THE ADANTA GROUP
FY 2007
STRATEGIC PLAN
Updated July 2006
MISSION STATEMENT
ADANTA
is dedicated to establishing and maintaining a standard of excellence in
providing community behavioral health care and developmental services to the citizens
of the 10 county Lake Cumberland area in order to enhance the quality of life
for those in need of such care and the family members of those served.
The
Adanta Group and its Board recognize the growing public awareness and interest
focusing on the problems of mental illness, the challenges that individuals
face due to developmental disabilities, and the disease concepts of chemical
dependency. The Board holds that mental
illness and the disease of chemical dependency and abuse are treatable and that
persons with developmental disabilities can learn to live in the community as
contributing and self-fulfilling members.
The Adanta Group and its
governing Board recognize that effective programs require an array of services,
planned and developed in response to community needs. Regional planning is the means by which staff
and consumers control the development of service delivery. The assessment of needs resulting from mental
illness, developmental disability, chemical abuse and misuse, emotional and
physical abuse, rape, sexual assault and/or sexual abuse, along with the
implementation of services to meet those needs, and the ongoing evaluation of
the quality of care provided by The Adanta Group and its Board are the means by
which citizens influence the delivery of services. The volunteers who serve on The Adanta Group
Board and the staff carry out a mandate from the Commonwealth to serve as the
responsible Mental Health-Chemical Dependency-Developmental Disability
authority in the 10 county region.
The Adanta Group and its Board
subscribe to the following tenets as the responsible planning authority in
Region XIV:
1. We
believe that every person is worthy of respect and is entitled to have an
opportunity to live and work in keeping with human dignity and worth.
2. We believe that the prevention and
treatment of mental illness and substance abuse, and intervention with the
developmentally delayed, support services for persons who have been emotionally
and/or physically abused, raped, sexually abused or sexually assaulted is a
vital and integral part of health care.
3.
We believe that the mind, body, and spirit function as
a harmonious unit and an adverse effect on one also affects the others,
requiring treatment of the whole to restore balance.
Implementation of the organization’s mission reflects
emphasis on three important key aspects:
1. Consumers
·
A commitment to the consumers of Adanta, which
includes referral sources, clients, funding sources, the community and society
at large
·
A commitment to utilizing our consumers’ time
and money efficiently
·
A commitment to a Quality Improvement process to
assist in providing consumers with innovative targeted intervention to meet
their needs
·
A commitment to providing an environment
conducive to Professional Services
·
A commitment to accept our responsibilities as a
mental health, substance abuse, and developmentally disabled, victim services,
and prevention regional authority by being a contributing community member
2. Staff
·
A commitment to staff excellence by providing
necessary resources to enable successful outcomes in their work
·
A commitment to a Quality Improvement process
which allows staff to meaningfully contribute to improving excellence in
fulfilling their professional responsibilities
·
A commitment to ongoing education and training
opportunities for staff
3. Organizational
Leadership
·
A commitment to provide those resources
necessary to ensure excellence in service delivery
·
A commitment to a Quality Improvement process to
maintain a constancy of quality service and purpose
·
A commitment to achieving financial stability
and success to assist in insuring our goals
·
A commitment to drive out fear through open,
honest, and direct communication
·
Ongoing change is recognized and valued as
essential to organizational success
ORGANIZATIONAL
DESCRIPTION
The
Lake Cumberland Regional Mental Health/Mental Retardation Board, inc., began operation in 1967.
The scope of the program was limited and for several years operated on a
“traveling team” model. Primary offices
were located in Pulaski and Wayne Counties; satellite offices were located in Clinton, Russell, and McCreary Counties. Comprehensive counseling, adult day
habilitation, and preschool services were the only services available. In the early 1970’s, the Commonwealth
mandated conformity of catchment areas with those of the Area Development
Districts. As a result, Adair, Casey, Cumberland, Green and Taylor Counties
were added to Clinton, McCreary, Pulaski, Russell, and Wayne creating a service
area of 3,613 square miles. By 1973,
there were offices in all 10 counties.
