WHS PQI Program Plan 2017-2018

The WHS PQI program was officially structured beginning in 2001 and has been growing, learning, changing and evolving every year since…
Most recently revised January 2018

  1. Wolverine Human Services -Philosophy of PQI

Wolverine Human Services, its Board of Directors and CEO promote a philosophy and expectation of vested and concentrated focus on continuous improvement, quality targeted change and evolving growth in all of its programs and facilities. The purpose of the Performance and Quality Improvement (PQI) program is to promote excellence and ongoing improvement of programs, systems and operations to the benefit of and in collaboration with clients, personnel and other stakeholders. The WHS Mission of “Helping Children to Be Victors” encompasses all aspects of service delivery and all agency programs and operations. WHS considers work done with children, their families and their communities to fall under this broad mission, allowing flexibility for prompt, responsive and innovative program development. We define our primary stakeholders as our clients and client alumni and their families, foster families, kinship families, the neighborhoods and community of our clients and their families, student interns, volunteers, donors, agency personnel, referring sources, collaborating treatment providers and referral networks, school systems, college and universities systems, the community members in which our programs operate, Michigan (and other) State licensing and regulatory entities, contracted services, partnering and collaborating agencies, the larger juvenile justice and foster care community of the State of Michigan and policy makers in Lansing.

The WHS PQI program supports the use data, qualitative and quantitative, to: identify opportunities or urgent need for improvement; define strengths and weaknesses; review effectiveness of resource utilization; to implement stakeholder informed improvement plans in support of achieving performance targets; to ensure program goals are in support of the Strategic Plan goals and monitor progress; track client satisfaction; develop and monitor client outcomes; to recognize staff contributions and expressions/input; and, to ensure compliance and quality implementation of guidelines required by contracts and regulatory entities. WHS goes even further by placing extreme value on the use of evidence based practice with clients in residential care programs in the use of fidelity based CBT (Cognitive Behavioral Therapy) to teach youth new core skills. PQI program activities occur in various forms throughout daily, weekly, monthly, quarterly and annual operations. PQI data is reviewed monthly, quarterly and annually to ensure benchmarks are met and continuous positive growth is in evidence. WHS takes a comprehensive approach to its PQI program and activities. WHS actively seeks to promote a broad-based, proactive, evidence informed organization-wide process of quality improvement and client care. It is important to the organization that this process is inclusive of as man of the staff and stakeholders as appropriate to the improvement and achievement of strategic goals of each department and program. PQI is a collaborative effort between the Board of Directors, CEO, Executive Team, Administrative Team, PQI Committee, Management teams, agency work groups, committees and sub-committees, employees from all areas of the agency, all agency programs and facilities and stakeholders defined above.

  1. PQI Structure

WHS understands that the PQI program, the agency clients, agency personnel and clinical programs are intricately and necessarily enmeshed. The structure of the PQI Department and Program is well-resourced by personnel experienced in cross-agency engagement, client care and clinical programs. The PQI staff is responsible to collect information, analyze data, and communicate outcomes and recommendations appropriately to stakeholders. Since July 2013 the PQI Department consists of the Director of Clinical & Quality Services, the Community Based Programs Clinical & Quality Manager and the Residential Programs Clinical & Quality Manager. Each of these key PQI primary staff has the support and cooperation of several other staff at various levels within their departments and programs. Contributors to the daily, monthly and quarterly PQI data collection and reporting include, but are not limited to; departmental and program clerical staff, training department staff, Human resources managers, case managers, health services staff, shift management staff, academic staff, operational staff, permanency specialists/family workers, therapists, program managers, clients rights advocate, DCWL (licensing) and DHHS (contracts).

The PQI Department works with leadership committees, site programs and auxiliary departments to identify and develop needed work groups or committees to support progress on strategic and program goals.

In addition to PQI Department personnel, a PQI Committee (PQIC) is charged with the overall monitoring and management of the PQI processes and activities in all agency programs. The primary purpose of this committee is to analyze outputs from the PQI processes, to review, share and discuss findings with all program site management and staffing teams, and to encourage and support stakeholders to implement program contextual corrective plans. The PQIC always seeks ways to improve process, timeliness, and evidence based practices for the clients WHS serves, including the PQI system and processes themselves. Throughout the fiscal year the committee identifies and addresses input from the programs, administrators, clients, families, personnel, board members and referral agents in an effort to improve service delivery. The PQI program imbeds various PQI activities throughout each fiscal quarter that are consolidated into a formal PQI reports for review and monitoring. The PQIC meet quarterly to review these indicators and to discuss effectiveness of changes made. The PQIC review risk, quality, contract, and needs data quarterly. Each program develops monthly and quarterly PQI reports from a variety of sources and measuring identified outputs and outcomes. The program based monthly PQI reports are consolidated quarterly site reports, and then into an all-agency PQI reports that summarizes key indicators, goals, initiatives, training, utilization review, and risk prevention, and others areas to obtain a larger agency picture. The PQIC meets quarterly to review both individual site and agency trends resulting from data analysis.

Recently the PQIC determined it prudent to utilize telecommunication more effectively for the quarterly PQIC meetings. As part of the PQIC process, ways to reduce time and cost associated with PQIC meetings were brainstormed, introduced and approved by the executive team. This example of quality improvement process may result in savings of wasted travel hours for PQIC members, less use of gas and mileage on agency vehicles, and less time overall quarterly in the meeting. Thus, PQIC meeting operations will change for the 2017-2018 Fiscal year, to having alternating quarters of teleconferencing and then in-person PQIC meeting.

