Management Standards

A. Values and Purpose
Man.
A. 1.1
The centre has written statements of its values, goals, and philosophy of
service delivery that are consistent with the overall direction set and
approved by the Board.

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A. 1.2
The centre's values, goals and philosophy of service delivery are based on a
careful consideration of the needs of the children and adolescents served
and the values of various stakeholders within the community.

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A. 1.3
The statements are reviewed at specified periods of time and revised as
needed.

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A. 1.4
Copies of the centre's statements of values, goals, and philosophy of service
delivery are provided to centre staff, and they are available to individuals
served and to the public.

B. Licensing and Regulations

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*B. 1.1 MANDATORY
The centre meets relevant licensing, regulatory requirements, and/or codes
of provincial and municipal authorities having jurisdiction over its program
of services.

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B. 1.2
Licenses or other documentary evidence of meeting regulations are readily
accessible.

C. Executive Director
THE EXECUTIVE DIRECTOR DEMONSTRATES EFFECTIVE LEADERSHIP IN AND
KNOWLEDGE OF THE MANAGEMENT AND OPERATION OF A CHILDREN'S MENTAL
HEALTH CENTRE, INCLUDING:

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C. 1.1
Communicating relevant Board directives and policies to the staff.

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C. 1.2
Developing, implementing, and reviewing policies related to the centre's
program of service.

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C. 1.3
Achieving the results approved by the centre's Board.

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C. 1.4
Actively participating with the centre's Board in planning, coordinating its
work, and assisting its members and committees in the performance of their
duties.

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C. 1.5
Ensuring that the Board is kept informed on matters affecting the centre's
finances, operation, and services.

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C. 1.6
Communicating the findings about the quality of the centre's services to the
Board and consumers as applicable.

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C. 1.7
Establishing effective management systems which enable staff to deliver
services that achieve the desired client outcomes.

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C. 1.8
Having a process for delegating authority and responsibility within the
centre.

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C. 1.9
Ensuring that the centre's managers and supervisors have appropriate
management skills.

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C. 1.10
Ensuring appropriate liaison, planning and collaboration within the local
community.

D. Centre Management
D.1 Policies

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*D. 1.1 MANDATORY
Behaviour management of children and youth.

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*D. 1.2 MANDATORY
Financial practices and records.

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*D. 1.3 MANDATORY
Clinical practices and records.

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*D. 1.4 MANDATORY
Human resource practices and records.

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*D. 1.5 MANDATORY
Administrative practices and records.

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*D. 1.6 MANDATORY
A process for receiving clients' complaints about the centre and/or services
received.

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D. 1.7
The nature of the services provided and eligibility to receive the centre's
services.

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D. 1.8
The contract between centre and clients regarding confidentiality, release of
information, involuntary treatment, and service coordination
responsibilities.

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D.1.9
The centre's policies are consistent with the laws and regulations relevant
to the operation of children's mental health centres in Ontario.

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D. 1.10
All policies are reviewed periodically to ensure that they are internally
consistent, compatible with recognized standards of professional practice,
and up-to-date.

D. 2 Management Structure and Communication
*indicates a mandatory standard

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*D. 2.1 MANDATORY
The centre's management structures define clear lines of accountability,
authority, and communication.

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D. 2.2
Accountability for supervision is clearly defined in a written job description.

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D. 2.3
Staff have the opportunity for peer consultation and informal meetings to
discuss professional issues.

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D. 2.4
Staff meetings are scheduled regularly.

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D. 2.5
Minutes of standing committee meetings are recorded and made available to
all participants.

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D. 2.6
Although the normal line of communication to the Board is through the
Executive Director, alternative routes of communication to the Board are
specified including under what circumstances they are used.

D. 3 Decision-Making
THE CENTRE HAS A CLEAR DESCRIPTION OF HOW MANAGEMENT DECISIONS ARE
MADE. THE PROCESS ENSURES THAT:

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D. 3.1
The centre's decision-making process is congruent with the centre's values,
philosophy, policies and procedures.

