CP-AM Standard. Generated 11/27/2022. ©2022 Council on Accreditation.
2022 Edition

Administration and Management Introduction

Purpose

Through sound administration and effective management, the public authority/agency achieves its mission and strategic goals; assures appropriate use of public resources for the public good; and remains responsive to the needs of the communities it serves.  

Introduction

COA’s Administration and Management standards outline the responsibilities of public authority/agency leadership to foster a culture of transparency, accountability, and community responsiveness; provide oversight of operations; and promote program and operational improvements. The responsibilities set forth in the standards represent the multi-faceted functions the leadership of a public authority/agency assumes in cooperation with relevant stakeholders.

Interpretation

Public authority/agency leadership can include the Chief Executive Officer, the public authority/agency director, the agency head, or the administrative team.
Note: This standard does not apply to private organizations.

Note: Please see CP-AM Reference List for the research that informed the development of these standards. 

​​​​​​Note: For information about changes made in the 2020 Edition, please see CP-AM Crosswalk. See also ETH Public Crosswalk for Ethical Practice standards that are now found in CP-AM.
 
2022 Edition

Administration and Management (CP-AM) 1: Mission

The public authority/agency’s mission:
  1. is responsive to the needs of the communities it serves;
  2. guides the public authority/agency’s administrative operations and delivery of services; and
  3. serves as a benchmark of organizational effectiveness.

Interpretation

COA recognizes that a public authority/agency’s mission may be established in statute, and its parameters framed by budget authorization.
1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • See agency mission statement provided during application
No On-Site Evidence
  • Interviews may include:
    1. Agency leadership
    2. Agency field personnel
    3. Contracted providers
 
2022 Edition

Administration and Management (CP-AM) 2: Implementing Public Authority/Agency-Wide Change

The public authority/agency ensures effective implementation of initiatives through sound leadership and strategic management of the change process that fosters support and emphasizes sustainability.
1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • For the most recent agency-wide initiative:
    1. Project vision
    2. Completed readiness assessment
    3. Implementation plan
    4. Evidence of actions taken to support plan implementation (e.g. meeting minutes, updated policy/procedures, reports, etc.)
  • Documentation of collaboration with stakeholders
  • Interviews may include:
    1. Agency leadership
    2. Community stakeholders
    3. Agency field personnel
    4. Contracted providers

 

CP-AM 2.01

Prior to initiating an initiative, the leadership:
  1. identifies the needed change or identifies the purpose of a mandated change;
  2. works with relevant stakeholders to establish a shared project vision that aligns with the public authority/agency’s core values; and 
  3. assesses the public authority/agency's readiness and capacity for change including strengths, needs, and available resources at the system, organizational, and personnel level.
Examples: The readiness assessment may include an assessment of:
  1. the sociopolitical climate; 
  2. available funding; 
  3. administrative resources and processes (e.g., computer systems); 
  4. policy and procedure alignment with the desired change; 
  5. communication mechanisms for knowledge and information sharing; and 
  6. the knowledge-base, attitude, and workload of staff who will be responsible for carrying out the change. 
Examples: Relevant stakeholders can include, but are not limited to: staff at all levels, individuals and families served, community-based providers, contracted providers when applicable, and universities.
 

 

CP-AM 2.02

An assessment-based implementation plan promotes the sustainability of the initiative by:
  1. identifying financial, organizational, and human resource needs;
  2. establishing communication protocols for ongoing, two-way communication;
  3. developing, revising, or implementing policies and procedures in accordance with new ways of doing work;
  4. updating human resources and personnel development and supervision practices  to reflect the attitude, knowledge, and skill set needed to effectively implement new practices with fidelity; and
  5. outlining ongoing implementation monitoring activities.
Examples: Examples of methods for identifying needed resources include, but are not limited to, making recommendations to oversight entities regarding resource allocation; collecting and regularly reporting barriers to successful implementation to oversight entities; and developing partnerships with external stakeholders who can help to advance the public authority/agency’s implementation goals by advocating on its behalf with the community, funders, and other entities as needed.
 
2022 Edition

Administration and Management (CP-AM) 3: Authority/Agency Leadership

Public authority/agency leadership oversee operations and sets the direction of the agency through the following activities:
  1. long-term and annual planning;
  2. developing, implementing, and evaluating policy; 
  3. succession planning and leadership development;
  4. providing financial oversight; and
  5. interfacing with other government entities and oversight entities. 