The PQIC is responsible for ensuring quality service delivery through the implementation of the PQI program and plan. The PQIC reviews data quarterly and annually to ensure that corrective steps or improvement initiatives have been consistently implemented and resulted in the desired/targeted improvement. All PQI reports, activities, and initiatives are shared back to all staff via routine program team meetings, the agency website, the annual State of the Agency Address and the annual report.

The PQI Department coordinate various personnel for specific PQI activities, such as participation in peer case file utilization reviews, and informs them of the objective to be achieved. Results from all PQI activities are reported to the PQIC and program managers with summary of findings and recommendations for corrective actions, as appropriate. Primary PQI activities include: quarterly case file utilization review; quarterly personnel file review; biannual stakeholder interviews with staff and clients with alternate quarter biannual review of client satisfaction surveys; quarterly risk management review; monthly physical plant/ASE inspection of program sites; quarterly review of the PQI program, measures and activities; quarterly review of challenges or needs in any area of the agency; quarterly contract compliance review and biannual review of committee goals/progress. Through this process all aspects of the agency’s programs are monitored and reviewed. By collecting and collating data about certain aspects of care, trends or patterns of care are efficiently identified, deficiencies corrected and opportunities to improve care are acted upon. This may include but is not restricted to policy/procedural revision; reassignment of personnel, establishing plans to assist units that are functioning substandard and needed training. All of this is integrated to improve the service delivery to the clients and families we serve and in response to stakeholder input and feedback. The PQI Plan is reviewed annually by the PQIC and then submitted for approval to the CEO and governing body.

Each program submits a PQI Month End report and a PQI Quarterly report specific to its site and operations. The program managers, Directors and program Vice-Presidents review all PQI reports monthly and quarterly to ensure proactive risk management. The PQIC reviews trends quarterly in Program and Agency PQI Quarterly reports. The following areas are integral for review and quarterly discussion:


A. Number of restraints (standing restraints and team restraints)
B. Number of clients restrained.
C. Number of restraints per shift
1. Days
2. Afternoons
3. Weekends
4. Midnights
D. Number of seclusions (WSTC only)
E. Number of Mechanical Restraints (WSTC only)
Number of incidents that clients posed a threat to self or others.
Number of client injury requiring off site urgent medical attention
Number and nature of client grievances
Number of medication errors or issues-operational runs
Client Satisfaction survey results
A. 3 areas least satisfied
B. 3 areas most satisfied
A. Rate of timely submission of reports to referral source for fiscal quarter
B. Rate of timely submission of reports to referral source fiscal year to date.
C. Success rate for fiscal quarter
D. Success rate for fiscal calendar year to date.
E. Percentage discharge to AWOL reporting quarter
F. Percentage discharge to AWOL Calendar Year to Date
Number of licensing complaints WITH citations
Number of Citations from Annual Licensing / Contract Review
Facility upkeep and environmental risks-ASE inspections
Summary of short term plans in support of long term strategic plan (Strategic and Program goals review and tracking)
Data collection narrative and needs (PQI program/activities)

– Review of Personnel and or Case File UR activities

-Progress on CAP’s or initiatives/projects pending

Staff Development and Training

Human Resources Summary

A. Number of staff injury reports
B. Number of employee grievances
Search Review

PREA data tracking


Areas of Risk Monitoring

  • AWOL
  • CPS Referrals
  • FCRB Appeals
  • Hospitalizations
  • Incidents (Serious)
  • Injuries
  • Special Evaluations Initiated (for Providers)

Citations, Reviews, and ongoing Monitoring

  • Repeat case file citations according to any of the mandating entities are monitored with additional focus.
    • Areas identified as needing focus during reviews are presented as Monthly Spotlight Trainings, addressed in individual supervision, addressed in team meetings, etc.
  • CBP participates in the following annual service reviews, in addition to quarterly internal utilization reviews:
  • Department of Health and Human Services (DHHS) Contract Review
  • Modified Settlement Agreement (MSA)/Implementation Sustainability and Exit Plan (ISEP) Review
  • Division of Child Welfare Licensing (DCWL) Review
  • Monitoring Mandates
  • Monthly Random Audits – CBP Supervisors are required to review 2 files (electronic and hard files) per worker per month.

Performance Measures/Outcomes

The following areas are monitored weekly for compliance by CBP Supervisors/Administrators for timeliness and compliance:

  • Child Replacements
  • MSA/ISEP Performance Measures/Indicators (Compliance Expectations)
    • CFC Plan Approval (95%)
    • CFC Service Plans (95%)
    • Dental (90%)
    • Medical (95%)
    • Worker Child Social Work Contacts (95%)
    • Worker Supervisor Social Work Contacts (95%)
    • Worker Parent Social Work Contacts (85%)
    • Parent Child Social Work Contacts (85%)
    • Unannounced Social Work Contacts (95%)
    • Sibling Visitation (85%)
    • Case Manager Case Load compliance (95%)
    • Supervisory Ratios (95%)
  • Child and Family Service Review (Feds)
Number of placements while in care:
(Breakdown of 2 or fewer placements for respective days in care)
Standard: 0-365 days = >86.00%
366-730 day = >73.00%
731+ days = >45.00%
Percentage in care 30 days or more:
Discharged to parent or guardian within 12 months (min std is 43%)
Discharged to a finalized adoption within 24 months
of removal (min std is 36.6%)
Percentage in care for the most recent 24 months discharged to a permanent placement prior to their 18th birthday (min std 29.1%)
Percentage in care for the last 12 months and legally free for adoption discharged to a permanent placement prior to their 18th birthday. (min std is 98%)
  • Additional Contractual/DCWL Compliance Measures
    • Staff Training Hours
    • Foster Parent Training Hours
    • Adoption Assessments (Child Assessments, Child Assessment Addendums, Quarterly Progress Reports, Supervisory Reports, Adoptive Family Assessments, Adoptive Family Assessment Addendums)
    • Licensing Assessments (Annual/Renewal Reports and Special Evaluation Reports)
    • Timely Michigan Adoption Resource Exchange (MARE) Registrations
    • Timely Family Team Meetings (FTM)
    • Timely Court Reports
    • Average time for achieving permanency
    • Average time for completing adoptions
    • Average time for licensing homes

