An effective performance improvement (PI) program gives your behavioral health organization a solid framework to continuously drive advancements in quality of care and business efficiency.

As a valuable proactive approach, your PI program guides efforts to measure, analyze, and track data on care and operational practices. The intent is to continuously improve services and outcomes by identifying opportunities for improvement and making adjustments that minimize potential risks and enhance quality of care and safety.

PI Program Required

Accreditation Commission for Health Care (ACHC) is committed to enhancing your organization’s ability to continuously deliver the best care and services.

Standards for ACHC Behavioral Health Accreditation require organizations to develop and implement a PI program. The standards in Section 6, Quality Outcomes/Performance Improvement, apply to your organization’s PI program.

Tips for Compliance

• Ensure your PI program identifies the framework and strategies in policies and procedures or a written PI plan.
  • Describe the program objectives, all service recipient care disciplines, how the program will be administered and coordinated, the methodologies for monitoring and evaluating the quality of care, priorities for resolution of problems, monitoring plan to determine effectiveness of actions, and who is responsible for oversight and reporting findings to the governing body/owner.
  • List the methods used by the organization for reviewing data.
• Designate a person to coordinate PI activities.
  • This may be the owner, manager, supervisor, or other personnel.
  • These duties must be included in the designated individual’s job description.
• Ensure there is documented evidence of the governing body/owner and organizational leaders’ involvement in the PI process. They ultimately are responsible for all actions and activities of the organization.
• Ensure there is documented evidence that all personnel receive training on PI activities and are informed of their PI-related duties.
• The monitoring and review of each PI activity or study must contain the following items:
  • A description of indicators to be monitored/activities to be conducted (e.g., service recipient record review).
  • The methods and frequency of activities (e.g., the percent of service recipient record reviews that will be conducted and when [weekly/monthly/quarterly/annually]).
  • Title of the individual responsible for collecting data and analyzing data (e.g., PI coordinator will collect and analyze data during an established time frame [weekly/monthly/quarterly/annually]).
  • Acceptable limits for findings/thresholds (e.g., the threshold percentage of all service recipient records containing all required and correct documentation).
  • Written plan of correction when thresholds are not met.
  • Who will receive the reports (e.g., governing body/owner, leadership team, etc.).
  • Plans to re-evaluate if findings fail to meet acceptable limits (e.g., repeat activity data analysis for continuous improvement).
• Ensure there is a comprehensive, written report that describes the PI activities/studies, findings, and corrective actions that relate to services provided.

Here to Help

ACHC is more than an accreditor. We are your partner. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242, ext. 457.