FY13 QI Report

Rebekah Children’s
Services
Performance & Quality Improvement
FY2012-2013 Annual Report
The Performance and Quality Improvement ("PQI") Program at RCS is a comprehensive approach to the
improvement process that is based on cooperative efforts encompassing the entire agency, including
consumers, and their families. The following PQI Annual Report provides significant positive
developments, challenges, and/or obstacles faced by RCS over the last year with regard to performance
and quality improvement.

FY13Rebekah Children’s Services Performance and Quality Management Report Page 2
Contents
Executive Summary......................................................................................................................................3
Mission Statement.........................................................................................................................................4
Vision............................................................................................................................................................4
Core Values...................................................................................................................................................4
Geographic Community Area.......................................................................................................................5
RCS Client Demographics............................................................................................................................6
Consumer Outcomes.....................................................................................................................................7
Fidelity to Wraparound Values and Principles .........................................................................................7
Children Adolescent Needs and Strengths................................................................................................8
Youth and Family Satisfaction Measures: ................................................................................................9
Ohio Scales Functioning Analysis..........................................................................................................10
Problem Severity Analysis......................................................................................................................10
Incident Reports..........................................................................................................................................11
Complaint and Grievances..........................................................................................................................12
Internal Case Record Review (MANGO)...................................................................................................13
Conclusion ..................................................................................................................................................14

Executive Summary
Rebekah Children's Services (RCS) is a Nationally Accredited organization that has been helping kids
find homes, get treatment, and overcome obstacles for 117 years. Our goal is to deliver services to
families and children across California in the most effective and efficient manner. To fulfill this goal,
RCS has embarked on creating several processes to evaluate different quality indicators to best prepare us
for the needs of the community and inform us on our quality targets. This report outlines the efforts made
by RCS to improve the lives of people, maintain accountability, and improve needed areas. Founded on
strong principles and consistent to best practices outlined in the Council on Accreditation, RCS presents
you the FY 2012-2013 Performance and Quality Improvement Report.
The Performance and Quality Improvement (PQI) Program at RCS is a comprehensive approach to the
improvement process that is based on cooperative efforts encompassing the entire agency, including
consumers, and their families. The following PQI Annual Report provides significant positive
developments, challenges, and/or obstacles faced by RCS over the last year with regard to performance
and quality improvement.
The PQI process is consumer-responsive and prevention-oriented. It is continually developing and
transforming based on information from ongoing reviews, outcome monitoring, consumer feedback and
satisfaction, organizational strategic planning, industry and professional information, and federal, state
and local regulations. The RCS PQI Plan provides details of the current process.
Showing major achievements in our PQI process we are proud to highlight the following performance
indicators, risk management efforts, and innovative initiatives.
Quality of Treatment Indicators:
 32% more children, youth and families were treated this fiscal year
 50% more counties were served
 Fidelity to Wraparound principles and values were met and exceeded above the National means
 Consumer satisfaction exceeded the State’s mean, and RCS scored above the average in Santa
Clara County.
 89% of consumers showed positive change as indicated in the Child Adolescent, Needs and
Strength (CANS) assessments.
 Consumers improve clinical functioning as indicated in the Ohio Scales Outcome analysis and
problem severity is managed below a clinical range during treatment.
Risk Management Indicators:
 60% less consumer complaints were received in FY13
 100% was achieved in the Santa Clara County Administrative Review
 98.7% in the Santa Clara County Clinical audit review; a 2.2% improvement from the previous
year.
Innovative Initiatives:
The Integrated Treatment Plan project was approved by Santa Clara County Mental Health and is
intended to improve clinical practices for a consumer who is receiving services from concurrent
programs. The idea is to share a one treatment and update goals and objectives between clinicians
who are providing services to the consumer as opposed to having a treatment plan for each program.
The pilot was approved on 7/1/2012 and has been active for approximately one year. A year after,
RCS was able to show improved clinical coordination, and we successfully integrated the
assessments, CANS Outcomes, and Treatment Plan, thus becoming more clinically sound, integrated,
and efficient.

