Unwavering Commitment to Excellence
Council on Accreditation – COA
The North Shore Neighbourhood House has been serving families and individuals on the North Shore for more than 70 years but what sets us apart as a leader in the work we do is the designation by the Council on Accreditation in 2005. This achievement came after a rigorous evaluation process against best-practice standards with input from a wide range of service providers, funders, experts, policymakers and consumers. It is yet another way that we are recognized for the quality of the work we do to improve the lives of the people we serve.
"The standards are grounded in a long-standing, widely held belief that individuals who receive services are the direct beneficiaries when organizations invest in strong management practice, and can validate the impact of their services on those served."
The House is committed to Continuous Quality Improvement (CQI) which is the accountability process that ensures the highest standards continue to be achieved in every element of our organization.
The Council on Accreditation (COA) is an international, independent, not-for-profit, child- and family-service and behavioural healthcare accrediting organization. It was founded in 1977 by the Child Welfare League of America and Family Service America (now the Alliance for Children and Families). Originally known as an accrediting body for family and children's agencies, COA currently accredits over 45 different service areas.
To find out more about COA please visit their website at www.coanet.org.
Commitment to Service Excellence
At the North Shore Neighbourhood House (NSNH), commitment to service excellence is more than a statement; it is part of our culture. It is reflected in our Mission, Vision and Values, in our programs and services, in the way we engage our community, and in the way staff interact with each other.
Our Continuous Quality Improvement (CQI) process monitors what we do to make sure we stay true to this commitment. CQI uses indicators and data collection mechanisms to spot trends and opportunities for improvement; it makes recommendations; follows up on those recommendations and monitors change. CQI involves staff from all levels of the organization and departments. The committee reports out to senior management and the Board of Directors.
Our commitment to service excellence is enhanced by other procedures and processes within the organization. As an organization, we have committed to each of the following:
North Shore Neighbourhood House conducts a comprehensive, long-term strategic planning review at least once every four years.
Each NSNH program prepares an annual program plan which supports the overall long-term goals of the organization and includes objectives for the year, methods for achieving objectives, timelines for completion of tasks, the individuals assigned to the tasks, and where appropriate, budgets.
Service Performance Measurement
NSNH is moving toward the development of meaningful program outcomes. We use a service logic model for those programs funded by the provincial government. Other programs provide service performance measures (outputs) annually.
Internal Quality Monitoring
North Shore Neighbourhood House examines its internal processes annually.
Senior Staff review outreach, intake, assessment, service delivery methods, deployment of employees within the organization, supervision and training to identify barriers to service or opportunities to improve service.
The Board of Directors receives reports on internal processes through the Executive Director (E.D.), may make policy changes based on information received and receives an annual report and presentation from the Chair of the CQI Committee.
Measurement of Consumer Satisfaction
NSNH surveys persons served each year to ascertain consumer satisfaction.
Provision of Information to the Community
The North Shore Neighbourhood House provides information about its annual activities to the community through an Annual Report and the NSNH website.
Mission, Vision, Guiding Principles
The North Shore Neighbourhood House is a not-for-profit registered charity serving the North Shore community since 1939. We believe working together to meet the grassroots needs of our neighbours, especially our most vulnerable residents, is essential to building a safe, healthy and strong community. The House values and promotes cooperation, respect and empowerment through the provision of programs and services designed to meet the needs of individuals and the community as a whole.
We are working to build a safe, healthy and strong community welcoming all ages, abilities and cultures – one where everyone has access to support, everyone is included, and where everyone matters.
The North Shore Neighbourhood House provides support, referrals, programs and services in specific areas:
Building Strong Families
Families come in many shapes and sizes – their needs are just as diverse. At the House we provide a wide variety of programs and services to help parents, caregivers and kids to reach their full potential in a safe, supported environment.
Whole Health for All Ages
Strong individuals make strong communities and every individual deserves the opportunity to reach their full potential. At the House, many of our programs incorporate aspects of physical and mental wellness, from nutritional information sharing and food security to fitness classes to cultural outings and educational workshops.
The North Shore Neighbourhood House is proud to work collaboratively with numerous local agencies and organizations to meet the needs of North Shore residents. Our goal for these partnerships is to benefit our neighbours of all ages and stages by sharing resources and supporting and building on each other’s strengths, providing a model for how strong communities are built.