The
corporation has experienced tremendous growth over the past few years. This growth is a result of the company’s
ability to provide quality professional service and care. Today, the corporation encompasses over 40
facilities across the region including mental health and substance abuse
outpatient clinics, workshops, and group homes.
These facilities are staffed by professional therapists, psychiatrists,
psychologists, case managers, trainers, educators, and support staff.
To
reflect the total care offered, the Board decided to unify its many group and
subgroups across the region under one name and identity. Therefore, on April 15, 1991, the Lake
Cumberland Regional Mental Health/Mental Retardation Board, Inc. changed its
business name to The Adanta Group. The
Adanta Group continues to offer services in a way that is geographically,
financially, and culturally accessible to the residents of the Lake Cumberland
area. The Adanta Group is dedicated to
the advancement of services in community mental health, chemical dependency,
prevention, and developmental disabilities.
This is accomplished by supporting, developing, and practicing innovations
in advocacy, education, and communication to enhance service effectiveness.
The
Board is comprised of 33 people from various professions who volunteer their
time and energy to improving the quality of life for the citizens in the
communities they represent. The Adanta
Group has five service divisions: Clinical Services, Human Development
Services, Child and Family Services, Alcohol and Other Drug Abuse Treatment
Services, and the Regional
Prevention Center. Each division is responsible for providing
services to a distinct part of the population, all relying on the expertise and
resources of the others in coordinating services.
The
Adanta Group offers some 40 programs in 10 counties of the Lake Cumberland Area
Development District. The Administrative
offices are located in Somerset. Adanta maintains full-time mental health and
substance abuse outpatient clinics, therapeutic rehabilitation programs,
substance abuse prevention and intervention, collaborative school projects
(Alternative Education Program, Youth Day Treatment, School-Based Services,
etc.) and IMPACT services in all 10 counties.
All locations maintain appropriate fire and safety licenses as mandated
by state and local authorities. Each
location is responsible for enforcing all of Adanta’s mandated security
policies and procedures. All physically
owned and leased locations are handicapped-accessible as enforced by both state
and local authorities.
The Lake Cumberland area has a resident population of approximately 200,000 people in a 3,613 square mile area. The Adanta Group serves approximately 10,000 consumers in this region, providing a full array of mental health, developmental disability, and chemical dependency services. The primary objective is to provide these services in accordance with Joint Commission Accreditation Standards, Kentucky Department for Mental Health and Mental Retardation Services regulations, and Medicaid/Medicare guidelines.
Somerset, county seat of Pulaski County, is the largest city within this area with an estimated population of 12,136. Next are Campbellsville, county seat of Taylor County, with 10,906; Monticello, county seat of Wayne County with 6,062; and Columbia, county seat of Adair County, with 4,174. Somerset and Campbellsville have established industrial and commercial bases with the ability to attract more industry to help alleviate insufficient employment and low income throughout the area. Commuting to these towns from the adjoining counties for work and trade is customary. Monticello, Russell Springs, and Columbia remain on the threshold of similar development. (All population figures from 2005, US Census Bureau).
According to the
Kentucky Workforce Development Cabinet, the 10 counties of the Lake Cumberland
Region have a labor force of 90,617 with a 6.3% unemployment rate. The 10 counties served by The Adanta Group
reflect a 20.4% average poverty rate compared to a state average of 17.7% for
the same period (Kentucky Cabinet for Economic Development). Nearly 19% of our region’s population is
uninsured.
ORGANIZATIONAL LEADERSHIP AND GOALS
Organizational
Goals
1. To provide quality behavioral health services to the Lake Cumberland
community. Services include mental
health; substance abuse; prevention; case management; education; rape, sexual
abuse and/or sexual assault advocacy and treatment; and programs for persons
with mental retardation and developmental delay.
2. To anticipate developments in both
clinical and administrative practices in order to provide the best possible
services to the community.
3. To provide services that
are minimally disruptive and enable the people of the Lake Cumberland
community to maintain a high quality of life.
4. To hire and retain staff and provide
opportunities for clinical, administrative, and personal improvement.
Lines of Authority
The formal organizational line of
authority begins with the Board of Directors.
