St. Leonard's Community Services

St. Leonard’s Community Services strives to provide the highest quality of service for clients through the ongoing implementation of quality improvement activities. The purpose of these quality improvement activities is to gather information in an organized fashion in order to compile and analyze the trends and patterns of services. The resulting reports will provide information to various levels of the Agency, which may result in changes, and/or improvements to client service delivery.

The Board of Directors sets overall standards for the quality of Agency services and assumes responsibility for service outcomes.

The Executive Director serves as the quality improvement manager and is responsible for developing and implementing a quality improvement process in the form of an annual program planning cycle.

The Agency employs a Planning and Evaluation Model (see Appendix 1) as a quality improvement tool to determine the needs of clients, to plan for program outcomes and program activities and to evaluate the quality of services delivered to clients.

The Agency utilizes the ongoing implementation of quality improvement activities such as:

The Agency regularly collects client and referral source feedback concerning the Agency’s quality of service.

Upon case closing, the Counsellor (Primary Worker) will give a satisfaction survey to the client, and where possible, their family and referral source(s). The Counsellor (Primary Worker) will retrieve and forward the completed forms to the Manager.
On the File Closure/Discharge Checklist, the Counsellor (Primary Worker) will indicate who received the feedback forms, the date they were returned, any follow-up required and who may still need to receive forms. This form serves as a prompt for tracking and follow-up by the Manager who will resend any outstanding feedback forms as indicated by the File Closure/Discharge Checklist.
The Manager tracks the forms and follows up by phone within 2 weeks on any incomplete feedback forms in an effort to complete the form over the phone with the client, family, or referral source.
On a semi-annual basis, the Managers forward the completed Satisfaction Surveys to the Executive Director, who reviews and shreds the information after preparing notes for discussion with the Management Team and the Board of Directors.
After review by the Board of Directors, the report may be shared with clients or referral sources as part the of the Executive Director’s regular community update or as part of the Annual Report. The Executive Director may direct follow up contact with clients as required.
Following the development of the report, the feedback forms will be shredded by the Executive Director’s Executive Assistant.

Serious Occurrences/Incident Reports (see 2-100 Incident Reports, 2-110 Serious Occurrences).

Serious occurrences and incident reports are reviewed monthly by each department with a view to preventing future occurrences and to assure improved quality services.

Serious occurrence and incident report reviews are documented in staff meeting minutes and/or Case Management minutes. The Serious Occurrences are also reported to the Board of Directors in the Service Director’s Board Report.

Client File Quality Review

As a quality improvement measure, client files are reviewed regularly to ensure consistency and thoroughness. (See Planning Appendix 2 Client File Audit Checklist)

On at least an annual basis, the Executive Director will have client files from each program randomly selected for review by administrative staff to ensure quality improvement. The staff member conducting the review will document the review by signing and dating the Client File Audit Checklist. The results of the review will be forwarded to the Executive Director for reporting to the Management Team.

1-10 QUALITY IMPROVEMENT

POLICY

Client File Quality Review