PQI activities are documented with minutes and/or summary reports and corrective action plans. Suggestions, expressions, online expression are forwarded to the Director of Clinical & Quality Services or the responsible Vice President as they arrive. The PQI Department and WHS Vice-Presidents express on open-door policy for all stakeholders at any time. The Director of Clinical & Quality Services provides a quarterly overview of the PQIC findings to the CEO and this is entered into the quarterly Board of Directors report by the CEO. Data and trends are tracked annually and a two-three year scorecard is maintained to gather and capture longer historical trends.

  1. Stakeholder Role in PQI


The PQI Department works actively to open venues for all stakeholder input and feedback, implements monthly and quarterly activities to increase feedback by clients and staff. WHS defines primary stakeholders as our clients and client alumni and their families, foster families, kinship families, the neighborhoods and community of our clients and their families, student interns, volunteers, agency personnel, referring sources, collaborating treatment providers and referral networks, school systems, college and universities systems, the community members in which our programs operate, Michigan (and other) State licensing and regulatory entities, contracted services, partnering and collaborating agencies, the larger juvenile justice and foster care community of the State of Michigan and policy makers in Lansing.

Specific 2017-2018 PQI activities to include stakeholders include:

  1. All staff receives orientation training on the PQI process upon hire and annually thereafter.
  2. All programs utilize a suggestion box located at each site and personnel and clients are encouraged to make suggestions that they believe will enhance services.
  3. Saginaw and Vassar residential program sites have Change Implementation Teams [the Transformers and the Motivators respectively] that solicit positive change and have a goal of working with staff on culture change, morale and implementation of evidence based practice. These teams are line to management staff and are essential in implementation and sustainability of the CBT initiative and have collaborated extensively with our Beck Institute and Indiana University consultant/advisors.
  4. Since 2013, the agency has maintained its Online Expressions Box link on the agency website at http://www.wolverinehs.org/who-we-are/resources/expression-box/ for any/all stakeholders to provide suggestions, feedback or ideas either anonymously, by just defining the type of stakeholder responding, or with the ability to provide anonymous entries.
  5. The Director of Clinical & Quality Services uses agency email blasts to ALL for increased awareness and sharing of PQI activities throughout the agency:

-“PQI Thought” email blast to all agency personnel with a different short targeted motivational PQI-related slogan from famous historical figures.

-The first day of each fiscal quarter email blast to all agency personnel outlining the upcoming quarter’s calendar of PQI activities and events.

– Each month an email blast to all agency personnel highlighting that month’s specific PQI activities and events.

-Monthly email blast include a reminder to use the anonymous online Expression Box with a link to the page, and invites any and all to contact Director of Clinical & Quality Services with ideas, thoughts, comments, suggestions, input, feedback, etc. The Directors email, office and cell phone are provided.

  1. The PQI Department and Training Departments work closely together to provide annual ‘refresher’ trainings to all program personnel about PQI program, activities and inviting input and involvement at all levels and roles.
  2. All staff is involved in staff meetings where input is solicited and information

is shared regarding the PQI process and outcomes, beneficial trainings, and possible policy or procedural improvements.

