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					                        Performance and Quality
                        Improvement Plan




CATHOLIC CHARITIES OF THE DIOCESE OF SANTA ROSA
987 AIRWAY COURT, SANTA ROSA, CA
Document Change Control

The following is the document control for the revisions to this document.

Version          Date of Issue              Author(s)             Brief Description of Change
Number
2.0              4/5/2012                   L. Farrell            Added Improvement Cycle
2.1              5/4/2012                   L. Farrell            Added BOD report review
                                                                  language
Table of Contents

1       MISSION STATEMENT .................................................................................................................... 1
2       PQI PRINCIPLES............................................................................................................................... 1
3       CCDSR MANAGEMENT STRUCTURE......................................................................................... 2
4       PQI STRUCTURE AND RESPONSIBILITIES .............................................................................. 2
    4.1          PQI STRUCTURE ......................................................................................................................... 2
    4.2          RESPONSIBILITIES ....................................................................................................................... 2
5       CCDSR PLANNING .......................................................................................................................... 4
    5.1          STRATEGIC PLAN ........................................................................................................................ 4
    5.2          ANNUAL OPERATIONS PLANS ..................................................................................................... 4
6       PQI PROCESS ................................................................................................................................... 5
    6.1          PQI REVIEW PROCESS ............................................................................................................... 5
    6.2          IMPROVEMENT CYCLE ................................................................................................................. 5
    6.3          REPORTING ................................................................................................................................. 6
FIGURE 1...................................................................................................................................................... 7
FIGURE 2...................................................................................................................................................... 8
FIGURE 3...................................................................................................................................................... 9
1       Mission Statement
The mission of Catholic Charities is to reach out to those most in need, offer hope through
service, and build better communities.
Catholic Charities Diocese of Santa Rosa (CCDSR) provides the highest quality services to
individuals and families in the communities that it serves. The agency has a rich tradition of
listening to the client and community needs, and planning programs that are responsive to
those needs and consistent with the agency’s mission.

CCDSR’s approach to maintaining Performance & Quality Improvement (PQI) is defined in
this document and reviewed by the staff and leadership on an annual basis. Catholic
Charities’ Executive Director and Board of Directors endorse and support all aspects of the
PQI process. The PQI program is fully responsive to the Mission, Vision, Values, and
Strategic Plan, and Annual Operations Plan of CCDSR.


2       PQI Principles
The PQI process generates a continuous cycle of activities that seek, and respond to
opportunities for ongoing improvement, guided by a set of PQI principles as follows:

       All staff members participate collaboratively in identifying opportunities for
        improvement and responding to all PQI findings.
       CCDSR conducts a systematic approach to improvement with a clear definition of
        tasks and timeframes.
       Using a data-based decision-making process, CCDSR continuously gathers and
        analyzes information from its stakeholders, consumers, and staff regarding services
        in every aspect of its service delivery. The data determines how the organization can
        make changes resulting in more efficient, effective, economical, ethical, and user-
        friendly services.
       Services are designed and delivered with the focus on the needs of clients and the
        community at the earliest possible stages.
       Families and individuals have convenient access to services and barriers to delivery
        of effective quality services are removed.
       Effectiveness of services is determined through quarterly and annual outcome
        indicators that are measured and reviewed.




                                               1
3        CCDSR Management Structure
The overall management structure is illustrated in Figure 1. Figure 2 shows another view
that indicates the Directors and Senior Management Team, who are directly responsible for
operations, services, and implementation of PQI recommendations. The Executive Director
has defined an Executive Team, shown in Figure 3, which provides management assistance
and reviews the PQI quarterly and annual reports.


4        PQI Structure and Responsibilities

4.1      PQI Structure

The Executive Director appoints the PQI Team Leader who is fully responsible for the PQI
Program at CCDSR. Representatives from each department are members of the PQI Team.
The Executive Director appoints each PQI representative, with the concurrence of both the
representative’s manager and the PQI Team Leader. The PQI representative is typically a
staff member rather than a Director or Senior Manager. A representative from the Executive
Team is also a member of the PQI Team, and provides direct assistance to the PQI Team
Leader.