This body is made of volunteers chosen from all 10 counties (Adair,
Casey, Clinton, Cumberland, Green, McCreary,
Pulaski, Russell, Taylor, Wayne)
served by Adanta. One of the main
functions of the Board is to ensure that the mission and goals of the
organization are met. The Board provides
oversight and direction to the Chief Executive Officer and staff through
monthly Board meetings.
The Chief Executive Officer
carries out the Board’s intentions and informs them of the operations of the
organization. The CEO provides vision
and focus for the organization and builds consensus when feasible so that
stakeholders affected by decision are involved and the optimal course of action
is taken. The
CEO is chosen by the Board to oversee the functions of the organization and is
directly responsible for operational activities.
The Chief
Executive Officer appoints various staff to assist with operations of the
agency. Assistants to
the CEO serve as a team to oversee Human Resources, Business
Office functions, and Operations.
The CEO also supervises the Performance
Improvement Director/Ombudsman. The Medical Director is
responsible for developing,
reviewing, and implementing plans for clinical
compliance. The Clinical Director
oversees the operations of Adult Clinical Services including
outpatient, therapeutic
rehabilitation, case management, crisis, peer support,
housing, and rape victim services.
This Director also
supervises the Associate Clinical Directors: the Mental Retardation/
Developmental Disability Director, the
Alcohol and Other Drug Treatment Director, and the Children’s Services
Director. Each of these Associate
Directors leads a division within their area of expertise. The Alcohol and Other Drug Treatment Director
oversees the Substance Abuse outpatient operations; the MR/DD Director oversees
the workshops, Tencos, and adult residential programs for the MR/DD population;
and the Child and Family Services Director is responsible for children’s
outpatient programs—school based, IMPACT, children’s residential, and day
treatment. The Prevention Director
oversees all aspects of alcohol, tobacco, and other drug Prevention
services. The Rape Victim Services
Director is responsible for all activities associated with referrals regarding
sexual/ physical/ domestic abuse. The
Corporate Compliance Officer is charged with oversight of investigation and
reporting of compliance violations or issues discovered through reviews and/or
audits. The Marketing Coordinator is
charged with marketing activities for the promotion of the agency, including
media placement, the quarterly newsletter, and program promotion. The
Performance Improvement Director/Ombudsman is responsible for JCAHO
organizational compliance and improvement as well as being the caretaker of
complaints from clients, family members, or other invested parties. All of these individuals comprise the
membership of the Regional Executive Committee.
The Regional Executive Committee
also serves as the Performance Improvement Committee. This team provides information to the CEO,
supervises the execution of organizational goals and tasks, and provides
direction to site and department managers.
This Committee meets regularly every month with specially called
meetings when appropriate.
Site Supervisors serve as
managers in each of the counties served by Adanta. These individuals manage the day-to-day operations
of the programs in their respective counties in conjunction with the members of
the Regional Executive Committee.
Program staff
complete the formal lines of authority.
This group comprises the heart of the organization and is responsible
for direct delivery of services, having the most direct contact with people
served by the organization. Program staff execute organizational goals and also fulfill an
informational role in the decision-making process.
Committees
Regional Executive/Performance Improvement Committee (REC/PI)
The primary committee is the
Regional Executive/Performance Improvement Committee as mentioned above. This committee provides all staff access to
the resources of the agency. Members of
the REC/PI give reports on the operations of their respective departments,
divisions, or programs. It is in this
committee that major issues are discussed and a consensus reached. Actions taken or recommended by other
committees area also reported here by various staff and approval granted before
implementation.
During the Performance
Improvement portion of the meeting, important aspects of care are reported and
monitoring results shared. This
reporting provides information, both statistical and programmatic, that results
in better decision-making and better client care. Through the monitoring process,
organizational focus areas are identified and appropriate staff
are notified so that proactive steps can be taken that will result in an
improvement of performance—clinical, administrative, and programmatic.
Clinical Leadership Committee
This is a focus group made up of
the CEO, Medical Director, Clinical Services Director, and all Associate
Clinical Directors/Division Directors.
