Performance Indicator (PI) Forms

The following forms are primarily for use by the group facilitator. However, group participants may be interested in knowing what information the group facilitator is collecting. Group participants may choose to use any of these forms to track their own attendance and response to the WSM program if desired. These performance indicator forms assist the group facilitator to better understand how participants are benefiting and responding to the program. PERFORMANCE INDICATORS 1. Attendance Tracking form to determine: A) How many people are attending each week (PI # 1) B) How many total lessons did each participant complete in group and on their own (PI # 6) 2. Reasons why a group participant discontinues participating in the group.(PI # 2) 3. Core Competency Checklist: This list gives group facilitators and supervisors a way of checking on skills and knowledge related to facilitating a WSM group. The WSM program emphasizes the importance of continually improving ones knowledge and skills. (PI # 4) 4. Group Leader Rating: This table helps group leaders organize and share their ideas related to how each participant is responding to the WSM group. Group facilitators may choose to discuss their observations with each participant individually. Group participants may choose to use this form to measure their own response to the program.(PI # 6)
NOTE: Performance indicator (PI) # 3 (Number of lessons completed by each WSM participant) has been integrated into the WSM Group Facilitator Rating Form (PI#6). Performance indicator # 5 is the Quality of Life Progress Checklist that participants are invited to provide at the completion of the WSM program.

ATTENDANCE TRACKING FORM: DATA TO ASSIST IN COMPLETING PERFORMANCE INDICATOR # 1 AND # 6

Program ______________Group Leader(s) ______________ Date Group Began _________ Group Name___________________________________ Initials # Lessons Completed: Circle the number for each lesson that the person attended in a scheduled group or completed in a make-up session. 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
23 43 24 44 25 26 27 28 29 30 31 32 33 34 35 36 37 45 46 47 48 49 50 51 52 53 54 55 56 57 38 39 40 41 42

2 3 4 5 6 7 8 9 10 11 12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57

Performance Indicator #2: Number and Reasons for Discontinuation

Agency _____________________ Program _________________Group Leader(s) _________________ Date Group Began ____________ Group Name_______
For each person who discontinued this month, please indicate the primary reason for discontinuing participation in the group (where possible, based on self report)
Person # 1 Primary Reason for Discontinuation (please check one box) Work schedule School schedule Family/Home Demands Relapse/De-compensation Hospitalized Incarcerated Loss of contact Deceased Work Schedule School Schedule Family/Home Demands Relapse/De-compensation Hospitalized Incarcerated Loss of contact Deceased Work Schedule School Schedule Family/Home Demands Relapse/De-compensation Hospitalized Incarcerated Loss of contact Deceased Work Schedule School Schedule Family/Home Demands Relapse/De-compensation Hospitalized Incarcerated Loss of contact Deceased Work Schedule School Schedule Family/Home Demands Relapse/De-compensation Hospitalized Incarcerated Loss of contact Deceased Work Schedule School Schedule Family/Home Demands Relapse/De-compensation Hospitalized Incarcerated Loss of contact Deceased Didnt get along with group members Did not follow ground rules Discharged from the agency/program Schedule conflict with other services Workbook is too difficult Group not helpful Physically unable to attend Didnt get along with group members Did not follow ground rules Discharged from the agency/program Schedule conflict with other services Workbook is too difficult Group not helpful Physically unable to attend Didnt get along with group members Did not follow ground rules Discharged from the agency/program Schedule conflict with other services Workbook is too difficult Group not helpful Physically unable to attend Didnt get along with group members Did not follow ground rules Discharged from the agency/program Schedule conflict with other services Workbook is too difficult Group not helpful Physically unable to attend Didnt get along with group members Did not follow ground rules Discharged from the agency/program Schedule conflict with other services Workbook is too difficult Group not helpful Physically unable to attend Didnt get along with group members Did not follow ground rules Discharged from the agency/program Schedule conflict with other services Workbook is too difficult Group not helpful Physically unable to attend Other, specify: ________________ ________________ ________________

Other, specify: ________________ ________________ ________________

Other, specify: ________________ ________________ ________________

Other, specify: ________________ ________________ ________________

Other, specify: ________________ ________________ ________________

Other, specify: ________________ ________________ ________________

PERFORMANCE INDICATOR # 4: Core Competencies Checklist for use by group facilitators and supervisors
Agency _____________________ Program _________________Group Leader(s) _________________ Date Group Began ____________ Group Name_______ Person who completed ratings __________________________ Date ratings completed ____________ One aspect of the implementation of WSM relates to the clinical competencies demonstrated by practitioners. Four core competencies have been identified: Engagement and motivational techniques Educational/teaching techniques Cognitive-behavioral techniques Group skills utilizing the ROPES format This checklist will be utilized by supervisors and practitioners to support the continuous enhancement of practitioner skills and knowledge in implementing the WSM group program. It focuses on the four core competencies plus the four WSM values, and allows supervisors to provide feedback to practitioners after observing the implementation of group session(s). It also provides practitioners with a summary of the key skills components of these core competencies. For each skill component listed below, supervisors will indicate by checking the box next to each item whether the component was Not observed, Sometimes observed or Frequently observed.
Not Observed Sometimes Observed Frequently Observed

