New York State Office of Mental Health
Clinic Quality Improvement Program: Second Annual Self-Evaluation
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Instructions. Provide information in the tables below. All areas should be completed unless otherwise instructed. If you have any questions, please contact your OMH regional support person.
After completion, it is highly recommended that the evaluation be submitted electronically to the OMH regional support person by attaching it to an email from the person who is primarily responsible for preparing it. Electronic versions of the additional materials requested (data tables and graphs as well as survey materials) may also be attached to the email. If it is not possible for you to submit these materials electronically, they may be submitted to the OMH regional support person by mail. If they are submitted electronically, it is not necessary to mail an additional copy.
The names and addresses of the OMH regional support staff are included on the letter that accompanies this evaluation form.
Agency and Clinic Information
Background: Participants are required to create an administrative structure to perform quality improvement activities through the designation of a Quality Management Committee that will meet regularly to coordinate and monitor the quality improvement function.
While this requirement may be met in a variety of ways, the core expectation is that there will be an officially designated group that meets at least 10 times per year and includes clinic leadership. In these regular meetings, the group will focus at a minimum on actively assessing and managing the clinic’s current quality improvement initiative(s).
It is ideal for both a family member and a consumer to be a member of the CQI team and attend meetings regularly. At a minimum, it is expected that providers of child and adolescent services will provide for the direct participation of a parent or parents in their quality improvement process, and that providers of adult services include participation of recipients.
Agencies providing licensed clinic programs vary widely in their nature, scope and complexity. In large multifunction social service agencies with an overall Quality Improvement Committee, active management of the clinic quality improvement process may be accomplished through a subcommittee or project team. Smaller clinics may simply convene a Quality Improvement Committee to accomplish this requirement. The group may be called committee or a team. In cases where a subcommittee or project team is responsible for the clinic initiative, that group may meet the requirement for 10 meetings per year.
How many of the meetings were attended by…
Background: Participants are expected to:
- Educate leadership and staff in the principles of quality improvement, performance measurement and evidence-based practice.
- Orient all new staff to quality improvement using the Clinic’s Quality Improvement Plan.
- In addition, clinics are expected to make quality improvement and evidence based practices part of the continuing education of all clinic staff.
Consumer and Family Member Participation
Background. Providers are expected to make consumers and/or family members active participants in the quality improvement process. This may be accomplished in a variety of ways, but first and foremost by including them as actual members of the Quality Improvement Committee, subcommittees or project teams. As a general principle, providers of child and adolescent services are expected to include participation of a parent or parents in their quality improvement process. Providers of services to adults are expected to include participation of consumers.
Quality Improvement Initiatives
Background: Participants are required to define two indicators during the second year of the program and use these measures as the basis for a planned improvement effort consistent with the clinic’s approach to quality improvement (for example, PDCA). The following section is provided to describe the indicators selected by your clinic, the actions you have taken to improve performance and the impact of these actions.
In many cases, clinics have continued during 2007 working with the indicator first identified during 2006. If this is the case, you may describe findings, conclusions and actions from the entire period or just for 2007.
Survey of Consumers, Families and Staff
Background. During the second year of the program, participants agree to survey individuals receiving services, their families and staff about the quality of care provided and suggested areas for improvement.
It is expected that the views of all three groups will be obtained and assessed during the year. Questions of sample size and methods are left to the discretion of the clinic provided that they meet the intent of the requirement. It is expected that this requirement will generally be met through traditional paper and pencil survey instruments. Providers are permitted to use other methods, however, as long as an adequate sample of opinion is obtained; a planned and systematic process is carried out; and the results are analyzed and documented; and the Provider is able to show the impact of this feedback in the Provider’s service delivery.
Providers may employ a general instrument for this purpose or they may focus their assessment activities on specific issues or questions related to their unique services or their unfolding quality improvement process.
Please provide copies or surveys, questions used in focus groups or any other materials you used in assessing the perceptions of recipients, families and staff with your self-evaluation.
Answer each of the questions below by placing an X in the “Yes” or “No” column beside each of the items. For each of the items answered “No,” you will be asked to describe actions taken or planned.
|1 Did your Quality Improvement Committee meet at least 10 times during 2007?|
|2 Did a recipient and/or family member directly and regularly participate on your quality improvement committee, subcommittee or project group?|
|3 Did you actively participate in an organized and ongoing discussion of quality improvement priorities and activities with recipients and/or family members during 2007?|
|4 Did you provide continuing education to your staff during 2007 on a topic related to quality improvement or evidence-based practices?|
|5 Are you orienting new employees to the principles of quality improvement as well as your Quality Improvement Plan and projects?|
|6 Did you systematically measure performance on two indicators during 2007?|
|7 Did you take action to improve performance on these two indicators during 2007?|
|8 Did you survey service recipients during 2007?|
|9 Did you survey family members during 2007?|
|10 Did you survey staff during 2007?|