All providers within the CMHPSM Affiliation Provider Network must operate a performance improvement (PI) system. All providers are required to submit performance improvement data that reports on standardized network indicators, based on type of service provided. These network indicators and reporting time-frames are set forth in the contract between the provider and the CMHPSM affiliate. Currently, co-occurring data cannot be entered into the Encompass system; however, the system supports the entry of all other network indicator data. Therefore, with the exception of co-occurring data, all network indicator data must be submitted through the Encompass system, unless otherwise agreed to by the CMHPSM affiliate holding a contract with the provider. The formats and instructions for the network indicators for each service category are included in this section of the CMHPSM Provider Manual for the current Fiscal Year.

This does not supplant the PI programs already being implemented by each provider agency. It is the understanding of the CMHPSM that each accredited provider within the Provider Network operates its own independent performance improvement system. For accredited providers, the providers PI system will be reviewed by the WCHO Provider Relations Unit during routine site visits. For non-accredited providers, additional requirements are set forth below. Additional information on how to create a PI plan may be obtained here:    http://mchneighborhood.ichp.edu/wagenetics/media/qsec5.pdf

Included in the Provider Manual are:

PI Network Indicators for the fiscal year as well information and tools for obtaining satisfaction data, by type of contract/ type of service, and definitions of network indicators for:

• Licensed Setting (AFC/group home): (PI Table, Definitions, Satisfaction Survey)
• Crisis Residential
• Community Living Supports (for adults and children)
• Supported Employment
• Child Waiver Professional Services
• Case Management/Outpatient Mental Health Services
• Drop-In Center
• Psychosocial Rehabilitation
• Fiscal Intermediary Services
• Substance Abuse Treatment Services (..., Compass Tool)
• Hospitals
  
  Additional Requirements for Non-Accredited Providers
  
  For those Mental Health agencies that are not accredited, or are in the process of obtaining accreditation, and have received an accreditation waiver from the CMHPSM, an annual plan describing your performance improvement system must be submitted to the WCHO Provider Relations Unit. This plan should address all areas of the PI system, but must minimally include: safety, infection control, and the network indicators. Exact parameters are at the discretion of the provider, but must be in compliance with JCAHO standards.

Annual Plan

For each identified area, you must identify the following:

• Goal   (ex: 95% of scheduled medical appointments will be completed on first attempt)
• Outcome to be measured
• Target for each outcome
• Identification of the data source
• Identification of how data will be collected
• Identification of who will collect the data
• Frequency of how often the data will be collected

For additional information on how to create a PI plan, click here: http://mchneighborhood.ichp.edu/wagenetics/media/qsec5.pdf

Periodic Reports Reports must be reviewed by the leaders of the provider agency (Board, senior management) on a periodic basis as determined by the provider agency.
           
Reports should include: 
                
        Overview/summary of significant events related to PI system
        Follow up from previous quarter(s)
        Progress towards goals
        For each outcome identified in your plan: -Identify the outcome
        Compare current data and previous data
        Analyze trends
        Report progress towards target
        Discussion
        Recommendations/follow up