Facilitating Community Development
Community development involves outreach, consultation, public participation and listening. The Neighbourhood House aims to engage the community in decision-making, planning and action. This brings people together, allows them to discuss important community issues such as poverty and homelessness, and to work alongside one another in bringing about change and building the kind of community we all want and need.
Celebrating Multicultural Connections
The North Shore Neighbourhood House celebrates diversity. We work with a number of other organizations to ensure the House is culturally inclusive and sensitive. We aim to provide accessible community space and to build a welcoming community for all where ideas and knowledge are respectfully shared.
- To effectively respond to community needs through the delivery of programs and services on the North Shore
- To ensure our programs, services and public spaces are accessible and affordable to all
- To engage in addressing specific issues which affect the well-being of our community
- To ensure all North Shore residents are aware of our programs and services
- To ensure both internal operations and external programming meet our guiding principles of:
- Equality: To be inclusive and accessible to all community members
- Respect: To celebrate diversity, creativity and individual expression
- Empowerment: To value and welcome the contributions each individual can make based on their ability
- Excellence: To adhere to and meet the highest national standards of professional performance
- Collaboration: To share resources and forge partnerships to benefit the community
- Accountability: To responsibly and ethically manage all financial and personal records
- Sustainability: to strive toward economic and ecological sustainability in our organization
- Courage: to advance our principles and vision in the face of adversity and challenges
OUR Continuous Quality Improvement (CQI) Plan
Continuous Quality Improvement (CQI) is a process by which we regularly and purposefully:
- evaluate the efficiency and effectiveness of programs and services;
- examine internal systems, procedures and outputs;
- examine input from participants; and
- examine relationships and interaction between NSNH and other key stakeholders.
This is done through:
- regular and structured review of internal procedures, program data, training, and day to day operations;
- informing staff, supervisors, managers and the Board of Directors of areas of success and areas needing improvement
- making and monitoring recommendations for improvement.
- Chairperson (See Job Description below)
- Review summarized data as available and report on:
- Questionnaires distributed to persons served regarding their satisfaction with NSNH services; Complaints, incidents, and accidents of persons served; Employee grievances, incidents, or accidents
- Summarize and report on information gathered from quarterly case record reviews in those programs where such records exist
- Review and report on any other issues relative to service delivery that come before the committee
- Youth Outreach
- Young Parents Program
- Teen Club
- Seniors Peer Support
- Child Day Care (for children requiring extra supports)
- Summary of Annual Questionnaire of persons served
- Summary of Annual Employee Satisfaction Survey
- Reports from Annual Youth Forums
- Report from Annual Child Care Parent Night
- Comments from persons served out of Suggestion boxes
- Minutes of AGM re member satisfaction
- Any other feedback from stakeholders, funders, persons served or partner organizations relative to service delivery.
- Sets meeting agenda, ensures minutes are maintained, and books facility space for committee meetings
- Facilitates Annual Review and Strategic Planning Session for CQI committee and generates Strategic Plan with target dates
- Follows and completes all tasks indicated on the CQI Review Schedule (see attached form); ensures committee members have all training, instruments and contact information needed for effective completion of quarterly case review; sets deadlines for all report submissions indicated in CQI Review Schedule; liaises with departments to request data as indicated by the CQI review schedule
- Reviews collected data on a quarterly basis and helps committee identify trends of quality concern; generates quarterly reports with recommendations based on CQI review schedule criteria for improvement in the organization
- Stores all documentation (e.g. minutes, reports) collected, aggregated and generated from CQI functions in CQI folder on shared files
- Schedules monthly meetings with ED; tracks issues that require follow up
- Produces Committee Annual Report
- Produces submission for NSNH Annual Report
- Prepares annual presentation to the NSNH Board of Directors
- Provides training to CQI committee members when needed or requested
- Promotes atmosphere that recognizes and celebrates the "culture” of Continuous Quality Improvement across the organization
- Champions the continued focus on systems, process and feedback through the use of set mechanisms and tools designed to help quantify the organization’s performance
- Encourages the involvement of all stakeholders in the CQI process
- Fosters an attitude of openness, respect, teamwork and accountability to excellence in service
- On an organizational level, provides training in the "culture” and function of CQI and how it is embraced and implemented by the NSNH
- Attends CQI training opportunities as provide by COA and agreed upon by ED
At every step of the way, the purpose is to improve programs and services for the people we serve. It is not about, nor can it be used as part of a supervisory or work performance process.