  1. Weekly site manager, team, clinical and operational staff meetings focus on problem resolution and site and client specific needs/risks/concerns.
  2. The Senior Vice President leads biannual ‘Senior Advisory Council Meetings” with field level non-management staff recognized as long term leaders in their departments and consisting of long term residential program staff at each program site. These are confidential focus groups and invite free expression by personnel to the VP without site supervisor or management involvement.
  3. All agency programs are involved in the case record review process. This process identifies problems along with suggested changes to improve service delivery.
  4. Once per year we solicit input and satisfaction surveys from personnel as well as our referral agencies.
  5. We administer biannual client satisfaction surveys and ongoing/continuous family satisfaction surveys and utilize them in our planning.
  6. We utilize biannual (alternate quarter from client satisfaction survey activity) Stakeholder interviews in which random staff and clients at each program are privately interviewed and surveyed by the Clinical and Quality Managers. These results are shared with Vice Presidents and Program Managers and reviewed in quarterly PQIC meetings.
  7. Client Advisory Boards (Victors Club) are present at each residential program site and clients provide input, suggestions, ideas for program/facility improvement. The results are provided and reviewed monthly and quarterly in PQI reports.
  8. Stakeholders are provided an overview pamphlet of the PQI process and its available on the agency website.
  9. An Overview of the PQI program is on the agency website.
  10. When a policy or protocol changes or is developed, and email dissemination blast occurs with both the attached new/revised document and statement of its posting to the agency P-drive for review and access by all personnel.
  11. An agency shared “P-drive” (policy drive) contains all updated and relevant policy and protocol for review by all personnel.
  12. The CEO discusses the agency goals with all staff at an annual State of the Agency meeting.
  13. Individual program units develop short term plans in support of the Strategic Plan and discuss with staff and provide updates on progress.
  14. Committee, work groups and sub-committees have replaced standing committees to ensure diverse and expert personnel participate in decisions related to their jobs. This includes process development, forms development, and resource planning directly from field staff.
  15. The CEO frequently converse informally with other stakeholders such as politicians, community leaders, vendors, competitors etc. about the PQI process.
  16. The board provides general direction and oversight over the PQI planning process quarterly and annually to ensure quality and effective service delivery in support of stakeholders and the WHS Mission to Help Children to Be Victors.
  17. The agency has engaged in a CBT fidelity and endorsement system in all residential programs for staff working with clients and recognizes staff endorsements at Levels 1-3. Level 2 and Level 3 CBT Endorsed Staff are recognized in the HR newsletter monthly.
  18. The monthly HR newsletter also recognizes “Staff Caught Being Victors’. This highlights staff doing above and beyond for each other, clients, families and other stakeholders of the agency.
  19. The agency has invested in some personnel incentive programs as the budget has improved and the agency has been successful. These are designed to increase recruitment of qualified staff and to retain the experienced staff the agency values. Some of these programs include: Tuition reimbursement to help staff pay for graduate level degrees, staff recruitment bonuses for staff that recruits and mentor new staff to the one year marker of success, CAADC & CBT and other professional training certification programs.
  20. The Human Resources department has increased staff access to their own personnel information 24/7 by transferring significant/key staff data to the ADP website/portal, and all staff have access to their own information, benefits, agency information and resources, vacation time, etc.
  21. In 2017 all personnel have access to an agency email address. This access is now expanded to all youth care workers, Safety Support team members and all other operational field staff. This allows far better access to agency-wide information and PQI sharing. This also expands all personnel ability to communicate within their own programs/departments and other agency departments and programs

D. WHS Strategic Plan and Goals in support of “Helping Children Be Victors!”

Five Year Strategic Plan

WHS administrative team engages in an annual Strategic Planning Meeting to review, monitor, modify and ensure positive progress on the five year strategic goals. This Strategic Planning meeting reviews cumulative trends, outcomes and outputs for the annum regarding all programs and departmental operations. The meeting provides a venue for review of the agency history and current standing, mission statement, values and long term strategic and annual program goals, as well as a review of agency strengths, resources, needs and weaknesses. All goals and task assignments are reviewed at next year’s strategic planning meeting. Every five year new Strategic Plans/goals are developed by each of the six leadership committees.

During the annual meeting, the administrative team reviews the following planning processes:

  1. Accessibility and barrier issues. This also includes evaluating public transportation, alternative community resources and servicing the disabled.
  2. The existing services provided by others in the community to meet those needs which are related to achieving the purposes of the organization.
  3. Identify gaps in services needed by the community.
  4. The needs to redirect, eliminate, and/or expand service in response to changing demographics and the needs and wishes of the community.
  5. Examining internal processes related to intake, assessment and service delivery.
  6. Human Resource deployment, training, recruiting and retention;
  7. Availability of qualified persons for the labor pool.
  8. The need to make required changes such as reassignments and transfers.
  9. The need for culturally responsive and competent practitioners.
  10. Personnel stakeholder interview findings and satisfaction summary
  11. HR personnel record utilization review activity/focus
  12. Risk Management Review and review of compliance with legal reporting including licensing and mandatory reporting laws, and/or prudent policy or procedural changes appropriate to improvement.
  13. Outcome measurement domains and development of useful, sustainable outcomes program.
  14. Case file utilization review summaries of activity/focus.
  15. Stakeholder Satisfaction summaries and Expressions (internal and external)
  16. PQI Program, plan and activities; data Collection and review of significant trends, changes, and developing outcomes program efforts.

Demographic data is presented at the Strategic Planning meeting to inform planning processes. Data includes client composition based on gender, age, race, annual income and primary language to ensure programs remain culturally competent to serve the presenting population.

Time is devoted at this meeting to clarify aspects of the PQI process that must be included in short-term planning as well as discussing the utility of the PQI plan any modifications that are needed. Upon completion, Strategic Plan is submitted, reviewed, if necessary revised and then approved by the Board.

2013-2018 Strategic Goals


There are six main Committees of WHS that are responsible for developing and monitoring the five year strategic plan goals. Each Committee is responsible for ensuring that appropriate input and participation occurs by relevant stakeholders. The Committees work together and in collaboration with internal and external stakeholders to implement change, improvements and systems to ensure quality services for clients and families we serve. Each program provides annual short term goals in support of the Strategic goals and plan. [Refer to the WHS 2013-2018 Strategic Plan (reviewed annually at Strategic Planning Meeting) for more detail]. The 2017-2018 annum marks the final year of the existing master Strategic Plan. During this year the executive team will determine the next duration and vision for the next period of Strategic goals. It is anticipated that in June 2018 the Administrative teams will meet and a new long term Strategic Plan will be developed covering FY 2018/19 through FY 2023/24.

Fundraising: Establish, develop and implement a fundraising strategy for WHS. Expand our Fundraising reach by continue to develop and maintaining a statewide support network: inclusive of individual supporters, WHS employees, vendor relationships, corporate partnerships, government officials, and referring sources.


Human Resources: Improve the processes governing recruitment, hiring and retention of quality WHS employees.


Marketing: Define the needs of the agency and market to effectively promote WHS programs.


Program: To evaluate, refine and assess areas for new program development within WHS residential and community based treatment services.


IT: The IT Department will continue to upgrade and repair technology infrastructure to provide a secure and efficient end user experience.


