, 1999 -- All Standards
Provincial/Territorial and Federal Legislation
DIAND/FNIHB Home and Community Care Directives

Review Process:
Dates:

Each community is responsible for developing and putting in place their own procedures. These procedures need to outline the practical steps to be taken to carry out the process guidelines for this policy.

Suggested Procedures

1. Procedure for developing and enhancing the Program plan, mission, vision and values.
2. Procedure for developing and enhancing the quality improvement plan.
3. Procedure for establishing accountability for quality planning.
4. Procedure for obtaining client, family and staff input on the Program's services and their delivery, processes, and satisfaction with the Program.
5. Procedure for identifying, monitoring, and recording key indicators and reporting on the changes that have occurred from one year to another, and, as appropriate, from one quarter to another.
   Suggested tools:
• List of key indicators in clinical, financial, human resources and quality areas
• Tool to measure indicators on a regular basis for comparison purposes over time

First Nations and Inuit Home and Community Care Program
Policies Template Manual
Community Logo

Part 5: Quality
Community Name

Policy: Quality Monitoring
Policy Number: 5.2

Approval:
Date:

Policy

The First Nations and Inuit Home and Community Care Program staff are accountable and responsible for monitoring performance indicators that measure both clinical and administrative structures, processes and outcomes.

Policy Rationale

To ensure that continuous quality improvement activities are regularly conducted for ongoing Program development.

Policy Details

Clinical services and processes promote positive client outcomes and client satisfaction with Program services and their delivery. These services and processes meet contract obligations, legislation, standards of practice and best practices.

Administrative programs and processes support the Program services and their delivery, and meet legislative and reporting requirements. Research and best practices are used to improve services and processes.

Program staff will participate in the analysis and evaluation of services and processes. Management staff are responsible for implementing quality monitoring and tracking trends in quality reports, as well as implementing a process to monitor incidents and track concerns. Changes in services and processes are communicated to all staff.

Process Guidelines

Clinical indicators to monitor process, structure and outcomes I include:

• Measurement of outcomes of service delivery according to standards of practice
• Client satisfaction with services
• Evaluation of clinical practice, policies and procedures
• Evaluation of Program scope, goals, objectives

Clinical indicators are measured using some or all of the following methods:

• Client satisfaction tools
• Client surveys
• Informal interviews with clients, families, staff, other providers and community members
• Incident monitoring
• Manual chart audits
• Electronic data audits, if applicable
• Direct observation of clinical practice

Administrative indicators to monitor process, structure and outcomes of program delivery include:

• Financial indicators such as:
• Overtime, paid hours, comparison of direct service hours to indirect service hours
• Human resource indicators such as:
• Orientation and training costs, recruitment costs, competency training costs
• Evaluation of each programs goals and objectives

All staff receive an orientation and ongoing training and education regarding the quality monitoring process. Particularly, changes that occur in services, policies, processes and procedures are highlighted during these sessions.

There is a process for monitoring successes on a regular, timely basis. The quality report system tracks trends in indicators. These indicators are selected to measure the performance of each specific service and process. Quality monitoring reports are submitted regularly to the appropriate authorities as required.

Investigation of all problems, issues or concerns identified through the incident monitoring process occurs immediately. Timeliness of response to concerns is closely monitored to ensure appropriate responses and response times. Documentation of quality monitoring activities is kept on file for a specified period of time. Program services and processes are reviewed and evaluated regularly, from both clinical and administrative views.

Performance Measurement Suggestions

Indicator: This information is to be developed by communities as they work with their Programs. For an example of the kind of measures that should be identified, refer to the Hiring Policy template.

