HSP XYZ Quality Policy Manual

DEPARTMENT: Administration

NUMBER: Draft

TOPIC: Quality Management Program

PURPOSE: To promote a culture of exemplary quality within HSP XYZ programs that
includes an organization-wide management and staff philosophy of continuous
quality improvement (QI) in programs, service delivery, and client outcomes.

POLICY: HSP XYZ will objectively, systematically, and continuously assess monitor
evaluate and improve the quality of processes, activities, programs and services
provided to clients and stakeholders. This requires establishing agency-wide
and/or program-specific goals, objectives and measures (performance indicators)
and includes training staff in QI methods and tools. To execute this policy, HSP
XYZ will establish an agency-wide annual quality plan. Components of the
plan will include, but not be limited to:

1. Roles and responsibilities of leadership, management and staff.

2. Quality improvement activities, projects, measures, resources and timelines.
3. Methods to evaluate processes, programs and services to identify
opportunities for improvement.
4. Provisions for the use of client satisfaction data and feedback.
5. Methods to address evaluation results and customer recommendations.
6. Methods to mobilize both data and team knowledge to improve decision
making.
7. Provisions for training of staff in QI methods.
MATERIALS/EQUIPMENT REQUIRED:

Mission and Value Statements

DEFINITIONS:

For the purposes of executing this policy within HSP XYZ, the following definitions will be used:

Quality Management is a strategy for continuously improving performance at every level, and in all
areas of responsibility. It combines fundamental management techniques, existing improvement efforts,
and specialized technical tools under a disciplined structure focused on continuously improving all
processes. Improved performance is directed at satisfying such broad goals as cost, quality, schedule, and
mission need and suitability. Increasing user satisfaction is the overriding objective.
Continuous Quality Improvement (QI) refers to a continuous and ongoing effort to achieve
measureable improvements in the efficiency, effectiveness, accessibility, performance, safety,
accountability, outcomes, and other indicators of quality in services or processes which achieve equity
and improve care and services to the community.

PROGRAM GOALS AND OBJECTIVES:

1. To promote the philosophy of continuous quality improvement providing staff with the
necessary knowledge and skills to implement the process.
2. To monitor community health status and social service needs, establishing priorities for
programs and services.
3. To ensure appropriate indicators of performance are identified and monitored for all
aspects of service provision.
4. To ensure optimal service provision through the auditing of established criteria and
standards.
5. To ensure compliance with applicable legislation and service agreements, including
externally required criteria/standards.

1.0 PROCEDURE
1.1 The quality management programs goals and objectives will be accomplished by:
1.1.1 Ensuring each programs quality management program is compatible with the
mission and values.
1.1.2 Ensuring mechanisms are in place to monitor compliance with applicable
legislative requirements.
1.1.3 Ensuring a program is in place to promote safety and monitor and reduce risk to
staff, visitors, volunteers, and clients.
1.1.4 Involving staff and clients in planning and defining the evaluation process.
1.1.5 Monitoring meaningful performance indicators to identify areas requiring
improvement and/or success of quality improvement activities implemented.
1.1.6 Ensuring each programs quality management program monitors the areas
needing attention and follow up.
1.1.7 Ensuring indicator analysis and plans of action are effective, comprehensive and
directed to improving or maintaining the quality of the services provided to
clients.
1.1.8 Encouraging the sharing of quality management knowledge and activities
between programs/services to eliminate the duplication of efforts.
1.1.9 Providing a means of ongoing evaluation and documentation of the effectiveness
of actions tried to overcome deficiencies.
1.1.10 communicating quality management activities to clients, staff, the Board, funders
and other stakeholders.
 1.1.11 Developing and supporting quality improvement teams in the resolution of
problems and to improve service.
1.1.12 Communicating to the Senior Management, Executive Director and Board issues
to be addressed in formulating future planning for program development and
service provision.

1.2 A quality plan will be presented to the HSP XYZ Board for review and approval on an
annual basis. At the end of the fiscal year in which the plan is implemented, the
leadership/management team will review the quality improvement activities conducted
during the year, including the targeted process or program outcomes, the performance
indicators (measures) utilized, and the improvements achieved as a result of the QI
initiatives taken in response to the findings.
1.3 Responsibilities
1.3.2 Board of Directors:
From a governance perspective, mandate the Executive Director and the
management team of HSP XYZ to implement and maintain an effective quality
management program that complies with the requirements as mandated by
external bodies and others as required.
1.3.3 Executive Director and Assistant Executive Directors:
Ensure an ongoing review of the processes to sustain the mission and
objectives of the HSP XYZ.
Ensure processes are in place to monitor the quality of care and services
provided which meet established evidence based practice benchmarks.
Ensure processes are in place to support the development and implementation
of a client safety program.
Receive and provide feedback to reports related to outcomes of care and
service provision, client satisfaction, ethical issues, client safety, risk
management and utilization trends.
Recommend policies and processes which enhance client safety and minimize
risk in provision of client care and service.
Ensure the Board has met its quality reporting requirements as mandated by
external bodies and others as required.

1.3.4 Director of Continuous Quality Improvement:

Support the accomplishment of corporate strategic plans that achieve high
impact and significant improvements in organizational performance.
Oversee and monitor the development and implementation of the quality
improvement program for the HSP XYZ.
Provide quality improvement expertise and knowledge to all levels of
management in the development and implementation of both program-specific
and corporate quality improvement plans.
Provide mentorship, support, education, and coaching to performance
improvement and quality improvement teams.
 Provide leadership for implementing changes targeted at systems/process
improvement. Measure and evaluate the attainment of results.
Assure that improvement activities are documented and reported within the
organization and externally as appropriate.

1.3.5 Program Directors:

Ensure a program/service-specific quality management program is developed
and implemented.
Ensure program staff receive training and follow established policies and
procedures for improvement initiatives.
Work with the Director of Continuous Quality Improvement to establish
criteria and standards for their areas of responsibility that meet both corporate
and external requirements.
Identify areas which require regular monitoring (e.g. critical procedures,
problem areas).
Track variances and outline strategies for improvement.
Evaluate the effectiveness of quality management and improvement strategies.
Report progress on improvement actions planned/taken.
1.3.6 Managers/Supervisors:

Identify and assess areas needing to be and/or are being monitored in their
programs/departments.
Develop, document, communicate and evaluate program/department
improvement plans.
Track, trend and analyze improvement activities and report to the program
Director or delegate on a monthly basis.
Report to the program Director any improvement activities that are not
producing the desired improvement.

1.3.7 Staff:
Work within the established policies and procedures of their
program/department.
Participate in activities related to continuous quality improvement.
Assist program management to establish and evaluate criteria and standards.

2.0 DOCUMENTATION
2.1 Each program director will maintain files of all quality improvement and management
activities including supporting documentation regarding performance indicators and audit
results.
2.2 Continuous quality improvement report summaries including performance indicators,
data analysis, variances, and strategies for improvement will be presented at monthly
Directors meetings.
3.0 REFERENCE SOURCES

APPROVED BY: Board of Directors

EFFECTIVE DATE: March 2014

REVIEW/REVISION DATE:

SUPERCEDES: