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The Monitoring Process - Sample Internal Reports


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Sample Internal Reports with Operational Definitions

BROADEST POLICY PROVISION:
The CEO shall not cause or allow any practice, activity, decision or circumstance in the organization that is unlawful, imprudent, or in violation of commonly accepted business and professional ethics.

CEO'S INTERPRETATION:
I believe that the board has already sufficiently defined everything that would be imprudent or in violation of commonly accepted business and professional ethics in its lower-level policies. The only part of this global policy that requires further definition is that of unlawfulness. I interpret unlawful to mean any action that is taken that is subsequently found by a court or arbitration to be contrary to the appropriate legislation under consideration.

Compliance will be demonstrated when I can provide evidence that none of these conditions have occurred. This will be accomplished by having Corporate Counsel, the Director of Human Resources, and the Standards Compliance Officer review all investigations, litigations, grievances, or safety inspections over the previous year and indicating how many there were and how many indeed were ultimately found to be contrary to the legislation or bargaining contract terms.

This interpretation was confirmed by Corporate Counsel, the Director of Human Resources, and the Standards Compliance Officer to be the current best practice standard of their professions and I therefore feel that it is justified as reasonable. The standard of 95% of all instances being found to be lawful is based on the factor of human error in implementing policies designed to prevent such occurrences and in the ability of those judging a dispute to be accurate. This standard is based on a report prepared by the Minnesota Bar Association, which showed that commercial and labor case review indicated that the decisions of judges were found to result in false positives (finding the innocent guilty) in 10% of all cases.

EVIDENCE
The standard of compliance with this policy will be that all of the lower-level policies will be found by the board to be reasonably interpreted and to have sufficient data to show compliance with that interpretation AND that the assessments by the Corporate Counsel, the Director of Human Resources, and the Standards Compliance Officer will show that at least 95% of the official investigations, inspections or arbitrations were found to be lawful.

DATA
Below are the assessments by each of the Senior Managers named and a summary of the board's vote, with specific date, for each of the lower-level monitoring reports in terms of compliance and sufficiency of evidence.

 

Internal Monitoring Report
Policy 2.5.1 Financial Conditions and Activities

Wording
The Executive Director shall not spend more funds than are available in the fiscal year.

Interpretation
This policy is interpreted to mean that it is not okay to spend more than is available. For this policy I interpret funds to include both current revenues as well as any positive or negative carryovers from previous years that were not dedicated to other purposes. I interpret expenses to include all operating and capital expenses.

Revenues and Expenses are ongoing, so a period of report must be defined. The appropriate period for this reporting is interpreted to be the current fiscal year-to-date, as the policy was first in place as of the first day of our fiscal year. Numbers will be drawn from the most recent audited quarterly financials.

Compliance will be shown when the numbers drawn from our audited books show that the Total Expenses (including operating and capital expenses) year-to-date subtracted from the Total Funds Available (revenues earned and received plus any operating net income from the previous year) year-to-date result in a positive number.

Consultation with our CFO and our Auditor confirm that this fits within standard practices for determining Funds and Expenses.

Data
There were no capital expenses, as can be seen by the fact that there was no change in any of the capital accounts with the exception of depreciation. There was a positive carryover from the previous year of $2,000,000 as can be seen on the balance sheet as increase in excess revenues under the equity accounts.

Copies of the Income Statement and Balance Sheet for this period are (attached/available for viewing upon request)

The calculation is:

Funds

 

Carryovers (+/-)

$  2,000,000

Earned and received revenues

$20,695,575

Total Funds Available:

$22,695,575

 

 

Expenses

 

Operating expenses from current year

$18,762,196

Capital expenses from current year to date

$ 0

Total Expenses:

$18,762,196

 

 

Calculation

 

Total Funds Available

$22,695,575

Minus Total Expenses

$18,762,196

= Resulting Number

$  3,933,379 (positive)

Statement of Compliance
I report compliance.


Internal Monitoring Report
Policy 1.0 Ends

Wording
People with addictions and/or mental health illnesses in Danforth County will have a quality of life similar or equal to that of those without these challenges at a cost per outcome equal to the average for all ADM Boards in the United States.

Interpretation
People in Danforth County is interpreted include both residents and visitors of all ages. Given the fact that the taxes are paid by residents they will be the primary beneficiary, but visitors can have access to emergency assistance.

