Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment changes the rule title and
updates the performance improvement requirements for certified and deemed
programs.
PURPOSE: This rule describes requirements for
performance improvement activities in Opioid Treatment Programs, Substance Use
Disorder Treatment Programs, Comprehensive Substance Treatment and
Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs,
Institutional Treatment Programs, Recovery Support Programs, Substance
Awareness Traffic Offender Programs (SATOP), Required Education Assessment and
Community Treatment Programs (REACT), Community Psychiatric Rehabilitation
Programs (CPRP), and Outpatient Mental Health Treatment
Programs.
(1) Performance
Improvement. The organization shall develop, implement, and maintain an
effective, ongoing, agency-wide and data-driven performance measurement and
performance improvement program/process. These activities allow the
organization to objectively review how well it is accomplishing its mission,
and develop and initiate performance improvement changes.
(A) The performance measurement and
performance improvement program encompasses the organization's full array of
clinical services and focuses on indicators related to improved behavioral
health or other healthcare outcomes for individuals served.
(B) Direct service staff and medical staff
shall be actively involved in performance measurement and improvement
activities including, but not limited to, clinical care issues and practices
related to the use of medications.
(C) Components of the organization's
performance measurement and performance improvement program includes, but is
not limited to:
1. A description of its
purpose, priorities, policies, and goals;
2. A description of the measurement analysis
and how it will help define future performance improvement
activities;
3. A description of
evaluation and quality assurance activities that will be utilized to determine
the effectiveness of the performance improvement plan;
4. A description of the organizational
systems needed to implement the plan including the functions, descriptions of
accountability, and roles and responsibilities of staff or performance
improvement committee; and
5. A
plan for communicating planned activities and processes to staff and the
governing body on a regular basis.
(2) Performance Improvement Plan. The
organization shall develop and implement an annual performance improvement
plan. The plan is updated on an ongoing basis to reflect changes, corrections,
and other modifications and reviewed annually with the organization's governing
body.
(A) Direct service staff, individuals
served, and family members/natural supports are involved in the planning,
design, implementation and review of the organization's performance improvement
activities.
(B) The performance
improvement plan shall include, but is not limited to:
1. A process for obtaining satisfaction and
other feedback related to service delivery from individuals served, family
members/natural supports, and other stakeholders;
2. A process to measure outcomes for
individuals served;
3. A review of
clinical records to ensure all required documentation is thorough, timely and
complete;
4. A process to evaluate
whether services are effective, appropriate, and relate to treatment
goals;
5. Activities to improve
access and retention in services;
6. Review of clinical staff training and
competencies;
7. Review of
critical/sentinal events, grievances, and complaints; and
8. A process for monitoring compliance of
subcontractors.
(3) Performance Measurement and Analysis.
Performance measurement is a process by which an organization monitors
important aspects of its programs, systems, and care processes. Qualitative and
quantitative data is collected, systematically aggregated, and analyzed on an
ongoing basis to assist organizational leadership in evaluating whether the
adequate structure and correct processes are in place to achieve the
organization's desired results.
(A) Properly
trained staff shall use valid, reliable processes to collect and analyze data.
The data may be used to-
1. Distinguish
between expected behavioral health outcomes and actual outcomes in areas such
as employment/return to school, stable housing, decreased involvement in the
justice system, improved physical health and wellness, and increased engagement
in services;
2. Establish baseline
measures before improvements are made;
3. Make decisions based on solid
evidence;
4. Allow performance
comparisons across sites;
5.
Monitor process changes to ensure improvements are sustained over
time;
6. Recognize improved
performance;
7. Determine the
effectiveness of evidence-based and/or best practices provided;
8. Monitor and continually improve
management, clinical services, and support services; and
9. Address undesirable patterns in
performance and sentinel events.
(B) Results of the performance analysis are
available to individuals served, family members/natural supports, other
stakeholders, and the department.
(4) The department may require, at its
option, the use of designated measures or instruments in the performance
measurement and improvement process in order to promote consistency in data
collection, analysis, and applicability. The required use of particular
measures or instruments applies to programs or services funded by the
department.
(5) Documentation. The
organization shall maintain documentation of its performance measurement and
performance improvement program and be able to demonstrate its operation to
staff of the department, accrediting body, or other interested parties.
(A) Documentation shall include, but is not
limited to, the following types of information:
1. Management reports;
2. Strategic plans;
3. Budgets;
4. Accessibility plans;
5. Technology plans and analysis;
6. Risk analysis reports and
information;
7. Environmental
health and safety reports;
8.
Financial reports;
9. Quality
assurance reports including review of clinical records to ensure documentation
requirements are being met;
10.
Data collected;
11. Demographic
information of individuals served; and
12. Satisfaction data of individuals, family
members/natural supports, and other stakeholders.
*Original authority: 630.050, RSMo 1980, amended 1993, 1995
and 630.055, RSMo 1980.