Financial: Deliver budgeted profit for fiscal year ending Sept 30, 2017 and 2018 to sustain for each year thereafter.

Annual Program Plans/Goals

WHS understands that it is crucial that all personnel and programs support the Strategic Plan. Each agency program submits site/program based Annual Goals in support of the Strategic Plan to their Supervising Vice President for review and approval each annum.

Program annual goals consider the following:

  1. Support of the long-term goals and the agency mission,
  2. Integrate stakeholder input and feedback from all PQI activities and data,
  3. Allow a flexible response to changing conditions,
  4. Address any budgetary constraints or needs,
  5. Timelines or target dates for reporting and progress monitoring; and,
  6. Personnel are designated to carry out tasks.

The Chief Financial Officer in conjunction with the Executive Team would analyze the annual budget to determine if the needs of the long term and short-term plans are feasible.

Annual Program Goals in support of Strategic Plan: 2017/18


Community Based Programs (Foster Care/Adoptions/SIL)

  1. Maintain and expand programs.
  2. Improve service delivery.
  3. Support the agency mission statement.

Residential Programs:

Pioneer Work & Learn Center (PWLC)

  1. Achieve 90% CBT implementation across site with endorsements
  2. Keep facilities well maintained & clean.
  3. Achieve a 95% positive release rate.

Vassar House (VH)

  1. Achieve 90+ % positive release rate
  2. Maintain 100% report compliance to funding source, while still maintaining a high quality of work being completed.
  3. Increase professionalism and staff culture in both clinical and operational teams.

Wolverine Growth and Recovery Center

  1. Achieve 90+ % positive release rate
  2. Maintain 100% report compliance to funding source, while still maintaining a high quality of work being completed.
  3. Maintain a clean and safe environment on site for staff and clients.

Clarence Fischer Center.

  1. Implement CBT Core Skills
  2. Staff Development
  3. The site will give more positive reinforcements to clients.

Wolverine Center (WC)

  1. Maintain an overall success rate of 90% for both short term and long term programs.
  2. Operate programs within budget guidelines.
  3. Meeting training requirements as outlined by licensing, contract and COA.

Wolverine Secure Treatment Center (WSTC)

  1. To continue to implement CBT as the facility’s treatment modality of choice. This evidence based practice will be implemented, within and at all levels of the milieu. All staff at WSTC will be fully endorsed in CBT by May 2018.
  2. Perform extensive staff development for new personnel

WHS Mandates and Regulatory Entities Review for Strategic Planning


WHS provides services or demonstrates compliance with the following entities and meets contract mandates required by each: State of Michigan Department of Health and Human Services (MDHHS), Children’s Services Administration-Juvenile Justice and Abuse/Neglect divisions; State of Michigan Division of Child Welfare Licensing (DCWL); State of Michigan Department of Licensing and Regulatory Affairs (LARA) for substance abuse facility licensing and health professional licensure; Wayne County Care Management Organizations (CMO’s); DWMHA for Substance Abuse Treatment Services; Wayne/Saginaw/Tuscola County Health and Fire Departments; Department of Justice for Prison Rape Elimination Act (PREA), and Council on Accreditation (COA).

  1. PQI Program Internal Activities and Procedures

Internal Quality Monitoring is addressed in Strategic Planning Meetings, Executive Meetings, Quarterly PQIC Meetings, Site Manager Meetings, Team Meetings, Clinical Meetings, Operational Meetings and Auxiliary Department Meetings and occurs on a structured schedule and as dictated by urgency, safety, risk management and need. Daily communication occurs between and among team members, frequent day to day informal contacts and problem solving, urgent responses to situations and problems happens in the routine course of the week due to the nature of our clients and operations. Any ‘unusual others’ that occur during operations are reported appropriately and with urgency ‘up the chain of command’ to the appropriate level of authority to address and correct the concerns, including program managers, directors and vice presidents, CEO, and the Board President, as appropriate to the situation.


Annual Strategic Planning Meeting Procedures:

  1. The CEO chairs and directs the course of the meeting by setting broad vision goals for the leadership team regarding the future and direction of quality services and programs at WHS. This ensures that the agency remains on course with its mission, values, long and short term goals, and all work to serve clients, their families and other stakeholder in the highest of quality throughout all agency workings.
  2. The Senior Vice President of Programs and Vice President of Community Programs report findings from ongoing analysis of the identification of barriers and opportunities for serving groups including gaps in services needed by the community. This includes the evaluation of clinical and operational plans, review of the availability and costs of private and public transportation, alternative community resources and servicing the disabled, and the direction of treatment program models to meet the existing and projected client population needs.
  3. The VP of Strategic Development and Senior VP analyzes and reports details regarding the existing services provided by others in the community to meet those needs which are related to achieving the purposes of the organization.
  4. The VP of Strategic Development and Senior VP analyze and report detailing the need to redirect, eliminate, and/or expand service in response to changing demographics and the needs and wishes of the community. Provides reports on client demographics for age, racial composition, annual income and primary language.
  5. The VP of Human Resources presents a report that describes how human resources were deployed since the last meeting and discussion will ensue regarding future deployment. The report includes the availability of qualified persons for the labor pool, the need to make required changes such as reassignments and transfers and the need for culturally responsive and competent practitioners.
  6. The Staff Training and Development Department reports regarding training accomplishments and future needs. Particular attention is focused on how that relates to supervision and evidence based, trauma informed services.
  7. The Director of Clinical and Quality Services reports on:
  8. Risk Management Review including research, and review of compliance with legal reporting including licensing and mandatory reporting laws, TCI and incident reporting, other risk related areas, clinical staffing systems overview of changes in quarter.
  9. Outcome measurement domains including success rates and Needs Assessment domain aggregate data review
  10. COA and accreditation updates and status or implementation/training of revised standards.
  11. Case file utilization review-summary of areas to focus/improve next quarter
  12. PREA staffing plans are reviewed, numbers reviewed and reported, staffing plans are formerly updated based on population and need.
  13. Stakeholder Satisfaction activities including any Online Expressions Box submissions submitted each quarter; biannual stakeholders interviews and other input/feedback provided by any stakeholder over that quarter.