Mission Statement
We are dedicated to promoting the social, emotional and physical well being of children and families.
Vision
To be the national leader in creating, shaping, teaching and providing services that achieve positive,
permanent outcomes for children and families
Core Values
 We are a family centered organization, connecting children, parents, caregivers and all we serve to
healthy, enduring relationships that offer them trust, safety and permanency. We hear and respond to
the voice and culture of the family.
 We operate with integrity and accountability demonstrating responsible stewardship of the funding,
resources and donations placed in our trust.
 We strengthen and mold our services and supports around the needs expressed by the child and
family using effective models of service. Our innovative work advances theory, policy and practice
while producing positive, measurable changes.
 We value and consult our stakeholders in our commitment to being a fully integrated organization
working together toward our vision.
 We believe staff is our greatest asset. Together we are committed to create an environment of
fulfillment, stimulation and opportunity for professional growth, founded on truth, transparency and
respect. We demonstrate consistent, supportive and effective leadership, promoting teamwork and
individual excellence. We invite and honor the contribution of all staff and challenge each other to
assume ownership for achieving the mission, vision and goals of RCS.
 We value the physical environment where we work and strive to keep it clean, safe, functional and
attractive.

Geographic Community Area
Rebekah Children’s geographic service and community extends out as far south to Kern County and
North to Placer County. Our main location is located in Gilroy CA, with concentration of delivering most
services in Santa Clara County. While our main location is in Gilroy, we have satellite offices in
Campbell, and Monterey County. During fiscal year 2012-2013, RCS provided services to consumers
from 19 Counties in California and touched about 2150 families and children. Counties in green are our
host counties, yellow and new Counties we partnered with this year, and the counties in light blue are
counties we had engagements prior to this fiscal year.

RCS Client Demographics
RCS served children and families, primarily from Santa Clara County, but also had strong relationships
with 19 other Counties. Consumers who receive services at RCS range from newborn to 21years of age.
Service models are Community, School Based, and Campus-Based Services. In fiscal year FY12-13, RCS
averaged 282 unduplicated active clients daily and 1159 (06% duplicated) clients were served during the
fiscal year. The following client demographic information best describes the population served. Our
geographic profile during the fiscal year reached as far south to Riverside, and north to Mendocino. In
addition, RCS serves an average of 1,000 (not shown in the tables below) consumers through the
Prevention and Education Program.
Gender Count % Count
Female 356 30.72%
Male 803 69.28%
Grand Total 1159 100.00%
Ethnicity Count % Count
Amer. Asian 1 0.09%
Asian Indian 2 0.17%
Black 30 2.59%
Cambodian 1 0.09%
Caucasian 110 9.49%
Caucasian/Afr. American 2 0.17%
Filipino 1 0.09%
Hawaiian Native 1 0.09%
Hispanic 340 29.34%
Latina 19 1.64%
Mexican American 47 4.06%
Other 6 0.52%
Other Pacific Islander 4 0.35%
Vietnamese 5 0.43%
White 54 4.66%
Missing Data 536 46.25%
Age Group Count % Count
Infant 11 1%
Children 613 53%
Adolescent 525 45%
Missing Data 10 1%
Total 1159 100%
County Count % Count
Alameda 7 0.60%
Calaveras 1 0.09%
Contra Costa 2 0.17%
Fresno 1 0.09%
Kern 1 0.09%
Merced 1 0.09%
Monterey 56 4.83%
Napa 1 0.09%
Placer 3 0.26%
Riverside 3 0.26%
San Benito 29 2.50%
San Joaquin 5 0.43%
San Luis Obispo 1 0.09%
San Mateo 12 1.04%
Santa Clara 808 69.72%
Santa Cruz 19 1.64%
Solano 2 0.17%
Sonoma 2 0.17%
Stanislaus 8 0.69%
Yolo 6 0.52%
Missing Data 191 16.48%
Program Count % Count
Outpatient Mental Health 276 23.81%
Day Treatment 122 10.53%
School-Linked Services 121 10.44%
Wraparound Services 102 8.80%
TBS 82 7.08%
First 5 69 5.95%
Hospital Diversion 61 5.26%
Monterey Wraparound 55 4.75%
Residential Group Home 54 4.66%
Non-Public School 39 3.36%
Vocational Services 39 3.36%
Home Visitation 34 2.93%
PEI Strengthening Families 32 2.76%
Family Linkage 30 2.59%
Campbell Mental Health 28 2.42%
Ranch Re-Entry 15 1.29%

