CQL | The Council on Quality and Leadership

Demystifying Factor 10

Posted 5/29/18 via Capstone e-Newsletter

By Mary Kay Rizzolo | CQL President & CEO

CQL | The Council on Quality and Leadership has created many tools to help human service providers improve the quality of their services and the quality of life for people receiving those services. Some of these aim to advance community inclusion, educate others about their rights, enhance organizational culture, or promote person-centered discovery. Along with these tools, the foundational guide for human service providers is the Basic Assurances®, which act as a prerequisite for being in business in our field. 

Basic Assurances® go beyond just compliance with licensing and certification standards, by looking at issues like health, safety, and security from the person's perspective. Alignment with the Basic Assurances® isn't only about what's written into policy, but more so how that policy plays out in practice, determined person by person. These essential, fundamental, non-negotiable requirements are organized into 10 different factors and 46 indicators within those factors.

  1. Rights Protection and Promotion
  2. Dignity and Respect
  3. Natural Support Networks
  4. Protection from Abuse, Neglect,
    Mistreatment and Exploitation
  5. Best Possible Health
  6. Safe Environments
  7. Staff Resources and Supports
  8. Positive Services and Supports
  9. Continuity and Personal Security
  10. Basic Assurances® System
Basic Assurances Monitoring

As you'll see in the data below, we find that organizations face the most difficulties in understanding and aligning with Factor 10: Basic Assurances® System. This factor involves how the organization monitors and evaluates the presence of Basic Assurances® at both the individual and organizational level. There are expectations that the organization will develop a formalized Basic Assurances® Monitoring Plan to evaluate the methods and procedures for the Basic Assurances®, involving collecting and analyzing data to assess the effectiveness of organizational efforts. In this Capstone article we share data about the challenges experienced in Factor 10, guidance for developing a Basic Assurances® Monitoring Plan, and a profile of an agency that has successfully implemented a Basic Assurances® Monitoring System.



By Carli Friedman | CQL Director of Research

In our PORTAL Data System, of the last 38 organizations that went through a Basic Assurances® review, Factor 10: Basic Assurances® System was the area that was present least often. Less than 20% of organizations had a Basic Assurances® System present in their systems or practices. Factor 10 is comprised of two indicators:

10a: The organization monitors Basic Assurances®

This indicator explores the policies and procedures for monitoring the presence of Basic Assurances, the implementation of the plan, continuous quality improvement, and the collection and analysis of data.

10b: A comprehensive plan describes the methods and procedures for monitoring Basic Assurances®

This indicator formalizes the evaluation process of 10a by organizations creating a Basic Assurances® Monitoring Plan. This plan details specific priorities, goals, and benchmarks that are set by the organization. Through the probes within this indicator, agencies will ensure that they have mechanisms in place to collect and integrate data, methods to analyze that data, and responsive approaches to use it effectively.


About one-fifth of organizations (21%) had a system in place related to indicator 10A; even fewer organizations had a practice present (16%).

Basic Assurances Factor 10a


  Most Likely To Be Present

The policy describes the organization’s commitment to attain and maintain the presence of Basic Assurances® outcomes over time 31.6%
The policy emphasizes personal and organizational outcomes rather than individual staff performance 31.6%

  Least Likely To Be Present

The process includes methods to inform and educate people, their families and support staff about Basic Assurances® and to solicit their involvement in the evaluation process 13.2%
The organization has a process for sharing the results of the plan with people, families, staff and others external to the organization 13.2%
People, families and support staff actively participate in collecting and analyzing data used to evaluate Basic Assurances® 10.5%


About one-fifth of organizations had a system in place (21%) and practice present (18%) for indicator 10B.

Basic Assurances Factor 10b


  Most Likely To Be Present

The key functions and activities of the organization that relate to Basic Assurances® are identified 23.7%
The plan is coordinated and interrelated across the organization’s various programs and departments around the flow of services and supports provided people 23.7%

  Least Likely To Be Present

Measures identified that indicate the presence or absence of important elements 15.8%
The methods of data analysis and evaluation are identified for each of the elements 15.8%
The plan describes how to use feedback from other sources including satisfaction surveys, complaints, audits and/or other applicable regulatory reviews 15.8%
The plan includes priorities, goals and objectives to ensure the presence of Basic Assurances® are integrated into the organization’s annual plan 15.8%

Considering that so few organizations had a Basic Assurances® Monitoring Plan and resulting practice present, the perfect place to start is taking steps to develop a Basic Assurances® Monitoring Plan. While it can seem like a daunting task, the information below provides some guidance to get organizations on the right path. 


