Quality Assurance

Why is Quality Assurance Important?

• Vital to ensuring the safety of children and staff

• Enables Installation ICYP Directors to monitor compliance with CYP policy and facilitate continuous quality improvement

• Prepares programs for inspections

• Saves time in the long run

QA Operating Manual• Ch 1: Intro to Quality

Assurance

• Ch 2: Quality Assurance Management Practices

• Ch 3: Health & Sanitation Inspections

• Ch 4: Fire & Safety Inspections

• Ch 5: Multi-Disciplinary Team Inspections

• Ch 6: CNIC HQ Inspections

• Ch 7: Systemic Approach to Quality Assurance

Managing and Sustaining a Quality Assurance Culture

Activity

• Take the next five minutes to list what you feel is the Installation CYP Director’s role in managing and sustaining a quality assurance culture.

• You may work alone or in small groups.

The Role of the Installation CYP Director/RAB

• Ensure compliance with DoD and CNIC CYP policies and procedures

• Develop local SOPs as needed

• Clearly define roles and responsibilities

• Coordinate CYP wide programs (e.g., IAT, PIB, etc.)

• Provide opportunities for

information sharing and a team

approach to maintaining a

quality programs

• Familiarize all staff with inspection criteria

• Utilize inspection results to make program improvements

• Stay informed and stay involved

Proactive vs. Reactive

Being proactive rather than reactive means to control a situation rather than letting it control you.

Proactive vs. Reactive

Reactive• ICYPD visits programs and

talks to staff only to resolve problems

Proactive• ICYPD is frequently at the

program to attend events, conduct spot checks, and provide support and positive feedback

• CYP staff feel comfortable approaching the Installation ICYP Director

• Opportunities are available for staff to provide suggestions for program improvement

Proactive vs. Reactive

Reactive• ICYPD delegates responsibility

and does not get involved unless there is a problem

Proactive• ICYPD actively oversees CYP

wide programs (IAT, PIB, etc.) • Maintains awareness of how

programs are operating by periodic spot checks, recurring staff meetings, etc.

• ICYPD delegates responsibility wisely, ensuring all know their roles and can perform assigned duties

• ICYPD watches trends and steps in before issues arise

• Trust but verify

Proactive vs. Reactive

Reactive• ICYPD only becomes aware of

a problem during inspections, when a serious incident occurs, or there is a complaint to the Command

Proactive• ICYPD conducts internal

audits, file reviews and facility walkthroughs, tracks trends, and seeks feedback from parents and staff

Proactive vs. Reactive

Reactive• Inspection deficiencies are

answered with short term remedies (one-time training, disciplinary measures, moving staff, etc.) and with non-sustainable long-term solutions.

Proactive• All inspections are reviewed

and serious health/safety concerns are addressed immediately.

• ICYPD establishes sustainable systems which help the program operate more smoothly and effectively.

• Other findings are remedied or a plan for correction is put into place and tracked until completion.

Proactive vs. Reactive

Reactive• ICYPD is unaware if required

inspections are taking place. Only when they are overdue and/or if deficiency is noted on an inspection report, does the ICYPD take action.

Proactive• ICYPD develops relationships

with proponents, creates tickler systems to ensure inspections are conducted, develops meaningful action plans, and maintains documentation.

Proactive vs. Reactive

Reactive

• Each year, when the CNIC HQ inspection team arrives, the programs scramble to gather needed materials

Proactive

• An “Inspection Box” is created

• Documentation noted on the Materials Needed List is maintained in an orderly manner

• The ICYPD ensures staff is familiar with the information that will be reviewed by the inspection team

CNIC HQ Inspections• CY16 Inspection Criteria will incorporate OSD standardized criteria

as well as minor changes to the current CY15 criteria.

• CY16 Inspection Criteria will contain a separate CYP inspection which will be scored. The ICYPD is the POC for verifying the inspectable items on the CYP inspection.

• Once the inspection responses have been reviewed and approved and any requests for extensions/exceptions have been processed, a request is sent to DoD for a Certificate to Operate.

• Three new Inspectors are onboard

Role of the Installation CYP Director

• Ensure staff are familiar with inspection requirements

• Help staff become comfortable with observations

• Ensure required inspections are conducted throughout the year and ensure proper follow-up

• Help programs develop organizational systems that will make the inspection process go more smoothly

Multi-Disciplinary Team Inspection

• One of four annual inspections required by the DoDI and MCCA

• Internal comprehensive review of CYP operations

• Provides opportunity to identify systems and processes in need of improvement

• Helps prepare programs for HQ inspection

MDTI Working Group

Kathryn HardebeckMary GrenierDesiree Clark

Overview of MDTI changes

• Compliments not replicates HQ process

• Allows more subjective feedback

• Allows local criteria to be added

• “Indicators” provided to help guide inspection

• Clearer distribution of work

• Standardized forms

MDTI Inspectable Areas

• Overall Child and Youth Programs

• General Management

• Facilities, Health, and Safety

• Family Partnerships

• Programming

Forming the MDTI Team• At least one parent

• Members to inspect General Management, Facilities, Health, & Safety, and Programming

• Designated Team Leader – will inspect CYP

• DoD 6060.2 requires representatives from HR, Fire, Health, and Safety

Team AssignmentsGeneral

Management (Bob)

CDC

SAC

CDH

GM(Bob)

GM(Mary)

GM(Sue)

CDC I CDC II

CDH

SAC Teen

The MDTI Process

– Orientation Meeting• Introductions• Purpose of MDTI• Team Member responsibilities• Appoint Team Leader• Discuss timeline for MDTI• Review checklists• Review resources

The MDTI Process• Kick-Off Meeting

– Hand out Appointment Letter– Clarify criteria to be inspected– Hand out MDTI Instruction Sheet– Distribute helpful info (base map, CYP

organization structure, etc.)– Distribute needed paperwork (Materials

Needed Lists, inspection checklists, etc.)

