# REFUGE HOUSE, INC.

| Policy Information | Details |
| :---- | :---- |
| **POLICY NAME** | Continuous Quality Improvement (CQI/PQI) Policy |
| **POLICY NUMBER** | FC-CQI-01 |
| **ORIGINATED** | 6/16/26 |
| **APPROVED BY** | Board of Directors |
| **EFFECTIVE DATE** | 6/16/26 |
| **REVISION DATE** | 6/16/26 |
| **LAST UPDATED** | 5/15/2026 |
| **LAST APPROVED** | 5/22/2026 |
| **RELATED PROCEDURE** | FC-CQI-01.1 Continuous Quality Improvement Procedure |

| APPLICABLE T3C PACKAGES: | APPLICABLE T3C ADD-ON SERVICES: |
| :---- | :---- |
| ☒ T3C Basic Foster Family Home | ☒ Transition Support Services for Youth & Young Adults |
| ☒ Substance Use Support Services | ☒ Kinship Caregiver Support Services |
| ☒ Short-Term Assessment | ☒ Pregnant & Parenting Youth or Young Adult |
| ☒ Mental & Behavioral Health |  |
| ☒ Sexual Aggression/Sex Offender |  |
| ☒ Complex Medical Needs or Medically Fragile |  |
| ☒ Human Trafficking Victim/Survivor |  |
| ☒ Intellectual or Developmental Disability (IDD)/Autism Spectrum Disorder |  |
| ☒ T3C Treatment Foster Family Care |  |

## PURPOSE:

To establish Refuge House's **Continuous Quality Assurance and Improvement (CQI/PQI) Program** — the systematic collection, analysis, and use of data to improve service delivery, outcomes, and compliance across all Service Packages — and to document the agency's **client and stakeholder satisfaction program** as a core component of that work. This program fulfills the required **T3C Continuous Quality Assurance and Improvement Infrastructure Function (Function #6)**.

## POLICY:

Refuge House maintains an ongoing, data-informed CQI/PQI program grounded in trauma-informed (TBRI®) principles. Quality improvement is a standing agency function, not a one-time activity: the agency continuously measures outcomes, gathers feedback from the people it serves and partners with, identifies improvement opportunities, implements changes, and evaluates results. Where an SSCC provider manual or the T3C System Blueprint imposes a stricter quality or reporting requirement than DFPS Minimum Standards, the **stricter requirement controls**.

This policy is intentionally a governing framework; it consolidates and points to quality activities already established elsewhere in the knowbase rather than duplicating them.

## PROGRAM COMPONENTS:

1. **Ownership and oversight.** The **CQI Coordinator** (T3C Infrastructure Function #6; may be fulfilled by a dedicated position, duty-based assignment, or contracted specialist) leads the program, supported by the **Director of Quality Development / HRQAD**, with Executive Director oversight and reporting to the Board of Directors.

2. **Logic Models and CQI Models (existing architecture).** The agency maintains an established **Logic Model** and a paired **CQI Model** for **each Service Package** — Basic, Mental & Behavioral Health, IDD/Autism, Short-Term Assessment, Substance Use, and Treatment Foster Family Care — published in the knowbase (cookbook/previewforms; wired into `data/placement-datasheets.json` as each package's `logicModel`/`cqiModel`) and governed by the master **CQI Plan / Logic-Model Integration**. Each Logic Model defines Mission/Vision, the TBRI® treatment model, Inputs → Activities → Outputs → Short-/Intermediate/Long-term Outcomes, and a **CQI Process** block (Data Collection · Program Review · Implementation Adjustments) per TAC §749.665. This policy does not replace those models; it is their governing umbrella. Outcome measurement integrates **CANS 3.0** data and tracks placement stability and disruption patterns (cross-ref FC6-01 placement-stability monitoring).

