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- INTRODUCTION
- SUMMARY CHARTS
- External Reviews
- Internal Reviews
- EXTERNAL REVIEWS
- Council on Accreditation Review
- Ministry Licensing/Compliance Reviews
- United Way Allocations Review
- Royal College of Physicians and Surgeons Review
- INTERNAL REVIEWS
- Prevention and Early Intervention Services
- Voluntary Treatment Services
- Mandated Services (YJA)
- Centre Support Services
- Internal Risk Management
The Hincks-Dellcrest Treatment Centre engages in a number of quality management activities
intended to monitor, maintain, and continuously improve quality. These activities include:
- Reviews by external bodies, which measure the Centre's functioning against industry
standards and expectations. Currently, the Centre is reviewed by:
- The Council on Accreditation for Services for Children and Families (COA) reviews the entire organization every four years. This review compares the Centre's functioning against twelve sets of "generic" standards (applicable to all organizations) and program-specific standards as relevant to the organization being reviewed (e.g., outpatient services, day treatment, residential treatment, etc.). COA accreditation is accepted by Children's Mental Health Ontario (CMHO) as equivalent to CMHO accreditation. The most recent review occurred in 2004.
- The Ministry of Children and Youth Services (MCYS) annually reviews all children's residences for licensing purposes. This review primarily focusses on the Child and Family Services Act regulations for children's residences.
- The United Way reviews the prevention and early intervention programs that it funds (and the organization's administrative structure for those programs) every two years. This review examines the Centre's functioning against four criteria: program effectiveness; accessibility; resource management; and agency support for United Way.
- The College of Physician's and Surgeons of Canada reviews the training of psychiatric residents at Hincks-Dellcrest as part of its overall review of the training program for University of Toronto psychiatry residents. This review occurs every six years, and focusses on such factors as: resources for trainees; adequacy of exposure to an adequate range of appropriate diagnostic and age categories; and interaction with the community (e.g., providing consultation).
- We are required by law, licensing requirements, and accreditation standards to conduct a number of different types of inspections of our facilities, at least on an annual basis. With the exception of those conducted by the Centre's own Joint Health and Safety Committee, these inspections are carried out by external bodies (e.g., fire department, public health).
- Internal reviews of program/department functioning and effectiveness. Currently, the Centre conducts the following reviews:
- A quality assurance program for service delivery includes reviews of client records and client surveys to measure client satisfaction. Both activities include measurement of service against the Centre's four service standards (Individualization, Client Involvement, Continuity of Care, Normalization).
- Three referral source surveys are conducted within each two year period, covering the three major streams of service (prevention/early intervention, voluntary treatment, mandated services). Referral sources are asked to rate the quality and effectiveness of the Centre's services, as well as specific aspects of the Centre's activities (e.g., respect for culture, involvement of the client, etc.).
- Formal evaluation/outcome studies are conducted both on an ongoing and specific basis. All programs are expected to be engaged in some form of client needs assessment and outcome evaluation. Two tools mandated by the Ministry of Community and Social Services are the primary instruments used by the Centre's voluntary treatment programs.
- Service statistics (total clients seen, new admissions, length of service, etc.) are collected and aggregated on a monthly basis.
- An employee opinion survey is carried out annually.
- All departments/programs are expected to carry out annual program reviews, incorporating all department/program-specific results from the above reviews, reviewing major goals that were set for the year, and setting new major goals that are consistent with the Centre's strategic plan.
- A Risk Management Committee, composed of two sub-committees (Health & Safety, and Clinical Risk Management) reviews risk incidents and reports, including the Serious Occurrence report that is sent annually to the Ministry of Community and Social Services.
The first section of the attached report contains Summary Charts that summarize both progress on the improvement plans of the previous Quality Management Report, the overall results of the quality management activities since the previous report, and current improvement plans. The next two sections of the attached report provide the details from which the Summary Charts are drawn - first, the results of the external reviews; second, the results of internal reviews.
- The Brief Child and Family Phone Interview (BCFPI), and the Child and Adolescent Functional Assessment Scale (CAFAS).
II. A. External Reviews
1. Council on Accreditation for Services for Children and Families (COA) (2004)
| |
Previous Improvement Plans/Results |
Strengths |
Needed Improvements |
2006 Improvement Status |
| Purpose, Relationship to Community, Stability |
---- |
Met 100% of COA standards. |
---- |
---- |
| Continuous Quality Improvement |
Need to ensure utilization (record) review occurs at least once every ninety days.
Result: Implemented as planned. |
Met 87 % of COA standards. |
More front-line involvement in record reviews.
More systematic review of quality measures, and discussion and improvement planning, at program/department level. |
Completed.
