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 performance processes that support care and establish a method of data collection and analysis to identify areas of needed improvement as well as develop and implement improvement plans that support achieving performance targets, client satisfaction, and positive client outcomes.
(B) Provider leadership is to do both of the following:
(1) Support performance improvement activities.
(2) Identify priorities for data collection with attention to both safety and quality. At a minimum, performance improvement methodologies are to address all of 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 is to develop a written performance improvement plan. The provider is to take an ongoing, systematic approach when developing its plan and ensure that the plan conforms to the national accrediting standards of the provider's national accrediting organization or, if the provider does not possess accreditation, appendix A of this rule. Regardless of whether the provider does or does not possess accreditation, the plan is to include all of the following:
(1) The data the provider will collect and analyze to assess performance improvement, as well as the frequency at which the provider will collect and analyze such data. If the provider possesses accreditation from an accrediting organization, the frequency of data collection and analysis is to be the same frequency mandated by the accrediting organization. If the provider does not possess accreditation, the frequency is to be at least annually in accordance with the definitions in appendix A to this rule.
(2) The areas the provider needs to improve.
(3) An action plan for improving the areas identified pursuant to paragraph (C)(2) of this rule.
(4) An inventory of the improvements the provider has implemented and how the provider will monitor and evaluate their effectiveness and success in achieving systematic consumer outcomes for children, youth, and families.
(5) The activities the provider will undertake to evaluate the effectiveness of the provider's overall performance improvement process.
(D) The provider is to report data, statistics, and other information to the department on the department's request, including the data described in paragraph (C)(1) of this rule, for purposes of the department's responsibilities under section 5119.61 of the Revised Code.
Last updated August 3, 2026 at 8:38 AM
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