Formula:

Related Standards

1.4 Resource Management
1.5 Contract Management
2.1 Program Management
2.2 Risk Management
3.1 Services Delivery
3.2 Continuity of Services
3.3 Health Promotion, Disease Prevention and Protection Services
3.4 Obtaining Consent
3.5 Client Rights
3.7 Confidentiality
4.1 Health and Safety
4.2 Equipment and Materials
4.3 Building/Physical Space
4.4 Partnerships/Community Linkages
5.1 Planning
5.2 Recruitment and Retention
5.4 Education, Training and Development
5.5 Quality of Work Life
All of Section 6: Information Management

Some Suggested References

The First Nations and Inuit Home and Community Care Planning Resource Kit: All sections
Draft Liability Documents: May, sections 2.2, 2.6, 3.4, 3.13, 3.18, 4 to 4.14

Occupational Health and Safety Act
CCHSA AIM Standards, 1999 -- All Standards
Provincial/Territorial and Federal Legislation
DIAND/FNIHB Home and Community Care Directives

Review Process:
Dates:

Each community is responsible for developing and putting in place their own procedures. These procedures need to outline the practical steps to be taken to carry out the process guidelines for this policy.

Suggested Procedures

1. Procedure for outlining the type and frequency of quality monitoring activities and reports.
2. Procedure for incident monitoring.
3. Procedure for obtaining client, family and staff input on the Program's services and their delivery, processes, and satisfaction with the Program.
4. Procedure for identifying, monitoring, and recording key indicators and reporting on the changes that have occurred from one year to another, and, as appropriate, from one quarter to another. Suggested tools:
• List of key indicators in clinical, financial, human resources and quality areas
• Tool to measure indicators on a regular basis for comparison purposes over time

First Nations and Inuit Home and Community Care Program
Policies Template Manual
Community Logo

Part 5: Quality
Community Name

Policy: Quality Improvement
Policy Number: 5.3

Approval:
Date:

Policy

The First Nations and Inuit Home and Community Care Program promotes a philosophy of continuous quality improvement throughout the organization.

Policy Rationale

To ensure that continuous quality improvement activities are conducted for ongoing Program development, process improvement and the reduction of risk to clients, families, staff, and the Program.

Policy Details

The Program's vision and activities promote a culture of continuous quality improvement. Program management is accountable to establish a quality improvement program with identified goals, objectives, and scope. Quality improvement to programs/processes is achieved by using benchmarks, best practices and reviews of the literature. Regular analysis and evaluation of quality improvements occurs. Quality improvement activities can assist in reallocation of resources.

At the time of hiring, staff receive orientation regarding the philosophy of continuous quality improvement and are involved in quality improvement activities. Education and training of staff about continuous quality improvement activities is provided regularly to promote the philosophy.

Quality improvement activities are coordinated with other service providers, programs and services in the community and other First Nations and Inuit Home and Community Care Programs.

Communication of quality improvement initiatives to staff, other community-based programs and services, community leadership and funders is the responsibility of Program management.

Process Guidelines

Quality improvement processes will be guided by the following:

• Coaching, counseling, mentoring and development of staff about continuous quality improvement activities is a key activity of Program management
• Benchmarks and best practices are adapted into Program practices and processes
• Clients, families, the community and staff are involved in decision making about quality improvement activities
• Identification of areas for improvement in services and processes occurs regularly
• Analysis of changes and improvements occurs
• Evaluation of the effectiveness of quality improvement activities regularly occurs
• Communication about changes to services and processes is timely

Performance Measurement Suggestions

Indicator: This information is to be developed by communities as they work with their Programs. For an example of the kind of measures that should be identified, refer to the Hiring Policy template.

Formula:

Related Standards

1.3 Capacity Building
2.1 Program Management
2.2 Risk Management
3.1 Services Delivery
3.5 Client Rights
3.7 Confidentiality
4.1 Health and Safety
4.4 Partnerships/Community Linkages
All of Section 6: Information Management

Some Suggested References

The First Nations and Inuit Home and Community Care Planning Resource Kit: All sections
Draft Liability Documents: May, sections 2.2, 2.4, 2.5, 4.1 to 4.19; June, pgs 4-12, 30-31

CCHSA AIM Standards, 1999 -- All Standards
Provincial/Territorial and Federal Legislation
DIAND/FNIHB Home and Community Care Directives

Review Process:
Dates:

Each community is responsible for developing and putting in place their own procedures. These procedures need to outline the practical steps to be taken to carry out the process guidelines for this policy.

