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

OMH Annual Evaluation for Quality Improvement
Initiatives Report FY06/07

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 the quality improvement activities during FY ’06/FY ’07.  The objectives established for the 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 was signed with the NYS Office of Mental Health (OMH ), regarding quality improvement activities which were met in part through the implementation of the NYC DOHMH Quality IMPACT initiative.

Summary of Objectives for 2006
The following is a list of the objectives that provided direction for the 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
The agency developed and submitted a Quality Improvement Plan.  The Office of Mental Health accepted the Plan.  As part of the Plan, a continuous quality improvement (CQI) project, utilizing the Quality IMPACT CQI model, was implemented.

Quality Improvement Committee/Team
The agency convened a Quality Improvement Committee.  The Committee included the following members:
(List here the members of your committee/team 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/Team addressed and acted upon the following issues during the year:
(List here the topics or issues that the Committee/Team 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.
List the details: date, description of the training topic(s), and who was trained (e.g., clinical staff, leadership, Board of Directors, etc)of your attendance at: the Quality IMPACT basic CQI course, each Interactive Project Group, The Quality IMPACT CEO meeting, and monthly phone calls.  Also list the details of any additional education events you may have participated in including: Program based CQI education through train the trainer or self-study versions of the basic CQI course, program project specific training, DMH priority project content courses, and state or other specific CQI training.)

Quality Improvement Indicator (Measure of Performance)
Attach your FY ’06 or FY ’07 project plan sheet and FY ’06 or FY ’07 final project outcome sheet.

Planned Quality Improvement Initiative for 2007
Based on a discussion of priorities, the plan to implement the Quality IMPACT/OMH project is (Quality Impact Programs who are in the first year of participation in Quality Impact should submit their FY ’07 Project Plan Sheet and FY ’07 Project Outcome Sheet along with this template.  Programs in Quality Impact two or more years should submit the Project Plan Sheet and Final Project Outcome Sheet that were submitted to OMH last year as part of the OMH Performance Improvement Plan.) 

All providers should attach their FY ’07 and FY ’08 Project Plan sheets.

There is also a plan to take the following steps to assess the needs and expectations of 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. Participation in the Quality IMPACT Perception of Care Survey will meet the consumer/recipient aspect of this requirement.

There is also a 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.)