Quarterly PQIC Meetings Procedures:

  1. Program Managers/Supervisors submit a report for discussion regarding the usage of restraint, and (WSTC specific) seclusion or mechanical restraint.
  2. Program Managers/Supervisors submit a report for discussion regarding all instances in which a client posed a danger to self or others.
  3. Program Managers submit a report for discussion regarding injuries to staff or clients.
  4. Program Managers submit a report for discussion regarding issues related to medication administration, dispensation and prescription. This includes a review of any cancelled or missed medication appointment runs to early identify care or access barriers based on transportation logistics or staffing needs.
  5. Monthly walk through of each program site are conducted by the Director of Operations and each site provided a written checklist summary report of findings. Program Managers/Supervisors submit a report for discussion on environmental risks in the maintenance of facilities report.
  6. The VP of Human Resources submits a report on employee grievances including harassment claims and discrimination claims.
  7. PQIC members review the suitability and relevance of data collection and PQI activities, changes to standardized UR tools or survey forms, more effective methods for gathering data more effectively, efficiently and relevantly in a dynamic way that supports the field and the mission.
  8. Director of Quality and Clinical Services reports on stakeholder input, suggestions, feedback received via Online Expressions Box or other venues.
  9. Program Managers submit a report on outcome measurement success.
  10. PQIC members review progress on Strategic and Annual Program plans and provide progress summaries of barriers, strengths and steps to continue.
  11. The Staff Training and Development Department submits a report on training accomplishments and needs with plans for the upcoming quarter. Input is sought from all PQIC members regarding training gaps or needs that may exist.
  12. Program Managers submit a report on all licensing reviews and contract reviews, including any accreditation or PREA-related concerns. Review of policy or procedural changes that are required or beneficial.
  13. Program Managers submit a report on Case File Utilization Review results and Satisfaction Survey results.
  14. Discussion of the need or lack of needs for specific stakeholder driven policy work groups, task oriented sub-committees or specific client advisory topics for the upcoming quarter.

Results from the Quarterly PQIC meetings are presented and discussed at the Executive Meetings as well as Site Manager Meetings, Team Meetings, Clinical Meetings, and Operational Meetings to encompass information and data sharing will all levels of personnel. Corrective actions and/or work groups or sub-committees can result from any PQI program outcomes or activities. The CEO reviews results quarterly and presents a summary to the Board during quarterly board meetings.

Biannual Client Satisfaction Survey and Summary Report Procedures

A standardized questionnaire is administered to all clients in our programs every other quarter. The tool is designed to be client friendly including both Likert scale of 1-10 and a corresponding smiley to frown face representing youth satisfaction. The questions were redesigned and tested by clients who provided ideas for improvement in the currently user version. Data is aggregated into a quarterly Client Satisfaction report by the Program Managers/Supervisors and the data integrated into the site quarterly PQI report. The PQIC reviews client and stakeholder content quarterly (alternate interviews and surveys). Trends of least and most satisfied areas are tracked and monitored to ensure progress is made each quarter in areas of least satisfaction. The Client Satisfaction Survey tool can be updated as appropriate by the PQIC as input, data and stakeholder feedback shape the tool.

Ongoing Family Satisfaction Survey procedures

Families and parent/guardians of clients are encouraged to send in an anonymous Family Satisfaction survey when their child discharges from the program. This survey is provided to a parent/guardian in person by a clinical staff during a final exit meeting in the clients’ home, along with a self-addressed and stamped envelope for the family to drop into the mail to return to the agency. This survey is also available in hard copy on the program site during on site visitation for families to complete as desired. Returned surveys are reviewed; results are aggregated and discussed in Strategic planning and PQIC.

Annual Personnel Satisfaction Survey and Summary Report Procedures

A standardized questionnaire has been made into a digital survey, and is administered annually via staff and personnel meetings, email blast ‘to all’ inviting participation and is available in an online anonymous survey. A standardized personnel satisfaction survey tool is utilized. The Vice President of Human Resources ensures that the data is aggregated and reported annually in Strategic Planning and PQIC meetings. Trends of least and most satisfied areas are tracked and monitored to ensure progress is made annually in areas of least satisfaction. The Personnel Satisfaction Survey tool is updated as appropriate by the PQIC and Human Resources Department as input, data and personnel feedback shape the tool.


Quarterly Clinical Case File Utilization Review Procedures:

The organization conducts case record utilization reviews of all of its programs. It is an evaluation of the quality of services provided to clients by the agency staff. The purpose of peer review is to assist staff so that quality of practice is improved by providing ‘friendly and internal’ pro-active feedback and alternatives.

Clinical personnel who do not have any vested interest in those program files under review are selected by the PQI Department to participate in the review process. This ensures that reviewers have no conflict of interest in program file outcomes. Reviewing other peers work is helpful not just for the one being reviewed but for the reviewer. Several structured questionnaires (UR Forms) are utilized. We utilize a different UR form for open vs. closed files and attempt to capture the diversity of programs and variances between programs. The PQI program allows flexibility to identify and target specific areas each quarter, and to modify and adapt the UR form as appropriate and helpful throughout each quarter.

