SECTION 450:65-7-8. Performance improvement program

(a)   The facility shall have an ongoing performance improvement program designed to objectively and systematically monitor, evaluate and improve the quality of consumer care in which the following is addressed:

(1)   Fiscal management of the facility;

(2)   Identity of a performance improvement officer; and

(3)   Cultural competency.

(b)   The facility shall document performance improvement activities. These activities shall include, but not be limited to:

(1)   Outcomes management specific to each program;

(2)   A quarterly quality record review to evaluate the quality of service delivery as evidenced by the consumer's record;

(3)   Staff Privileging;

(4)   Review of critical and unusual incidents and consumer grievances and complaints;

(5)   Review of policy related to cultural competence; and

(6)   Activities to improve access and retention within the treatment program. The activities shall include an annual "walk through" of the admission process. Steps of the "walk through" include, but are not limited to:

(A)   Select two staff from the facility, including one member of management, to play the roles of "consumer" and "family member";

(B)   Notify all staff prior to doing the "walk-through" exercise;

(C)   Complete the admission process as defined by facility policy as a typical consumer and family member would experience;

(D)   At each step, ask the staff what changes (other than hiring new staff) would make it better for the consumer and what changes would make it better for the staff. Write all ideas of the staff and participant(s) in the exercise;

(E)   Documentation of the annual "walk through" process includes, but is not limited to:

(i)   The observations and feelings of participants in this exercise;

(ii)   A list of the process barriers and the improvements that could be made to address these barriers;

(iii)   Address the needs from both the consumer and staff perspectives; and

(iv)   Identification of an area(s) for change and a description for implementing the change(s).

(c)   The facility shall monitor the implementation of the performance improvement plan on an annual basis and shall make adjustments as needed.

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

(1)   the governing authority,

(2)   facility staff,

(3)   consumers,

(4)   stakeholders, and

(5)   ODMHSAS, as requested.

(e)   Compliance with 450:65-7-8 may be determined by a review of:

(1)   policy and procedures;

(2)   performance improvement program documents and reports;

(3)   staff interviews; and

(4)   any other relevant documentation of the facility.

[Source: Added at 24 Ok Reg 2623, eff 7-12-07; Amended at 25 Ok Reg 2551, eff 7-11-08; Amended at 34 Ok Reg 1824, eff 10-1-17]