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Performance Improvement Plan

Providing for Quality Assurance



Approved by the Executive Team












Objectives of Performance Improvement Activity

Continuous Performance Improvement

Data Collection Methods

The Framework


Annual Evaluation



The Cambridge Counseling Center is responsible for promoting the development of a mental health system that maximizes the quality of life of each person served. It is also the policy of the Cambridge Counseling Center to deliver services to persons served in the least restrictive manner possible.

Cambridge Counseling Center is committed to developing and maintaining the highest possible quality of care. Cambridge Counseling Center is responsible for the operation of a Performance Improvement Program that aims to monitor, protect and enhance the quality of care offered by the services of our center.

The Cambridge Counseling Center aims to fulfill its mission to persons served, staff and our community. The organization’s leaders, directors, clinical staff, and support staff are committed to plan, design, measure, assess, and improve performance and the performance improvement process in order to fulfill our mission.

As part of our commitment, this written Performance Improvement Plan for The Cambridge Counseling Center was established in 2005 and will be modified and reviewed annually. It has been determined by the Quality Improvement Team and Approved by the Executive Team that this 2015 revision is appropriate and will remain current until modified or updated.

This plan is designed to provide a consistent process for improving the care provided, improving the satisfaction of our consumers, comparing performance against benchmarks and reducing inefficiencies. Quality improvement activities cross all programs and services in order to respond to the needs of person served, staff, and community.

This document presents the comprehensive and systematic plan for the operation of the performance improvement plan focusing on quality assurance of the Cambridge Counseling Center. It is the standard that guides business function and service delivery and applies to all programming and services at the agency. Cambridge Counseling Center understands the need to strategically monitor and assess its performance as defined by the Agency’s performance Indicators. The Performance Improvement Plan will serve as the foundation for quality assurance. The continuous Performance Improvement process is an organizational approach. The program crosses all functions, programs, staff, and focuses on key improvements to promote long-term gains.


The Executive Team, who has the ultimate responsibility for the quality of care and services provided, establishes the Performance Improvement Program. Through activities of the Quality Improvement Team and other performance improvement activities, the Executive Team is given information it needs in order to fulfill The Cambridge Counseling Center’s mission and the responsibility for quality of care for stakeholders. Performance improvement initiatives are implemented by the Quality Improvement Team, selected by the Executive Director. A team leader is appointed by the Executive Director annually. The Quality Improvement team leader is responsible for communication and coordination of pertinent information to team members, leaders and other stakeholders.


Performance Improvement and Performance Improvement Activities at The Cambridge Counseling Center are developed to insure that the center meets its responsibilities to stakeholders. Activities are designed to meet the following objectives:


To assure that services rendered are within acceptable standards of practice.

To provide a means whereby consumer care meets the highest possible within a clean, safe, and therapeutic environment.

To promote efficient and effective services.

To assure that the clinical and clinical support staff both objectively and systematically monitor and evaluate the quality and appropriateness of important aspects of care and services on an ongoing basis.

To assure that as opportunities to improve care and services are identified, the appropriate action is taken and follow-up occurs, resulting in resolution and improved care and services.

To provide mechanisms to assure accountability of each clinical staff member for the care provided.

To provide ongoing review and revision of performance improvement and the Performance Improvement Program.

To minimize risks within the center through the development and implementation of risk management activities.

To provide annual evaluation and revision as appropriate to the Performance Improvement Program.


The Performance Improvement Program is composed of the following standing committees or teams:

Executive Team

Quality Improvement Team

Safety and Risk Management Team

Utilization Team

Staff Development Team

Cultural Competency Committee

Corporate Compliance Committee

Clients Rights Committee

Quality Records Review

Clinical Supervision (Case Management and Counselor)

The Quality Improvement Team leader is responsible for the coordination and integration of the performance improvement activities within the Cambridge Counseling Center and serves as a liaison among programs, services and other committees/teams. Leadership is responsible for implementing an ongoing system to monitor and evaluate the quality and appropriateness of person centered care and services. The system encompasses the scope of care and services provided within each program. The Quality Improvement Team leader will recommend specific responses and time frames for action to findings and will assess the effectiveness and efficiency of such actions after implementation.