The reviewers include a rotation of practicing clinical personnel with no interest in the program under review, interns, and two standing therapist reviewers and are headed by a Clinical & Quality Manager. No one chosen to conduct the review has supervisory and/or case management responsibilities for that program. The number of files reviewed varies from program to program based on the program capacities but 10% open and 10% discharged per quarter (40% annually per program) is a minimum standard. Files are tracked as reviewed during an annum to avoid redundancy in the sampling. Reviewers attempt to review at least one open file from each clinical staff per program each quarter. We use random sampling techniques when selecting files for review.

Some of the areas the reviewers look at include: quality of screening and assessments; service plans-treatment goals; continuity of services and provision of needs; appropriate consents and legal documents; outcomes and outputs of services; aftercare planning; weekly progress case notes or summaries; stage of change assessment and matched goals; evidence of quarterly case supervision; relevant signatures; services needed and provided; length of stay and remaining need; changes in status or level; need for continued service; compliance with established time frames; psychiatric and psychological services; other prescription medication disbursement and health service provision. Following each UR activity, the chairing Clinical and Quality Manager provides a ‘UR Wrap-Up” summary to Directors, Program Managers, Clinical Managers/Supervisors and available clinical staff of the site reviewed. The corrective action processes involves that programs team engaging in problem solving deficits, reviewing the UR tools itself for improvement, and identifying systemic and/or individualized corrective plans. For a more extensive listing please refer to the currently approved UR form, available via PQI Department and on the agency P-drive.

Biannual Stakeholder Interviews Procedure

Each quarter the Clinical and Quality Manager chairing the case file utilization review process also conducts stakeholder interviews with staff and clients from each program. An effort is made to conduct at least five client and five personnel interview per program, though this can vary with census or need. A private, anonymous and informal interview occurs with a random pull of staff and clients from each program. A simple questionnaire related to program conditions and issues is followed by a one to one interview with the PQI Manager. Input, suggestions, concerns and ideas are solicited and encouraged as a main component of the interviews. Anonymous outcome reports are submitted by the responsible PQI Manager, and provided to the responsible Vice President, Director of Clinical and Quality Services and the Program Manger of the site. Any urgent or risk areas are immediately flagged and resolved with appropriate personnel or procedures/policy reviewed for change as needed.


Biannual Residential Senior Staff Advisory Council Meetings Procedure

The Senior Vice President leads biannual Senior Staff Advisory Council Meeting with leadership oriented mission based long term residential program staff from each program site. These are open forum for discussion with direct care staff that has worked for the agency at least five years. This allows for the experienced voice of direct care to have access and brainstorming opportunity directly with a senior leader. These are confidential focus groups and invite free expression by personnel to the VP without site supervisor or management involvement. All topics are open for review and discussion related to program, client services, personnel work environment, staff training and challenges/strengths, development needs, safety concerns and overall morale and retention. Outcomes are summarized by the Senior VP in an anonymous way to all Program Managers and RCC’s throughout the residential system. Meeting minutes are anonymous and topic and improvement focused.


Monthly Residential ASE inspection and Report Procedure

Every month a physical plant inspection and summary ASE report is conducted for each residential program site. This ensures safe and clean facilities that remain in compliance with licensing, health and fire code, contract and accreditation standards. The Director of Operations and Facilities engages in a monthly tour/inspection of each program site and physical plant. (Refer to ASE facility checklist tool) The Director of Operations and Facilities submits a summary report and recommendations to the Program Manager/supervisor of the inspected site by the 25th of each month. The site Program Manager/Supervisor and RCC of the reviewed site will review outcomes, develop corrective plans and implement on that site. The Program Manager/Supervisor includes this data in the program Month End PQI report for review and monitoring.

Quarterly Human Resources Personnel File Review Procedures:

The organizations Human Resources Department conducts a quarterly internal personnel file utilization reviews of all of the agency personnel records. HR personnel engage in cross regional peer review. This ensures that reviewers have no conflict of interest in reviewing their own product and fresh eyes review records. A structured Personnel File Utilization Review form is used. The Utilization Review form is updated as necessary to continue to be current in meeting the requirements of all regulatory entities for personnel monitoring, training and credentialing. The reviewers provide a summary of findings to the Vice President of Human Resources. The Vice President of Human Resources determines the needs for a CAP and works within the HR department to enact and monitor progress on improvements.


  1. Outcomes and Output Measurements

WHS determines and regularly reviews the desired expectations and service outcomes for each of its programs and integrates improvement as a continuous process. WHS has struggled to build and maintain a consistent outcomes program as the environment, contract demands, federal MSA’s and other entities have change their expectations, systems and required documents many times. WHS has participated in multiple and various stakeholder collaboration meetings conducted by DHHS and other funding entities and provider agencies, and with policy makers in Lansing to identify appropriate, universal, culturally competent, trauma informed, strengths based outcomes measurement tools and systems for adolescents in the state of Michigan. At this time, each provider responds to contract requirement outcomes and focuses on compliance outputs, and there is no universal measure for performance based program evaluation or contracting. This is becoming a focus of much state-wide attention. As yet, WHS continues to struggle with building a dynamic, effective, affordable and user-friendly program of outcomes. This is a priority of the agency. In late 2013 a five year plan/project was implemented in coordination with the Beck Institute of Philadelphia and Indiana University to partner a project for CBT model implementation within WHS programs. As WHS enters it last year of the five year partnership, the focus on sustainability of CBT as the evidence based model will include identifying attainable, measurable outcomes to ensure and edify the anecdotal success of the project. The agency will be working to identify and implement program based individual and aggregate outcome measures and program quality measures. With this consultation and university support and resources, WHS positions itself to develop a research informed outcomes program with a long term goal of being evidence based. Funding for longer term outcomes around this project remains a formidable obstacle to this plan as yet to be determined.