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D. 3.2
During the decision-making process, the chairperson facilitates an analysis
of issues, discussion and critical examination of the relevant issues.

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D. 3.3
Staff present the centre's management and/or Board with relevant facts,
options, and recommendations for decision-making.

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D. 3.4
Administrative decisions are made as close as possible to the level in the
organization that will be affected by the decision.

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D. 3.5
Decision-making affecting individual clients is made as close as possible to
the client level.

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D. 3.6
Major program decisions are based on needs assessment and consultation
with staff, clients, and relevant community organizations.

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D. 3.7
The centre has the opportunity for children, youth and parents to provide
advice about the development and planning of services.

E. Clinical Records
E. 1 Clinical Records- General
*indicates a mandatory standard

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*E. 1.1 MANDATORY
The centre maintains a clinical record for each registered client. Registered
clients are those clients who are identified by name and have a clinical file.

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E. 1.2
For registered clients, the clinical record clearly documents the presenting
problem, assessment findings, individualized goals, services provided,
progress, treatment outcomes, and termination plans.

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E. 1.3
The clinical record is written without jargon so that it may be easily
understood.

E. 2 Clinical Records- Policies
THE CENTRE HAS A WRITTEN POLICY GOVERNING ITS CLINICAL RECORDS WHICH
ADDRESSES:

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E. 2.1
Confidentiality of information in the clinical records.
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E. 2.2
Protection from destruction or loss and unauthorized removal or access of
confidential information.

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E. 2.3
Rough notes.

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E. 2.4
Secure procedures for record destruction.

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E. 2.5
Provisions for client access to records.

E. 3 Clinical Records- Practices
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E. 3.1
The clinical records are kept up-to-date according to written centre
guidelines.

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E. 3. 2
The centre has a written description of the types of information that are to
be documented in each client's clinical record at the time of intake.

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E. 3.3
Information recorded in the client's clinical record at the time of intake is
updated periodically.

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E. 3.4
At the time of each review of treatment progress, the information recorded
in the clinical record includes the progress achieved for each original
treatment goal and any new or revised treatment goals.

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E. 3.5
At specified times, the centre conducts an audit of a sample of clinical
records to ensure that the records contain current, accurate, and complete
information.

E. 3.6
The centre has written procedures for the release of information regarding
clients served and information from third parties (e.g., teacher reports).

F. Financial System
*indicates a mandatory standard

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*F. 1.1 MANDATORY
There is a bookkeeping and accounting system that accurately tracks
movements of the centre's funds.

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F. 1.2
The centre follows written accounting procedures which are consistent with
recognized accounting practices.

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F. 1.3
The centre's management reviews revenues and expenses on a monthly
basis.

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F. 1.4
All on-going purchase-of-service and fee-for-service agreements are in
writing, contain all terms and conditions, and comply with provincial
standards.

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F. 1.5
The centre's revenues and expenses are managed according to the budget
approved by the Board.

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F. 1.6
The approved budget is based on an assessment of the centre's program
priorities and reflects a realistic appraisal of funding anticipated during the
program year and all costs of operating the centre's program of services.

G. Human Resource System
Note: The term “staff” includes contract workers. Consultants who are not
employees of the centre are not required to have a human resource record;
however, the centre should have a written agreement for on-going consultants,
consistent with Financial Standard F. 1.4.
*indicates a mandatory standard

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*G. 1.1 MANDATORY
The centre maintains a human resource record for each staff member.

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G. 1.2
The centre has written human resource policies.

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G. 1.3
The centre's written human resource policies and its practices regarding
salaries, benefits, and working conditions promote the employment and
retention of qualified staff, and encourage high productivity and quality of
service.

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G. 1.4
The centre has formal procedures for the review of human resource policies
and for notifying staff of changes.

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G. 1.5
The centre has written guidelines that govern disciplinary action, up to and
including termination.

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G. 1.6
The centre has a clearly defined process, in writing, for termination which
includes evaluations and opportunities for remedial action.

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G. 1.7
The centre has formal policies concerning lay-offs and these are described
in the human resource policies and/or union contracts.