Addictions include only those that result as a chemical dependency (including alcohol, prescription and non-prescription pharmaceuticals, daily items used and consumed in a similar nature to pharmaceuticals but not including tobacco products) and mental illnesses as those illnesses are described in the DSM-IV.

Quality of life will be impacted by both the addiction and/or illnesses and the life situations usually associated with it, so it is unrealistic to believe that that those affected will have a life similar to others in all categories, but they should have a life that approximates those without those illnesses and addictions, including adequate housing, access to medical care, and employability.

There will be a continuum of quality from the onset of treatment to completion, and so the quality of life should improve over time. This will be measured by a survey of the identified clients once every year and of the general population of the county once every five years. The survey will specifically ask whether or not the clients and/or general population identifying themselves as have an addiction or mental illness indicate that 50% of those who are not in treatment or have just begun it are finding or know where to find medical help, that 70% of those with at least three months of treatment are also able to have a private place to live (apartment or home) and that 80% of those with at least 12 months of treatment also can report that they are employed.

The reason for the standard being 50%, 70% and 80% comes from accepted research by the (xxx) showing that these are averages in Ohio for these conditions and circumstances because awareness is never complete, treatment is not always followed, and employment is not possible for everyone.

Data
This policy has only been in force for one year so we have not yet conducted the general population survey.

The results of the annual survey are as follows:

Question

Percentage responding positively

 

New to treatment or not in treatment

At least 3 months

At least 12 months

1. Do you know where to find medical help for your addiction or mental health illness?

40%

93%

95%

2. Are you receiving medical help for your addiction or mental illness?

20%

89%

99%

3. Are you able to pay for your own housing or are you living with friends or relatives?

42%

73%

80%

4. Are you currently employed?

61%

72%

85%

 

Statement of Compliance
I report compliance on those with 3 months of treatment having a place of their own (73% with a standard of 70%) and those with 12 months of treatment having jobs (85% with a standard of 80%).

I report non-compliance on those new to treatment or not in treatment knowing where to get it and actually accessing it (40% and 0% with a standard of 50%).

It is apparent that our efforts to communicate to those with untreated issues about treatment and how to begin it is not working. I will provide a presentation outlining my plan to correct this within the next 365 days.


Actual Policy Language

POLICY TYPE: EXECUTIVE LIMITATIONS

2.2  POLICY TITLE: TREATMENT OF STAFF


With respect to the treatment of paid and unpaid staff, the EXECUTIVE DIRECTOR may not cause or allow conditions that are unfair, undignified, disorganized, or unclear.

Further, without limiting the scope of the foregoing by this enumeration, he or she shall not:

  1. Operate without written personnel rules that: (a) clarify rules for staff, (b) provide for effective handling of grievances, and (c) protect against wrongful conditions, such as nepotism and preferential treatment for personal reasons.
  2. Prevent staff from grieving to the board when (A) internal grievance procedures have been exhausted or (B) the employee alleges that board policy has been violated to his or her detriment.
  3. Fail to acquaint staff with the Executive Director's interpretation of their protections under this policy.

CEO Monitoring Report


INTERNAL MONITORING REPORT
POLICY # 2.2: Treatment of Staff

 

CEO AFFIRMATION
I hereby present my monitoring report on your Executive Limitations policy [Name the policy being monitored] according to the schedule set out. I certify that the information contained in this report is true.

 

Signed____________________________, CEO

Date___________________________

 

BROADEST POLICY PROVISION (Policy 2.2.0):


With respect to the treatment of paid and unpaid staff, the EXECUTIVE DIRECTOR may not cause or allow conditions that are unfair, undignified, disorganized, or unclear.

CEO'S INTERPRETATION (and Justification as to its Reasonableness):

In general I interpret this policy to mean that I should avoid a negative workplace. There should be clear rules of unacceptable behavior, effective processes should be maintained, the environment should be a healthy one, and it should be both productive and constructive. This would mean that employees have positive energy, work well together, be efficient, be empowered by training and information, and clearly understand what is expected of them.

Beyond that, I believe that all of the further statements at this level are encompassed in the interpretations of the lower-level Policies below.

DATA TYPE

I believe that the data which will best show evidence of my compliance is the compliance of the lower-level Policy Provisions below.