Consumer Outcomes
To ensure consumers at RCS are receiving high quality and effective services, we have adopted a variety
of consumer driven and informed measures. This section of the report provides a brief overview of the
Fidelity Measures we use to evaluate that our values are being honored and embraced in care, that
consumers are satisfied with the services they receive, and to assess that our service is effective in
promoting the consumer’s well being.
Fidelity to Wraparound Values and Principles
In fiscal year 12/13, RCS consumers rated RCS above the national average in 4 process areas;
engagement, planning, implementation, and transition. Additionally, RCS met or exceeded the national
baselines 9 of the 10 wraparound principles of care. The Wrap Fidelity Index, not only speaks to how
consumers feel we treat them, it speak to how RCS honors our values and principles for treatment. RCS
uses these fidelity measures to work on improving services that are delivered to our consumers in addition
to compare against the national average for performance improvement opportunities.
87 88 91
84
0
10
20
30
40
50
60
70
80
90
100
Phase 1:
Engagement
Phase 2: Planning Phase 3:
Implementation
Phase 4:
Transition
PercentFidelity
Overall Fidelity by Phase
RCS
National Mean
89
79 83
98
74
97
85
93 88 92
0
20
40
60
80
100
120
PercentFidelity
Overall Fidelity by Principle
RCS
National Mean

Children Adolescent Needs and Strengths
The Children’s Adolescents Needs and Strengths (CANS) Assessment is an industry standard
tool that has been implemented at RCS. It takes a client centric approach to assist in identifying
what consumers feels they need to improve their wellbeing. This report is used to provide
information on the effectiveness of treatment and to show how RCS is meeting consumer needs.
Based on this analysis, 89% of consumers indicated there was a progress toward their identified
needs. This analysis also that RCS had 51% reliable change in one or more identified needs.
The report includes inpatient, outpatient, school, and home-based services for all clients older
than 5 years of age. To be included in this report a client has to have been actively receiving
services and have two CANS assessments on file , the most recent having been between 7/1/2012
and 6/30/2013.
Assessments are completed by
clinicians with the family and entered
into the client's electronic health
record. CANS assessments are required
to be completed for each client at
intake, a six month interval
reassessment, and discharge.
For this analysis, the two most recent
assessments for each client falling into
the scope defined above are used.
 Score - Each line item on the
CANS has a possible score of
[0,1,2,3]
 “Identified Actionable” Items
are line items that have a score
of 2 or 3 (moderate to severe
problems needing intervention)
and are identified on the onset
of treatment. “Actionable”
items are identified after the
onset of treatment with the same
scoring method. This excludes
the Youth Strengths domain.
89%
54% 51%
0%
20%
40%
60%
80%
100%
Improvement in
identified
actionable items
Improvement on
actionalble items
Improved
strengths building
Actionable Items n=275
(Actionable Items are issues identified after the onset of
treatment)
17% 20% 19% 16%
40%
51%
0%
10%
20%
30%
40%
50%
60%
Reliable Change n=275

