OMH Updating Survey Process for Clinics
Updated March 2013
From the Division of Quality Management
In April 2010, the Bureau of Inspection and Certification (BIC) implemented a new process for surveying Clinic Treatment programs. This moved clinic licensing reviews from a Tiered Certification Process to one that incorporated a tracer methodology and review measures which derived from the Standards of Care developed by the New York State/New York City Mental Health-Criminal Justice Panel.
While the revised licensing process set high standards for the delivery of clinic services which are individualized, integrated and effective, this initiative also made resources available to the clinics to assist them in meeting the 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 were made available. Feedback from providers has described the new licensing process as more clinically relevant than the former methodology.
Following two years of utilization, a process was begun to update the survey instruments. The comments and suggestions of providers, trade organizations and licensing staff were solicited and performance data for each standard was examined. In addition, subject experts were consulted in order to ensure that standards reflected not only current knowledge and practice expectations but also identified opportunities to enhance service delivery. Examples include the promotion of health services and attention to integrated dual disorder services. As a result of this process, standards were combined to eliminate redundancy, some practices which were previously identified as “Exemplary” practices are now an expectation for all clinics, and new standards for tobacco dependence and cultural competence have been added. It is intended that the modifications to the Clinic Standards of Care anchors provide greater clarity and less redundancy while continuing to promote practices and procedures associated with quality services and positive outcomes for individuals served.
In addition, a new resource document has been developed to assist providers in implementing best practices in clinics. The document provides links to a variety of tools and information associated with many of the survey anchor areas, and will be updated periodically.
A copy of the revised Clinic Standards of Care anchors and the resource document are being sent to each licensed clinic program and are available at
Licensing staff will begin using the updated version of the survey standards on May 1, 2013. Note that providers are not required to meet the new tobacco dependence standards for the first six months of implementation. The survey protocol and scoring for clinic surveys remain unchanged at this time.
Clinics are encouraged to share feedback on the instrument and the process at
- 2010 Clinic Licensing Survey Process
- 2010 Clinic Recertification Letter Appendix A
- Clinic Licensing Toolkit
- Clinic Satellite Protocol
- Clinic Standards of Care Anchor Element (Updated 3/13)
- Clinic Standards of Care - Resources, References and Tools (64kb)
- Family Questionnaire
- Recipient Questionnaire
- Report on Pilot Surveys
- Standards of Care Anchor Elements Guidance (Draft)
- Tracer Flowing Questions
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.