Interpretation

The individual or entity (i.e. office, unit, committee, etc.) responsible for carrying out each of the functions in this section can vary depending on the agency’s size and administrative structure. Agencies should establish for themselves a consistent definition for “public authority/agency leadership” and identify the applicable parties responsible for carrying out the responsibilities outlined.
1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Manual or procedures detailing communication protocols and reporting information
  • Summary of task forces/committees, including responsibilities
  • Long-term and annual planning procedures
  • Long-term plan
  • Annual Plan(s)
  • Procedures for policy development, implementation and evaluation
  • Agency leadership:
    1. Job description(s)
    2. Resumes or curricula vitae
  • Succession planning procedures
  • Succession plan
  • Meeting schedules, agendas, and minutes from the current year for annual planning
  • Policy drafts with comments from senior staff
  • Documentation of policy release and implementation (memos, training content, etc.)
  • Agency leadership testimony at budget hearings
  • Copies of relevant reports
  • Interviews may include:
    1. Agency leadership
    2. Policy development or legal/regulatory/compliance personnel
    3. Operations/program field personnel
    4. Community stakeholders

 

CP-AM 3.01

The public authority/agency establishes the following in an accessible, written format:
  1. communication protocols and reporting information for major functions/operations; and
  2. other structures or processes for implementing leadership responsibilities, including establishing task forces/committees.

 

CP-AM 3.02

Leadership involves personnel across positions and departments in long-term planning every four to five years that includes:
  1. a review of the public authority/agency’s mission, values, mandates, and strategic direction;
  2. a review of the demographics of its defined service population;
  3. an assessment of the previous long-term planning cycle, including current strengths and areas for opportunity;
  4. measurable goals and objectives that support fulfillment of its mission, mandated responsibilities, and quality improvement priorities; and
  5. strategies for meeting identified goals.
Examples: To enhance its review, the public authority/agency can draw upon the findings of other external needs assessments, such as those conducted by municipal planning boards, universities, public health records, or other agencies with a community-wide focus. 

 

CP-AM 3.03

The public authority/agency develops and implements an annual plan that integrates the priorities and objectives of each of its departments and programs, and:
  1. is staff driven;
  2. operationalizes the public authority/agency’s long-term strategic plan;
  3. reflects changing conditions and needs, such as resource allocation, funding and regulatory changes; and
  4. responds to information from PQI activities.
Examples: Annual plans can also incorporate other regular planning processes, including:
  1. HR planning;
  2. evaluation of training needs;
  3. budget planning;
  4. technology and information management; and
  5. the annual PQI report.

 

CP-AM 3.04

Leadership’s policy development, implementation, and evaluation responsibilities include:
  1. establishing, reviewing, and revising policy;
  2. analyzing and adopting any changes to policies resulting from recommendations from various stakeholder groups;
  3. providing clear, timely, and thorough communications when policies are established or revised;
  4. ensuring front line supervisors have the information and support needed to guide staff on implementing policies;
  5. providing feedback to those establishing policy on recommendations from various stakeholder groups, including front line staff and their supervisors; and
  6. evaluating the costs and benefits of implementing policies for consumers and for the agency.

 

CP-AM 3.05

Leadership’s financial oversight responsibilities include: 
  1. setting resource development targets and goals, as reflected in federal, provincial/territorial, and municipal budgets and/or consolidated plans; and
  2. working with relevant public entities to advocate for adequate and timely flow of resources to implement the strategic planning and budgeting decisions.

 

CP-AM 3.06

Public authority/agency leadership establishes and maintains collaborative partnerships with personnel from other government entities.

 

CP-AM 3.07

Leadership provides regular, timely reports on operations, finances, and implementation of the long-term plan and system-wide initiatives to the appropriate oversight entities.
Examples: Reports to oversight entities on finances can include:
  1. current financial status and any anticipated problems;
  2. shifting strategic priorities and their financial implications; and
  3. financial planning and funding alternatives.

 

CP-AM 3.08

Leadership have demonstrated competence in the public authority/agency’s mission and services as well as public human services administration, including human resources management, financial management, and cross-system collaboration.

Interpretation

Competence to fulfill the core functions of the position can be demonstrated through any combination of experience, formal education, and training.

 

CP-AM 3.09

To ensure continuity during transitions in leadership, the public authority/agency maintains succession planning procedures and a succession plan.
Examples: Information included in a succession plan may include, for example:
  1. under what conditions interim authority can be delegated and the limits of that authority;
  2. relevant positions and the key leadership and management functions of those positions;
  3. to whom various leadership and management functions will be delegated; and
  4. the mechanisms for assessing personnel’s readiness to assume leadership positions and for providing training, mentorship, and other leadership development opportunities to ensure readiness.
 