Below is an outline of those outputs and outcomes we have tracked successfully over the years. All aggregate data is presented at the quarterly PQIC meetings, appropriate personnel meetings and the Board Meetings, as well as the annual Strategic Planning meeting.

Note: any domains in Month End and Quarterly PQI reports that do not meet quality expectations or demonstrate opportunity for improvement require a narrative in the programs indicating the particulars what is being done to correct the issue.


Success Rates and Discharge Rates

Timely Service Plan Compliance

Timely completion of required Screenings

Percentage of clients’ with quality, completed assessment tools in timeframes.

Percentage of clients provide quarterly Ansell-Casey testing (life skills assessment)

Family Services Compliance:

-Percentage of FOA (Family Orientation and Assessments) on time

-Service Plan Reviews

-RSR /aftercare contacts and summary reports

Academic/grade level progress (Vassar and WSTC)

-individual and aggregate

Aggregate RSR tracking (beginning January 2014)

-Agency Permanency Specialist and Family Workers have continued contact with clients for 60 days after discharge. Permanency Specialists (on a case by case basis) may continue aftercare tracking client’s progress from 60 days and could be up to 6 full months. Depending on the timeframes for tracking as determined by the referring source, a final report is completed either day 90 following discharge or day 210 following discharge. This Reintegration Summary Report outlines the continued progress of clients in the community. This summary reports the following items for tracking and analysis:

-School enrollment

-Employment status

-Abidance of household rules

-Utilization of coping and life skills learned while in program

-Engagement in positive recreational activities

-Negative contact with law enforcement

-Participation in community-based or outpatient services

-Utilization of resources to follow recommendation of release plan

Community Based Programs:

Case File Citations:

-CBP staff conducts monthly “spotlight” audits errors/citations regarding on specific topics identified through BCAL/Contract audits

-Monthly full audits in each office

Timely Court compliance

Timely Service Plan Compliance

Timely medical/dental service provision compliance

Rate of reports of incidents including placement changes, injuries, or medical situations

MSA mandated outcomes are reviewed and monitored in quarterly PQI reports:

  1. Number of placements while in care:

Standard: 0-365 days = >86.00%

366-730 day = >73.00%

731+ days = >45.00%

  1. Percentage in care 30 days or more:
  2. Discharged to parent or guardian (min std is 43%)
  3. Discharged to a finalized adoption within 24 months

of removal (min std is 36.6%)

  1. Percentage in care for the most recent 24 months discharged to a

Permanent placement prior to their 18th birthday (min std 29.1%)

  1. Percentage in care for the last 12 months and legally free for adoption discharged

to a permanent placement prior to their 18th birthday (min std is 98%)

G. Feedback and Sharing with Stakeholders

Monthly, quarterly and annual summaries of the PQI program results are discussed and reviewed in agency weekly staff and manager meetings. Policy updates are blasted then posted on the agency shared P-drive. Larger outcomes and events are posted on the agency website and the HR newsletter; trends are included in the agency annual report and reviewed by the CEO at the annual State of the Agency Address, disseminated and made available to personnel, clients, families served and referring workers. In addition as mentioned elsewhere we obtain input into the PQI program from clients, families, staff and referral agencies via surveys or focus groups and the online Expressions Box. Email blasts are provided by the PQI Department of PQI calendar of upcoming activities with invitation for input. There is continuous, spontaneous and frequent informal discussion of such issues via the CEO with a variety of stakeholders such as personnel via open doors and stakeholder activities, politicians, vendors, agencies who are members of organizations that we belong to etc. Data from Outcome measurement and other PQI processes are either aggregated for the Quality Committee Meetings (quarterly) or the Strategic Planning meeting (yearly).

Quarterly, the CEO provides a written comprehensive report to the Governing body. The CEO Report to the Board contains all relevant information on PQIC activities, Risk Management Review and Outcome Reports.

H. Corrective Action and Dynamic Improvement Initiatives

Any area of risk or opportunity for improvement in the PQI Program and activities is subject to review and intervention by the Executive Team, Program Managers/Supervisors, and PQI Department, as appropriate to urgency level and departmental authorities involved. Responses are dynamic and in context to the defined issue and risk management effectiveness.

Interventions may include, but aren’t limited to: formal corrective action plan (i.e. clinical case file utilization review CAPs are required), the development of a short term solution or task focused work group or sub-committee, PQIC topic review and solution seeking in quarterly meeting; small management meetings with appropriate VP; additional trainings and proactive training curriculum adjustments, policy and procedure review by policy work groups, etc. Regardless of the intervention implemented, follow up is defined and the following communicated: the changes, corrections or initiatives that will be made; the target date of the changes or action step progress; personnel responsible for seeing that changes are made and for monitoring compliance; and, the resources and challenges to implementation.

The task of the PQI Program and activities is not to search out errors or problems or to implement negative consequences in response to outcomes. The focus is on collaboration and using our resources, hearing our clients and our teams, supporting our collective expertise and learning, honoring our innovation and creativity to remain viable and effective in a changing landscape.

01/2018r; draft approved by board 12/2017