In process. Completion expected by next site visit. |
| Management of Human Resources |
---- |
Met 98 % of COA standards. |
Need for better communication between different levels of staff and programs/ departments. |
Improvement plans from previous Employee Opinion Survey implemented. Results of for 2005 survey indicate openness in communication experienced greatest improvement (of all survey questions). |
| Financial and Risk Management |
---- |
Met 90 % of COA standards. (Reviewer error in 2 standards) (Would bring it up to 94%) |
Need to include criteria for contracting with investment advisors or firms in operational procedures. |
In process. |
| Quality of Service Environment |
Implementation of accessibility changes as resources allow.
Result: Automatic door openers added at Sheppard site in redesign of lobby. |
Met 100% of COA standards. |
---- |
---- |
| Professional Practices Assessment, Planning, Service Delivery |
Continue with form standardization process.
Result: Still a problem at 2004 site review. |
Met 99 % of COA standards. |
Consistency in structure, forms, "look" of client records. |
In process. Anticipate completion by next site visit.. |
| Outpatient Services |
---- |
Met 97% of COA standards. |
---- |
---- |
| Day Treatment Services |
---- |
Met 100 % of COA standards. |
---- |
---- |
| Residential Treatment Services |
---- |
Met 98 % of COA standards. |
---- |
---- |
| Open Custody Services |
---- |
Met 100 % of COA standards. |
---- |
---- |
| Prevention/ Early Intervention Services |
---- |
Met 100% of COA standards. |
---- |
---- |
2. Ministry Licensing/Compliance Reviews
| |
Previous Improvement Plans/Results |
Strengths |
Needed Improvements |
2006 Improvement Status |
| Weston Road (Residential Treatment Services) |
Ensure appropriate documentation of monthly fire drills.
Response: Recording system adjusted to meet requirements |
In compliance. Licensed renewed. |
Maintenance needs were seen as an area of concern. Work plan requested by the Ministry. |
Submit maintenance plan to Ministry.
(Status: Plan approved and work completed.) |
| 440 Jarvis St. (City Residential) |
---- |
In compliance. License renewed. |
Need for personnel records to be kept up to date regarding: immunizations; orientation to and review of agency policies; staff training regarding physical restraints and fire safety. |
Implement system for ensuring personnel record requirements are maintained on an ongoing basis. |
| Heathcote (Rural Treatment Centre - The Farm) |
Submit an annual water report for previous period.
Result: Compliance noted in 2006 review. |
In compliance. License renewed. |
Need for personnel records to be kept up to date regarding: immunizations; orientation to and review of agency policies; staff training regarding physical restraints and fire safety |
Implement system for ensuring staff record requirements are maintained on an ongoing basis. |
| Dovercourt (Phase II Open Custody) |
Prepare for successful initial licensing under the Youth Justice Services of MCYS.
Result: Successful licensing review occurred. |
In compliance. License issued. Commended for depth and detail of new Policies and Procedures Manual under YJS. |
Need for personnel records to be kept up to date regarding immunizations |
Develop system for ensuring personnel record requirements are maintained on an ongoing basis |
3. United Way Allocations Review
| |
Previous Improvement Plans/Results |
Strengths |
Needed Improvements |
2006 Improvement Status |
| Prevention/ Early Intervention Services (i.e., those funded by United Way) |
---- |
Performs strongly against all United way funding criteria. Provides innovative and highly effective programs that focus on prevention, builds community capacity and ensures optimal access for community members in the agency's catchment area. Panel recognized the excellent work of the management team and Board and the quality of the 2005/06 submission. Excellent resource management and support of the United Way. |
---- |
---- |
4. Royal College of Physicians and Surgeons of Canada
| |
Previous Improvement Plans/Results |
Strengths |
Needed Improvements |
2006 Improvement Status |
| Hincks- Dellcrest Component of Psychiatry Resident Training |
---- |
Excellent resources. Comprehensive exposure to broad range of ages, diagnoses, types of services.
Next Review: 2007 |
---- |
---- |
| |
Previous Improvement Plans/Results |
Strengths |
Needed Improvements |
2006 Improvement Status |
|
Prevention/ Early Intervention Services |
Work through issues in evolving relationships with new service partners, e.g., Multicultural Infant/Preschooler Program
Result: Ongoing
To develop a pamphlet describing services in Prevention and Early Intervention
Result: Completed
To complete evaluation of Baby Connection Project.
Result: Complete |
86 % of goals met at "expected" or "above expected" level. Wide spectrum of high quality, innovative services provided. Large volume maintained. Evaluations indicate continued high client satisfaction and positive outcomes. Services consistently exceed Centre targets for quality. |
Community needs assessments continue to indicate higher levels of poverty, and families without English.
