Quality Improvement Policy
To promote a culture of quality improvement within Helping Hands that includes an organization-wide management and staff philosophy of continuous quality improvement (QI) in program and service delivery.
Helping Hands will objectively, systematically, and continuously assess, assure, monitor, evaluate, and improve the quality of processes, activities, programs, services, and products provided to all Helping Hands clients. This requires establishing agency-wide and/or specific program goals, objectives, and measures (performance indicators) and includes training staff in QI methods and tools. To execute this policy, Helping Hands will establish and implement an agency-wide QI Plan and QI committee. Components of the plan will include, but not be limited to:
- Designation of a Quality Improvement Officer and/or a QI Committee
- Roles and responsibilities of the board, directors, coordinators, QI officer, and staff
- Quality improvement activities, projects, measures, resources, and timelines
- Methods to evaluate processes, programs, and services to identify opportunities for improvement
- Provisions for the use of client satisfaction data and feedback
- Use of the Plan-Do-Study-Act or other recognized QI method to address evaluation results and client recommendations
- Methods to mobilize both data and team knowledge to improve decision making
- Provisions for training staff in QI methods
All staff, management, and the Board is responsible for being aware of, implementing, and maintaining the quality system as appropriate to their role and responsibilities. At the end of the fiscal year in which the plan is implemented and each year thereafter, Helping Hands leadership/management team will review the quality improvement activities conducted during the year, including the targeted process/program outcomes, the performance indicators (measures) utilized, the findings, data aggregation, assessment, and the QI initiatives taken in response to the findings.
Quality: Quality is the degree to which policies, programs, services, and products for the population increase desired outcomes and conditions for our clients.
Quality Assurance (QA): Assurance of quality is the planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled. Quality Assurance may also be defined as a retrospective review of processes, programs and services. It provides for the systematic monitoring and evaluation of the various aspects of a project or service to ensure that standards of quality are being met. QA is frequently used to guarantee quality.
Quality Improvement (QI): Use of a deliberate and defined improvement process, such as Plan-Do-Study-Act, which is focused on activities that are responsive to community needs and improving client satisfaction. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improvement of our services and products.
Plan-Do-Study-Act: The Plan-Do-Study-Act (PDSA) method is a way to test a change that is implemented. Going through the prescribed four steps guides the thinking process into breaking down the task into steps and then evaluating the outcome, improving on it, and testing again.
Decision Tree: A decision tree is a graphical representation of specific decision situations that are used when complex branching occurs in a structured decision process. A decision tree is a predictive model based on a branching series of Boolean tests that use specific facts to make more generalized conclusions.
The main components of a decision tree involve decision points represented by nodes, actions, and specific choices from a decision point. Each rule within a decision tree is represented by tracing a series of paths from root to node to the next node and so on until an action is reached.
Call Log: The call log is used for the collection, evaluation, and reporting of statistical data about telephone calls. The goal of the call logging is to interpret the raw data to produce summarizing reports.
A systematic approach to improving quality and performance, which includes the following
elements: monitoring, assessment, action, evaluation, and feedback (feedback is integral to all
parts of the cycle).
Adequate resources, tools, and support are provided to staff, the Directors, the Board, and key
stakeholders to fully engage in its quality improvement system and processes.
Helping Hands is committed to the widespread involvement of staff, management, the Board,
and clients in its quality improvement activities.
Staff, management and the Board are aware of and practice continuous quality improvements
which are designed to increase the client experience in all facets of Helping Hands operations
Helping Hands utilizes evidence-based and innovative work practices where the staff is recognized
for participating in best practices and innovative ideas to improve the client experience.
Helping Hands commitment to quality improvement is pervasive in all areas of its business. To
ensure this, all staff are required to seek ways to improve the quality of their own activities and
areas of responsibility, while looking at the organization as a whole without sacrificing the client
experiences and care.
- Functions and Delegations
Position Delegation/Task Board of Directors
- Approve Helping Hands strategic direction which guides quality improvement processes.
