Quality assessment and performance improvement

A facility shall have a performance and quality improvement plan that advances efficient, effective service delivery, effective management practices, and the achievement of strategic and treatment program goals and outcomes. 1. A facility shall have a written performance and quality improvement plan that operationalizes the organization's performance and quality improvement system and: a. Defines the organization's approach to quality improvement; b. Defines employee roles and responsibility for implementing and coordinating the performance and quality improvement plan; c. Identifies what is being measured; d. Defines data collection processes and applicable time frames; e. Outlines processes for reporting findings and monitoring results; and f. Provides a document or chart that describes the organization's performance and quality improvement plan, including committees and members, as appropriate. 2. A facility performance and quality improvement plan must include guidelines for performance and outcomes which identify measures to build organizational capacity, improve services, and meet licensing, contracting, and reporting requirements, by evaluating the: a. Impact of services on resident outcomes; b. Quality of service delivery; and c. Management and operations performance. 3. A facility shall use a department-approved standardized tool to measure resident outcomes approved by the department and in compliance with national accreditation standards. 4. A facility shall conduct the department-approved postresidential outcomes survey at the conclusion of the six-month required followup aftercare period.