I. Engagement and Motivational Techniques Connects topic to members goals and values Uses reflective listening and empathic responding (avoids judgmental and critical comments) Emphasizes the benefits of learning the topic area Makes inspiring comments that promote hope Expresses appreciation for participants efforts
Not Observed Sometimes Observed Frequently Observed

II. Educational/Teaching Techniques Engages people in reading out loud Asks questions about main points to increase comprehension Respectfully assists member to stay on topic Clarifies ideas via examples relevant to participants lives Asks questions to check on participants comprehension

Not Observed

Sometimes Observed

Frequently Observed

III. Cognitive-Behavioral Techniques Reframes ideas or beliefs that are self-defeating Breaks information down into small segments to shape understanding Models behavior via demonstrations and/or self disclosure Provides specific feedback to participants Provides positive reinforcing comments to participants
Not Observed Sometimes Observed Frequently Observed

IV. Group Skills Utilizing the ROPES Format Prior to group session, describes the plan for the session with specific goals that can be observed Prior to the group session, describes the progress made by each participant Checks on the outcome of Action Steps from previous session Reviews participants experiences with and knowledge about todays topic Presents an Overview of todays session Leads a discussion about the importance of todays topic for participants Leads a discussion focusing on the Important Information presented in todays lesson Assists participants with the completion of Personalized Worksheets In session, assists members planning for Action Steps Encourages participants to Summarize the important points of the lesson
Not Observed Sometimes Observed Frequently Observed

V. WSM Values (Please rate how often the group leader incorporated the 4 values of the WSM Program) Hope (emphasizes positive possibilities, acknowledges setbacks without a sense of defeat) Choice (emphasizes options, encourages informed decision making, helps people identify pros and cons) Involvement (emphasizes learning from others, encourages action about getting needs met) Recovery (emphasizes personal strengths, values and goals)

PERFORMANCE INDICATOR # 6: WSM GROUP FACILITATOR RATINGS:

RATING GUIDELINES : To answer the questions accurately, you may want to meet individually with the participant. Place numbers in the corresponding boxes for each member of the WSM group across two (2) points of time: lesson 34 and the end.
Agency _____________________ Program _________________Group Leader(s) _________________ Date Group Began ____________ Group Name_______ Group 1st Ratings at midpoint (lesson 34) 2nd Ratings at completion of WSM program GROUP st Member Date 1 Rating Completed ___/___/___ Date 2nd Rating Completed ___/___/___ MEMBER Number
1) LESSONS COMPLETED

INITIALS
(for local use, DO NOT ENTER INTO WEB-BASED DATABASE))

1) LESSONS COMPLETED

2) PARTICIPATION

3) ACTION STEPS

4) INVOLVEMNT OF OTHERS

5) HEALTH CHECKUP

6) GOAL PROGRESS

4) INVOLVEMNT OF OTHERS

6) GOAL PROGRESS

2) PARTICIPATION

3) ACTION STEPS

5) HEALTH CHECKUP

1 2 3 4 5 6 7 8 9 10 11 12
1) LESSONS COMPLETED: Please indicate the number of lessons completed by each member of the group for two time-points (Lesson 34 and lesson 57). This is the total number completed since the group began and include all lessons completed during the group session, as well as lessons completed in individual meetings. 4) INVOLVEMENT OF OTHERS: Indicate the extent to which each consumer involved other people (e.g., family /friends/peers) in getting the most out if the WSM program. 1 = No involvement 2 = Low level of involvement (discuss few of the lessons with others) 3 = Moderate level of involvement (e.g. discuss many lessons with others, received support such as help with reading some lessons) 4 = High level of involvement (discuss most lessons and received help with reading and completing action steps; others met with group leader to discuss their involvement 5) HEALTH CHECK UP: How many times did the person visit a physical healthcare professional (e.g., doctor, dentist, nurse, optometrist) in the past 6 months? 0 = never 1 = once 2 = twice 3 = three or more times 6) GOAL PROGRESS 1 = Person is doing worse in many of their goal areas 2 = Little or no progress made in any goal area 3 = Significant progress made in one or more goal areas 4 = Achieved one or more goals

2) PARTICIPATION 1 = Infrequent participation in group discussion even when prompted 2 = Usually participates only when prompted 3 = Often participates without prompting 4 = Very active participation throughout in group discussion throughout the program without prompting 3) ACTION STEPS: the person completed Action Steps for: 1 = less than 25% of the lessons he/ she completed 2 = 26-50% of the lessons he/ she completed 3 = 51-75% of the lessons he/ she completed 4 = 76-100% of the lessons he/she completed