5122-28-03 Performance improvement.

 

 

 

TO BE RESCINDED

 

5122-28-03                  Performance improvement.

 

 

 

(A)    The purpose of this rule is to ensure that an agency's leaders have established a planned, systematic, organization-wide approach to performance improvement that is both collaborative and interdisciplinary. Such an approach will help guarantee the successful design of new, modified, and/or existing agency processes.

 

The performance of such processes must be continuously monitored, analyzed and enhanced so that the ultimate goal of improved client outcomes can be realized. The judicious use of current evidence-based practices in making decisions about the care of individuals is integral in achieving improved client outcomes.

 

(B)     This rule is designed to parallel and be compatible with current performance improvement standards of the accrediting bodies listed in paragraph (B) of rule 5122-25-02 of the Administrative Code. At a minimum, the utilization of acceptable performance improvement methodologies as outlined in paragraph (D) of this rule, must address the following areas:

 

(1)  Consumer satisfaction;

 

(2)     Client protection, i.e., special treatment and safety measures, client rights, complaints and grievances, and incident notification; and

 

(3)   Consumer outcomes as defined in rule 5122-28-04 of the Administrative Code.

 

Additional areas where performance improvement methodologies may be utilized include evidence-based practices and other measures of local importance. With the exception of paragraph (F) of this rule, requirements of this rule shall be waived for those agencies that are deemed according to rule 5122-25-03 of the Administrative Code.

 

(C)  The following definitions apply to this rule:

 

(1)    "Evidence-based practices" means those interventions and services that have demonstrated good outcomes for consumers. These practices are derived from:

 

(a)   Rigorous scientific evidence that has demonstrated the effectiveness of the intervention or service. This level of evidence usually involves multiple controlled trials or replications;

 

(b)   Formal consensus by a group of experts, taking into account the existing

 

 

research in the area; and

(c)      Research evidence that supports an intervention or program as an evidence-based practice but has not reached the level of rigor of multiple replications.

(2)     "Leader" means any individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the agency's governance, management, clinical, and support functions and processes. Leaders include at least, members of the governing body, the chief executive officer and other senior managers; clinical leaders (clinical leaders include health care professionals with overall responsibility to plan, organize, and operate a clinical service or program and may include but are not limited to the clinical director, discipline chief, and unit or service director); and staff members in a leadership position within the agency.

(3)     "Performance improvement" is the continuous study and adaptation of an agency's functions and processes to increase the probability of achieving desired outcomes and to better meet the needs of individuals and other users of services.

(4)       "Process" means a goal-directed, interrelated series of actions, events, mechanisms, or steps.

(D)   The agency shall develop a process for planning, doing, checking, and acting upon its performance. This process includes, at minimum, utilization of the following four performance improvement methodologies:

(1)   Designing a performance improvement process (planning)

(a)   The agency shall demonstrate the existence of performance improvement activities that are planned in a collaborative and interdisciplinary manner. Leaders shall use appropriate resources and involve those individuals, disciplines, and departments closest to the process, function, or service identified for improvement.

(b)    Such processes, functions or services should include those identified as high volume, high risk, or problem prone, and should be aligned with the agency's mission, vision, and goals.

(c)     Measures should be specific, meaningful, understandable, attainable, reliable, valid, responsive, and time-specific.

(2)   Monitoring performance through data collection (doing)

(a)   Data shall be collected for the purpose of paragraph (D)(1)(a) of this rule, in order to identify opportunities for improvement, identify changes that will lead to improvement, and sustain improvements.

(b)   Types of performance measures for which data are collected may include, but are not limited to:

(i)   Consumer outcomes, meaning indicators of health or well-being for an individual or family as measured by statements or observed characteristics of the consumer/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. Such outcomes are clinical status, community functioning, quality of life, and safety and health;

(ii)    Consumer satisfaction, as defined by the response of an individual to services received from a mental health provider or program. Data from consumer quality review teams (CQRT) shall be considered a satisfactory source of consumer satisfaction;

(iii)    Client protections, as defined and identified in rules 5122-26-16 to 5122-26-16.3, 5122-26-13 and 5122-26-18 of the Administrative Code;

(iv)   Risk status, (intermediate outcome), as defined by a change (or lack of) in the risk demonstrated or assumed to be associated with health status;

(v)    Process, as defined by what is done to, for, with, or by selected individuals or groups as a part of the delivery of services such as performing an assessment or procedure, or offering an educational service; and

(vi)   Capacity, as defined by the ability to provide specific services, such as clinical screening and needs assessment.

(3)   Analyzing current performance (checking)

(a)      Data  shall  be  systematically  analyzed  on  an  ongoing  basis  using

performance    improvement    techniques    and    display    methods,   as appropriate.

(i)   Performance improvement tools that may be considered include:

(a)   Run charts that display summary and comparative data;

(b)   Control charts that display variation and trends over time;

(c)   Histograms;

(d)   Pareto charts;

(e)   Cause-and-effect or fishbone diagrams; and

(f)   Other performance improvement tools.

(b)    For processes, functions, or services identified according to paragraph (D)(1)(a) of this rule, the agency shall establish performance expectations and shall compare its performance internally over time and with other external sources of information.

(4)   The agency shall demonstrate that data collected and analyzed pursuant to this rule are used to improve performance, practices, and processes, (acting)

(a)     Undesirable patterns or trends in performance shall trigger additional analysis or focused review. The agency shall initiate such an analysis or focused review when the comparisons show that important single event(s), level(s) of performance, pattern(s) or trend(s) vary significantly from set expectations.

(b)    The agency shall provide information to and gather feedback from, as appropriate, staff, leaders, consumers and families about the redesigned processes and other changes.

(c)    The agency shall establish and sustain a culture supporting continuous performance improvement through such activities as offering opportunities for education and training, involvement in ongoing performance improvement activities, and conducting focused training on improved processes.

(E)     The agency shall maintain documentation demonstrating utilization of the four performance improvement methodologies.

(F)   The agency shall routinely submit reports to the department regarding the status of its performance improvement process. Such reports shall be submitted no less than annually and no more than semi-annually on forms prescribed by the department.

Effective:
R.C. 119.032 review dates:     WITHDRAWN ELECTRONICALLY	11/30/2010
Certification

11/30/2011

Date

Promulgated Under:                           119.03

Statutory Authority:                           5119.61 (A), 5119.611 (C)

Rule Amplifies:                                  5119.61 (A), 5119.611 (C)

Prior Effective Dates:                        1/1/04