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ACF Administration for Children and Families	U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Administration on Children, Youth and Families
	1. Log No.: IM-07-08	2. Issuance Date: 10-09-07
	3. Originating Office: Children's Bureau
	4. Key Words: Program Improvement Plans, Child and Family Services Reviews

To: State and Territorial Agencies Administering or Supervising the Administration of Titles IV-B and IV-E the Social Security Act, ACF Regional Offices

Subject: Guidance and Suggested Format for Program Improvement Plans in Child and Family Service Reviews (CFSRs)

Legal and Related: Titles IV-B and IV-E of the Social Security Act, Section 1123 A of the Social Security Act, 45 CFR 1355, OMB Control No.: 0970-0214, Expiration Date: 1/31/2010

Purpose: To provide guidance and assistance to States in developing Program Improvement Plans in response to the findings of the CFSRs, and a suggested format for preparing the Program Improvement Plan (PIP) for the second round of CFSRs.

Information: In accordance with 45 CFR 1355.35(a), States are required to develop and implement PIPs that address any of the outcomes or systemic factors determined not to be in substantial conformity as a result of a CFSR. The regulation, at 45 CFR 1355.35(a), requires States to include certain information in the PIP, although no specific format for developing the PIP is prescribed. Further, at 45 CFR 1355.35(d)(4), States are required to submit quarterly status reports to the Administration for Children and Families (ACF), unless less frequent reports are mutually agreed upon, to inform ACF of the State's progress in implementing the provisions of the PIP. In ACYF-CB-IM-02-04, we provided guidance for States in developing their PIP during the first round of CFSRs. Through our work with the first round of CFSRs, ACF recognizes a need to provide further clarification and guidance to States on the required content of the PIP to address the key concerns from their review and provide a framework for broad strategy approaches to program improvement. These approaches may include overarching reforms and continuing strategies that build on prior PIP activity. ACF will track States' approaches and progress in implementing PIPs over time. Using the attached suggested format and tracking matrix will better assure the ability of States and ACF to develop realistic, achievable PIPs and to identify progress and barriers to improving outcomes for children and families.

The attached document provides clarification on the required content of the PIP. It also provides a suggested format that States are encouraged, but not required, to use in preparing the PIP and for use in providing quarterly status reports to ACF. Additional detailed information concerning developing PIPs including examples may be found on the Children's Bureau website at: http://www.acf.hhs.gov/programs/cb/cwmonitoring/tools_guide/pip_instruct.htm

Inquiries: Children's Bureau Regional Program Managers

________________ Date:

_________________________ Joan E. Ohl Commissioner

Attachment

Program Improvement Plan Suggested Standard Format

1. PIP General Information
2. PIP Strategy Summary and TA Plan, Matrix Instructions and Quality Assurance Checklist
   1. PIP Strategy Summary and TA Plan Instructions
   2. PIP Matrix Instructions
   3. PIP Quality Assurance Checklist
3. PIP Agreement Form
4. Amendments
   1. Part A: Strategy Measurement Plan and Quarterly Status Report
   2. Part B: National Standards Measurement Plan and Quarterly Status Report
   3. Part C: Item-Specific and Quantitative Measurement Plan and Quarterly Status Report

Children's Bureau Child and Family Services Reviews Program Improvement Plan Suggested Standard Format OMB Control No.: 0970-0214 Expiration 1/31/2010
States are encouraged to use this PIP standard format to submit their PIP to the Children's Bureau Regional Office. The standard format includes the following sections: I. PIP General Information II. PIP Strategy Summary and TA Plan, Matrix Instructions and Quality Assurance Checklist III. PIP Agreement Form (authorizing signatures) IV. PIP Matrix
I. PIP General Information
CB Region:	I		II		III		IV		V		VI		VII		VIII		IX		X
State:
Lead Children's Bureau Regional Office Contact Person:									Telephone Number:
									E-mail Address:
State Agency Name:									Address:
									Telephone Number:
Lead State Agency Contact Person for the CFSR:									Telephone Number:
									E-mail Address:
Lead State Agency PIP Contact Person (if different):									Telephone Number:
									E-mail Address:
Lead State Agency Data Contact Person:									Telephone Number:
									E-mail Address:
State PIP Team Members* (name, title, organization)
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*List key individuals who are actually working on the PIP and not necessarily everyone who was consulted during the PIP development process.