ACTUAL DATA

See data for lower-level Policy Provisions below.

I report compliance.

 


 
POLICY PROVISION #1 (Policy 2.2.1):


Operate without written personnel rules that: (a) clarify rules for staff, (b) provide for effective handling of grievances, and (c) protect against wrongful conditions, such as nepotism and preferential treatment for personal reasons.

CEO'S INTERPRETATION (and Justification as to its Reasonableness):

In general I interpret this to mean that I must develop and share with staff a set of personnel policies that outline expected and off-limits behavior as well as how administrative process works in general (like payroll, benefits, etc.)

Beyond that, I believe that the content of those policies is clearly defined by the language of the policy.

I believe this is a reasonable interpretation because it also meets the standards of practice as published by …. (Currently under research)

DATA TYPE

I believe that the type of data that will best provide evidence of my compliance is the fact that a Staff Policy and Procedures Handbook is in place (and is available for viewing in my office if a board member wishes), along with a list of the dates of initial communication of its contents to each staff member and the dates when each staff member attended a review session to explain the personnel policies. In addition I am including a list of any and all suits or won grievances alleging violation of those policies.

ACTUAL DATA

  • Copies of the actual Staff Policy and Procedures Handbook are available for your review upon request.
  • Dates for employee review of the Handbook:

Employee

Hire Date

Initially Read and Signed

Most Recent Review session and Signature

Compliant?

Thomas Benson

12/01/96

12/01/96

1/12/13

Yes

Nanci Edwards

5/21/99

5/21/99

1/12/13

Yes

Duane Elder

8/31/02

8/31/02

1/12/13

Yes

Colleen Hayes

7/12/04

7/12/04

1/12/13

Yes

Sandra Bohm

10/05/07

10/05/07

1/12/13

Yes

Jake Domordi

6/23/10

6/23/10

1/12/13

Yes

 

 

 

 

 

  • There have been no suits or grievances alleging violations of these policies.

I report compliance.


POLICY PROVISION #2 (Policy 2.2.2):


Prevent staff from grieving to the board when (A) internal grievance procedures have been exhausted or (B) the employee alleges that board policy has been violated to his or her detriment.

CEO'S INTERPRETATION (and Justification as to its Reasonableness):

In general I interpret this to mean that I cannot create a condition where staff does not have, or does not feel safe taking, genuine issues to the board.

I further interpret "prevent staff" to mean that I may not put any pressure on them to not proceed with a genuine grievance including obstructing their path, threatening punishment if they proceed, creating a perception of potential negative consequences for proceeding, or actually practicing or threatening retribution if they do.

I further interpret "when (A) internal grievance procedures have been exhausted or (B) the employee alleges that board policy has been violated to his or her detriment" to mean that staff can go to the board with any complaint for which they do not like the outcome as long as they have exhausted the internal procedure, OR when an employee feels that they have personally suffered as a result of a violation of board policy by myself, my staff, or the board.

I believe that with these additional interpretations, the meaning of the remainder of the policy is self-evident and clear.

I believe that this is a reasonable interpretation because it fits within the common standards of practice as identified in … (based on research that I am conducting now)

DATA TYPE

The type of data that I believe would be evidence of my compliance is a list of all grievances within the prior reporting period indicating a) whether or not they were resolved before going to the board or b) that they were not resolved before going to the board and the date on which the board heard the grievance. Such a list can be found below.

ACTUAL DATA


Employee

Grievance Date

Action

Result

Colleen Hayes

1/15/09

Brought to board at regular meeting on 3/14/09

Board found no violation

I report compliance.


POLICY PROVISION #3(Policy 2.2.3):


Fail to acquaint staff with the Executive Director's interpretation of their protections under this policy.

CEO'S INTERPRETATION (and Justification as to its Reasonableness):

I interpret "acquaint staff" to mean that I will develop policies and communicate them to staff when they are hired and on an ongoing basis annually.

I interpret "their protections" to mean a list of what they are protected from that would be considered mistreatment and constitute an unsafe workplace (including things such as a being physically dangerous, not allowing their intellectual/emotional/professional growth, not being respectful of their professional contribution, and not having clear policies).

