Ala. Admin. Code r. 580-2-20-.07

Current through Register Vol. 43, No. 1, October 31, 2024

Section 580-2-20-.07 - Performance Improvement

(1) The Performance Improvement (PI) System shall provide meaningful opportunities for input concerning the operation and improvement of services from recipients, family members, recipient groups, advocacy organizations, and advocates. The provider shall operate and maintain a Performance Improvement (PI) System that is designed to:

(a) Identify and assess important processes and outcomes.

(b) Correct and follow-up on identified problems.

(c) Analyze trends.

(d) Improve the quality of services provided, and to improve recipient and family satisfaction with services provided.

(2) The PI System shall be described in writing and shall include, at a minimum, the following characteristics:

(a) Identifies and covers all program service areas and functions including subcontracted recipient services.

(b) Is reviewed and approved by the Board of Directors/Governing Body at least every two (2) years and when revisions are made.

(c) Outlines the agency's mission related to Performance Improvement.

(d) Contains the agency's goals and objectives related to Performance Improvement.

(e) Defines the organization of PI activities and the person(s) responsible for coordinating the PI System.

(f) Defines the methodology for the assessment, evaluation, and implementation of improvement strategies for important processes and outcomes.

(g) Specifies the manner in which communication of Performance Improvement findings and recommendations for all six (6) PI components is done at the governing body, clinical and administrative supervisory levels, staff levels, recipients, families and advocates and the manner in which it is documented.

(h) At a minimum, identifies and monitors important processes and outcomes for the six (6) components of Performance Improvement, Quality Improvement, Incident Prevention and Management, Utilization Review, Recipient and Family Satisfaction, Review of Treatment Plans, and Seclusion and Restraint (if applicable) consistent with the definitions described in this section.

(i) Specifies that the agency will participate in all required performance indicators and Quality Improvement Reporting requirements as specified by the ADMH Mental Health and Substance Abuse Services.

(j) Requires that the person(s) responsible for coordinating the agency's PI System or designee attend training on ADMH MHSAS approved Incident Management process.

(k) Specifies the manner of cross-departmental and cross-discipline staff input from all levels of the agency regarding the selection of QI indicators to be monitored and improvement activities to be implemented.

(l) Specifies the manner of recipient and family member input regarding the selection of QI indicators to be monitored and improvement activities to be implemented.

(m) Where applicable, ensures that the manner of data collection assures recipient/family member confidentiality.

(n) The plan is implemented as written.

(3) The Quality Improvement component of the PI System shall, at a minimum, include indicators to be monitored including any system level performance measures as specified by the ADMH MHSAS and the following:

(a) A description of a process for periodic and timely review of any deficiencies, requirements, and Quality Improvement suggestions related to critical standards from DMH Certification site visits, Advocacy visits, and/or from other pertinent regulatory, accrediting, or licensing bodies. This shall include a specific mechanism for the development, implementation, and evaluation of the effectiveness of Action Plans designed to correct deficiencies and to prevent reoccurrence of deficiencies cited.

(b) A description of a process for conducting an administrative review of a representative sample of recipient records to determine that all documentation required by these standards and agency policy/procedure is present, complete, and accurate. This function may be performed by the agency's Electronic Health Record (EHR)._

(c) A review of aggregate findings from the administrative review of recipient records at least annually with recommendations and actions taken for improvement as indicated by the data, unless performed by the agency's EHR.

(d) The Plan shall specify frequency of monitoring for each indicator and the period of time that monitoring will continue after goal attainment is achieved.

(e) The Plan shall specify that the agency shall participate in System Level activities (including the use of DMH sanctioned External Monitoring) to assess and to identify actions for improvement.

(f) Substance Abuse Only Outcome Measures:

1. At a minimum, the entity shall collect information at time of assessment and at transfer or discharge to provide measures of outcome as specified in the following domains:

(i) Reduced Morbidity:

(I) Outcome: Abstinence from drug/alcohol use.

(II) Measure: Reduction/no change in frequency of use at date of last service compared to date of first service.

(ii) Employment/Education:

(I) Outcome: Increased/Retained Employment or Return to/Stay in School.

(II) Measure: Increase in/no change in number of employed or in school at date of last service compared to first service.

(iii) Crime and Criminal Justice:

(I) Outcome: Decreased criminal justice involvement.

(II) Measure: Reduction in/no change in number of arrests in past thirty (30) days from date of first service to date of last service.

(iv) Stability in Housing:

(I) Outcome: Increased stability in housing.

(II) Measure: Increase in/no change in number of recipients in stable housing situation from date of first service to date of last service.

(v) Social Connectedness:

(I) Outcome: Increased social supports/social connectedness.

(II) Measure: Increase in or no change in number of recipients in social/recovery support activities from date of first service to date of last service.

2. The entity shall provide reports of outcomes to DMH in the manner, medium and period specified.

(4) The Incident Prevention and Management System component of the PI System shall include, at a minimum, the following:

(a) PI review of special incident data.

(b) Includes and describes a process for the timely and appropriate review of special incident data at least quarterly via the PI System. Such reviews shall focus on the identification of trends and actions taken to reduce risks and to improve the safety of the environment of care for recipients, families, and staff members.

(c) Identify and implement a quality improvement plan for medication errors for residential programs.

(d) Findings and recommendations from the quarterly Special Incident reviews shall be reported at least quarterly to the executive and clinical leaders including the Board of Director/Governing Body.

(e) Pertinent data regarding improvement strategies shall be communicated to staff level employees.

(5) The Recipient and Family Satisfaction component of the PI System shall include tools to assess the satisfaction of recipients and families with services provided and to obtain input from recipients and their families regarding factors which impact the care and treatment of recipients. This component shall include at a minimum the following characteristics:

(a) A description of the mechanism for obtaining recipient input regarding satisfaction with service delivery and outcomes.

(b) A description of the mechanisms for obtaining family member input regarding satisfaction with service delivery and outcomes for recipients.

(c) A description of the mechanism for obtaining input from recipients and family members when either are deaf, limited English proficient, or illiterate.

(d) A periodic review (at least annually) of data collected via the tools as described above.

(e) A periodic review (at least annually) of complaints/grievances filed according to the process required in 580-2-9-.02(3).

(f) Identifies agency specific performance indicators for recipient and family satisfaction.

(g) Substance abuse agency's shall assess the satisfaction of recipients and families, including but not limited to the following:

1. The recipient's perception of the outcome of services.

2. The recipient's perception of the quality of the therapeutic alliance.

3. Other perceptions of recipients and families that impact care and treatment, including, but not limited to:

(i) Access to care.

(ii) Knowledge of program information,

(iii) Staff helpfulness.

(6) The Utilization Review (UR) component of the PI system shall include the following:

(a) The agency shall perform at least quarterly reviews of the findings from the UR monitor for all MI_ residential programs and for all SA levels of care. At a minimum, this review will assess the agency's compliance with Length of Stay (LOS) expectations and will determine and implement actions to improve performance when variations in Length of Stay (LOS) expectations occur.

(b) The agency shall review at least annually a representative sample in each certified program to assess the appropriateness of admission to that program relative to published admission criteria.

(7) The treatment review component shall include, at a minimum, the following characteristics:

(a) A description of the process for conducting a clinical review of a sample of all direct service staff records every 12 months to determine that the case has been properly managed. The review shall include an assessment of the following:

1. The appropriateness of admission to that program is relative to published admission criteria.

2. Treatment plan is timely.

3. Treatment plan is individualized.

4. Documentation of services is related to the treatment plan and addresses progress toward treatment objectives.

5. There is evidence of attempts to actively engage recipient, family and collateral supports in the treatment process to include linguistic and/or auxiliary support services for people who are deaf, hard of hearing, or limited English proficient as well as any other accommodations for other disabilities.

6. Treatment plan modified (if needed) to include linguistic and/or auxiliary support services for people who are deaf, hard of hearing, or limited English proficient as well as any other accommodations for other disabilities.

(b) An aggregate review of the clinical review findings described above at least annually to assess trends and patterns and to determine actions for improvement based on findings.

(8) The organization collects restraint and seclusion data in order to ascertain that restraint and seclusion are used only as emergency interventions, to identify opportunities for incrementally improving the rate and safety of restraint and seclusion use, and to identify any need to redesign care process.

(9) Using a recipient identifier, data on all restraint and seclusion episodes are collected from and classified for all settings/units/locations at the frequency determined by the agency on by:

(a) Time.

(b) Staff and title of who initiated the process.

(c) Length of each episode.

(d) Date and time each episode was initiated.

(e) Date and time each episode was ended.

(f) Day of the week each episode was initiated.

(g) Type of restraint used.

(h) Description of injuries sustained by the individual or staff, if applicable.

(i) Age of the individual.

(j) Gender of the individual.

(k) Multiple instances of restraint or seclusion experienced by an individual within a 12-hour timeframe.

(l) Number of episodes per individual.

(m) Instances of restraint or seclusion that extend beyond two (2) consecutive hours.

(n) Use of psychoactive medications, including name of medication and dosage, as an alternative to, or to enable discontinuation of, restraint and seclusion.

(o) Documentation of the one hour face to face physical and behavioral assessment.

(p) Documentation of the debriefing/trauma check within twenty-four (24) hours.

Ala. Admin. Code r. 580-2-20-.07

Adopted by Alabama Administrative Monthly Volume XXXVII, Issue No. 01, October 31, 2018, eff. 11/30/2018.

Author: Division of Mental Health and Substance Abuse Services, DMH

Statutory Authority:Code of Ala. 1975, § 22-50-11.