Completing the MDTIInspection Process

• Address all inspection findings.• Prepare MDTI Cover Letter to forward

inspection results and corrections to CO.• Maintain a copy of the MDTI inspection

and corrections, with CO’s signature, in a file.

Role of the Installation CYP Director

• Oversee the MDTI process• Recruit MDTI members • Provide support (e.g., resources, guidance, etc.)

as needed to MDTI Team• Ensure MDTI is conducted each calendar year

within 15 months• Ensure deficiencies are corrected and the CO

reviews results

Developing Improvement Plans

Regardless of how a deficiency is discovered, informal and/or formal plans should be developed for correction and process improvement.

“If you continue to do what you’ve always done, you’ll always get what you’ve always got.”

- Henry Ford

Developing Improvement Plans

• WHO is responsible?

• WHAT is being done to correct the deficiency?

– Short-term remedies

– Long-term remedies (including interim measures)

• WHEN will the action be complete?

• Is the correction sustainable?

Inspection Response Activity

• Finding 1: A teacher did not respond appropriately when redirecting a child who hit another child and knocked the child down for taking his hat away. One teacher grabbed the child by the arm and said in a stern voice, “No thank you! We do not hit our friends!” Positive guidance techniques were not used to help the child develop self-control and manage his feelings appropriately.

• Finding 2: The playground equipment was not well maintained. The badminton net was torn and the slide was blocked off due to a split in the slide which was identified during the comprehensive safety inspection three months prior. The poured-in-place surfacing around the play structure was cracking and pitting in numerous places.

Finding #1

• Finding 1: A teacher did not respond appropriately when redirecting a child who hit another child and knocked the child down for taking his hat away. One teacher grabbed the child by the arm and said in a stern voice, “No thank you! We do not hit our friends!” Positive guidance techniques were not used to help the child develop self-control and manage his feelings appropriately.

• Response: The T&C immediately began observations modeling in this classroom. During the same week, she met the Lead caregivers to conduct observations and model developmentally appropriate guidance techniques in all classrooms. Caregivers observed needing additional support are reviewing the applicable modules and undergoing one-on-one training with the assigned Leads. The T&C has also scheduled a program-wide training on positive guidance for 15 March as part of the annual training requirements.

Finding #2• Finding 2: The playground equipment was not well maintained. The badminton net was torn

and the slide was blocked off due to a split in the slide which was identified during the comprehensive safety inspection three months prior. The poured-in-place surfacing around the play structure was cracking and pitting in numerous places.

• Response: A new badminton net was purchased by the Director and was installed during the inspection. A meeting was immediately held with all opening and closing staff to discuss the opening checklist and the importance of a thorough inspection. A process has been implemented for the Director, or administrator on duty, to review the opening checklist each day and identify items that need to be addressed. Safety was called to look at the slide. On 12 June, they determined that the crack did not pose an immediate safety concern and the slide could be used until it was replaced. The playground equipment vendor was contacted on 13 June to inspect, and either repair or replace the slide. The surfacing was checked by the Director and the Safety Office on 12 June for tripping hazards and has been determined to be safe. The playground will continue to be checked daily. An extension request for both the slide replacement and the surfacing replacement is included with this response.

Responding to Inspection Findings• It is the responsibility of the ICYPD to review and provide input to all inspection

responses.

• The expectation is that by the time an HQ inspection response reaches HQ, the CYPD and the RAB member have reviewed for accuracy and sustainability as well as incorporated their input by communicating with the installation CYP personnel. Currently these reviews are documented in different ways, depending on the region.

• There should be a single response received by CNIC HQ, incorporating the recommendations/reviews of both the CYPD and the RAB member.

Common Pitfalls with Responses

• The response only addresses the staff/classroom that was observed• An inspection response is forwarded to HQ with a non-concurrence by the

region• The ICYPD/region endorses without reviewing responses resulting in back and

forth communication between HQ and the Region/Installation• Responses include only short-term corrections and no long-term solutions• Actions are not sustainable• Responses do not address all of the findings or are not detailed• Challenges to the inspection findings are brought up in the inspection response• Extension requests are not included with responses

Extensions and ExceptionsExtension – additional time needed to complete a correctionException – request to NOT meet Navy policyWaiver – request to NOT meet a DoD policy. Can only be approved by OSD

❖ If submitted as a result of an inspection, should accompany the inspection response

❖ Must be routed through CO and Region

Installation ICYP Director’s Role

• Review all Extension/Exception requests for reasonableness

• Review requests for completeness

• Ensure each milestone has an ECD and there is an ECD for the completion of the project

• Track Extension/Exception expiration dates

QUESTIONS

“You can delegate authority, but you cannot delegate responsibility.”

• Byron Dorgan