The purpose of this chapter is to state the requirements and procedures for performance improvement activities, consumer outcome activities, and research activities for providers providing mental health and addiction services.
Chapter 5122-28 | Quality Assurance Activities, Service Evaluation Activities, and Research Activities
Rule 5122-28-02 | Applicability.
The provisions of the rules contained in this chapter are applicable to each provider subject to certification by the department in accordance with section 5119.36 of the Revised Code.
Rule 5122-28-03 | Performance improvement.
(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.
Rule 5122-28-04 | Consumer outcomes.
(A) The purpose of this rule is to ensure that each provider collects data on consumer outcomes in order to improve its ability to provide quality mental health and addiction services.
(B) The following definition applies to this rule:
"Consumer outcomes" means indicators of health or well-being for an individual or family as measured by statements or observed characteristics of the consumer or family, not characteristics of the system. These measures provide an overall status measure with which to better understand the life situation of a consumer or family.
(C) Each provider shall use a system to measure consumer outcomes for children, youth and adults.
(1) Data to be collected shall include:
(a) Whether treatment plan goals were met; and
(b) Satisfaction with services.
(2) The frequency of data collection shall be:
(a) Beginning of services;
(b) End of services; and
(c) At intervals as defined in agency polices.
The provider shall include attention to client population and needs in determining the appropriate intervals at which to collect data. The provider may describe different intervals based on varying population characteristics.
(D) A service provider may determine when to clinically or administratively discharge a client from provider services, if ever. However, for the purposes of required reporting in accordance with section 5119.61 of the Revised Code, a service provider shall report data if requested by the department.
Rule 5122-28-05 | Research and evaluation activities.
(A) The purpose of this standard is to ensure that research and evaluation activities are conducted in an ethical manner, that each participant's rights regarding such activities are respected and protected, and that evaluation activities enhance the overall performance of the provider.
(B) Research activities shall be evaluated by and adhere to the requirements of an independent institutional review board.
(C) Evaluation activities shall be conducted in accordance with the requirements of a nationally recognized accrediting body, such as the American evaluation association.