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

First Year Evaluation
Template 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 | Download Adobe Acrobat Reader

Insert the name of your clinic here
Insert the date when your evaluation was completed here

Introduction
The following is a summary of our quality improvement activities during 2006.  The objectives we established for our program during this year form the framework of the evaluation.  These objectives address the requirements of the first year of the Memorandum of Agreement that we signed with the NYS Office of Mental Health (OMH) regarding quality improvement activities at our Clinic.

Summary of Objectives for 2006
The following is a list of the objectives that provided direction for our Plan during 2006.

(Add a brief paragraph here describing how the objectives of your plan, particularly the measure of performance you have selected, relate to the mission and/or strategic plan or your clinic or agency.)

Quality Improvement Plan
Based on a workshop provided by OMH, we developed and submitted a Quality Improvement Plan.  The Office accepted the Plan.  As part of our Plan, we adopted a specific approach to quality improvement.
(Indicate the name of your approach and the steps it involves.  This refers to the PDCA approach or other approach you may have adopted this year or earlier.)

Quality Improvement Committee
We convened a Quality Improvement Committee.  The Committee included the following members:
(List here the members of your committee by title.  If you are part of a larger agency with a quality improvement program, describe how the activities of the clinic fit into those to the larger agency.)

As indicated the membership included recipient and family representatives.  They were able to attend the following number of meetings during the year: 
(Provide the number of meetings that were actually attended by a recipient and/or family member.  Note that it is expected that a recipient will participate on Committees serving adults and a family member will participate on Committees for clinics serving children or adolescents.  For clinics serving only adults or children/adolescents, the text should be modified accordingly.  You may also wish to comment, at your option, on any special contribution made by these individuals with regard to content or perspective.)

The Committee addressed and acted upon the following issues during the year:
(List here the topics or issues that the Committee discussed and/or acted upon during the year.  Be sure to explicitly describe any cases in which data were used as the basis for decisions and other actions.)

Staff Training in Quality Improvement
The following training related to our quality improvement activities was provided during the year.

Quality Improvement Indicator (Measure of Performance)
The following is a summary of our actions during 2006 that focused on
(provide the name of your indicator).  (In this section of the evaluation, you will describe how your work based on the indicator unfolded.  We have included steps that correspond to the PDCA approach.  If you employed a different approach, you should feel free to organize this section according to the steps of that approach.)

Rationale (Prioritize).
(Briefly describe why you chose this indicator.  Consider the selection criteria described in your Plan.)

Assessment of the Process (Plan).
(What did you do to better understand the process(es) and/or systems related to your indicator?  This may include consultation with staff (brainstorming), obtaining feedback from recipients as well as reviewing available research and consulting with other providers.  What were the findings and conclusions of this assessment?)

Implementing the Action Plan (Do). 
(What actions did you take to improve the process or system?  Briefly describe the performance indicator you used to assess the impact of your actions.)

Evaluation of the Impact of the Actions (Check). 
(What was the impact of your actions to date on your indicator?  Insert here a table or graph showing your data.)

Next Steps.
(If your initiative was successfully completed, describe what you plan to do to “hold the gains.”  This may be as simple as your Committee continuing to monitor and assess the performance indicator.  If you are not yet satisfied with impact of your actions and/or you are continuing to work toward the results you desire, describe the additional actions that you plan to take.)

Planned Quality Improvement Initiative for 2007
(Note that the MOA requirements for 2007 are listed on the memo that accompanies this form.  The MOA requires that you work with two performance indicators during the second year.  We generally expect that one of the indicators will be carried over from the first year.  Even if you have achieved the desired result with the indicator you worked with during 2006, you should consider continuing to monitor performance to assure that you are holding the gains.  If you elect to continue with the indicator employed during the first year, you should describe that indicator in the table below titled, Performance Indictor 1.)

Based on a discussion of our priorities, we plan to focus on the performance indicators described in the following tables during 2007. 
(Provide a brief description of why each of these indictors is important and what you plan to accomplish with each of them.)

Performance Indicator 1

Name Provide a brief two or three word title.
Definition Further define the indicator by describing the data elements and the type of numerical value to be used to express the indicator (percentage, rate, number of occurrences etc.).
Data Collection Describe how the data will be collected as well as the method and frequency of collection.  Who will be responsible for collecting the data?
Assessment Frequency State how often the Quality Improvement Committee will assess information associated with the indicator.

Performance Indicator 2

Name Provide a brief two or three word title.
Definition Further define the indicator by describing the data elements and the type of numerical value to be used to express the indicator (percentage, rate, number of occurrences etc.).
Data Collection Describe how the data will be collected as well as the method and frequency of collection.  Who will be responsible for collecting the data?
Assessment Frequency State how often the Quality Improvement Committee will assess information associated with the indicator.

We also plan to take the following steps to assess the needs and expectations of our recipients, their families and their staff.

(Describe here what you may have already done or plan to do with regard to these assessment activities.  They would most typically be accomplished through written surveys although other methods may also meet the intent of the Memorandum of Agreement.)

We also plan to provide further training in quality improvement. 
(Describe here any additional training you plan during 2007.  Note that the MOA requires that you provide training in quality improvement principles to all new employees.  If you have already done this, you may note this here or you may summarize the training in the earlier section on staff training.)