Joint report about group home health and safetyPutting A Plan In Place

By Katherine Dunbar | CQL Director of Accreditation

In January 2018, the U.S. Department of Health and Human Services Office of Inspector General, the Administration for Community Living, and the Office for Civil Rights issued a joint report titled “Ensuring Beneficiary Health and Safety in Group Homes Through State Implementation of Comprehensive Compliance Oversight.” The objective of this report was “to determine if group homes complied with Federal and State requirements for reporting, recording, and detecting critical incidents in group homes.” The agencies focused on three states: Connecticut, Massachusetts, and Maine. Their findings indicated “serious lapses in basic health and safety practices in group homes.”

Like Mary Kay detailed, CQL's nationally-recognized tool Basic Assurances® looks at those essential, fundamental, and non-negotiable requirements. At CQL, we urge agencies to develop a Basic Assurances® Monitoring Plan. While maintaining and evaluating a system of Basic Assurances® is critical for overall organization health, agencies often find it difficult to interpret and manage. Ongoing evaluation occurs on two levels: the person and the larger organization. Once the organization is aware of individual concerns or larger trends in assessing Basic Assurances® for people, action can be taken to correct the situation.

One recommendation to get started on developing a Basic Assurances® Monitoring Plan is for agencies to gather all the metrics they are already collecting and determine where they might fit into their Basic Assurances® Monitoring Plan. For example, most agencies already have data regarding staffing (Factor 7: Staff Resources and Supports), finances (Factor 9: Continuity and Personal Security), survey data (Factor 6: Safe Environments, Factor 9), incident management (Factor 4: Protection from Abuse, Neglect, Mistreatment and Exploitation), positive behavior support and interventions (Factor 8; Positive Supports and Services), and a myriad of other metrics that would readily incorporate into a plan. The more difficult part may be for an organization to determine which metrics are most important to analyze.

So, it’s not enough just to collect the data. Organizations must also analyze and use the data to make overall quality improvements. For instance, an organization may be collecting data that shows an overall Direct Support Professional (DSP) turnover rate of 27%. Since that is less than the national average, the organization might initially be satisfied with its data so it decides to make no changes. However, if the organization drilled deeper into the metric, they may determine that 85% of the turnover is happening in one service location. The organization could then conduct a root cause analysis and discover that the DSPs do not feel appreciated in that service location. After setting up some focus groups, the organization could identify changes to improve employee satisfaction and decrease their turnover rate.

Questions To Ask When Developing A Basic Assurances® Monitoring Plan:

  • What data is already being collected? (Also include POMs Data)
  • Of that data, how does it fit into the Basic Assurances®?
  • What does the data reveal?
  • Is it meaningful and relevant?
  • Based on the data, what actions can be taken?


Building A Basic Assurances® Monitoring System

By Michael Clausen | CQL Quality Enhancement Specialist
mclausen@thecouncil.orgAbility Building Services Logo

Nestled on the banks of the Missouri River in southern South Dakota, Ability Building Services provides an array of supports to people with developmental disabilities. The organization espouses the principle that quality is a journey, not a destination. Ability Building Services has built a Basic Assurances® Monitoring System that promotes continuous quality improvement across the organization, and most importantly, a high quality of life for people receiving supports.

While Factor 10 can be mystifying, organizations are encouraged to build their Basic Assurances® Monitoring Systems around the data that they already collect, and then allow their plan to evolve. While raw data cannot always be used as a tool to inform decision making, cross-analysis (looking at different data points together) is extremely valuable. For example, in order to monitor Factor 4: Protection from Abuse, Neglect, Mistreatment and Exploitation, Ability Building Services examines data from Critical Incident Reports alongside staff overtime and POMs data.

Ability Building Services uses their Basic Assurances® Monitoring Plan to identify areas of organizational planning and to measure how successful those plans have been. In the area of rights, the organization’s goal was to ensure that restoration plans were successful. A plan to provide more rights education for staff was implemented. The organization saw a positive trend of more restrictions being discontinued because people were meeting the restoration plans. While Ability Building Services was happy with this result, they decided to dig a little deeper, and observed the most common restriction was related to managing personal finances. As a result of this discovery, the organization assisted teams to try different methods of teaching people financial management and sought out additional resources in the community to help with financial education.

Learn more about '12 Reasons Why Data Is Important
Data collection and analysis can seem daunting, but it doesn’t need to be. While some organizations do have the capacity to produce flashy, automated reports with charts and graphs, other organizations have developed equally effective narrative-based systems. Regardless of an organization's methods for gathering, evaluating, or sharing data - data is critically important. It does often take some effort to get organizations and employees invested in data collection and analysis, along with being informed about its advantages. To assist agencies in embracing data and its uses, CQL has produced an online article and print resource titled '12 Reasons Why Data Is Important.' We encourage you to review this resource and share it with colleagues to advance the use of data in human services.



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