GOAL ACHIEVEMENT PLAN

Timeframe for implementation of strategies and achievement of objectives is by June 30, 2006 unless otherwise specified.

Positions identified in brackets (   ) are assigned lead in coordinating and/or reporting progress of specific strategies.  The Office of QA and Planning will monitor overall implementation of the plan and report upon status to the Quality Improvement  and Risk Management Committee. 

Strategies:

A 1      Systematically implement and document use of at least two new best-practice/science-based interventions in treatment programs.  (Chief Operating Officer, Chief Research Officer, Directors of Adult and Adolescent Services)

A 2      Continue to participate in the NIDA Clinical Trials Network (CTN).  Complete Women’s Substance Abuse and Trauma Study and contribute to other CTN proposals with Maryhaven as a study site.  (Chief Research Officer)

A 3      Become an accredited Opiod Treatment Program (OTP), adding Methadone as a medication available at Maryhaven.  (CCO, Chief Research Officer, Medical Director, Director of Adult Services)

Measures:

·        Documentation of NIDA CTN activities conducted at Maryhaven

·        Minutes of meetings of the Committee on Science-Based Practices

·        Reports documenting best-practice interventions implemented by Maryhaven programs

·        Opioid Treatment Program certificate; patients receiving Methadone

Strategies:

B 1      Achieve accreditation through the Commission on Accreditation of Rehabilitation Facilities (CARF) by October 1, 2005.  (Dir. of QA and Planning, CARF Steering Committee)

B 3      Achieve re-certification from ODADAS for all treatment program by May 31, 2005.  (Dir. of QA and Planning, CCO, Directors of Adult and Adolescent Services)

Measures:

• Letters of Accreditation/Certification from CARF, OANO, and ODADAS

Strategies:

C 1      Analyze data from ongoing Addiction Severity Index study and produce at least one comprehensive report of adult patient outcomes.  (Dir. of QA and Planning) 

C 2      Retrieve and analyze data from ODMH Ohio Scales surveys and produce at least one comprehensive report on adolescent patient outcomes.  (Dir. of QA and Planning)

C 3      Conduct at least one study focused on cost-offset  (Dir. of QA and Planning)

Measures:

• Completed outcome and cost-offset reports
• Minutes of QI Committee and other meetings where reports are discussed
• Evidence of references to outcome reports in funding applications and electronic and print media

Strategies:

D 1      Decrease the overall rate of staff turnover.  (Dir. of Human Resources and Diversity Development, Management Team)

D 2      Conduct and complete Employer of Choice project (including revision of job descriptions, re-evaluation of compensation package, succession planning, staff survey, and other components.  (Dir. of Human Resources and Diversity Development)

Measures:

·        Staff turn-over reports; analyzes of trends in turnover, including high-turnover positions and programs, and plans to address

·        Minutes of Senior Staff and Personnel Committee meetings

Strategies:

A 1      Through high levels of program occupancy and counselor productivity, earn down Maryhaven’s full allocation through the ADAMH Board. (COO, Dirs. of Adult and Adolescent Services)

A 2      Develop contingency financial plan related to outcome of upcoming ADAMH Board tax levy campaign.  (CFO and Director of Business Operations)

A 3      Expand Adolescent Residential Program with addition at least 20 beds, with FCCS as primary referral and funding source. (CCO, Dir. of Adolescent Services, and CFO and Director of Business Operations)

Measures:

• Monthly financial reports reflecting ADAMH billing by programs and services
• Contingency financial plans
• Adolescent Residential Program occupancy reports and related financial reports

Strategies:

B 1      In collaboration with National Church Residences and the Community Shelter Board, complete the development phase and begin operation at Chantry Place, providing permanent supportive housing and services for 50 homeless adults/families affected by substance abuse.  (CCO, Dir. of QA and Planning)

B 2      Explore the potential and pursue if financially feasible, program initiatives or expansions in the following areas:

• Opioid Treatment Program

• Additional Outpatient services for adolescents and adults

• Geographic expansion of Adolescent Residential services through statewide marketing

• Expansion of primary healthcare services for patients in addiction treatment

• Expansion of adolescent and/or adult driver intervention programs

• Expansion of programming for dually-diagnosed patients

• Anger management and domestic violence programming

• Prevention and school-based programming

• Entrepreneurial initiatives including catering services

• Other mission-congruent services and programs

(Management Team, with lead assigned by content of program)

B 3      Aggressively pursue public and private sector program grants, applying for at least $750,000 in new program funding over the plan period. (Dir. of QI and Planning, CCO, Directors of Adult and Adolescent Services)

B 4      Accommodate expanded programming (particularly Adolescent Programs) through acquisition of additional space in the community and renovation of present space; relocate outpatient programs.  (CEO, CCO, CFO and Dir. of Business Operations, Dir. of Community Relations and Support Services, Dirs. of Adult and Adolescent Services)

Measures:

·        Development plan finalized and Chantry Place construction completed by National Church Residences; move-in by initial tenants with supportive services by Maryhaven

·        Reports of needs assessment and program planning/funding activities and documentation of programs implemented and/or expanded

·        Reports of program grant proposals that have been submitted for funding

·        Lease for new office space; completed renovation of present space; certification by ODADAS and provision of outpatient services in new setting

Strategies:

C 1      Create a Development Office to expand activities (Dir. of Community Relations and Support Services)