Executive Team

The Executive Team meetings are held monthly. The Executive Director can invite other team leaders to the Executive Team meetings as needed.

Quality Improvement Team

The Quality Improvement Team is composed of staff members who represent key elements of the center. Selection is based on the needs of the center and the strengths, knowledge, abilities and skills of individual staff members. The Executive Director will serve as Team Leader. All staff members have the opportunity to participate as a team member based on the needs of the Quality Improvement Team and the Center. Other individuals, including persons served may be asked to attend particular meetings based on the needs of the team. Quality Improvement Team meetings will be held at least 6 times per year.

Safety and Risk Management Team

The Safety and Risk Manager Team is composed of the Safety and Maintenance Coordinator, the Quality Improvement Team leader, and other staff members. The team members are selected and assigned by the Executive Director. The team meetings are held at least quarterly. The Quality Improvement Team Leader is responsible for directing the implementation, monitoring and evaluation of all adverse incidents within the center.

Utilization Team

The Utilization Team members are based on the needs of the center and the strengths, knowledge, abilities and skills of the individual staff members. The utilization team meets as needed for project reviews as outlined by the Executive Director.


Staff Development Committee

The Staff Development Committee members are selected and assigned by the Executive Director. The committee meets as outlined by the Executive Team.

Cultural Competency Team

The Cultural Competency Team members are selected and assigned by the Executive Director. The team meets at least twice a year.

Corporate Compliance Committee

The Corporate Compliance Committee members are appointed by the Executive Director and are led by the Corporate Compliance Officer (CCO). The committee will meet quarterly.

Client’s Rights Committee

The Client’s Rights Committee is composed of the designated Consumer Advocates and representatives from clinical and clinical support areas within the center. Committee members are selected and assigned by the Executive Director. The Client’s Rights Committee will convene when efforts to process advocacy issues are not met to the person’s served satisfaction. The consumer advocate will call meetings and notify members of the team as needed.

Quality Records Review Team

The Quality Records Review Team will consist of a team leader, the Clinical Director and the Deputy Director. The team will meet monthly to review records of the persons served to ensure quality of service and documentation.

Clinical Supervision Team

The Clinical Supervision Team leaders will consist of the Clinical Director, Site Supervisors and Case Management Program Coordinator. Counseling Staff and Case Management staff are required to attend monthly meetings held by the team leaders. Meetings will include education, support and peer review.


The scope of the Performance Improvement Program shall encompass all clinical services, clinical records review, utilization review, and review of safety/risk management data. The teams and committees are established to routinely organize, manage, monitor and report on aspects of care and critical areas of operation. Membership is designate by the Executive Director based on the strengths and abilities of individuals and what is in the overall best interest of the organization.

Cambridge Counseling Center’s Performance Improvement Program focuses on the quality of care areas concerning the delivery and outcome of treatment of direct and indirect clinical services. Admission and continued stay reviews are conducted according to admission and continued stay criteria established by the center. The scope of Quality Improvement Activities also includes:


Monitoring and Evaluation System

Quality Record Reviews to include completeness and quality of care;

Medical Records billing review;

Corporate Compliance Reviews;

Utilization Reviews;

Clinical Outcome Reviews including development, implementation, and report of efficiency and effectiveness measures within each service area;

Stakeholder satisfaction survey reviews;

Reviews of service data and reports.

Scope of Committees/Teams

Executive Team Responsibilities include:

implementation of ODMH directives,

implementation of agency policies and operational procedures

Approve credentialing and clinical privileging standards, which include: review of applications and documentation, designation of privileging status of clinical staff members, ensuring credential folder of each clinician is updated annually. The staff record includes a copy of diploma, copy of licenses or certification, license renewal dates, description of services privileged to render, quality improvement data pertinent to the individual’s practice. The Executive Team

Ensuring care and services meet all state, federal, regulator and accreditation standards.

Quality Improvement Team responsibilities include:

Organizational planning and performance improvement.

