New York City Department of Health and Mental Hygiene Early Intervention Program (EIP) Quality and Compliance Self-Assessment Tool for New York City EIP Providers The self-assessment is a powerful tool to help you meet and even exceed your obligations as NYC EIP providers. A rigorously applied self-assessment is a first step in maintaining compliance with the requirements for NYC EIP providers. It is a way for an organization to measure its strengths and weaknesses and identify areas for improvement. Use of this self-assessment is optional. It is for your own internal use, not for NYC EIP. The first section of this document provides the standards and citations used by the NYC EIP for provider monitoring, by service area. Following that is an explanation of the elements of a self-assessment, and examples of completed self-assessments. Before conducting the self-assessment
1. Outline a process for the self-assessment, including a timeline and identification of people to gather the information and review results. A team approach is recommended, followed by a review of the results with senior management and any oversight bodies, such as a Board of Directors.
2. Review the standards, suggestions and citations for each service area. The citations list the rules, regulations, policies, and contract terms applicable to the standard. The citations clarify how the associated standard is measured. Create a list of the expectations outlined in the citations, as related to compliance and quality.
3. Identify what your organization will use as performance criteria for each standard. Criteria answer the question: What performance do we expect on this standard, and how will we know we have reached that level of performance? There may be information about your organization’s expectations regarding performance, quality assurance and monitoring in your policies, procedures or trainings.
4. Identify data source(s), such as children’s files, or service coordination logs. Then identify the number of files, logs, etc. that you will review by asking “How many do we need to review in order to feel confident that they are representative of our overall performance?”
5. Review the self-assessment explanation of terms table and the four examples provided. Please note that where there is a reference to parents or families, surrogates are included if applicable.
6. Identify a method for collecting data on your findings, such as a spreadsheet with the names and results of the files you review.
NYC EIP providers are responsible for complying with all provisions of the citations related to the following standards, as outlined in the accompanying table of citations. Each standard is presented with some items for consideration when determining how to define and measure performance.