3. **Client and stakeholder satisfaction program.** Refuge House gathers structured feedback from **children/youth and young adults, foster/kinship/adoptive caregivers, staff, and external partners (DFPS, SSCC, community providers)** through periodic satisfaction surveys, feedback forms, exit interviews, and an accessible concern/feedback channel, ensuring **youth voice** in improvement decisions. Satisfaction data is compiled and used to assess program effectiveness and drive improvement **(2INgage Provider Manual, Rev. 1.2026, §12 Quality Improvement, p.51 — Client and Stakeholder Satisfaction Surveys; OCOK Network Management Operations Manual, Rev. 7-1-2025, §4.09 Stakeholder Satisfaction Survey — annual stakeholder satisfaction surveys covering clients, client team members, CPS workers, and employees, and §4.04 PQI; consistent with the 2INgage "DO-RITE" and OCOK "DMAIC" QI methodologies and COA accreditation standards; EMPOWER Provider Manual, Rev. 1.2026, §12 Quality Improvement — parallel satisfaction/feedback requirement)**. Refuge House also participates in and supports the SSCC's own stakeholder satisfaction process.

4. **Incident and trend review (PQI).** Serious and non-serious incidents are reviewed for patterns and trends and fed into the quarterly PQI process (cross-ref **FC-SIR-01 Serious Incident Reporting**, which operates the monthly review → quarterly PQI meeting → action plan → Executive Director cycle).

5. **Internal audits and corrective action.** The agency conducts internal quality audits and documentation/compliance reviews (TAC §749, DFPS contracts, T3C Blueprint), and develops **corrective action plans / Quality Improvement Plans (QIPs)** when deficiencies are identified, including any QIP requested or approved by an SSCC.

6. **Reporting.** Quality metrics and outcomes are reported **at least quarterly** to agency leadership and the Board, and to regulatory and contract bodies as required, with audit-ready documentation maintained throughout.

## METHODOLOGY:

Quality improvement follows the agency's established **Plan-Do-Study-Act (PDSA) CQI cycle**, run **quarterly** per Service Package as set out in each package's CQI Model: **Plan** (review Logic Model, set measurable goals, develop strategies — Program Director/QA team, beginning of quarter) → **Do** (implement TBRI®, collect data, document services — Case Specialists/foster parents, weeks 1–10) → **Study** (analyze data, compare to model, identify trends — QA Coordinator/Program Director, weeks 11–12) → **Act** (develop improvements, adjust approach, modify training — CQI team, week 13). This cycle is compatible with, and responsive to, each SSCC's quality methodology — e.g., the **2INgage "DO-RITE"** cycle (Define, Observe, Record, Intervene, Test, Evaluate) and the **OCOK "DMAIC"** cycle (Define, Measure, Analyze, Improve, Control; OCOK Operations Manual Rev. 7-1-2025, §4.04).

## QUALITY ASSURANCE:

The CQI Coordinator monitors program implementation, maintains the quality dashboard/metrics, and ensures the satisfaction program, PQI review, internal audits, and reporting occur on schedule. The program itself is reviewed at least annually for effectiveness.

## REGULATORY ALIGNMENT:

- **26 TAC §749.665 (Quality Assurance)** — the CQI Process anchor used across the agency's Logic Models and procedures
- **T3C System Blueprint** — Continuous Quality Assurance and Improvement Infrastructure Function (Function #6); per-Service-Package Logic Models and outcome measures
- **SSCC — 2INgage Provider Manual (Rev. 1.2026): §12 Quality Improvement & Contract Management** (Client & Stakeholder Satisfaction Surveys, DO-RITE methodology, QIPs, COA-accreditation support); **§11 Risk Management & Reporting** (data collection/reporting cadence)
- **SSCC — OCOK Network Management Operations Manual (Rev. 7-1-2025): §4.04 Continuous Quality Improvement Process** (PQI/DMAIC; annual provider monitoring; COA RPM 2), **§4.09 Stakeholder Satisfaction Survey** (annual), **§4.05 Quality Management**
- **SSCC — EMPOWER Provider Manual (Rev. 1.2026): §12 Quality Improvement & Contract Management** (client/stakeholder satisfaction & feedback) and **§11 Risk Management & Reporting** (Monthly Case Status Report by the 10th)
- **SSCC — Belong Stage I & II Provider Manual (Accepted Changes Aug 2025): Quality Assurance** (p.56 — measuring satisfaction of individuals served and Network Providers; QA reviews, grievances/appeals, outcome indicators feeding system improvement)
- Other SSCC manuals (SFCS): apply the stricter quality/reporting requirement where one controls