II. PIP Strategy Summary and TA Plan, Matrix Instructions, and Quality Assurance Checklist

A. PIP Strategy Summary and TA Plan Instructions

States are strongly encouraged to develop a PIP Strategy Summary and TA Plan, using the format that appears on the next page. Using this format helps to both provide a focus on overarching reforms and simplify the PIP document. The PIP Strategy Summary and TA Plan comprises three elements:

• Primary Strategies: In this section of the PIP Strategy Summary and TA Plan, the State summarizes the broad strategy approaches that address the key concerns from the review and serve as a framework for goals/negotiated measures, benchmarks, and action steps. These approaches include the overarching reforms and continuing strategies that build on prior program improvement plan activity. The primary strategies should reflect integration with the timeframes of other plans, such as the CFSP. Primary strategies should be assigned unique numbers to allow cross-walking to action steps and benchmarks.
• Key Concerns: In this section, the State summarizes the key concerns that will be addressed over the course of the PIP implementation period. These key concerns should be consistent with those identified through the CFSR and included in the Final Report.
• TA Resources Needed: In this section, the State identifies the technical assistance resources needed to carry out the provisions of the strategies for each year of the PIP. The source, frequency, and duration of the TA should be summarized, including both Federal and non-Federal sources.

PIP Strategy Summary and TA Plan

State:
Date Submitted:

Primary Strategies	Key Concerns	TA Resources Needed

B. PIP Matrix Instruction

States are strongly encouraged to use the PIP Matrix form for both PIP submissions and PIP quarterly reports. The matrix is designed to allow States to enter information by themes or broad strategy areas or approaches, under which each of the items out of conformity is addressed. Using a theme or broad strategy approach helps to both provide a focus on overarching reforms and simplify the PIP document.

• Introductory information: At the top of the PIP Matrix, States should enter the information requested to identify their State, the type of report being submitted (PIP or quarterly report), and the date submitted.
• Part A: Strategy Measurement Plan and Quarterly Status Report: This section of the PIP Matrix is designed to allow States to detail action steps that address the goals/negotiated measures and benchmarks. It also allows States to report quarterly progress on each action step.
  
  States will need to copy the table framework for part A as many times as appropriate to the number of strategies and action steps contained in their PIP such that all of the outcome items, data composite indicators and systemic factor items that contributed to non-conformity are addressed.
  
  States should complete the shaded cells in the matrix only when using the matrix for quarterly reporting or reporting the results of renegotiation.
  
  The following is information about each cell in part A:
  • Primary Strategy: States should note each broad strategy approach that addresses the key concerns from the review and serves as a framework for the goals/negotiated measures, action steps and benchmarks. These include the overarching reforms and continuing strategies that build on prior PIP activity. The primary strategies should reflect integration with other plans such as the CFSP.
  • Goal: States should describe the overall accomplishment that is to be achieved through the primary strategy that addresses applicable areas requiring improvement based on the Final Report.
  • Applicable CFSR Outcomes or Systemic Factors: States should identify the outcomes or systemic factors being addressed through the primary strategy and action steps.
  • Applicable CFSR Items: States should indicate the specific item(s) addressed based on items requiring improvement in the Final Report.
  • Action Steps and Benchmarks: States should provide a brief description of each action step that will be undertaken to create improvements under each goal. Benchmarks in this section can be qualitative processes and/or incremental quantitative measures of progress toward achieving the action step. States should list as many benchmarks as appropriate for adequate monitoring of progress for each action step. Action steps and benchmarks should be numbered according to the primary strategy that they are associated with.
  • Person Responsible: States should identify the individual(s) responsible for the action steps and benchmarks, clarifying staff and stakeholder engagement and responsibility.
  • Evidence of Completion: States should detail the specific documents or reports that will be used to provide the Children's Bureau Regional Office with evidence of progress and eventual completion of the action step.
  • Quarter Due: States should provide the quarter in which each action step or benchmark will be completed.
  • Quarter Completed: The Children's Bureau Regional Office will determine, based on review of State reports, the quarter in which each action step or benchmark is completed.
  • Quarterly Update: States should enter and report information regarding each action step or benchmark that is due during the quarter.
  • Renegotiated Action Steps and Benchmarks: If applicable, States should note whether the action step and benchmarks were renegotiated and provide a detailed description.
• Part B: National Standards Measurement Plan and Quarterly Status Report: This section of the PIP Matrix is designed to allow States to enter and report information regarding each national standard data indicator that is to be addressed in their PIP, including (1) their performance as measured in the Final Report, and the source data period for the data indicator; (2) the performance as measured for the baseline established, and the source data period for the data indicator; (3) the negotiated improvement goal; and (4) the renegotiated improvement goal, if applicable. When using the PIP Matrix for quarterly reporting, they also should enter the status based on available measurement of the data indicator for each reported quarter.
• Part C: Item-Specific and Quantitative Measurement Plan and Quarterly Status Report: This section of the PIP Matrix is designed to allow States to enter and report information regarding each CFSR item or action step with quantitative measurement that is to be addressed in their PIP, including (1) the status of the item in the Final Report; (2) the performance as measured for the baseline established and the source data period for the measure; (3) the negotiated improvement goal; (4) the method of measuring improvement; and (5) the renegotiated improvement goal, if applicable. When using the PIP Matrix for quarterly reporting, they also should enter the status of the item or action step for each reported quarter. States will need to copy the table framework for part C as many times as appropriate to the number of items contained in their PIP.

States should submit the PIP Summary Work Plan and PIP Matrix to the Children's Bureau Regional Office staff member responsible for the State's CFSR.

C. PIP Quality Assurance Checklist

State child welfare agency staff and their external partners may use the following quality assurance checklist to review the State's PIP to determine whether it meets the requirements necessary to contribute to a successful PIP process that will result in improvements to child welfare practice:

___ Did the State negotiate with the Children's Bureau Regional Office the level of improvement to be achieved for outcome and systemic factor determined not to be in substantial conformity and addressed in the PIP, including a percentage of improvement for statewide data indicators that did not meet the national standards?

___ Does the plan contain action steps for each goal that build on strengths identified in the Final Report on the CFSR?

___ Does the plan identify the person(s) responsible for overseeing the development, implementation, and oversight of each action step for achieving the goals?

___ Does the plan contain realistic timeframes for implementing the action steps and achieving the goals?

___ Have the goals been prioritized to ensure that action steps for achieving the most important goals (for example, those related to safety) are implemented first and within the timeframes outlined in the PIP instructions?

___ Does the plan explain how action steps targeted to one jurisdiction will lead to positive outcomes and adequate systemic functioning statewide?

___ Does the plan include benchmarks for measuring the progress of improvements towards goal achievement?

___ Are those benchmarks consistent with the level of effort required to improve performance and achieve PIP goals?

___ Does the plan include the State's method for evaluating the progress being made toward the goals and action steps?

III. PIP Agreement Form

The PIP should be signed and dated by the Chief Executive Officer of the State child welfare agency and by the Children's Bureau Regional Office responsible for the State. The approved PIP with original signature must be retained in the Children's Bureau Regional Office. A hard copy of the approved PIP must be submitted to the following parties immediately upon approval:

• State child welfare agency
• Children's Bureau (Child and Family Services Review staff)
• Child Welfare Review Project, c/o JBS International, Inc.

Agreements

The following Federal and State officials agree to the content and terms of the attached Program Improvement Plan:

__________________________________________________________________
Name of State Executive Officer for Child Welfare Services          Date

__________________________________________________________________
Children's Bureau                                                                 Date

Amendments

This section should be completed only in the event of renegotiations regarding the content of the PIP, pursuant to 45 CFR 1355.35(e)(4). Copies of approved, renegotiated PIPs must be retained and distributed as noted above immediately upon completion of the renegotiation process.

