Continuous Quality Improvement

SUS embarked on a mission in 2002 to live up to its core values which includes “Continuous Quality Improvement.” Recognizing that the agency was growing with new programs at both its day habilitation and residential housing sites, SUS launched the Quality Improvement Initiative to maintain and assure high quality services.

Throughout the last five years, the initiative has expanded its scope and has given rise to an invaluable Quality Assurance (QA) department within the SUS support team. Quality Assurance touches aspects of every operation within SUS – staff training, Medicaid reviews, consumer complaints and incident management. The Quality Assurance department also has one individual designated to work with staff to improve the environment at the SUS Program sites.

This Q&A was conducted with Lesmore Willis, Director of Quality Assurance, Training and Development

Q: What is involved in a routine audit by public funding sources?

Public funding sources have minimum standards that the programs are audited by. Usually these audits concentrate only on the deficits and rarely note positives or best practices.

Q: How do internal audits differ from those conducted by public funding sources?

The internal audits are more detailed and may entail more than one day at a particular site. Internal audits often have focus areas of review based on past noted deficiencies. The internal audit also looks at the internal controls and is able to point these out to highlight best practices to be employed agency-wide.

Q: SUS is often described as a “go to agency” by our public funders. How does Quality Assurance contribute to this high praise?

SUS is known for its high standards. There is a lot of good staff at the programs. We would like to believe that QA has heightened staff awareness of areas in the program for which improvements are needed. QA has strengthened the incident management process, aiding staff by recommending additional safeguards.

Q: Was there ever a problematic audit experience? If so, what was learned or achieved as a result?

There was a past fiscal audit that did not go as well as hoped. Subsequently it was recognized that QA could have played a greater role in heightening management awareness more. Since then QA has been more proactive in alerting all SUS departments to situations which may pose liabilities to the organization.

Q: What do public funding auditors learn that you would want all our private funders to know about SUS?

That SUS maintains a standard of transparency and ethical values that are unparalleled.

Q: What are the most common reactions by SUS staff members and consumers to “surprise” audits?

SUS staff have become accustomed to the QA unannounced audit, as it is a common practice within the QA operational procedure. Staff, as well as consumers, welcomes surprise audits as integral to the SUS support system. Consumers very often use this process as a venue for expressing concerns. The QA audit team employs a user friendly approach and strives to make each audit a learning experience for program staff.

Q: What are the goals of the SUS Quality Assurance department in the coming year, and in the years ahead?

The overall objective is to strengthen internal controls within the entire SUS organization. This goal includes building the capacity and capability of individual SUS programs to self monitor and increasing the awareness of high risk areas. The desired result in all QA efforts is a reduction in the agency’s liability, and the health and safety of every SUS consumer.