Suggested Procedures

1. Procedure for outlining and monitoring quality improvement monitoring activities and results.
   Suggested tools:
• Tracking tool for quality improvement activities
• Evaluation tool for quality improvement activities
2. Procedure for monitoring Program and Program services results.
3. Procedure for communicating quality improvement activities and results.
   Suggested tools:
• Communication tool for quality improvement activities (ie newsletter, information sheet)
4. Procedure to detail accountability of quality improvement activities.

First Nations and Inuit Home and Community Care Program
Policies Template Manual
Community Logo

Part 5: Quality
Community Name

Policy: Risk Management
Policy Number: 5.4

Approval:
Date:

Policy

The First Nations and Inuit Home and Community Care Program has a clearly defined, coordinated system of incident monitoring that is used to assess, analyze, report, evaluate and improve quality.

Policy Rationale

To ensure that risk issues related to clients, families, staff and Program liability are addressed in a timely and effective way.

Policy Details

At a minimum, the First Nations and Inuit Home and Community Care Program has clear processes and procedures for reporting incidents and ensures that:

• The responsibilities of Program management and staff are clearly defined in writing
• All staff receive ongoing education and training about incident monitoring
• All staff are involved in incident monitoring
• Potential hazards and risks are minimized wherever the client receives service
• All incidents are reported within 24 hours from the time they occur
• Response to incidents and undesirable events occur in a timely way
• Ongoing monitoring, analysis and evaluation of incidents are important activities within the Program
• Results of improvements are communicated effectively Process Requirements

The First Nations and Inuit Home and Community Care Program ensures that there is:

• Completion of an incident monitoring form within 24 hours of the event
• Investigation and identification of the cause of incidents and undesirable events
• Recording of incidents and undesirable events on the client's record, including the management of each incident or event
• Ongoing monitoring and evaluation of incidents
• Ongoing collection and analysis of data over time
• Ongoing identification of high-risk clients and client groups and areas of potential risk in processes and practices

Performance Measurement Suggestions

Indicator: This information is to be developed by communities as they work with their Programs. For an example of the kind of measures that should be identified, refer to the Hiring Policy template.

Formula:

Related Standards

1.4 Resource Management
1.5 Contract Management
2.1 Program Management
2.2 Risk Management
3.1 Services Delivery
3.3 Health Promotion, Disease Prevention and Protection Services
4.1 Health and Safety
4.2 Equipment and Materials
4.3 Building/Physical Space
4.5 Emergency and Disaster Planning
5.3 Evaluating Performance
5.4 Education, Training and Development
6.1 Information Needs
6.2 Data Collection and Reporting
6.4 Information Exchange
6.5 Program Changes and Improvements
6.6 Confidentiality and Security

Some Suggested References

The First Nations and Inuit Home and Community Care Planning Resource Kit: All sections
Draft Liability Documents: Entire May document and entire June document

CCHSA AIM Standards, 1999 -- All Standards
Provincial/Territorial and Federal Legislation
DIAND/FNIHB Home and Community Care Directives

Review Process:
Dates:

Each community is responsible for developing and putting in place their own procedures. These procedures need to outline the practical steps to be taken to carry out the process guidelines for this policy.

Suggested Procedures

1. 1. Procedure for reporting, recording and handling incidents and complaints, with a specific procedure for high-risk complaints.
   Suggested tools:
• Incident report form
2. Procedure for identifying and classifying low, medium and high risk situations.
   Suggested tools:
• Guidelines for low, medium and high risk situations
3. Procedure for investigating risk issues, including the course of action to be taken by the Program and the staff and Program management roles in that action.
4. Procedure for communication of risk issues.
5. Procedure for tracking incidents and appropriate discipline.
   Suggested tools:
• Tool to record and track the response to each incident, including disciplinary actions taken
6. Procedure for progressive discipline, including monitoring and reviewing the progress of the employee on a timely basis.
   Suggested tools:
• Form outlining progressive discipline and dates for implementation, review and decision as to next steps
• Sample letter of warning
7. Procedure for forwarding incident reports to appropriate people.
8. Procedure for securing and keeping incident reports for a specified period of time.