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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

First Year Evaluation
Instructions for
Central, Hudson River, Long Island, and Western Regions

Evaluation Template in Microsoft Word

This template can be downloaded in Microsoft Word format. If you experience difficulty accessing the Word version, or require a different format or other support, please call OMH at (518) 474-6587 Monday through Friday, 9:00 a.m. to 5:00 p.m.

View Adobe Acrobat Version of Memo | Download Adobe Acrobat Reader

Office of Mental Health Letterhead

To: Executive Directors and Program Directors of Clinics Participating in the Continuous Quality Improvement Initiative – Central, Hudson River, Long Island and Western NY Regions
From: Jayne Van Bramer, Director
Office of Quality Management
Date: November 21, 2006
Subject: OMH Continuous Quality Improvement (CQI) Initiative
Template for the Annual Evaluation of Clinic Quality Improvement Programs
Due February 1, 2007

Introduction
The purpose of this document is to provide a template for participating clinics to complete a summary and self-evaluation of quality improvement activities that occurred during 2006. This evaluation will provide a basis on which to plan for second year activities. You may download a copy of the enclosed template through the OMH website: http://www.omh.ny.gov/omhweb/omhweb/resources/index.html#cqi

OMH will also use this summary to evaluate performance as related to our Memorandum of Agreement. A key to successful quality improvement is a willingness to innovate, to experiment, and to learn from experience. Given that, we encourage objectivity and candor in completing the self-assessment. The focus of OMH’s evaluation will be a good faith effort in adopting quality improvement as an attitude, orientation and practice.

The Assessment Tool
Due to the diversity among participating clinics both in administrative structure and the level of development of a formal quality program, we have attempted to make provision for this diversity by creating a comprehensive assessment template. You are encouraged to further edit the template to include whatever additional information you feel will best “tell your story.”

OMH strongly recommends but does not mandate use of this assessment tool. If you choose to complete an evaluation of your own design rather than use the template provided, please refer to the enclosed instructions entitled, “Required Information for Evaluation of Quality Improvement Activities during 2006.”

Framework of the Template
Because we view this primarily as a self-assessment, the template has been designed as an annual report to the leadership, clinic staff, and recipients who are the clinic quality stakeholders themselves. Features of the template include generalized introductory and transitional comments, as well as instructions for completion which appear in italics. Your specific program information should be written where these instructions occur, and the instructions subsequently deleted. You are encouraged to add to the template to better describe your activities and results.

Note: The language provided in the template describes a clinic which is not a part of a larger agency and which is initially developing a quality improvement program. You are encouraged to modify this language in any way you wish to better describe the individual circumstances of your program.

Requirements for 2007
In addition to the current year’s assessment, completion of the template will also communicate your plans for activities in 2007. Following is a list of requirements for second and third year activity as described in the MOA:

“…During the second and third years of this Agreement, the provider shall:

  • Include its QI Plan in its new employee orientation.
  • Monitor on a regular basis two performance indicators. One of such indicators may be the indicator selected in year one of this Agreement.
  • Document routinely using data from monitoring such performance indicators for decision-making purposes.
  • Implement a process designed to survey individuals served, families and staff about their perceptions of the quality of care received, and to identify areas for improvement.
  • Conduct and submit to its Board and the Director of the relevant OMH Field Office an Annual QI Evaluation by not later than February 1, 2007 (covering activities in year 1) and February 1, 2008 (covering activities in year 2). Such evaluation shall included a description of the previous year’s QI activities and how they relate to the Provider’s strategic plan or mission; an evaluation of the Provider’s achievement of its QI goals and objectives; an assessment of the extent to which the program’s monitoring was successful in improving processes and outcomes; and recommendations for changes to the QI Plan and future performance improvement activities.
  • Upon request, submit an informational copy of the Quality Improvement Plan to the local governmental unit (LGU).

If you have already satisfied some or all these requirements, they should be addressed in your assessment of 2006. The MOA provides minimum requirements of your quality improvement programs, and you should include any additional objectives you may have for 2007 in this section of the assessment.

Submission of the Evaluation
Your completed self-evaluation should be sent both as a paper document and electronically to the person listed on the following chart for your region.

CQI Regional Coordinators

Central New York Liaison:
Thomas Cheney
Hutchings Psychiatric Center
620 Madison Ave.
Syracuse, NY 13210

Hudson River Liaison
Alan McCollom
Bronx Psychiatric Center
1500 Waters Place
Bronx, NY 10461

Long Island Liaison
Jim Masterson
Pilgrim Psychiatric Center
998 Crooked Hill Rd.
West Brentwood, NY 11717

Western New York Liaison
Thomas Cheney
Hutchings Psychiatric Center
620 Madison Ave.
Syracuse, NY 13210

You will receive an initial response indicating that your submission has been received and a later email indicating whether your report has been accepted.

Enclosures (2)

cc:  County Mental Health Director
       Field Office Director
       CQI Regional Coordinator
       Robert Myers
       David Woodlock