**SSCC alignment (FY-26):** Reviewed against the 2INgage Provider Manual Rev. 1.2026; aligned — 2INgage provider-specific provisions were captured in the prior reconciliation pass; no further changes required. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC coverage tracker (`temporary-reference/fy26-sscc-joint-monitoring/sscc-alignment/`).

**SSCC alignment (FY-26) — EMPOWER:** EMPOWER Provider Manual Rev. 1.2026 — aligned (parallel template to 2INgage); EMPOWER provider-specific provisions captured in the EMPOWER pass; no additional changes required. Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — OCOK:** OCOK Network Management Operations Manual Rev. 7-1-2025 — reviewed; OCOK provider-specific provisions are carried in the companion procedure/policy (see the FY-26 SSCC variance matrix). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — 4Kids:** 4Kids4Families Joint Operations Manual (Dec 2025) / Subcontractor Agreement — reviewed; 4Kids provider-specific provisions carried in the companion procedure/policy (see the FY-26 SSCC variance matrix). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — Belong:** Belong Stage I & II Provider Manual (Aug 2025) / Provider Services Agreement — reviewed; Belong provider-specific provisions carried in the companion procedure/policy (see the FY-26 SSCC variance matrix). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

**SSCC alignment (FY-26) — SFCS:** SFCS Placement Provider Manual (July 2020, publicly-sourced) / 2019 Affiliate Provider Agreement — reviewed; SFCS provider-specific provisions carried in the companion procedure/policy (see the FY-26 SSCC variance matrix). Cross-reference: FC-CQI-01 Continuous Quality Improvement Policy; FY-26 SSCC variance matrix.

## RELATED POLICIES AND PROCEDURES:

- FC-CQI-01.1 Continuous Quality Improvement Procedure
- **Per-Service-Package Logic Models + CQI Models** (Basic, MBH, IDD/Autism, STASS, SU, TFFC) — cookbook/previewforms; `data/placement-datasheets.json` (`logicModel`/`cqiModel`); master **CQI Plan / Logic-Model Integration**
- FC-SIR-01 Serious Incident Reporting Policy/Procedure (PQI incident/trend engine)
- FC6-01 Admission Matching & Criteria for Child Placement (placement-stability monitoring)
- T3C Discharge & Permanency Planning Procedure §3 (Disruption Mitigation Process)
- Recruitment & Retention of Foster Families Procedure §5 (caregiver support; family-satisfaction analysis)
- Aftercare Services / Youth Transition Support (youth satisfaction surveys; caregiver feedback)
- T3C Professional Staffing Plan (CQI Coordinator — Infrastructure Function #6)
- Continuous Quality Improvement (CQI) Coordinator Job Description

## DEFINITIONS:

**CQI/PQI:** Continuous Quality Improvement / Performance Quality Improvement — the ongoing, data-informed cycle of measuring outcomes, gathering feedback, improving, and re-measuring.

**Logic Model:** a Service-Package-specific framework linking inputs, activities, outputs, and outcomes used to measure effectiveness.

**Client & Stakeholder Satisfaction Program:** the structured collection of feedback from children/youth, caregivers, staff, and external partners used to measure program effectiveness.

**Quality Improvement Plan (QIP):** a documented corrective plan addressing identified deficiencies, including any plan requested/approved by an SSCC.

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*This policy document establishes the governing principles for Continuous Quality Improvement. The corresponding procedure (FC-CQI-01.1) operationalizes these principles. While policies require Board approval and remain relatively stable, procedures may be updated by the Executive Director to adapt to regulatory or operational changes without requiring Board approval, provided such changes maintain alignment with the policy's intent.*