First Year Evaluation Template for New York City with Instructions
M E M O
|To:||Executive Directors and Program Directors of New York City Clinics Participating in the Continuous Quality Improvement (CQI) Initiative|
|From:||Jayne Van Bramer, Director
Office of Quality Management
|Date:||February 7, 2007|
|Subject:||OMH Continuous Quality Improvement (CQI) Initiative Template for the Annual Evaluation of Clinic Quality Improvement Programs Due May 30, 2007|
The purpose of this document is to provide a template for participating New York City 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:
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."
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 and clinic staff 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 the QI Plan in the 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 May 30, 2007, (covering activities in year 1) and May 30, 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.
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 either on the template provided should be sent as a paper document and electronically to Alan McCollom, Ph.D.
Alan McCollom, Ph.D.
Bronx Psychiatric Center
1500 Waters Place
Bronx, New York 10461
You will receive an initial response indicating that your submission has been received and a later e-mail indicating whether your report has been accepted.
cc: Robert Myers
Lloyd Sederer, MD