This committee is designed to compliment the REC/PI Committee by
focusing more on the treatment aspects of service deliver as opposed to
administrative issues. All
recommendations are presented to the REC/PI Committee.
Environment of Care Committee
This Committee develops, reviews,
and revises all policies and procedures related to infection control and
safety. The Environment of Care
Committee provides updates on infection control and safety education for all
staff. The Committee also provides risk
management assessment, which is conducted through a review of all adverse
incidents, evaluation of areas that may cause potential incidents, and
evaluation of areas of potential liability.
This Committee reviews all reports containing data related to the
physical environment from inspections by accrediting, licensing, certifying,
and other outside inspection agencies.
Policies and Procedures are also reviewed/revised pertaining to Safety
Programs. Recommendations are presented to
the REC/PI Committee.
Behavior Management Committee
The Behavior Management Committee
develops, reviews, and revises all policies and procedures related to managing
client behavior. This Committee reviews
and approves all behavior management plans.
All recommendations are presented to the REC/PI Committee.
Pharmacy & Therapeutics Committee
The Pharmacy Committee develops,
reviews, and revises all policies and procedures related to physical health,
such as drug dispensing and drug administration. Agency reports are monitored related to
adverse drug reactions within the agency.
Staff training for new employee orientation and annual continuing
education is provided. This Committee
reviews all reports containing data related to drug dispensing and drug
administration from inspections by accrediting, licensing, certifying, and
other outside inspection agencies.
Policies and Procedures are also reviewed/revised pertaining to
Infection Control. Recommendations are
presented to the REC/PI Committee.
Peer Review Inspection, Documentation, and
Education (PRIDE) Committee
The purpose of the PRIDE
Committee is to review the records of active and discharged clients to ensure
timely and appropriate documentation of clinical data, and ensure the adequacy
and appropriateness of treatment plans.
The Committee uses pre-established screening criteria to pull the sample
of medical records to review. After
reviewing records, the Committee is charged with making recommendations to the
Performance Improvement Committee.
Recommendations may include training, special treatment procedures,
treatment planning, symbols and abbreviations, and admission and discharge
activities. The final result of the
reviews is the promotion of high standards in medical record maintenance.
Incident Report Review Committee
The Incident Report Review Committee was formed to regularly
examine the types of incidents occurring in agency programs (particularly
client injury and staff injury), look for trends, and make recommendations
toward reducing the occurrence of these types of incidents. Recommendations may
include training, policy revision, special procedures, and evidence-based
practice guidelines.
Language Assistance Committee
As
a recipient of federal funds Adanta is obligated to provide meaningful access
for Limited English Proficient (LEP) individuals to all programs and
services. Individuals who do not speak
English as their primary language and who have a limited ability to read,
write, speak, or understand English at a level that permits effective
interaction with service providers may be eligible to receive language
assistance with respect to a particular type of service, benefit or
encounter. This Committee conducts
assessment and planning to ensure that program goals and objectives address the
provision of language assistance and meaningful access to Limited English
Proficient (LEP) individuals and for all the people we serve or will
encounter. (Note: According to Census
Bureau estimates, there are over 1700 Latinos living in the Lake Cumberland
Region.)
PERFORMANCE IMPROVEMENT PLAN
I. PURPOSE
The Purpose of the
Performance Improvement Plan is to guide and describe the organization’s
responsibilities, the methods used to measure and improve the quality of care
and services, the methods used to identify problems, and the methods used to
identify opportunities to improve care and services incurred to increase the
probability of desired outcomes and satisfaction to the individuals served.
II. AUTHORITY
Performance Improvement activities conducted at
The Adanta Group, occur as a mandate of the governing body of the Adanta Board,
with the CEO as Chairperson and designee of the governing body. Ultimately, the overall responsibility of
Performance Improvement activities rests with the governing body.
III. MISSION
The mission the Performance Improvement Program
is to ensure the provision of the highest quality care by helping each employee
to improve the process in which he/she is involved in the delivery of services
to individuals in all Adanta programs. This is accomplished through a systematic and
objective process of measurement of important processes and the identification
of opportunities to improve services and the quality of care.
