Quality Improvement

Standard Assessment
1. A quality improvement program for mental health care is in place.
  1. A quality improvement plan is in place for mental health services which includes:
    • Documentation of a quality improvement plan for evaluating care;
    • Indicators for quality that are clearly identified and measured on a regular basis; and
    • Performance data that is followed over time.
2. A process for quality improvement is in place.
  1. Evidence of quality improvement activities exists to deal with opportunities for performance improvement, including:
    • The program's response to monitoring and/or evaluation data; and
    • Performance data that is communicated back to relevant staff.
  2. There are clear lines of accountability established for implementation of quality improvement strategies that include the following:
    • Responsibility for managing implementation of quality improvement efforts;
    • How the program is multidisciplinary;
    • Response and feedback from management to QI recommendations;
    • All levels of the organization are made aware of lines accountability for quality improvement activities; and
    • Staff receives training on quality improvement.
3. A systematic approach exists for ongoing data collection & evaluation to set priorities, plan changes in program design, study and monitor processes, and sustain improvements.
  1. The organization conducts monitoring and evaluation on performance based criteria that includes:
    • Type of monitoring/evaluation in place;
    • Identifying who conducts the monitoring and evaluation; and
    • The methods of monitoring: medical records, computerized programs, etc.
  2. The agency monitors the overall rate of medical and mental health adherence and uses the information to modify or develop program strategies.
  3. The program meets or exceeds the projected number of clients served and number of services provided annually.
4. Structures are in place for HIV consumer involvement and active participation in the development and quality improvement of the HIV mental health program.
  1. There are mechanisms for consumer input to the mental health program itself and not just the overall agency consumer involvement plan.
  2. There are written policies and procedures for consumer participation, including information on the frequency of the activities.
  3. Consumers of mental health services participate in the development and improvement of the mental health program through advisory committees, focus groups, consumer satisfaction surveys or other opportunities.
  4. Client identified issues are integrated into the agency's quality improvement process.
  5. Results/recommendations are reported back to management.
  6. Management's response is documented.
  7. Feedback on recommendations is provided to staff, committee/group members and other consumers.