2022 Edition

Administration and Management (CP-AM) 4: Community and Provider Engagement

The public authority/agency fosters a culture of community responsiveness by:
  1. conducting public outreach and education;
  2. engaging a diverse group of stakeholders in collaborative, purposeful, and ongoing partnership; and
  3. incorporating recommendations from collaborative efforts into its organizational decision-making related to regulatory processes, risk management, quality improvement, and long-term planning activities.
Examples: Stakeholders can include, but are not limited to: the courts, legal system, and law-enforcement officials; individuals and families; internal staff; community-based agencies including mental health, substance use, and domestic violence service providers; provincial and local governments; advocacy and professional organizations; health care providers; educators; representatives from communities of faith; business community representatives; other public agencies and providers; contracted providers; and the media.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • See website URL and links to social media sites provided during application
  • Summary of public outreach and education activities
  • List of stakeholder groups/entities
  • Assessment of existing and potential community partners
  • Community and provider engagement plan
  • Stakeholder advisory group bios
  • Communications plan and/or procedures for responding to critical incidents
  • Community Demographic Profile
  • Informational materials available in communities served
  • Documentation of:
    1. Collaboration with stakeholders (e.g. meeting minutes, agenda, correspondence, etc.)
    2. Decisions made and/or actions taken in response to stakeholder feedback (e.g. progress/data reports)
  • Training curricula and materials for:
    1. Stakeholder training, as applicable
    2. Staff training related to engaging and collaborating with consumers
    3. Consumer training and/or other supports to facilitate their active involvement
  • Stakeholder advisory group meeting minutes
  • Communications plan/procedures training curricula and materials
  • Documentation tracking staff completion of training on the communications plan/procedures for responding to critical incidents
  • Interviews may include:
    1. Agency leadership
    2. Management and program field personnel
    3. Communication/public information personnel
    4. Individuals and families served
    5. Stakeholders
    6. Contractors
    7. Stakeholder advisory group chair and members

 

CP-AM 4.01

The public authority/agency’s public outreach and education activities include:
  1. regularly providing the public with clear, timely, and accurate information about its mission, programs, activities, service recipients, and finances;
  2. informing the public of the positive impact its programs are having on the community and its residents;  and
  3. fostering a positive relationships with the local media.
Examples: Ongoing communication with the public and the media provides an opportunity for the public authority/agency to communicate information on its initiatives, policy and advocacy efforts, proactive problem solving efforts, and stories of success.  This cultivates a working relationship with the media and builds public awareness of the positive work being done by the public authority/agency, which can mobilize public support for policy issues or changes that impact the public authority/agency’s work. 

 

CP-AM 4.02

The public authority/agency assesses its existing relationships with key community partners, both existing and potential, and develops an assessment-based community and provider engagement plan that:
  1. outlines community and provider engagement goals and strategies for achieving them;
  2. allocates sufficient resources to support community and provider engagement initiatives; 
  3. establishes centralized oversight and coordination when the public authority/agency has partners in different communities or jurisdictions; and
  4. includes mechanisms for monitoring progress towards meeting engagement goals.

Interpretation

Community and provider engagement goals should be incorporated into the public authority/agency’s long-term plan (CP-AM 3.02).
Examples: Various structures may be in place to sustain community and provider engagement and the model(s) chosen will vary based on the public authority/agency’s community partnership goals. Examples of mechanisms to facilitate community and provider engagement include, but are not limited to:
  1. work groups;
  2. advisory boards;
  3. decision-making boards;
  4. memoranda of understanding;
  5. systems of care;
  6. quality improvement structures;
  7. collaborative contract monitoring procedures;
  8. long-term planning structures; and
  9. case-level service delivery teams.

 

CP-AM 4.03

The public authority/agency communicates and collaborates with stakeholders by:
  1. establishing a shared purpose and goals for partnership;
  2. setting clear guidelines for participation including defined roles, resource expectations, rules of engagement, and dispute resolution;
  3. identifying and addressing the needs of participating stakeholders, including  training resources;
  4. documenting all important decisions; and 
  5. developing clear mechanisms for frequent, ongoing, two-way communication.

 

CP-AM 4.04

The public authority/agency encourages active consumer participation in advisory activities by:
  1. partnering with local consumer or advocacy groups to reach consumers and encourage their involvement;
  2. training staff on strategies for partnering with consumers in advisory activities;
  3. developing outreach and informational materials that target consumers and provide them with information necessary to make an informed decision about participating;
  4. creating an environment that welcomes consumers and values their voice; and
  5. offering trauma-informed training and mentorship to consumers participating in advisory activities.

 

CP-AM 4.05

The public authority/agency fosters community responsiveness by establishing and maintaining a stakeholder advisory group or groups that include representatives of:
  1. relevant community groups;
  2. consumers;
  3. families;
  4. service providers;
  5. advocates; and 
  6. others with an interest in the success of the public authority/agency at achieving its mission or purpose.

 

CP-AM 4.06

The public authority/agency:
  1. incorporates recommendations of advisory groups and collaborative efforts into its risk management, emergency preparedness, quality improvement, and long-term planning activities; and 
  2. periodically reports back to its partners on decisions made and actions taken.