Youth and Family Satisfaction Measures: The Youth and Family Satisfaction is an assessment that
is facilitated by Santa Clara County Department of Mental Health. It is intended to measure the
satisfaction of different providers of the consumers they fund for service delivery. These outcomes are
part of a larger State system and are shared with the CA Health and Human Services Division. This
assessment includes four measurement domains (1. Access, 2.Treatment Planning, 3. General
Satisfaction, 4 Quality and Appropriateness of Treatment) and are measured using the following
methodology and baselines.
“The Mental Health Department Consumer Perception Surveys (MHDCPS) for Youth and Family are rated on a five-point scale,
with “5” indicating the greatest satisfaction, or excellent rating. Adult Consumer responses to the surveys are analyzed
according to the Domains listed above. During data analysis, the items that comprise each of the Domains were averaged and
then grouped into the following categories: 3.44 and below (68% and below) = Unsatisfactory; 3.45- 3.99 (69%-78%) =
Satisfactory; 4.00-4.44 (79%-88%) = Good; and 4.45-5.00 (89%-100%) = Excellent. As a general guideline, for interpretation,
the national benchmark for satisfaction is an overall scale score above 3.5.”
RCS is proud to report that we have exceeded the State’s baseline of 3.5 in all domain areas and we
scored higher than the average in all domain areas across our County. Through this analysis, consumers
rate the services they received at RCS are near excellent in satisfactory.
4.33
4.23
4.41
4.51
4.3
4.19
4.3
4.49
3
3.2
3.4
3.6
3.8
4
4.2
4.4
4.6
Satisfaction with Service
Access
Satisfaction with
Treatment Planning
Satsifaction with Services
Provided
Satisfaction with Quality
and Appropriateness of
Service
Consumer Satisfaction Measures n=62
RCS Score System Average Satisfaction Baseline

Ohio Scales Functioning Analysis
The "Functioning Scale" is comprised of 20 items that rate the youth's level of functioning in a variety of
areas of daily activity (e.g., interpersonal relationships, recreation, self-direction and motivation). Each
item is rated on a five-point scale (0 "Extreme troubles" to 5 "Doing very well"). Although the problem
severity scale is similar to many other existing symptom rating scales that focus on the severity of
behavioral problems, the functioning scale provides a broader range of ratings including “OK” and
“Doing very well”. This provides an opportunity for raters to identify areas of functional strength. A total
functioning score is calculated by summing the ratings for all 20 items. Higher scores are indicative of
better functioning. The “Clinical Range” are items that are below a 50 baseline. Based on this analysis,
consumers receiving Monterey County Wraparound services show increased functioning when comparing
intake to discharge.
Problem Severity Analysis: The "Problem Severity Scale" is comprised of 20 items covering
common problems reported by youth who receive behavioral health services. Each item is rated for
severity/frequency (0 "Not at all" to 5 "All the time") on a six-point scale. A total score is calculated by
summing the ratings for all 20 items. The graphs below show client progress in services in different RCS
programs. The “Clinical Range” is items that are above a 20 baseline. This analysis shows that consumers
who participated in this evaluation managed problems under the clinical range from intake to discharge.
51.49
54.94
60.63
59.09
40
45
50
55
60
65
Intake 6-months 12-months Discharge
Ohio Scales Functioning Scales n=51
Score
Clinical Range
19.75
13.39
14.63
19.71
0
5
10
15
20
25
Intake 6-months 12-months Discharge
Ohio Scales Problem Severity Scales n=51
Score
Clinical Range

Incident Reports
One method RCS improves quality is by tracking and analyzing incident reports. In fiscal year 11/12, 593
incident reports were recorded. A qualifying incident report at RCS is based on the situations our external
guarantors, such as Community Care Licensing, Department of Mental Health, or other partners mandate
us to report. They range from physical interventions to allegations of mistreatment or select acting out
behaviors. One critical area that RCS pays special attention to is physical intervention. Of the 593
incidents 40% were physical interventions. A physical restraint is only applied in our Campus Services
Programs when a client is a danger to themselves or others.
0
10
20
30
40
50
60
70
80
90
100
Incident Report Trends n=653
Community Services
Campus Services
244 235
31 30 39
233
60 51
5
29
4 6 2
0
50
100
150
200
250
300
Incident Types n=653
Many incident reports contain more than one incident category so the total incidents will not match the
incident types.

