SECTION 450:23-13-1. Performance improvement program

(a)   The CBSCC shall have an ongoing performance improvement program designed to objectively and systematically monitor, evaluate and improve the quality of consumer care.

(b)   The Performance improvement program shall also address the fiscal management of the organization.

(c)   There shall be an annual written plan for performance improvement activities. The plan shall include, but not be limited to:

(1)   Outcomes management processes specific to each program component minimally measuring:

(A)   efficiency;

(B)   effectiveness; and

(C)   consumer satisfaction.

(2)   A quarterly record review to minimally assess:

(A)   quality of services delivered;

(B)   appropriateness of services;

(C)   patterns of service utilization;

(D)   consumers, relevant to:

(i)   their orientation to the CBSCC and services being provided; and

(ii)   their active involvement in making informed choices regarding the services they receive;

(E)   the consumer assessment informationthoroughness, timeliness and completeness;

(F)   treatment goals and objectives are based on:

(i)   assessment findings; and

(ii)   consumer input;

(G)   services provided were related to the goals and objectives;

(H)   services are documented as prescribed by policy;

(I)   the treatment plan is reviewed and updated as prescribed by policy;

(3)   Clinical privileging;

(4)   Fiscal management and planning, which shall include:

(A)   an annual budget that is approved by the governing authority and reviewed at least annually;

(B)   the organization's capacity to generate needed revenue to produce desired consumer and other outcomes;

(C)   monitoring consumer records to ensure documented dates of services provided coincide with billed service encounters; and,

(5)   Review of critical incident reports and consumer grievances or complaints.

(d)   The CBSCC shall monitor the implementation of the performance improvement plan on an ongoing basis and makes adjustments as needed.

(e)   Performance improvement findings shall be communicated and made available to, among others:

(1)   the governing authority;

(2)   CBSCC staff; and

(3)   ODMHSAS if and when requested.

(f)   Compliance with 450:23-13-1 shall be determined by a review of the following: written program evaluation plan; written program evaluations annual, special or interim; program goals and objectives; and other supporting documentation provided.

[Source: Added at 18 Ok Reg 531, eff 10-13-00 (emergency); Added at 18 Ok Reg 2690, eff 7-1-01; Amended at 19 Ok Reg 1443, eff 7-1-02; Amended at 20 Ok Reg 1324, eff 7-1-03]