C 2      Create a multilevel, comprehensive Development Plan including: 1) an annual fundraising campaign, 2) special major campaigns, and 3) a planned giving program. (Dir. of Community Relations and Support Services)

C 3      Reach the halfway point in Maryhaven’s fundraising campaign for adolescent programs: A Healthier Tomorrow for Our Children.  (Dir. of Community Relations and Support Services)

Measures:

·        Additional staffing in Development Office; creation of development infrastructure including comprehensive fundraising policies and procedures

·        Presentation and approval of Development Plan

·        Completed capital campaign kick-off and regular status reports on donations

Strategies:

D 1      Continue efforts to identify appropriate organizations and enter into discussions of potential for merger/acquisition. (CEO, participation of Directors, Management Team)

D 2      Market Maryhaven’s administrative capacities and respond to proposals to provide services as an A.S.O. (Administrative Services Organization).  (CEO, CFO and Director of Financial Services, Management Team)

Measure:

·        Documentation of contacts and discussions regarding merger/acquisition

·        Documentation of A.S.O. proposals Maryhaven initiates or responds to

Strategies:

A 1      Continue intensive training of clinical staff and monitoring through patient record reviews and financial chart audits.  (COO, Dirs. of Adult and Adolescent Services, CFO and Dir. of Business Operations, Dir. of QA and Planning)

A 2      Implement new standardized chart format, SOQIT forms, jointly developed by ODMH and ODADAS.  (CFO and Dir. of Business Operations, CCO, Directors of Adult and Adolescent Services)

Measures:

·        Documentation of training

·        Results of record reviews and financial chart audits and ODADAS certification report

·        Verification of use of SOQIT forms

Strategies:

B 1      Improve intra-organizational communication through increased use of Maryhaven computer common drive around: policies and procedures, new programs and program changes, quality improvement activities, organization’s plan and achievements, personnel changes, and other matters.  (CFO and Dir. of Business Operations, Directors and Supervisors)

B 2      Continue to assess computer skill needs of staff and provide necessary training in response.  (CFO and Dir. of Business Operations, Network Administrator, Dir. of HR and Diversity Development)

B 3      Continue to improve and expand the features and content of the Maryhaven’s website, www.maryhaven.com  (CFO and Dir. of Business Operations, Network Administrator, Director and Supervisors)     

Measures:

·        Documentation of intra-organizational communication reported through QI Committee

·        Attendance of staff in computer training; increased use of computer applications by staff

·        Periodic reviews of Maryhaven website

Strategies:

C 1      Maintain high occupancy rate in all residential programs and high productivity in outpatient programs; implement improvement plan in case of program identified as falling short.  (CCO, CFO and Dir. of Business Operations, Dir. of QI and Planning, Dirs. of Adult and Adolescent Services, Program Supervisors)

Measures:

·        Review of program census and productivity reports

·        Program improvement plans and analyzes of results

Strategies:

D 1      Maintain excellence in financial management and reporting, producing accurate and useful budgets and financial reports that are recognized as such by funders and auditors.  (CFO and Dir. of Business Operations)

Measure:    

·        Annual financial audit report and documented feedback from funders and accreditation/certification organizations reviewing Maryhaven’s financial management 

Strategies:

A 1      Conduct customer service training across all levels of personnel.  (Dir. of HR and Diversity Development; Management Team)

A 2      Implement strategies to improve the admissions process, consistently responding to referrals in a timely manner.  (Dir. of QA and Planning, CFO and Dir. of Business Operations, Central Admissions Supervisors, Supervisor of Receptionists)

A 3      Continue to maintain Maryhaven’s high level of recognition and positive reputation in the community through active and ongoing media relations and marketing.  (CEO, Dir. of Community Relations and Support Services)

A 4      Actively participate in ADAMH Board levy campaign activities.  (CEO, Dir. of Community Relations and Support Services)

Measures:

·        Documentation of customer services training

·        Data on referrals, timeliness of screening calls and assessment appointments

·        Results of satisfaction surveys of patients and referral sources

·        Number of positive media exposures

·        Review of participation in levy campaign activities

Strategies:

B 1      Continue activities of Cultural Diversity Council, involving all Maryhaven associates. (Dir. of HR and Diversity Development, Cultural Diversity Council)

B 2      Improve accessibility of Maryhaven services to the Latino community through outreach, recruitment of Spanish-speaking staff, and program development.  (Dir. of HR and Diversity Devlopment, HR Generalist/Latino Liaison, COO)

Measures:

·        Review of Cultural Diversity Plan and achievements, minutes of Cultural Diversity Council

·        Measures of staff involvement; staff survey

·        Measures of outreach efforts to Latino community, number of Spanish-speaking staff, linguistically-accessible programs, and number of Latino patients served

Strategies:

C 1      Anticipate and proactively address risk issues in all Maryhaven programs and operations; monitor and report risk management activities through QI and Risk Management Committee.   (Program Directors and Supervisors, Dir. of Community Relations and Support Services/Safety Officer, Dir. of QA and Planning, CFO and Dir. of Business Operations)           

C 2      Enhance the organization and focus of staff training in safety and risk management topics including first aid and CPR, crisis prevention and intervention, and others.  (Dir. of HR and Diversity Development, Dir. of QA and Planning, CCO)

Measures:

·        Review of content of risk management plans; reports of risk management activities in monthly QI Committee meeting

·        Review of training plan and comparison with certification and accreditation standards; staff attendance in required trainings