Complaint and Grievances
Consistent to our service values and principles, we value and honor the voice of the consumer and their
family, therefore providing us another opportunity to improve services. In this fiscal year four (4)
consumers voiced a total of 10 complaints. Some consumers voiced more than one complaint at a time
and others complained more than once at different stages of care. Of the 10 complaints,
 Six were unsubstantiated (there was no evidence to validated the acts),
 Four were substantiated (the acts were shown to be true), and
Of the 10 complaints, 1 was voiced from the Outpatient MH program, 3 from our campus services
programs, five from our non-public schools, and 1 from the TBS program. All complaints were handled
within RCS policy and procedure, and addressed in a timely manner. Consumers who voice complaints
are engaged within one workday from when they made their report, and are provided an outcome report
explaining the resolution of the complaint. All complaints were handled to the consumer’s satisfaction
within RCS.
4, 40%
6, 60%
Consumer Complaint
Resolution n=10
Substantiated Unsubstantiated
2, 20%
5, 50%
1, 10%
1, 10%
1, 10%
Program Complaints n=10
Hospital Diversion Non-Public School
Outpatient MH - Campbell Residential
TBS

Internal Case Record Review (MANGO)
RCS’s uses Federal, State and County guidelines to assess that clinical documents are completed
accurately, timely, and consistent to best practices and the regulations. This process is another area for
opportunity to improve quality on how we record services, and defeat system or programmatic challenges.
Consistent to our values, we feel that accurate recording of services increases credibility and integrity. In
this year, RCS created an innovative solution to internal risk management as it relates to clinical
documentation compliance and quality. Through the review of internal and external sources, we can
determine, with confidence that we are compliant on 98% of required clinical documentation.
 Introducing the new MANGO
MANGO is a new document tracking application, built from the ground up to leverage the EHR and
better support the various types of
documents we use at RCS. Document
types include Assessments, Treatment
Plans, Outcome Measures and
Authorizations. It allows clinical staff,
managers, and executive to review
performance levels using standardized
methods that represent great quality in
the different RCS services. The Mango
system can do the following:
 View Deadlines
From the Deadlines section you can
view all the coordinated care documents
due within the selected month. Use the
left/right arrows to navigate through the
months. The location icon will return you to the current month. The search icon will allow you to
filter the list by document type, responsible staff, program and more.
 Prioritized For You
Your homepage dashboard will highlight for you the oldest items requiring your attention. For
clinicians, these will be documents that are pending review or have failed review. For supervisors,
these will be documents that failed review for your staff. For reviewers, these will be the items that
you indicated were not ok, but are correctable. To see the full list of "Items Requiring Your
Attention" you can click on the See Full List button or click the Document Icon at the top of any page
in MANGO. The number next to the symbol indicates the number of documents/deadlines requiring
your attention.
 Collaborate
You can share MANGO content with your coworkers. Using the icon on any page will allow you to
email that page to anyone with an RCSKIDS.ORG email address. They will receive a link to that
page plus your comments to check out the information.
 Staying On Top of It!
MANGO has been designed from the ground up to leverage the power of the EHR/EMR to help RCS
stay on top of the documentation timelines. Whether clinician, supervisor or reviewer you can spend
less time figuring out the timelines and deadlines and more time on your primary responsibilities.

Conclusion
Consistent to the RCS Strategic Plan, the goal and objective of our PQI process during this fiscal year,
RCS improved the consumer experience by integrating practices for increased coordination and
collaboration between clinical teams; we leverage the use of the EHR to increase quality of care, increase
operational efficiency, and overcame access to service barriers. In the course of this fiscal year RCS
effectively managed risk, provided effective treatment, showed fidelity to wraparound principles and
values, achieved consumer satisfaction, and effectively positioned ourselves strong for the demands of the
future.
Overall, RCS continues to improve quality care for consumers, uses innovative thinking and technology
to become efficient and responsible to our community, our funders and those who we treat. RCS
continues to learn methods in which to become more consumer-driven, increase efficiency, and manage
costs in a way that will improve the economy of scales on how we use resources for effective outcomes.
The performance and quality improvement goals of RCS were met this fiscal year.

FY13 QI Report

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