Review and evaluating program goals and objectives to ensure coordination with the overall philosophy and purpose of each program.

To initiate Continuous Quality Improvement Teams by identifying mission and objectives, and ensuring teams/committees have adequate resources to facilitate effective team functioning.

Review, monitor and evaluate short and long term outcomes.

Review, monitor and evaluate aspects of staff development and overall satisfaction.

Review, monitor and evaluate aspects of care dealing with the rights of the persons served and customer satisfaction.

To identify and reduce barriers to the quality improvement process.

Facilitate smooth and consistent operation between teams, committees and programs to promote organizational quality in the delivery of services to the persons served.

Safety and Risk Management Team responsibilities include:

Investigating and reporting on specific functions and aspects of care dealing with risk management issues.

Investigation adverse incidents

Evaluating adverse incidents

Reporting incidents to an executive team member

Use information on a routine basis to improve accessibility, health, safety and other pertinent risk management issues that have direct or indirect impact on stakeholders.

Responsibilities are ongoing and include appropriate and timely responses for addressing areas of concern or deficiency.

In addition to investigating reportable incidents, the SRMT identifies that certain major incidents of a more urgent nature must be referred to the Executive Director immediately. These incidents include:

Homicide involving a person served, staff or visitor.

Suicide of an active consumer or staff member.

Major injuries to persons served, visitors or staff.

Any other major occurrence or tragic event.

Safety and Risk Management Team Goals include:

Assuring implementation of a center-wide safety program that includes development of policy and procedures and subsequent staff training relation to fire safety, disaster preparedness, hazard reporting, etc.

Assuring tracking and documentation system for all incidents, including follow up and implementation of any corrective action until follow up is no longer indicated.

To review safety and incident related data and to identify trends and patterns associated with risks or to identify problem areas.

To conduct root cause analysis on incidents as appropriate.

To provide thorough investigation on all sentinel events.

To promote performance improvement activity through identifying opportunities towards maximizing a safety of physical and therapeutic environment and reducing The Cambridge Counseling Center, staff and consumer risks.

Utilization Team responsibilities include directing the implementation, monitoring, and evaluation of trends and patterns pertaining to utilization management within The Cambridge Counseling Center. The utilization management process uses various ongoing and systematic techniques related to specific aspects of care and the utilization review tool.

Staff Development Committee meets as needed to plan for assessment of staff training needs and assuring that the mechanisms are in place to maximize compliance with minimum training requirements and the provision of training opportunities to meet priority needs identified by staff. Specific responsibilities of the Staff Development Committee include:

Identification of training needs of clinical and clinical support staff.

Promote staff awareness of internal and external training opportunities.

Identify opportunities and strategies for enhancement of staff development activities.

Plan required training opportunities through in-house training.

Corporate Compliance Committee purpose is to:

Advise Executive Team and implement all aspects of corporate compliance.

Examine existing standards and procedures, assess alternative courses of action, determine a course of action and implement the necessary policies and procedures.

Design and implement a monitoring program consistent with the Corporate Compliance Plan using audit tools.

Client’s Rights Committee’s purpose is to ensure effective resolution of consumer concerns and/or possible rights violations and to advocate for the rights of the persons served.




The Cambridge Counseling Center has determined that a strong Performance Improvement Program that utilizes improvement/design teams is the most effective use of our current resources. The main emphasis is to improve the quality of the organization in fulfilling its mission and vision addressing efficacy, appropriateness, availability, timeliness, effectiveness, continuity, safety efficiency, respect and caring. These components include, but are not limited to:

Enhancement of the Quality Improvement Team from past experience.

Focus on efficiency of the processes and desired outcomes (benchmarking).

Collaboration of activities.

Education/training on identified issues.

Use of improvement teams for complex issues.

