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Commissioner Michael F. Hogan, PhD
Governor Andrew M. Cuomo

OMH Implementing New Survey Process for Clinics

Updated February 2010

From the Office of Quality Management

The New York State/New York City Mental Health-Criminal Justice Panel, in its June 2008 report, focused on opportunities to improve services for individuals with mental illnesses who are at risk for poor outcomes, violence and involvement with the criminal justice system. As one of its findings, the panel recommended that the Office of Mental Health (OMH) issue and monitor the use of standards of care for mental health clinics.

In response to this recommendation, the panel's report also contained “Guidelines for Mental Health Clinic Standards of Care and Sequential Screening of Risk for Violence,” which represents interpretations based on existing OMH regulatory requirements.

These Mental Health Clinic Standards of Care provided OMH with the opportunity to examine its clinic licensing process to ensure that appropriate community standards of care are understood, employed and supported. Traditionally, the OMH Bureau of Inspection and Certification (BIC) has licensed clinics according to a Tiered Certification Process that surveys five target areas, with the specific standards reviewed based on applicable regulations.

In the Fall of 2008, BIC initiated a project to change clinic licensing reviews from the current Tiered Certification Process to one that incorporates the Standards of Care. Project work sessions were conducted with licensing staff statewide to develop survey standards and tools that would help determine how well a clinic was adhering to the Standards of Care. Over several months, bi-weekly meetings were held and many staff worked on materials for the group to review and suggest changes. Assistance was also sought from the New York State Psychiatric Institute (NYSPI) Division of Mental Health Services and Policy Research and OMH's Bureau of Evaluation and Performance Measurement, to operationalize the standards in the most clear and consistent manner possible.

From October 2008 to the present, the survey standards, as well as the concept of the tracer methodology, have been shared with provider groups, recipient and family groups as well as city and county representatives. The overall impression of these groups was that this proposal shifts the focus from process to a more clinically relevant survey. In addition, the feedback and suggestions obtained from each session have helped to shape and refine the new survey instruments and process.

Under the new survey standards, programs will still be expected to demonstrate the delivery of effective and appropriate clinical services, but reviewers will also seek evidence that services and care plans reflect the needs and preferences of individual recipients, attend to co-occurring needs, respond to the individuals changing life circumstances, and support the achievement of chosen life roles. The standards also include a significant emphasis on engagement and collaboration between clinic, recipient, and those individuals identified as potential sources of support for the recipient. Length of clinic operating certificates will be based on adherence to the care standards, and recognition and incentives will be provided to promote the achievement of exemplary practices by all clinics.

The revised survey process adds the use of a tracer methodology, and will carefully examine assessment and service components in a more meaningful way that is clinically driven and comports well with the standards of care. Surveyors using tracer methodology select an individual and move through his or her care processes in order to assess compliance with the Standards of Care. In doing so, they review the person's medical record, interview staff and leadership, the involved individual, significant others, and other providers.

Following a series of field tests and additional provider feedback, the survey instruments and process have been further modified. In addition, OMH Division of Children and Families representatives have been involved to insure that the standards reflect the clinical and administrative practices which should be in evidence in a clinic serving children, adolescents, and their families.

The new licensing process was piloted at eleven clinics which volunteered to be reviewed under the new standards. The pilot included clinics from all regions of the state which served either adults, children or both. The sample included not for profits, state operated, county operated, and hospital affiliated clinics. Some had satellite clinics. The pilots provided valuable information to make further modifications to the survey process and licensing tools. All in all, everyone agreed the new licensing process was more clinically relevant than the former methodology.

While the revised licensing process sets high standards for the delivery of clinic services which are individualized, integrated and effective, this initiative also makes resources available to the clinics to assist them in meeting this challenge. Training modules on best practices, links to online resources, and other opportunities for identifying and sharing successful programs and practices are some of the types of materials which will be made available with this initiative.

We invite you to review the 2010 clinic licensing materials and send us your feedback.

You may also want to review our list of Questions and Answers (revised 3/10), and submit additional questions which may be added to the list.

Send us your feedback and questions.