4.2      Responsibilities

PQI Team Leader
Responsibilities of the PQI Team Leader include oversight of the PQI processes to ensure
ongoing implementation and coordination of PQI activities. In particular, The PQI Team
Leader, with support from the PQI Team:

     Collects, summarizes key findings, and submits PQI Quarterly Reports to the Executive
      Director and the Executive Team

     Conducts surveys of Clients. Collects, organizes, analyzes, and reports data to the
      Executive Team

     Solicits, collects, and reports feedback and assessments from volunteers, funders, and
      community and government stakeholders

     Conducts internal audits to review compliance with established Policies and Procedures,
      and accuracy of outputs and outcomes measured

     Submits PQI recommendations to the Executive Team

PQI Representatives



                                                2
The PQI representatives coordinate PQI processes, collect data from their programs and
services, review program case files, ensure consistent adherence to PQI principles, and
report findings to the PQI Team Leader. Responsibilities:

   Collects, and tracks Department/Program metrics
            o Outcome measurements
            o Tracking vs. Annual Operation Plan
            o Services supplied
            o Improvements and changes implemented as recommended

   Reviews program case files
          o Compliance with agency policies and procedures
          o Ensure service quality
          o Services supplied are appropriate to assessments

   Encourages PQI participation by all staff and volunteers
          o Provides opportunities for continuous improvement, consolidates and
              reports proposed improvements to the PQI Team Leader
          o Provides PQI training resources to ensure that staff receive ongoing PQI
              training as appropriate

   Policies and Procedures (P&Ps)
            o Ensure that respective Department/Programs P&Ps are current
            o Monitors and reviews adherence to the P&Ps
            o Reports non-compliance and makes recommendations to the Director or
                Senior Manager, and PQI Team Leader

   PQI Quarterly Reports submitted by the PQI Team Leader
          o Reports on all metrics
          o Identifies issues, problems, changes and improvements
          o Proposes specific opportunities for improvement

Directors and Senior Managers
The Directors and Senior Managers are responsible for implementing and promoting a
culture of PQI in each of their departments. They provide opportunities for all staff and
volunteers to contribute to PQI on a regular basis and include PQI goals in their operations
plans. They are responsible for the implementation of findings and recommendations made
by the PQI Committee with the concurrence of the Executive Director. Directors and
Senior Managers submit quarterly and annual outcome measurements to the PQI Team.

Executive Director
The Executive Director has ultimate responsibility for the PQI program at CCDSR. He
reviews the Annual and Quarterly PQI Reports, with the assistance of the Executive Team,
approves findings and actions, and assigns specific action and improvement responsibilities
to the Directors and Senior Managers. The Executive Director is responsible for the
Strategic Plan and approves and reviews the Annual Operation Plans.




                                              3
Board of Directors
The Board of Directors contributes to the PQI process by responding to the Annual and
Quarterly PQI Reports. The Board ensures that the yearly Operational Plans address desired
outcomes established by in the Strategic Plan and reflect PQI goals.

Additional Stakeholders
In addition to the above positions, other stakeholders and their roles are summarized as
follows:

     All staff members – implementation, identification of PQI opportunities
     Clients – direct feedback, survey response, identification of PQI opportunities
     Volunteers - implementation, identification of PQI opportunities, feedback
     Funders, donors – assessment, feedback
     Local government agencies and representatives – assessment, feedback



5        CCDSR Planning
5.1      Strategic Plan

The Strategic Plan guides the management and operation of CCDSR, and sets requirements
for the Annual Operation Plans. The PQI program ensures that the operation of CCDSR is
consistent with the Strategic Plan, Annual Operation Plans, and all approved Policies and
Procedures

 The Strategic Plan includes: Mission, Vision, Values, Strategic Goals (2-5 broad objectives),
and Action Steps (1-2 year objectives). Every three (3) years, the organization conducts an
organization-wide, long-term strategic planning process, which is based upon an assessment
of the organization’s strengths and weaknesses, feedback from the Stakeholders and client
surveys and inquiries, and human resource needs. Annually the Action Steps are reviewed
and updated and the 1- 2 year objectives are defined. The Action Steps review includes an
assessment of PQI needs and opportunities, and defines appropriate actions.

The Strategic Plan and Annual Operation Plans are developed by the Executive Director,
and reviewed and approved by the Board of Directors.


5.2      Annual Operations Plans

In response to the Strategic Plan and annually updated Action Steps, the Senior Management
Team develops annual Operation Plans for their programs and departments. The Operation
Plans include:




                                                4
     1-2 year objectives that are measurable
     Timeline
     Performance metrics
     Outcome measurements
     Resource requirements
     PQI activities


6        PQI Process


6.1      PQI Review Process

Quarterly, the PQI Team Leader, supported by the PQI Team, conducts a review of case
files in each program area to assist practice and compliance with agency procedure and
policy. Services maintaining fewer than 100 clients per year review 100% of their clients’
records per year (80% open/20% closed). Services maintaining 100 or more clients per year
review a minimum of 100 records per year (80% open/20% closed). Additional case records
may be requested for review dependent upon identified trends, risks, or noncompliance with
indicator thresholds across time. The PQI Team Leader compiles a summary of findings,
works with the staff to develop a corrective plan of action if necessary, and provides a report
to the department supervisors.

Copies of case record reviews conducted are provided to the appropriate Director or Senior
Manager. A plan for corrective action or change in practice is developed by the supervisor
and provided to the Executive Director. An analysis of the reviews is included in each
Quarterly Report.

