Continuous quality improvement plan

1. In order to maintain a continuous focus on quality improvement, the certified clinic shall develop, implement, and maintain an effective, certified clinicwide continuous quality improvement plan for the services provided. The continuous quality improvement plan must focus on indicators related to improved behavioral and physical health outcomes and take action to demonstrate improvement in certified clinic performance. 2. The certified clinic shall establish a critical review process to review continuous quality improvement outcomes and implement changes to staffing, services, and availability that must improve the quality and timeliness of services. 3. The certified clinic shall involve the medical director in the aspects of the continuous quality improvement plan which apply to the quality of the medical components of care, including coordination and integration with primary care. 4. The certified clinic's continuous quality improvement plan must address how the certified clinic shall review known significant events including, at a minimum: a. Deaths by suicide or suicide attempts of individuals; b. Fatal and nonfatal overdoses; c. All-cause mortality among individuals; d. Thirty-day hospital readmissions for behavioral health reasons; and e. Such other events the state or applicable accreditation bodies may deem appropriate for examination and remediation as part of a continuous quality improvement plan. 5. The continuous quality improvement plan must be data driven and the certified clinic shall use quantitative and qualitative data in its continuous quality improvement activities. The certified clinic's continuous quality improvement plan must be in the form and manner prescribed by the department.