Impact

Key results included:

• 100% uptake of the program by management and staff throughout the organization.
• 89% of organization programs are now rating in control limits for client and staff satisfaction.
• 50% of programs have completed corrective action plans to strengthen services for clients or staff using the data from the program as a starting point.
• 100% of the programs continued to have consistent performance throughout the pandemic and were able to monitor progress using the Health Index Report System.
• 10% reduction in leadership team time to find and identify areas for improvement to watch by using a new quarterly meeting structure.

Qualitative results included:

• strong participation of staff in corrective action plans
• solid attendance at the quarterly quality meetings
• positive feedback from the leadership team on the ability to maintain and use the process to improve overall quality in the organization
• comprehensive report illustrating the status of indicators and summary of corrective actions plans to share with stakeholders, leadership team and clients
• the CEO is pleased with the results as outlined in the 2019-2021 Annual Report.

Context and challenges

ICAN is a non-profit organization that provides services to enable clients to live independent, productive lives. Located in Sudbury, Ontario, clients access services in English and French. The services include post-stroke transition, supportive housing, outreach services, temporary housing, assessment and progressive independence training.

The leadership team consists of managers involved in client services and administration such as finance and accounting. Collectively, they work together to provide leadership to support staff throughout the organization and client services. In addition, they work together to ensure the quality improvement process and model support the ability of ICAN to serve clients in the community.

Context – The ICAN leadership team worked extensively on rebuilding our Quality Improvement Manual and Model. Quality of services is a crucial element expressed by clients, staff and third-party stakeholders (e.g., Funding bodies, Accreditation Standards). Clients provide feedback regularly on services and they are required to capture data on service delivery.

Emerging opportunity – The organization participates in the CARF Accreditation Program. CARF provides advice and direction to its standards upon the completion of an on-site survey. The past CARF survey identified the need for the organization to rethink how it was:

• analyzing performance indicators
• using the indicators for improvement opportunities
• communicating results to staff, clients and stakeholders.

Key challenge – What can we do, as an organization, to rebuild our processes to collect performance indicators, review and learn from the data quarterly, make adequate changes as required and report our learning journey?

Project objectives

Upon completion of the project, ICAN would have a:

• set of quality performance indicators to support staff and clients
• process to capture, record, analyze and act to improve services for clients
• framework for quarterly meetings to review the data
• data approach to starting quality improvement projects to support organizational change.

Approach

Clarifying the problem – A working session with the facilitator to outline the existing challenges with the quality program, the role of the CARF Accreditation Standards and current practices in the organization.

Building a facilitation design – A series of design meetings to identify the session objectives, essential resources to assist the group, existing materials and practices and framework for interactive working sessions.

Team briefing on the session – A conversation with the facilitator to review the facilitation design, proposed plan and materials to support the three-day session.

On-site facilitation event – The three-day event on the following topics.

• Inside the current organizational challenges with quality indicators and reporting.
• Exploration of the CARF Requirements – what are we missing?
• Building a Health Index Report – a tool to support seeing and using data for individual program and organizational analysis of the client experience.
• The creation of tools and activities to support quality activities as part of the organizational culture and full implementation.

Debrief with the facilitator – A conversation between the CEO and facilitator to review the session results, session report and learning points for future sessions.

Ongoing dialogue – Follow up phone calls and dialogue with the facilitator on the implementation status and how the work aligns with the agency's strategic priority – CARF Standards, client expectations.