 

CP-AM 4.07

Personnel receive training on the communications plan and/or procedures for responding to critical incidents, including position-specific communication guidelines for responding to inquiries from the media and the public. 
 
2022 Edition

Administration and Management (CP-AM) 5: Service Array and Resource Development

The public authority/agency partners with stakeholders in the service delivery system to integrate, advocate for, and coordinate the array of services public and/or private providers deliver to meet the needs of the service population.
Examples: Partnership in this context can include the pursuit of contracts when agencies are purchasing social or human services to meet an identified need within the service population.   

Examples: The service delivery system can include services and benefits provided by other federal or federally assisted programs serving the same population.
 
1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Service utilization goals
  • Utilization data
  • Access guidelines
  • Procedures for monitoring and adjusting the service array including procedures for obtaining feedback from regions and line staff about regional service needs and the quality of services
  • Resource development plan or relevant portions of strategic planning documents related to service array and resource development
  • Completed community assessment
  • Interviews may include:
    1. Agency leadership
    2. Contract management personnel
    3. Contracted providers
    4. Program field personnel
    5. Community stakeholders
    6. Persons served

 

CP-AM 5.01

Ease of entry into a system of highly accessible services is achieved through:
  1. access guidelines responsive to the service population; 
  2. staff that understand the services provided by other community providers;
  3. clearly articulated service utilization goals; and
  4. mechanisms for monitoring service utilization and addressing identified concerns.

 

CP-AM 5.02

The public authority/agency partners with local communities to continually improve the service array by:
  1. conducting periodic assessments of community need and existing resources;
  2. developing a plan for resource development to meet identified needs; and 
  3. monitoring the effectiveness of plan implementation.

Interpretation

Assessments of community need may be conducted by a third party and utilized by the public authority/agency to make resource development plans.
Examples: Partnerships with local communities should aim to address issues of mutual concern, for example improving supports and accommodations for individuals with special needs or marginalized communities and identifying solutions to community-specific needs including racial equity and cultural and linguistic diversity.
 
2022 Edition

Administration and Management (CP-AM) 6: Conflict of Interest

The public authority/agency prevents the enrichment of insiders and other abuses through the enforcement of a conflict of interest policy.
1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Conflict of interest policy
  • Policy prohibiting preferential treatment
  • Ethical referral procedures
  • Documentation of policy communication to staff
  • Management meeting minutes documenting discussions of potential and apparent conflicts of interest from the previous 12 months
  • Interviews may include:
    1. Agency leadership
    2. Ethics officer/in-house counsel
    3. Oversight Entity/Stakeholder Advisory Panel members
    4. CFO or equivalent
    5. Persons served
    6. Community stakeholders
    7. Personnel

 
Fundamental Practice

CP-AM 6.01

A conflict of interest policy is tailored to the public authority/agency’s specific needs and characteristics, and:
  1. defines conflict of interest;
  2. identifies groups of individuals within the organization covered by the policy;
  3. addresses transactions between oversight entities and the public authority/agency;
  4. ensures that contracts and business arrangements serve the public authority/agency’s and service recipients’ best interests, not private interests;
  5. addresses policy enforcement;
  6. provides a framework for evaluating situations that may constitute a conflict; and
  7. invests management with developing procedures that facilitate disclosure of information to prevent and manage potential and apparent conflicts of interest.
NA The public authority/agency is not responsible for developing the conflict of interest policy.

 
Fundamental Practice

CP-AM 6.02

Advisory group members, personnel, and consultants who have a financial interest in the public authority/agency’s assets, business transactions, leases, or professional services:
  1. disclose this information; and
  2. do not participate in any discussion or vote taken with respect to such interests.

 
Fundamental Practice

CP-AM 6.03

The public authority/agency prohibits:
  1. making or accepting payment or other consideration in exchange for referrals; 
  2. preferential treatment of community partners, advisory group members, personnel, or consultants in applying for and receiving services; and
  3. steering or directing referrals to private practices in which personnel, consultants, or the immediate families of personnel and consultants are engaged.

Interpretation

It is permissible to include on referral lists personnel and consultants with private practices, or family members of personnel and consultants, but the public authority/agency may not actively direct service recipients to the practices of these individuals and must clarify in writing the relationship between the private practitioners and the organization.
 
2022 Edition

Administration and Management (CP-AM) 7: Protection of Reporters of Suspected Misconduct

The public authority/agency prohibits employment-related retaliation against employees and others affiliated with the public authority/agency, who come forward with information about suspected misconduct or questionable practices, and provides an appropriate, confidential channel for reporting such information.
1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Whistle-blower provisions in legislation or administrative code
  • Documentation of policy communication to staff (e.g. memos, staff meeting minutes, training documents)
  • Documentation of any grievances/incidents related to retaliation
  • Interviews may include:
    1. Agency leadership
    2. Personnel
    3. HR director
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