IV. SCOPE
Performance improvement activities include all
departments and services at Adanta through participation in multidisciplinary
teams as identified by leadership. Areas
identified for improvement emanate from individual and aggregate assessment and
the monitoring of facility wide functions and the goals and objective set by
the leadership which are consistent without the
mission of Adanta.
Any planning for new or changing of services
provided by Adanta is consistent not only with its mission and vision but also
with the changing of the health care delivery system within the State. Planning for new, changing, or improved
services therefore goes beyond the facility or sites and includes the needs and
expectations of patients and staff of Adanta, as well as the needs of the south-central
area of Kentucky. Adanta is recognized as the legally mandated
entity for the planning of behavioral health services within our 10 county region. Performance of proposed or planned processes that exist in
other organizations, KARP, or similar facilities or sites within Kentucky are used where
appropriate and available to compare performance.
PROGRAM
IMPLEMENTATION
Adanta continuously seeks opportunities to
improve care and services it provides in order to
increase the probability of desired outcomes and satisfaction to the individuals
it serves. To achieve this end, Adanta
cultivates and nurtures an attitude of quality in all of its processes and
every decision that is made. Quality is
defined as either meeting or exceeding the expectations of all those that we
serve. Consequently, Adanta will design
or modify its operational procedures in order to constantly make improvements
and to prevent errors. Management’s role
in the Performance Improvement processes is not only to adopt standards for
quality consistent with the organizations mission, goals, and values, but also
to support employees by participation in teams and eliminating barriers to
efficiency and performance. The
Governing Body of Adanta will dedicate the resources and make the commitment to
performance improvement by monitoring the progress of the teams and when
appropriate, acting on their recommendations.
A. Philosophical Framework
The philosophical framework for performance
improvement at Adanta is based upon its definition of meeting or exceeding the
expectations of those it serves. This is
based upon technical, functional, or professional standards and the perception
of its customers. Customers, in turn,
are defined as the staff, family, regulators, and the community at large. Errors are regarded as contrary to
performance and relate to problems with structure or process. Performance improvement must center on the
reduction of errors through an attitude that no level of error is acceptable. Management functions effectively by
anticipating errors, taking steps to avoid them and when errors do occur,
identify root causes to eliminate and prevent recurrences.
Performance can be measured and measurement is
required to improve. Performance at
Adanta is measured by the development of indicators utilizing some or all or
the following nine (9) components:
1. Efficacy: The degree to which the care for the patient
results in the desired outcomes.
2. Appropriateness: The degree to which the care provided is
relevant to the patients’ clinical needs.
3. Availability: The degree to which the care provided is
available to the patient’s need.
4. Timeliness: The degree to which the care is provided
to the patient at the most beneficial or necessary time.
5. Effectiveness: The degree to which the care is provided,
in correct manner, given the current state of knowledge and produces the
desired outcome of the patient.
6. Continuity: The degree to which care is coordinated
among practitioners, among organizations and over time.
7. Safety: The degree to which the risk of an
intervention and risks within the care environment are reduced to patients and
others.
8. Efficiency: The relationship between outcomes and the
resources used to deliver patient care.
9. Respect
and Caring: The degree to which the patient or designee is involved in care
decisions and the degree to which it is provided with sensitivity and respect
for the patient’s needs, expectations, and individual differences.
To take action for improvement, a systematic process
must exist for defining opportunities for improvement, identifying the
customers and expectations, determining action, improving the outcome,
implementing the action, and measuring the effect of the action taken. Finally, for performance improvement to
achieve its potential, all employees must feel a sense of ownership,
responsibility, pride, and involvement.
B. Process
1. Team
Start-Up
Ideas for Performance Improvement teams may be generated by
the results of assessment activities or facility or site management and staff
and are communicated either through the department or organizational structure
to Leadership. Suggestions for projects
will be reviewed to be consistent with the facility or site’s mission, values,
and goals and will be selected based upon the following criteria.
a.
Controllability of Variables
b.
Measurable Results
c.
Achievable
d.
Data Availability
e.
Resource Availability
f.
Significant/Importance
g.
Timely Completion
h.