The content of the attached PIP was renegotiated on [enter date]. The renegotiated content of the attached PIP has been approved (initialed) by State personnel and the Children's Bureau Regional Office with authority to negotiate such content and is approved by Federal and State officials:

Renegotiated Action Steps, Benchmarks or Improvement Goal	Date	Person Responsible	Evidence of Completion	Quarter Due	Quarter Completed	Approval of State Executive Officer for Child Welfare Services
						Approval Children's Bureau

State:
Type of Report:       PIP:___       Quarterly Report:___       (Quarter:___)
Date Submitted:

Part A: Strategy Measurement Plan and Quarterly Status Report

Primary Strategy:				Applicable CFSR Outcomes or Systemic Factors:
Goal:				Applicable CFSR Items:
Action Steps and Benchmarks	Person Responsible	Evidence of Completion	Quarter Due	Quarter Completed	Quarterly Update
Renegotiated Action Steps and Benchmarks

State:
Type of Report:       PIP:___       Quarterly Report:___       (Quarter:___)
Date Submitted:

Part B: National Standards Measurement Plan and Quarterly Status Report

Safety Outcome 1: Absence of Recurrence of Maltreatment
National Standard	94.6%
Performance as Measured in Final Report/Source Data Period
Performance as Measured in Baseline/Source Data Period
Negotiated Improvement Goal
Renegotiated Improvement Goal
Status (Enter the current quarter measurement for the reported quarter.)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12
Safety Outcome 1: Absence of Maltreatment of Children in Foster Care
National Standard	99.68%
Performance as Measured in Final Report/Source Data Period
Performance as Measured in Baseline/Source Data Period
Negotiated Improvement Goal
Renegotiated Improvement Goal
Status (Enter the current quarter measurement for the reported quarter.)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12

State:
Type of Report:       PIP:___       Quarterly Report:___       (Quarter:___)
Date Submitted:

Permanency Outcome 1: Timeliness and Permanency of Reunification
National Standard	122.6
Performance as Measured in Final Report/Source Data Period
Performance as Measured in Baseline/Source Data Period
Negotiated Improvement Goal
Renegotiated Improvement Goal
Status (Enter the current quarter measurement for the reported quarter.)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12
Permanency Outcome 1: Timeliness of Adoptions
National Standard	106.4
Performance as Measured in Final Report/Source Data Period
Performance as Measured in Baseline/Source Data Period
Negotiated Improvement Goal
Renegotiated Improvement Goal
Status (Enter the current quarter measurement for the reported quarter.)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12

State:
Type of Report:       PIP:___       Quarterly Report:___       (Quarter:___)
Date Submitted:

Permanency Outcome 1: Achieving Permanency for Children in Foster Care for Long Periods of Time
National Standard	121.7
Performance as Measured in Final Report/Source Data Period
Performance as Measured in Baseline/Source Data Period
Negotiated Improvement Goal
Renegotiated Improvement Goal
Status (Enter the current quarter measurement for the reported quarter.)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12
Permanency Outcome 1: Placement Stability
National Standard	101.5
Performance as Measured in Final Report/Source Data Period
Performance as Measured in Baseline/Source Data Period
Negotiated Improvement Goal
Renegotiated Improvement Goal
Status (Enter the current quarter measurement for the reported quarter.)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12

State:
Type of Report:       PIP:___       Quarterly Report:___       (Quarter:___)
Date Submitted:

Part C: Item-Specific and Quantitative Measurement Plan and Quarterly Status Report

Outcome/Systemic Factor:_____       Item:_____
Performance as Measured in Final Report
Performance as Measured in Baseline/Source Data Period
Negotiated Improvement Goal
Method of Measuring Improvement
Renegotiated Improvement Goal
Status (Enter the current quarter measurement for the reported quarter.)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12
Outcome/Systemic Factor:_____       Item:_____
Performance as Measured in Final Report
Performance as Measured in Baseline/Source Data Period
Negotiated Improvement Goal
Method of Measuring Improvement
Renegotiated Improvement Goal
Status (Enter the current quarter measurement for the reported quarter.)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12
Outcome/Systemic Factor:_____       Item:_____
Performance as Measured in Final Report
Performance as Measured in Baseline/Source Data Period
Negotiated Improvement Goal
Method of Measuring Improvement
Renegotiated Improvement Goal
Status (Enter the current quarter measurement for the reported quarter.)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12
Outcome/Systemic Factor:_____       Item:_____
Performance as Measured in Final Report
Performance as Measured in Baseline/Source Data Period
Negotiated Improvement Goal
Method of Measuring Improvement
Renegotiated Improvement Goal
Status (Enter the current quarter measurement for the reported quarter.)	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12