EAGLE ACCREDITATION

1. EAGLE ACCREDITATION THE ROAD TO ORGANIZATIONAL EXCELLENCE

2. Matt Obert, MSW, LCSW • Director of Quality Assurance and Facilities Quincy, Illinois mobert@chaddock.org Debi Armstrong, MS, LCPC • Vice President of Quality and Information Systems Normal, Illinois darmstrong@thebabyfold.org

3. MOST COMMON CHALLENGES • QUALITY IMPROVEMENT and SERVICE EXCELLENCE • CORPORATE COMPLIANCE • RISK MANAGEMENT • TECHNOLOGY SECURITY and DISASTER RECOVERY

4. EAGLE Principle 8.3 Risk Management • How does your organization systematically manage liability and risks in order to protect the interests of clients, staff, and stakeholders and to ensure the ability of the organization to carry on its Christian mission?

5. Risk Management • Any procedure or practice that an agency uses to reduce exposure to liability • Practicing Risk Management is living the commitment to “prevent harm”

6. Why Risk Management? • Increased enforcement of financial and reporting controls at State and Federal levels • Significant $$ involved in paybacks and fines • Legal liability – cost of defense and retribution • Loss of agency licensure or accreditation • Loss of funding sources • Damage to reputation of employees/agency • If cost of liability is huge – can close an agency

7. Responsibility and Accountability • Board of Directors • CEO • Leadership and management • Supervisory employees • Individual employees • Legal action, penalty, and fines against individuals or agency as a whole

8. Identifying Risk - Financial • Insurance Coverage • Fundraising activities • Investment risk • Tax liabilities • Fraudulent billing • Loss or damage of assets • Safety of environment and facilities • Reviewing contracts • Financial mismanagement

9. Identifying Risk - Workforce • Ethical misconduct • Training competencies • Staff injuries • Screening employees and volunteers • Employment practices • Legal duties and responsibilities • Harassment, sexual misconduct, retaliation and discrimination

10. Identifying Risk – Service Delivery • Client Rights • Ethical client boundaries • Behavioral interventions • Client injury • Therapy malpractice • Confidential information • Critical decisions in service delivery - liability

11. Create a culture • Ethics and Values • Clear expectations for professional behavior • Methods of reporting suspected misconduct • Leadership and supervisors model ethical and legal behavior • Published laws, regulations, and standards • Established rules to maintain safety and security • Fair and consistent enforcement and discipline • Culture of transparency in reporting

12. Mitigating risk - financial • Legal consultation • Strong accounting and internal controls • Annual audits by outside firm • Regular investments and investment policy • Annual review of insurance policies • Annual review of contracts • Regular safety and maintenance inspections • Regular vehicle and facility maintenance

13. Mitigating risk - workforce • Legal review of Employee Handbook and employment practices • Background checks for criminal history • Abuse/neglect registry checks • Drug testing • References • Verify credentials and licensure • Appropriate supervision • Orientation and training • Establish clear policy and procedures

14. Mitigating risk – service delivery • Oversight by Human Rights Committee • Institutional Review Board – research protections • Behavioral intervention training • Report and analyze use of behavioral interventions • Report and analyze client injuries • Inform and document client rights, release of information, consent to treatment • Establish expectations and guidelines for acceptable treatment interventions or care • Clear service delivery policy and procedures

15. Reporting and review processes • Establish areas of risk to monitor and measure • Establish goals related to risk management • Develop methods of reporting incidents, health and safety issues, injuries and accidents • Collect and analyze reports • Establish a team responsible for review of data • Develop thresholds and benchmarks that trigger action • Develop and implement corrective action plans or quality improvement actions

16. EAGLE Principle 7.4 Emergency Preparedness How does your organization: • Plan for emergencies or disasters affecting its facilities, equipments and information • Ensure staff and volunteers know duties and responsibilities to minimize negative effects on clients, facilities, and themselves • Evaluate and improve the effectiveness of its emergency preparedness

17. Types of Emergencies • Natural disasters • flood, hurricane, tornado, fire, earthquake • Epidemic/contagious outbreaks • Workplace violence • Bomb threats or explosions • Terrorist or acts of random violence • Chemical spills • Nuclear contamination • Intruder or suspicious activity • Out of control client behaviors

18. Elements of Crisis Plan • Establish a Crisis Response Team • Leadership, Technology, Operations • Develop notification systems • Call trees • Emergency communication methods • Full activation versus standby • Establish “crisis center” • Primary and back up sites • Assign coordination responsibilities

19. Establish Emergency Procedures • In case of fire • In case of tornado or inclement weather • Hostile intruder or “lock down” • Bomb threats • Evacuation due to environmental hazards • Major medical emergency

20. Provisions to Include • First Aid Kits in all areas • Emergency supplies • Flashlights • Radio • Drinking water • Cell phones • Emergency contacts list/phone numbers • AED Machines

21. Ongoing Activities • Establish a system of codes • Evacuation maps • Emergency procedures posted in common areas or areas used by the public • Establish a schedule of drills • Monthly fire drills in residential programs • Evacuation drills • “Lock down” drills • Emergency assistance needed drills

22. Post Crisis Actions • Reporting to licensing or accreditation entities • Crisis Team Debriefing • Post crisis support to clients • Post crisis support to employees • Follow up with emergency personnel or law enforcement • File insurance claims • Incorporate any corrective action needed into risk management processes

23. Crisis Plan Maintenance • Review plan annually • Update any changes in procedures or sites • Update call tree and phone numbers • Review codes or systems of designating emergencies • Review effectiveness of drills • Re-train employees annually

24. Questions?