Probability of Success
i.
Motivation/Involvement
j.
Leadership Support
When a project is identified a Process Improvement, a
Written Narrative Form should be completed and forward to the Quality
Improvement Office. The QI office will
review the form and complete the QI Initiative Form. Once the QI Initiative Form is completed and
is determined to meet the appropriate criterion and prioritization has been
determined the PI Initiative will be forwarded to the Leadership for approval
or a rejection letter with an explanation to the initiator.
Leadership will sanction the formation of the team based
upon the recommendation of the initiator of the project and help the team to
identify the theme, provide timeframes for completion and be available for
consultation throughout the process. The
team will identify the team leader, team facilitator and recorder. The team leader may become an active member
of the Leadership throughout the duration of the team to provide monthly
updates of the teams’ progress.
2. Method
Adanta employs the Quality Improvement Eight-Step
Model. This model is performed in four
phases: 1) Plan; 2) Do; 3) Study; and 4)
Act. The effectiveness of the
improvement activity depends on judgment in the Planning phase and on execution
in the Do-Study-Act phases. Within each
step, a logical flow of planning, analysis, study and action occurs, which
repeats the cycle of the overall model.
The model is not intended to be a recipe for success. It is a guide, or a logical process, which
should be modified to fit the situation.
Teams need this flexibility, particularly when barriers are encountered
and the team needs to return to an earlier step.
The Eight Step Model
Phase 1 - Plan
Step 1 –
Select Improvement Opportunity
The purpose of this step is to define and select an
important project and to obtain management’s support for that project. The tasks involved in selecting a problem or
process improvement opportunity follow a systematic
approach:
·
Identify general and specific problems or
opportunities.
·
Clarify each one to ensure that team members understand
them.
·
Combine these problems or opportunities into
related groups and identify high-priority ones based on rational selection
criteria.
·
Select the highest priority or most critical one
and write a statement defining the current “as is” situation and the “desired
state” in measurable terms.
Step 2 – Analyze Current Situation
The purpose of this step is to define the process to be
improved in terms of its current configuration (using Flowcharts and operating
policies or procedures), the participants in the process, and the performance
measures that define customer expectations and supplier specifications. The team will use existing and additional
data to narrow the focus of the study, to document baseline performance, and to
identify gaps relative to expected performance.
Defining the process has several distinct steps that begin
with a Process Analysis Worksheet. The
Process Analysis Worksheet includes the following items:
·
Process Output
·
Customer/Supplier Relationships
·
Customer Needs and Expectations
·
Performance Indicators
·
Supplier Specifications
·
Top-Down Flowchart
·
Deployment Flowchart
·
Table of Performance Indicators and Drivers
Step 3 – Identify Root Causes
The purpose of this step is to identify potential root
causes of poor performance, rather than secondary causes and symptoms, and to
ultimately verify these root causes.
Identification of the root causes of undesirable outcomes is perhaps the
most important activity in process improvement.
It gets to the heart of what needs to be fixed or changed.
Once the team has identified potential causes, it needs to
establish a data collection plan that defines what data are needed, where and
how they should be collected, how long they should be collected and why
whom. Areas of potential bias should be
addressed before the plan is implemented.
The need to collect statistically significant, unbiased data is a common
requirement in quality improvement.
Step 4 –
Select and Plan Solution
The overall purpose of this step is to identify and select
the solution to solve the problem or improve the process based on the analysis
in Step 3.
First, the potential solutions for process improvement are
analyzed and selected based on various criteria. Second, an implementation plan is
developed. The objective here is to
select the best possible solution based on the data and facts available. An implementation plan is developed that is
sufficiently detailed to be actionable and that considers countermeasures for
reasonable barriers to successful implementation.