This document outlines our quality improvement process. It details how we carry out the gathering of important information and how that information is reviewed and acted upon.
The CQI Committee
The Committee is composed of staff representatives from all program areas.
The CQI Committee selects its own chairperson and minute taker.
Committee members attend as part of their regularly scheduled work day (with no loss of pay).
The committee meets monthly to perform the following functions:
Each calendar year the CQI Committee produces an annual report on its activities and a work plan for the coming calendar year. The report is delivered to the Executive Director (by March 1st) and the Board of Directors of NSNH (by April 1st) and is then available to all employees and stakeholders.
The attached flow chart visually demonstrates the flow of information and resulting work.
Information to be reviewed
1. Records of persons served (Case Records)
Records of persons served are reviewed quarterly in the five programs where records are kept. Case records are maintained in the following programs:
Records are reviewed to ensure that the NSNH is delivering service in an effective manner. Compiling information on people we serve ensures that we are (1) gathering important demographic information, (2) denoting emergency contacts and medical information, (3) keeping careful progress notes, and (4) making appropriate referrals to other community resources.
Results of the case record review are summarized and reported to the CQI Committee.
2. Complaints, critical incidents and accidents involving persons served
The Committee looks at all the complaints and incidents for that quarter. These reports are kept in a central location by program. The Committee summarizes the information in their quarterly report and reports on issues they deem appropriate.
3. Program Feedback
NSNH is moving toward the development of meaningful program outcomes. CQI will be involved in monitoring both the development of these outcomes as well as the indicators of achievement. Program objectives/outcome measures/or Service Performance Measures (titled differently depending on the program) are reviewed and revised each year by Program Managers and their employees. A copy of the program objectives is to be passed on to the CQI Committee once a year.
(a) From Persons Served
Program Managers pass on to the CQI Committee any surveys, questionnaires, or important informal feedback which is provided by persons served regarding their satisfaction with services.
(b) Grievances from employees
The Union Representative is invited to submit a quarterly report to the CQI Committee outlining in general terms any recent grievances. The CQI Committee makes recommendations, if warranted, to the Executive Director.
The CQI Committee is given copies of the following documents (quarterly or as appropriate) by the Executive Director or Program Managers.
5. Risk Management
The CQI Committee quarterly reviews overall risk to the organization.
CQI Committee Review Process
All of the data described above is discussed by the CQI Committee at its monthly meetings as part of the quarterly review process.
Data is reviewed on the basis of the following criteria: a) issues and concerns regarding policy and procedure; b) issues and concerns regarding health and safety; c) trends that need to be addressed in a preventative way.
Observations and recommendations of the CQI Committee, including comments regarding service areas that are not performing according to established policy and procedures, are compiled in a quarterly report and distributed to the Executive Director. The CQI Committee report includes suggestions for change and recommendations regarding serious trends or issues that need to be reviewed by management. The ED distributes the report to Senior Staff for comment as well as schedules the report on a Senior Staff Team meeting agenda.
In addition, the chair of the CQI committee can bring forward any item from the review or otherwise ascertained with the ED in their monthly meetings.
Implementation of CQI Committee Recommendations
The Executive Director discusses recommendations with the Senior Management team at their bi-weekly meetings. Senior Managers review, comment, strategize, propose solutions and develop timelines for the implementation of changes, if change is deemed necessary. Depending on the nature of the change required, either the Executive Director sets new policy or procedures or asks the specific program managers assigned to the area in question to develop new policy or procedure. The CQI Committee is informed by the Executive Director of what action has been taken on CQI recommendations.
The Executive Director may choose to bring CQI recommendations to the Board of Directors for their comment.
CQI Committee Chairperson – Job Description
The Chair of the CQI committee is selected annually by members of the Committee. Working collaboratively with other committee members, the Chair assumes primary responsibility for leadership of the CQI committee. As such, the Chair guides the CQI Committee with respect to the following:
In addition, the Chair of the Committee undertakes the following tasks as time and opportunity permits: