(A) The purpose of this rule is to ensure that a provider's leaders have established a planned, systematic, organization-wide approach to performance improvement that is both collaborative and interdisciplinary. It is important that each provider measure the performances processes which support care and establish a method of data collection and analysis in order to identify areas of needed improvement, and develop and implement improvement plans which support achieving performance targets, client satisfaction, and positive client outcomes.
(B) Provider leadership shall:
(1) Support performance improvement activities.
(2) Identify priorities for data collection with attention to both safety and quality.
At a minimum, performance improvement methodologies must address the following areas:
(a) Business operations;
(b) Client satisfaction;
(c) Stakeholder satisfaction;
(d) Client outcomes;
(e) The quality of service delivery, including appropriateness, and efficiency; and
(f) Client protections, including seclusion and restraint, if applicable, client rights, complaints and grievances, and incident notification.
(C) A provider shall develop an on-going, systematic approach to performance improvement. The process shall include:
(1) Collect and analyze data;
(2) Identify areas of needed improvement;
(3) Develop an action plan;
(4) Implement improvements, and monitor and evaluate their effectiveness; and
(5) Activities which evaluate the effectiveness of the provider's overall performance improvement process.
(D) Each provider shall develop a written performance improvement plan and document its performance improvement activities.
The provider shall include in its performance improvement plan the frequency of data collection and analysis. The provider shall collect and analyze data as required by its accrediting body, if applicable, or for a provider without behavioral health accreditation, at least annually.
Five Year Review (FYR) Dates: 04/21/2015 and 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5119.36, 5119.61
Rule Amplifies: 5119.36, 5119.61
Prior Effective Dates: 1/1/04, 7/1/11, 1/1/12, 4/1/12