LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 1100.01 Quality Assurance and Performance Improvement Program
 
Policy Category:  Clinical
Distribution Level:  Directly Operated and Contracted
Responsible Party:  Quality Improvement

Approval completed on Jul 10, 2026
 
 
 
I.  PURPOSE
 
To ensure the quality and appropriateness of care delivered to members of the mental health system meets or exceeds the established local, state, and federal service standards. Los Angeles County Department of Mental Health (DMH) is dedicated to implementing a comprehensive evaluation and improvement strategy. This strategy will leverage various methodologies, tools, and frameworks designed to rigorously assess our current service delivery and identify areas for enhancement. DMH will employ quantitative and qualitative research methods to gather actionable insights into the quality, access, and timeliness of the services provided. Tools such as client/member perception surveys, feedback forms, and service performance metrics will be integral in its evaluative processes.

To define the structure and process of the Quality Assurance and Performance Improvement (QAPI) Program within DMH.

To comply with standards set by the California Department of Health Care Services (DHCS) through the Mental Health Plan Contract.

Contracted agencies shall develop internal policies and associated procedures that are consistent with their organizational practices and meet the requirements set forth in this policy.
 
II.  DEFINITION

Licensed Practitioner of the Healing Arts (LPHA): A licensed mental health professional legally authorized to diagnose, evaluate, and treat mental health conditions.

Member: A Medi-Cal beneficiary who is enrolled in, or receives Specialty Mental Health Services through, the Los Angeles County Mental Health Plan.

Quality Assurance and Performance Improvement (QAPI) Program: A comprehensive, collaborative effort among leadership, management, direct service staff, and members to create and sustain a culture of continuous improvement using data and Quality Improvement (QI) best-practice techniques. This program is structured around a clear framework that delineates the roles and responsibilities of all participants, ensuring active engagement and accountability at every level of the department.
 
III.  POLICY

All providers (Directly Operated, Contracted and Individual/Group) have a shared responsibility with the DMH Quality, Outcomes, and Training Division (who is responsible for the QAPI Program) in maintaining and enhancing the quality of service, delivery framework, and disposition. This is achieved by establishing processes for continuous monitoring and improvement of services and by resolving program and foundational issues through systematized evaluation and feedback loops tailored to available resources.

Management Responsibilities:

  1. The QAPI Program shall be under the general auspices of the Deputy Director of the Quality, Outcomes, and Training Division (QOTD). The QOTD includes the Quality Improvement (QI) and Outcomes Unit, the Quality Assurance (QA) Unit, ACCESS Call Center, and the Training Unit, inclusive of Workforce Education and Development programs. 

  2. The QAPI Program is responsible for tracking and reporting out on all quality management activities including quality improvement, quality measures, performance monitoring and over/under utilization of services.

Contracted Agency Responsibilities:

  1. Contracted agencies must develop and implement internal policies that align with DMH QAPI Program standards. This includes establishing a dedicated QA/QI team within the agency to oversee compliance and continuous improvement efforts.
  2. Agencies should integrate QI processes into their existing operational framework, ensuring that QI initiatives complement and enhance organizational practices. For example, if an agency strongly focuses on community-based interventions, its QI efforts should include measures to assess and improve community engagement and outcomes.
  3. Agencies identified as meeting criteria for participation in the annual Consumer Perception Survey (CPS) shall distribute and collect surveys from clients served during the survey period as instructed by DMH.

  4. Contracted agencies are required to attend Regional Quality Improvement Committee (QIC) meetings and to adopt the following guidelines to ensure consistency with DMH policies:

  • Conduct regular training sessions for staff on DMH policies and QI methodologies, ensuring everyone is informed and equipped to contribute to quality improvement efforts.

  • Establish a structured process for collecting and analyzing feedback from service users and staff. This should include mechanisms for incorporating feedback into service delivery improvements.

  • Implement performance monitoring systems that align with DMH's quality indicators, ensuring that data collection and analysis are integral to the agency's QI efforts.

  • Maintain open lines of communication with DMH, participating in departmental-wide performance improvement efforts and providing updates on QI activities and outcomes.
IV.  PROCEDURES
 
Procedures - Quality Improvement Program
 
V.  AUTHORITIES
 
V.  ATTACHMENTS
 
There are no attachments associated with this policy.