
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
Interpretation
Public authority/agency leadership can include the Chief Executive Officer, the public authority/agency director, the agency head, or the administrative team.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.
Administration and Management (CP-AM) 1: Mission
- is responsive to the needs of the communities it serves;
- guides the public authority/agency’s administrative operations and delivery of services; and
- 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.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.
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.
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.
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 Evidence | On-Site Evidence | On-Site Activities |
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Administration and Management (CP-AM) 2: Implementing Public Authority/Agency-Wide Change
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.
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.
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.
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 Evidence | On-Site Evidence | On-Site Activities |
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CP-AM 2.01
- identifies the needed change or identifies the purpose of a mandated change;
- works with relevant stakeholders to establish a shared project vision that aligns with the public authority/agency’s core values; and
- assesses the public authority/agency's readiness and capacity for change including strengths, needs, and available resources at the system, organizational, and personnel level.
- the sociopolitical climate;
- available funding;
- administrative resources and processes (e.g., computer systems);
- policy and procedure alignment with the desired change;
- communication mechanisms for knowledge and information sharing; and
- the knowledge-base, attitude, and workload of staff who will be responsible for carrying out the change.
CP-AM 2.02
- identifying financial, organizational, and human resource needs;
- establishing communication protocols for ongoing, two-way communication;
- developing, revising, or implementing policies and procedures in accordance with new ways of doing work;
- 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
- outlining ongoing implementation monitoring activities.
Administration and Management (CP-AM) 3: Authority/Agency Leadership
- long-term and annual planning;
- developing, implementing, and evaluating policy;
- succession planning and leadership development;
- providing financial oversight; and
- 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.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.
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.
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.
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 Evidence | On-Site Evidence | On-Site Activities |
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CP-AM 3.01
- communication protocols and reporting information for major functions/operations; and
- other structures or processes for implementing leadership responsibilities, including establishing task forces/committees.
CP-AM 3.02
- a review of the public authority/agency’s mission, values, mandates, and strategic direction;
- a review of the demographics of its defined service population;
- an assessment of the previous long-term planning cycle, including current strengths and areas for opportunity;
- measurable goals and objectives that support fulfillment of its mission, mandated responsibilities, and quality improvement priorities; and
- strategies for meeting identified goals.
CP-AM 3.03
- is staff driven;
- operationalizes the public authority/agency’s long-term strategic plan;
- reflects changing conditions and needs, such as resource allocation, funding and regulatory changes; and
- responds to information from PQI activities.
- HR planning;
- evaluation of training needs;
- budget planning;
- technology and information management; and
- the annual PQI report.
CP-AM 3.04
- establishing, reviewing, and revising policy;
- analyzing and adopting any changes to policies resulting from recommendations from various stakeholder groups;
- providing clear, timely, and thorough communications when policies are established or revised;
- ensuring front line supervisors have the information and support needed to guide staff on implementing policies;
- providing feedback to those establishing policy on recommendations from various stakeholder groups, including front line staff and their supervisors; and
- evaluating the costs and benefits of implementing policies for consumers and for the agency.
CP-AM 3.05
- setting resource development targets and goals, as reflected in federal, provincial/territorial, and municipal budgets and/or consolidated plans; and
- 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
CP-AM 3.07
- current financial status and any anticipated problems;
- shifting strategic priorities and their financial implications; and
- financial planning and funding alternatives.
CP-AM 3.08
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
- under what conditions interim authority can be delegated and the limits of that authority;
- relevant positions and the key leadership and management functions of those positions;
- to whom various leadership and management functions will be delegated; and
- the mechanisms for assessing personnel’s readiness to assume leadership positions and for providing training, mentorship, and other leadership development opportunities to ensure readiness.
Administration and Management (CP-AM) 4: Community and Provider Engagement
- conducting public outreach and education;
- engaging a diverse group of stakeholders in collaborative, purposeful, and ongoing partnership; and
- incorporating recommendations from collaborative efforts into its organizational decision-making related to regulatory processes, risk management, quality improvement, and long-term planning activities.
Self-Study Evidence | On-Site Evidence | On-Site Activities |
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CP-AM 4.01
- regularly providing the public with clear, timely, and accurate information about its mission, programs, activities, service recipients, and finances;
- informing the public of the positive impact its programs are having on the community and its residents; and
- fostering a positive relationships with the local media.
CP-AM 4.02
- outlines community and provider engagement goals and strategies for achieving them;
- allocates sufficient resources to support community and provider engagement initiatives;
- establishes centralized oversight and coordination when the public authority/agency has partners in different communities or jurisdictions; and
- 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).- work groups;
- advisory boards;
- decision-making boards;
- memoranda of understanding;
- systems of care;
- quality improvement structures;
- collaborative contract monitoring procedures;
- long-term planning structures; and
- case-level service delivery teams.
CP-AM 4.03
- establishing a shared purpose and goals for partnership;
- setting clear guidelines for participation including defined roles, resource expectations, rules of engagement, and dispute resolution;
- identifying and addressing the needs of participating stakeholders, including training resources;
- documenting all important decisions; and
- developing clear mechanisms for frequent, ongoing, two-way communication.
CP-AM 4.04
- partnering with local consumer or advocacy groups to reach consumers and encourage their involvement;
- training staff on strategies for partnering with consumers in advisory activities;
- developing outreach and informational materials that target consumers and provide them with information necessary to make an informed decision about participating;
- creating an environment that welcomes consumers and values their voice; and
- offering trauma-informed training and mentorship to consumers participating in advisory activities.
CP-AM 4.05
- relevant community groups;
- consumers;
- families;
- service providers;
- advocates; and
- others with an interest in the success of the public authority/agency at achieving its mission or purpose.
CP-AM 4.06
- incorporates recommendations of advisory groups and collaborative efforts into its risk management, emergency preparedness, quality improvement, and long-term planning activities; and
- periodically reports back to its partners on decisions made and actions taken.
CP-AM 4.07
Administration and Management (CP-AM) 5: Service Array and Resource Development
Examples: The service delivery system can include services and benefits provided by other federal or federally assisted programs serving the same population.
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.
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.
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.
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 Evidence | On-Site Evidence | On-Site Activities |
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CP-AM 5.01
- access guidelines responsive to the service population;
- staff that understand the services provided by other community providers;
- clearly articulated service utilization goals; and
- mechanisms for monitoring service utilization and addressing identified concerns.
CP-AM 5.02
- conducting periodic assessments of community need and existing resources;
- developing a plan for resource development to meet identified needs; and
- 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.Administration and Management (CP-AM) 6: Conflict of Interest
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.
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.
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.
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 Evidence | On-Site Evidence | On-Site Activities |
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CP-AM 6.01
- defines conflict of interest;
- identifies groups of individuals within the organization covered by the policy;
- addresses transactions between oversight entities and the public authority/agency;
- ensures that contracts and business arrangements serve the public authority/agency’s and service recipients’ best interests, not private interests;
- addresses policy enforcement;
- provides a framework for evaluating situations that may constitute a conflict; and
- invests management with developing procedures that facilitate disclosure of information to prevent and manage potential and apparent conflicts of interest.
CP-AM 6.02
- disclose this information; and
- do not participate in any discussion or vote taken with respect to such interests.
CP-AM 6.03
- making or accepting payment or other consideration in exchange for referrals;
- preferential treatment of community partners, advisory group members, personnel, or consultants in applying for and receiving services; and
- 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.Administration and Management (CP-AM) 7: Protection of Reporters of Suspected Misconduct
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.
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.
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.
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 Evidence | On-Site Evidence | On-Site Activities |
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