Adequate space for services at Growing Together continues to be a problem.
Funding reductions necessitate reductions in programs |
Continue to seek more stable funding for Growing Together programs, including special projects whose funding is coming to an end. Seek new partnerships and strengthen existing partnerships to maximize prevention/early intervention services. |
Voluntary Treatment Services
OP Jarvis
CTS Day Treatment
RTS City Residence
Farm P180 |
Create more timely and efficient intake procedures within available resources
Result: All programs have revised and clarified intake procedures. Ongoing
To develop service proposals in response to new funding invitations from the Ministries.
Result: Proposals have been regularly submitted as opportunities arose. Ongoing
Standardization of reporting practices and forms across programs.
Result: Serious Occurrence reporting is standardized across programs. Ongoing. |
75 % of goals (n = 40) met at "expected" or "above expected" level for the 2004/05 program year. 15% dropped due to changing circumstances. All programs met and sometimes surpassed Ministry expectations re volume, occupancy, etc. Outcome data (CAFAS) indicates significant positive outcome in all treatment programs. Referral sources indicate satisfaction with quality and effectiveness of treatment services. Client satisfaction and quality ratings continue to be high. |
Waiting time for active service to begin better, but still a concern.
Still need for more standardization of client records across programs.
Some difficulty in ensuring standardized outcome measures and client record reviews are completed in timely way.
Communication with Boards of Education and community partners needs frequent monitoring to ensure a high level of treatment and classroom collaboration. |
Expand/enhance management of waiting lists.
Develop approaches within each treatment programs to reduce trouble-spots in record keeping.
Improve consistency in timely completion of outcome measures. |
Mandated Services (YOA)
Dovercourt Day Program
Y.O.A.S. Open Detention |
Monitor new service and consultation opportunities within new Youth Justice Act.
Result: Open Detention has received ongoing funding. Ongoing.
Update Policy and Procedures Manual for new licensing
Result: Completed Licensing reviewer commended program for excellence of product.
Mandatory and non-mandatory staff training occurs as planned and is recorded in HR records.
Result: Completed. |
93 % of goals (n=14) met at "expected" level.
At discharge, 87% of residents are positive or very positive about their level of success in the program. Ratings of referral sources/ community partners continue to be unanimously positive and enthusiastic regarding the programs. Flexibility and responsiveness to youth with special needs was seen as most helpful. |
Rapid changes in Ministry environment.
Ongoing collection of pre-post measures disrupted during many changes over past two years.
Need for protocols with Toronto Police Service. |
Monitor and respond to opportunities resulting from formation of Youth Justice Services within MCYS.
Ensure routine collection of pre-post progress within program.
Implement recommendation from security review regarding establishment of protocols with Toronto Police Service. |
Centre- Support Services
Information Syst. Program Eval. Research Clinical Services Finance Properties HR & Vol. |
Continue implementation of Centre's salary grid.
Result: Ongoing
Complete properties improvements as required by municipal inspections and licensing.
Result: Ongoing
Implementation of plans for improved internal communication.
Result: Completed. |
85% of goals (n = 34) were met at "expected" or "above expected" levels. High productivity in all support services. Many efficiencies continue to be found and implemented. No management letter from audit. Research activities very active. Program evaluation building outcome data based on the CAFAS measure over time. Areas measured in the annual Employee Opinion Survey continue to indicate 75% to 91% satisfaction. Significant improvement in internal communication. |
Computer systems/ equipment beginning to age.
Additional resources required for property improvements and maintenance as buildings age.
Staff involvement in program issues and planning |
Refinement and implementation of Client Information System across the agency.
Find ways to manage property maintenance needs with available resources.
Continue emphasis on staff communication and staff involvement in quality improvement planning. |
|
Internal Risk Management |
Develop ARM committee knowledge and skills in analysing risk data and providing relevant feedback to the Centre.
Result: Ongoing
Ensure staff mandatory behaviour management training occurs as required by the Ministries, COA, and the Centre.
Result: Complete. Behaviour management training occurs at planned intervals annually. |
Financial risk management systems received positive recognition from auditors.
Fewer staff lost-time injuries and claims from previous year. Clean bill of health re Health and Safety.
Pattern of serious occurrences remains similar to previous years except frequency of physical interventions is dropping over past two years. No concerns expressed by Ministry.
There were no complaints to the CEO from clients over year. |
Clinical Risk Management Committee having difficulty arranging for consistent quarterly meeting times. |
Establish consistent meeting schedule for Clinical Risk Management Committee. |
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