I believe that this a reasonable interpretation because it is as comprehensive and fair as anything I have found in researching the topic and more comprehensive and fair than anything I have either seen or experienced elsewhere. I have also consulted our labor attorney, and the attorney agrees that this is reasonable.

DATA TYPE

The best data that would illustrate my compliance is a record of each new hire and when he or she received an explanation of the policies and a record of what date each existing employee received a review of those same policies. A list is provided below.

ACTUAL DATA

  • Dates for employee review of the Handbook:[[?Again, update to more recent years?]]

Employee

Hire Date

Initially Read and Signed

Most Recent Review session and Signature

Compliant?

Thomas Benson

12/01/96

12/01/96

1/12/13

Yes

Nanci Edwards

5/21/99

5/21/99

1/12/13

Yes

Duane Elder

8/31/02

8/31/02

1/12/13

Yes

Colleen Hayes

7/12/04

7/12/04

1/12/13

Yes

Sandra Bohm

10/05/07

10/05/07

1/12/13

Yes

Jake Domordi

6/23/10

6/23/10

1/12/13

Yes

 

 

 

 

 

I report compliance.


INTERNAL MONITORING REPORT
POLICY NAME & NUMBER: ENDS POLICY 4.2 "STUDENT PROFICIENCY IN SPECIFIC TECHNOLOGY APPLICATIONS"

I hereby present my monitoring report on your Ends policy "Global End" according to the schedule set out. I certify that the information contained in this report is true.
Signed:  _________________________________________ , Superintendent  

BROADEST POLICY PROVISION:
4.2 Upon graduation, the Excelsior student will demonstrate proficiency in specific technological applications.

SUPERINTENDENT'S INTERPRETATION:
I interpret this to mean that students who complete their education at Excelsior will have the understanding, practice, and skills necessary to use technology to their advantage. This includes being able to use technology to enhance their school, work, or personal needs and goals. Realistically, it is not likely that 100% of students graduating will achieve this goal; however, it is challenging but reasonable to expect that 90% will and that the remaining 10% will improve their ability to use technology.

DATA:
I believe that evidence of this would be provided by seeing increases in the following measures:

  • An ability to pass the 8th-grade tech test
  • Completion of the full range of technology training.
  • A change in overall proficiency between the 8th-grade test and graduation.
  • A higher percentage of proficiency for students who have been with us longer.

The actual data for these measures are:

 

2007-2008

2008-2009

% of students passing the 8th-grade test

88%

92%

% of students completing all technology training

97% (34 students dropped out before completion)

99%

Change in proficiency over time:

  • Average score on tech test at 8th grade
  • Average score on graduating test

 

82%

88%

 

80% (had students of choice from more challenged districts)
90%

Higher proficiency due to training:

  • Average score of students with 6 years of training
  • Average score of students with 4 years of training
  • Average score of students with 2 years of training

 

94%

90%

86%

 

94%

91%

88%

 

 

 

 

POLICY PROVISION 4.2.a:
Current graduates will demonstrate proficiency in the following performance categories:
Research
Presentations
Quantitative analysis
Word processing
Database management

SUPERINTENDENT'S INTERPRETATION:
I interpret this to mean that graduates will have a range of technology skills, including the specific areas listed. This should include both the individual skills and an ability to integrate them when appropriate.

DATA:
I believe that evidence of this would be provided by seeing increases in the following measures:[[?Should the final point in this list also be expressed as a percentage, so increase can be shown?]]

  • 90% of all students receive a passing grade in each of the classes designed to build the specific skills.
  • The remaining 10% shall show an improvement in their performance.
  • The ability to integrate multiple technologies as measured by a capstone technology project.

The actual data for these measures are:

 

2007-2008

2008-2009

% of students passing the research class

88%

91%

% of students passing the presentation class

91%

92%

% of students passing the quantitative analysis class

89%

93%

% of students passing the word processing class

90%

92%

% of students passing the database management class

78%

90%

% of students completing all technology training

92%

90%

Average score of students who do not pass as they enter and exit each class (enter/exit)

(enter/exit) 76%/81%

(enter/exit) 77%/83%

Performance on the capstone technology project (average score)

85%

86%

STATEMENT OF COMPLIANCE:
I report that I am in compliance with the provisions of this Policy.

________________________________________________________________________________
(Superintendent Signature)                    (Date)