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

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

Agency Name

Name of Agency Director

Address

Phone Number

Fax Number

Clinic Name (Complete only if different from Agency information)

Name of Clinic Director

Address

Phone Number

Fax Number

Contact Person

Provide the name and title of person responsible for completion of the evaluation. This person will be our contact for feedback and questions.

Email Address

Phone Number

Organizational Structure

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.

List the members of the Quality Improvement Committee by title.

How many times did the Committee meet during 2007 or during the 12 month project period?

How many of the meetings were attended by…

A recipient?

A family member?

List or describe the major topics or issues that the Committee dealt with during the second year. Include a description of any example in which your indicator data influenced the decisions you made. NYC Quality Impact Participants may attach final project outcome sheet and materials.

Staff Education

Background: Participants are expected to:

Briefly describe what is provided in your new staff orientation about quality improvement and evidence-based practices.

Briefly describe any continuing education you provided to staff on quality improvement and/or evidence-based practices during the second year.

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.

Describe as specifically as possible how recipients and/or family members were involved in the quality improvement activities of your clinic. Describe the nature and auspice of the involvement and frequency. NYC Quality Impact members can note they participated in the MHSIP Adult Survey Process.

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.

Indicator One

Briefly describe the quantitative measure used as the indicator. Specifically describe how the indicator number itself is defined or obtained.

Briefly describe any significant findings you have made or conclusions you have reached regarding factors that you believe may affect performance on your indicator. In other words, how has your understanding of the nature of the problem you are working with changed?

List the actions taken to improve performance as measured by the indicator. Describe the impact of the specific actions you have taken based on indicator data. Have your actions effectively improved performance as measured by your indicator? Attach tables or graphs that support your findings and conclusions. NYC Quality Impact Participants may attach final project outcome sheet and materials.

Based on your current assessment, describe any further actions that you are taking or plan to take to further enhance performance as measured by this indicator.

Indicator Two

Briefly describe the quantitative measure used as the indicator. Specifically describe how the indicator number itself is defined or obtained.

Briefly describe any significant findings you have made or conclusions you have reached regarding factors that you believe may affect performance on your indicator. In other words, how has your understanding of the nature of the problem you are working with changed?

List the actions taken to improve performance as measured by the indicator. Describe the impact of the specific actions you have taken based on indicator data. Have your actions effectively improved performance as measured by your indicator? Attach tables or graphs that support your findings and conclusions. NYC Quality Impact Participants may attach final project outcome sheet and materials.

Based on your current assessment, describe any further actions that you are taking or plan to take to further enhance performance as measured by this indicator.

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.

Describe how you assessed the needs and expectations of service recipients during 2007.

Describe any significant findings from your survey of recipients and actions that you took based on these findings.

Describe how you assessed the needs and expectations of family members during 2007.

Describe any significant findings from your survey of family members and actions that you took based on these findings.

Describe how you assessed the views of your staff during 2007.

Describe any significant findings from your survey of staff and actions that you took based on these findings.

Summary 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.

Question Yes No
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?    

Action Plan

For each of the questions you answered “no,” describe the actions that you have taken or will take to be able to answer “yes.” Place a number at the beginning of your response to correspond to the item you are addressing. For example, if you answered “no” to item 4, place a number 4 at the beginning of your planned action.