Findings reported by external review processes, such as licensing reviews, compliance
reviews by local, state and federal agencies, and other reviews are analyzed and reported to
the Executive Team by the PQI Team Leader, and integrated where appropriate.

Each quarter the PQI team reviews reports of incidents, accidents and grievances and
includes the results of the review and recommendations for improvement, as appropriate, in
the quarterly PQI report.


6.2      Improvement Cycle

Agency and program improvement recommendations are provided to the Executive Team
by the PQI Team for review and consideration of implementation. The Executive Team
may choose to implement a recommendation or to take an alternative course of action. At
the discretion of the Executive Director, the Executive Team’s recommendation may be
taken to the Board of Directors for approval prior to implementation.




                                                5
When a decision is made to move forward with a recommended improvement, a plan,
including specific goals and metrics will be developed. Program or department managers
will be assigned, as appropriate, to implement the improvement.

Outcomes generated from the change or improvement are reported to the PQI team and
documented in the quarterly PQI Reports.


6.3      Reporting

The PQI Team writes a Quarterly Report based on the data collected from each Director
and Senior Manager of each department. . The Quarterly Report is reviewed by the
Executive Director and finalized by the PQI Team Leader. The Quarterly Reports include
an assessment of progress with respect to the Annual Operations Plan, recommended
appropriate revisions, and supporting data provided through the PQI program.

The Quarterly Reports include:

     Results of case file reviews
     Staff/volunteer satisfaction, needs, issues
     Program operations including metrics defined in each Operational Plan with regard to
      service to clients, outcomes, functional operation
     Information technology and data collection
     Changes in administration and personnel
     Finance changes and funding mandate review, if appropriate
     Training updates
     Safety and security of clients and staff
     Grievances reported
     Audit results, if any
     Legal, licensing or regulatory issues, if any
     Improvements implemented based on PQI recommendations and outcomes, as
      applicable

The PQI quarterly reports are submitted to the Board of Directors at the second monthly
meeting following the end of each quarter. The Board of Directors reviews the effectiveness
of the PQI plan and the PQI committee performance on an annual basis and makes
recommendations for improvement in the plan and performance as appropriate.




                                               6
                                                        BOARD OF
                                                        DIRECTORS

  Figure 1
                                                        EXECUTIVE
                                                        DIRECTOR
  Management Structure



                                               EXEC OFFICE
                                                  SPECIAL
                                                 PROJECTS
                                               COORDINATOR




DIRECTOR—     DIRECTOR—                                         DIRECTOR--                                       DIRECTOR—
ACCOUNTING      HUMAN                                           PROGRAMS                                        ADVANCEMENT
AND FINANCE   RESOURCES                                                                                          AND COMM.
              AND ADMIN
               SERVICES




CONTROLLER    FACILITY     MANAGER--     MANAGER—       MANAGER—       COORDINATOR   MANAGER—    COORDINATOR     MANAGER—
              MANAGER       QUALITY,      SHELTER       RURAL FOOD       —NAPA         SENIOR    —IMMIGRATION      COMM.
                            GRANTS,      OPERATIONS      PROJECT        SERVICES      SERVICES       AND          MANAGER
                           COMPLIANCE                                                            RESETTLEMENT   STEWARDSHIP




                          GRANT WRITER      C2C
                                         COORDINATOR




                                                                7
Figure 2

Directors and Senior Management




DIRECTOR—     DIRECTOR—                                          DIRECTOR--                                       DIRECTOR—
ACCOUNTING      HUMAN                                            PROGRAMS                                        ADVANCEMENT
AND FINANCE   RESOURCES                                                                                           AND COMM.
              AND ADMIN
               SERVICES




CONTROLLER    FACILITY     MANAGER--     MANAGER—      MANAGER—         COORDINATOR   MANAGER—    COORDINATOR     MANAGER—
              MANAGER       QUALITY,      SHELTER      RURAL FOOD         —NAPA         SENIOR    —IMMIGRATION      COMM.
                            GRANTS,      OPERATIONS     PROJECT          SERVICES      SERVICES       AND          MANAGER
                           COMPLIANCE                                                             RESETTLEMENT   STEWARDSHIP




                          GRANT WRITER      C2C
                                         COORDINATOR




                                                             8
Figure 3

Executive Team




                                       EXECUTIVE DIRECTOR




                      EXEC OFFICE
                         SPECIAL PROJECTS
                           COORDINATOR




DIRECTOR—ACCOUNTING       DIRECTOR—HUMAN           DIRECTOR--PROGRAMS     DIRECTOR—
     AND FINANCE         RESOURCES AND ADMIN                            ADVANCEMENT AND
                              SERVICES                                  COMMUNICATIONS




                                                            9

				
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