Performance improvement activities are part of the everyday duties of the staff throughout the facility. The goal of this process is to:

Identify areas in need of improvement

Develop and improvement plan that clearly defines steps to take for corrective actions, reevaluate outcome measures if needed, revise performance indicators if needed

Assign responsibilities to ensure completion of corrective action

Develop a summary report to be shared with clients, staff and other stakeholders to ensure transparency, accountability and to gather valuable feedback to be used for continual quality improvement activities


The Cambridge Counseling Center employs a systematic approach for improving the organization’s performance by improving existing processes. The committees/teams involved in the review of performance activity will make decisions on what improvement needs to be made. In cases where priorities need to be set, assistance may be obtained from committee, team or Cambridge Counseling Center leadership. It shall be the continual goal of the Cambridge Counseling Center to demonstrate the effectiveness of the data collection system in place by addressing the following areas:



Data will be collected consistently across the board. For example, the intent is to guarantee that multiple data gatherers can replicate the information being reported.

The following safeguards will be in place to ensure data is reliable:

Performance Indicators will be clearly identified and reviewed with all staff

Results will be collected and validated by the Quality Improvement Team

Staff will receive training when asked to collect a particular data element.



Performance Indicators and data elements will be chosen to measure what is mandated to measure as well as what is agreed upon by the Quality Improvement Team

The following safeguards will be in place to ensure data is valid:

Performance Improvement Plan will be reviewed by the Quality Improvement Team and the Executive Team to ensure thoroughness and validity.

The Agency will ensure that input from clients, stakeholders and employees is gathered and that their input is incorporated in the performance indicators that are included in the Performance Improvement Plan.


Steps will be taken to ensure that the data used for decision making is as complete as possible, no accredited programs are omitted from the information and performance improvement effort, no groups of persons served are omitted from the data gathering or analysis, no data elements or indicators are systematically missing, and any databased is checked for completeness of records before final analyses are run and decisions made.

Staff members assigned to data collection will be trained on appropriate methods of data collection. Results will be shared with the Quality Improvement Team in a summary report. Recommendations and edits/additions will be included in the report.


Steps will be taken to ensure that data is recorded appropriately and that errors are caught and corrected.

Staff members will be encouraged to re-run reports to ensure accuracy. Data will be reviewed with historical data to monitor variance/accuracy.


Although quality service is a function of the relationship between the service provider and the client who receives the service, quality is evidenced by complete and appropriate record keeping. Methods of review are therefore based on data that should routinely be found in any client record at any given time. The following is a modest overview of methods that will be used to verify quality and identify problems that are related to service provision:

Quality Record Review (Individual Client Record)

Annual Review of Performance Indicators

Clinical Supervision/Peer Review

Safety Drill Reporting Form

Review of Emergency Drills and Procedures

Review of Grievances and Formal Complaints

Financial Audit

Consumer Satisfaction Surveys

Stakeholder Satisfaction Surveys

Staff Satisfaction Surveys

Exit Interviews

Review of Critical Incidents

Financial Information

Accessibility Status Reports

Technology and Systems plans

Health and Safety Reports

The data collected by the agency will address:

The needs of the persons served

The needs of the personnel

The needs of other stakeholders

The business needs of the agency

The Framework

The Cambridge Counseling Center will gather feedback and establish performance indicators in the following areas:



How well the programs work and what outcomes are being achieved



How well resources are used to accomplish outcomes achieved



Our capacity to provide services to those who desire them



The general experience clients have with our services and overall satisfaction



The general experience clients have with our services and overall satisfaction



The safety of guests in our facility and the elimination of risks identified



Business functions to remain competitive and relevant in the field



The following GRID will be used to report the performance Indicators:

Indicators    Objectives Measure   Data Source   Data Collection By   No in Sample Size   Expected Rusults   Actual Results   Anaysis   Action Plan






Consumer Satisfaction

Stakeholder Satisfaction

Outcome Measures

Safety and Risk Management


Business Function




The deliberations and findings of the Quality Improvement Teams/Committees are confidential in nature. Consumer related information and staff related findings follow the guidelines within the CCC confidentiality Policy.


The Performance Improvement Program is to be evaluated annually for appropriateness and effectiveness by the Quality Improvement Team and the Executive Team, or at any time such actions indicate. The annual evaluation data will be incorporated in the Quality Improvement Team meeting minutes and provided to the Executive Team.



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