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: 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.
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.
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.
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.
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.
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.
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
Leadership involves personnel across positions and departments in long-term planning every four to five years that includes:
- 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;
- an assessment of equity, diversity, and inclusion strategies;
- 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
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.
CP-AM 3.10
The agency develops an equity statement outlining its commitment to equity, diversity, and inclusion (EDI) that is shared with its stakeholders.
Interpretation: The equity statement should reflect the agency’s history, connect EDI to its mission, and outline how the agency demonstrates its commitment to EDI.
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.
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.
- 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.
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.
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.
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.
Administration and Management (CP-AM) 7: Protection of Reporters of Suspected Misconduct
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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.