- Endorse the Quality Improvement Policy.
- Ensure QIP is reviewed at each Board meeting
- Develop, review and implement the QIP
- Endorse the Quality Improvement Policy.
- Participate in internal and external audit activities, as appropriate.
- Comply with the Quality Improvement Policy and demonstrate its values.
- Monitor client advocate line after hours.
- Support staff to coordinate Helping Hands’ continuous quality improvement systems and practices.
- Participate in and lead quality improvement activities, as relevant.
- Provide leadership and resource support to quality improvement staff and activities.
- Escalate issues outside Coordinators’ scope to Departmental Director level
- Report to the Director team QI summaries monthly
Quality Improvement Committee
- Analyze trends and recommend actions systemically.
- Advise QIP officer
- For the first 12 months, test processes and procedures
Quality Improvement Officer or Designate
- Monitor client Quality Improvement telephone line during regular business hours and after hours, as needed.
- Identify areas of opportunity for quality improvement
- Code complaints by the level of severity and forward to departmental managers
- Identify and track trends, train staff accordingly.
- Comply with the Quality Improvement Policy.
- Promote and demonstrate a commitment to quality improvement
- Assist management to carry out tasks related to quality improvement activities
- Risk Management
This policy will be reviewed in line with Helping Hands’ quality improvement system and the review of associated policies yearly, and on an as-needed basis. The need for improvements in procedures/systems/products/service delivery can be identified by any Board member (through Board established channels), management, staff or client through feedback or quality monitoring systems, all of which will be presented to the QI Committee for review.
- Policy Implementation
This policy is to be part of all Helping Hands’ staff orientation processes and reviewed annually. The Board, management, and staff should also be familiar with their functions and delegations outlined in this policy. This policy should be referenced in relevant Helping Hands policies, procedures and other supporting documents to ensure that it is familiar to all staff and actively used and reviewed yearly.
- Policy Detail
Helping Hands is committed to continually improving the quality of its services in order to fully realize its goals and strategic outcomes, and be inclusive and responsive to clients, staff, volunteers, and stakeholders. The quality improvement process and system is coordinated by the departmental Coordinators, though all staff and management participate in quality improvement practices.Helping Hands undertakes quality improvement activities based on the quality cycle detailed below. A structured Quality Improvement Action Plan outlines the specific tasks to be undertaken by staff during a quality cycle. Helping Hands goals and outcomes, as outlined in the Strategic Plan, should be considered in all stages of the quality cycle.
Analyzing information from the monitoring stage can provide an assessment of the current situation and identify the best approaches to take for improvement. All staff has a responsibility to fill out the appropriate call log identifying any issues reported by clients, concerning quality. Individual assessment activities and recommendations that come from assessment activities should be shared with relevant staff through staff or team meeting presentations, group discussions or other suitable mechanisms to communicate findings and reach an agreed approach for subsequent improvement activities. Such activities will typically occur through the QIP Committee and be reported on to senior management and the Board, through the Leadership Report.
Through the assessment phase, quality improvement actions should be decided upon and/or prioritized through the priority matrix. If the activity requires financial resources, an adequate budget should be identified before the activity commences. Similarly, if the activity requires significant time/human resources, discussions should take place with management, prior to commencing. Suitable and practical solutions should take into account the needs of the organization, staff, clients, and stakeholders that might be affected. Actions may range from procedure documentation or policy development to system redesign or creation, e.g. electronic filing, human resources system
Once the action has been taken, individuals involved should evaluate the results of that action to ensure the required result was achieved. Key questions to ask to evaluate an activity include:
- Did the action achieve the desired result or outcome?
- Is there any further action to be taken in this area?
- Have all necessary steps been taken to reduce or eliminate any further risk to clients or the organization?
Evaluation information should be collected in a similar way to monitoring information.
All individuals involved in, or affected by, quality improvement actions/activities should be aware of changes made to the organization and the results of these activities (both internal and external) where applicable. Communication at all stages is critical to achieving sustainable results and facilitating organizational change.