Define
Revised Process. The key tasks here
include:
·
Identify Expected Outcomes
·
Revise Output and Supplier Specifications
·
Identify Target Process Values
·
Modify Deployment Flowchart
Develop Implementation Plan:
The detailed implementation and contingency plan is a major milestone in
the improvement process. This plan
should provide periodic monitoring of performance indicators to ensure that
expected changes occur. Elements of the
plan should describe:
·
Sequence and Timing
·
Resources and Controls
·
Responsibility
·
Pilot Activities
·
Contingency Actions
Management Review: Up
to this point, no decisions to change the organization have been made. Here, the team presents its findings and,
more importantly, makes recommendations for change. The primary object is to gain management’s
concurrence and approval to continue. If
the team has kept management advised of its progress, then the team should not
have difficulty in gaining management’s concurrence.
Phase 2 – Do
Step 5 –
Implement Pilot Solution
The purpose of the pilot implementation is to test the
solution on a small scale in order to ensure that the revised process is
capable of producing an output with the desired outcomes. The pilot activity verifies the effectiveness
of the solution and proves whether or not the solution should be standardized
across the organization.
Phase 3 – Study
Step 6 –
Monitor Results and Evaluate Solution
During this phase of the process, the team validates the
effectiveness of the solution to improve the process. The review of the pilot results will help the
organization decide if change should be implemented throughout the
organization.
During this step, the pilot activity is monitored to
determine whether the desired change has occurred. The key question is: Was the root cause eliminated? If not, the team must cycle back to an
earlier step to determine the reasons why the desired outcomes were not
achieved.
Results need to be monitored relative to targets, process changes,
and controls defined in the implementation plan.
Management Review:
The management review here assesses the pilot and determines if the
process change should be standardized across the organization. Extraneous events that influence the outcomes
need to be isolated to ensure that the desired change in the process has
occurred as expected. If the desired
change has occurred, then the team is ready to begin to standardize the change
throughout the organization, which is the next step.
Phase 4 – Act
Step 7 –
Standardize
The purpose
of this step is to implement the process improvement in similar work units
throughout the organization. This
standardization of work processes will comprehend changes identified in Step 6,
where the effectiveness of the solution was evaluated.
A key activity included in this step is the development of
training materials to enable the standardization. This training will build upon the knowledge and
experience gained by the pilot organization and often requires preparation of
formal training materials. Training
developed here will be based on new policies and procedures or on changes to
existing ones affected by the process improvement. Good ideas need to be communicated well, and
training is a key element of success in standardizing process improvement.
The monitoring and evaluation of results need to continue to
ensure that the desired results observed in the pilot are achieved by all
organizations affected.
The team needs to complete the road map that documents and
communicates its journey. Documentation
can be in various forms, including written reports, data files, abstracts in project tracking systems, videotapes, and
Storyboards. Documentation should meet
the minimum requirement of enabling subsequent teams to learn from their
experience and continuously improve the same process.
Finally, the team should determine long-term monitoring
requirements and future actions. The
team should meet again when unsatisfactory changes in performance measures or
outside trigger events occur or a specified time has elapsed.
Management Review: Before
leaving this step, the team needs to conduct a final management review to
acknowledge closure, to adjourn the team activities, and to provide management
with an opportunity to recognize and reward the team.
Step 8 –
Recycle
The
purpose of this final step is to ensure that the organization becomes focused
on continuous improvement. Step 8
becomes Step 1 in the next cycle of quality improvement.
OMBUDSMAN
The Ombudsman is the caretaker of complaints
from clients, family members, or other invested parties. Under the Clients Bill of Rights, any person participating
in treatment may file a client grievance if a situation arises that infringes
upon their rights or is inconsistent with the Mission of Adanta. The Ombudsman ensures that client concerns
are addressed in a timely fashion by investigating complaints, incidents, etc.
and developing a plan or action as warranted. Client confidentiality is of
utmost importance; therefore the Ombudsman takes all precautions to maintain
confidentiality while investigating grievances.
The Ombudsman submits a written report of
findings and recommendations within thirty days. A summary report is submitted to the Adanta
Board of Directors on a quarterly basis.
If
the procedure is unacceptable to the aggrieved individual, or if it fails to
address the issue to their satisfaction, they may contact the State Ombudsman’s
office for further assistance. Contact
information for the Adanta Ombudsman as well as the State Ombudsman’s office is
posted in all Adanta locations.
CORPORATE COMPLIANCE PROGRAM