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G. 1.8
The centre has formal policies and procedures for responding to complaints
about harassment and discrimination.

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G. 1.9
The centre has formal grievance procedures and these are described in the
human resource policies and/or union contracts.

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G. 1.10
The centre specifies in writing the conditions under which it employs
persons related to board members or centre staff as well as current or past
clients.

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G. 1.11
The centre's written human resource policies are readily available to the
staff.

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G. 1.12
The staff human resource record contains the application for employment;
terms of employment; health certificate, where required; criminal reference
checks; verification of education; job description; and written performance
evaluations.

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G. 1.13
Completed in-service training is documented in the human resource record
of each staff member.

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G. 1.14
Human resource records are kept up-to-date.

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G. 1.15
The centre has a formal policy regarding the confidentiality of human
resource records.

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G. 1.16
Human resource records are secured against loss, destruction, or
unauthorized access.

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G. 1.17
Written procedures exist for staff to access human resource records to
review it and file notices to amend or correct inaccurate information.

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G. 1.18
The centre has a written policy concerning the content of letters of
recommendation.

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G. 1.19
The centre has a written policy that defines the time-frame for the
destruction of staff human resource records, except for the information
required to confirm employment by the centre.

H. Information System and Technology
H. 1 Client Information Collected

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H. 1.1
The centre has a written statement that defines the type and amount of
client information to be collected.

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H. 1.2
Number of clients referred and the number of registered clients.

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H. 1.3
Number of clients served by age, gender, and place of residence.

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H. 1.4
Number of clients served by presenting problems.

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H. 1.5
The number of clients whose service was terminated.

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H. 1.6
The centre uses a system (e.g., Brief Child and Family Phone Interview) to
collect accurate aggregate information that describes the children, youth,
and families served, for the purposes of planning, evaluation, and research
and meeting Ministry reporting requirements.

H. 2 Information System and Technology Policies
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H. 2.1
The information system is governed by written policies and procedures that
ensure the security of confidential information.

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H. 2.2
Electronic mail.

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H. 2.3
Voice mail.

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H. 2.4
Use of staff's home phones to contact clients.

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H. 2.5
Answering machines.

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H. 2.6
Fax machines.

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H. 2.7
Computer networks.

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H. 2.8
Cellular phones.

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H. 2.9
Laptop computers.

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H. 2.10
Diskettes, disks and other methods of electronic data storage.

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H. 2.11
Videotapes.

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H. 2.12
Hard copy (paper) transfer of files.

I. Safety and Risk Management
*indicates a mandatory standard
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*I. 1.1 MANDATORY
There are established procedures for referring risk issues to the centre's
management for action.

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*I. 1.2 MANDATORY
The centre carries fire, theft, and liability insurance.
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*I. 1.3 MANDATORY
The centre carries liability insurance that covers board members, trustees,
officers, employees, and volunteers.

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I. 1.4
The centre maintains its facilities and equipment in good working condition
and repair.

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I. 1.5
Services are provided in a healthy and safe environment

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I. 1.6
The centre has health and safety programs that address the health and
safety needs of children, youth and families, staff, and others.

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I. 1.7
The centre has regular reporting, at least annually, that documents health
and safety issues affecting consumers, staff, and others.

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I. 1.8
Evidence exists to show that action has been taken to correct the issues
identified in the health and safety reports.

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I. 1.9
The centre has a written plan for emergencies and disasters.

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I. 1.10
All centre staff review the plan for emergencies and disasters during their
orientation and at least annually thereafter.

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I. 1.11
The centre has written safety and risk management policies to identify and
manage risks to clients, staff, and others, and to the centre's property.

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I. 1.12
To document its risk management activities, the centre creates reports on
an annual basis that include risks identified, the actions taken to manage
the risks, and the effectiveness of the those actions.

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I. 1.13
There are established procedures for presenting risk issues to the Board for
information or action.

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I. 1.14
The insurance program of the centre is evaluated annually.

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I. 1.15
All persons delegated the authority to sign cheques or manage funds are
bonded or insured.