LAC Department of Mental Health Public Portal

	LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH
	POLICY 1100.01 Quality Improvement Program
	PROCEDURES

The Los Angeles County Department of Mental Health (DMH) Quality Improvement (QI) Unit shall:
1. Be administered by a licensed mental health professional and have adequate knowledge of QI and data, ensuring a robust data-driven approach.
2. Engage with various Department divisions who are responsible for monitoring performance, covering:
  1. Outcome measurement and data analytics for QI.
  2. Management of service utilization to ensure service capacity and quality of service.
  3. Oversight of clinical records and utilization.
  4. Provider appeals.
  5. Credentialing and monitoring.
  6. Resolution of beneficiary grievances.
  7. Assessment of beneficiary and provider satisfaction.
  8. Monitoring of the safety and effectiveness of medication practices by a person licensed to prescribe or dispense prescription medication.
  9. Evaluation of fair hearing and requests to change providers; and
  10. Address meaningful clinical issues affecting clients/consumers systemwide.
3. Develop an annual Quality Assessment and Performance Improvement (QAPI) Work Plan and Evaluation Report that includes the following:
  1. Annual Work Plan Goals that include time frames for each QI activities completion and identification of staff responsible for activities.
  2. Evaluation of the QI program as a separate Work Plan Goal each year.
  3. Review of beneficiary grievances, appeals, expedited appeals, State hearings, expedited State Hearings, provider appeals, and clinical record reviews.
  4. Evidence that QI activities, including performance improvement projects (PIPs) have contributed to improvement in clinical care and client satisfaction by way of collecting and analyzing data.
  5. Evidence of compliance with requirements for cultural and linguistic competence.
  6. Track performance and report to Department of Healthcare Services (DHCS) annually on a set of required quality performance measures.
  7. Evaluation of service accessibility, including the 24-hour toll-free ACCESS phone line, access to after-hours care, and timeliness of services.
  8. Identify and implement at least two (2) PIPs annually, one clinical and one non-clinical, in accordance with 42 CFR § 438.330(a)(2).
  9. Description of completed and in process QI activities including PIPs that shall include:
    1. Monitoring previously identified issues and tracking progress over time.
1. 1. 1. Objectives, scope, and planned QI activities for each year; and
    2. Targeted areas of improvement.
2. Distribute the QAPI Work Plan to all Short-Doyle/Medi-Cal Organizational Providers (directly operated and contractors), fostering a unified quality framework.
3. Implement Consumer Perception Survey (CPS) according to State guidelines and circulate key findings to identify areas of strength and improvement related to consumer satisfaction with their services.
4. Provide quarterly updates and appropriate recommendations to the DMH Leadership Team on related projects and activities, External Quality Review Organization (EQRO) review items, and DHCS mandates.
5. Include the Compliance, Privacy, and Audit Services Unit on the DMH Countywide Quality Improvement Committee (QIC) monthly meeting agenda for purposes of reporting and discussing policy updates.
The DMH QIC shall be informed by practitioners, consumers, and family members who will have an active role in the planning, design, and execution of activities. The DMH QIC shall:
1. Recommend policies.
2. Review and evaluate results of QI activities including PIPs.
3. Institute needed actions.
4. Ensure follow up on action items and processes identified by QIC leadership and team members.
5. Review the Department's Work Plan; and
6. Meet at least quarterly. Minutes of these meetings shall be taken. The signed and dated meeting minutes shall reflect all decisions and actions. Virtual meeting video recordings with a written follow-up plan are acceptable in place of minutes. The virtual meeting video recordings and/or minutes shall be maintained for a minimum of three (3) years and will be posted on the QI public facing website.
Regional Quality Improvement Committees
1. Regional QICs shall be composed of at least one (1) staff from each organizational provider within the Region, as well as being open to family members and clients.
2. DMH QI Unit’s Support of Regional QIC structure:
  1. Participate in the Regional QIC meetings and assist in creating unified agendas for both Regions.
  2. Review and respond to issues and/or recommendations raised by the Regional QICs.
  3. Assist the Regional QICs in determining and developing PIPs relevant to regional issues; and
  4. Provide information and support to the Regional QIC Chairs on problem/issue resolutions.
3. Regional QICs shall:
  1. Meet at least quarterly.
  2. Be led by a member of the QI Unit and an appointed representative from a Directly Operated or Legal Entity Provider.
  3. Discuss pertinent issues related to areas identified in developing an annual Work Plan and Evaluation Report.
  4. Develop and implement feedback loops to organizational provider staff and practitioners regarding quality-of-care issues, policy and procedure implementation challenges, and problem resolutions discussed at the QIC meeting obtaining their feedback to be brought back to the DMH Countywide QIC; and
  5. Minutes of these meetings shall be taken. The signed and dated meeting minutes shall reflect all decisions and actions. The minutes shall be in the same format as used for DMH QIC meeting minutes. Minutes shall be maintained for a minimum of three (3) years and will be posted on the QI public facing website.
Organizational Provider Quality Improvement Activities:
1. All organizational providers, directly operated and contracted, shall implement means of information dissemination to direct service providers at the organizational provider site, minimally on a quarterly basis or more frequently based on the agency's needs.
2. Information dissemination structures may include, but are not limited to, at least one of the following:
  1. A stand-alone Organization Provider level QIC meeting.
  2. Inclusion of Quality Improvement and Quality Assurance updates in regularly scheduled staff meetings; and
  3. Inclusion of Quality Improvement and Quality Assurance updates in regularly scheduled management and team meetings.
3. Direct Service Staff meetings shall include updates on Quality Improvement and Quality Assurance as well as regular monitoring of the following:
  1. Service accessibility: including cultural, linguistic, and communication needs, accessibility for individuals with physical and cognitive disabilities, and accessibility for individuals with challenges traveling to the clinic site.
  2. Beneficiary satisfaction: including consumer perception survey results.
  3. Service delivery system and meaningful clinical issues affecting beneficiaries.
  4. Coordination of care with other human service agencies; and
  5. Beneficiary grievances.
4. The Provider shall maintain documentation of the meeting including attendees, information shared, and data reviewed. Agenda and meeting sign-in sheets are sufficient documentation for this purpose.
5. All providers identified as meeting criteria for participation in the annual Consumer Perception Survey by the QI Unit shall distribute and collect Consumer Perception Surveys from consumers served during the survey period.
6. Utilization Review (UR)
  1. Each organizational provider shall establish a UR process within the agency.
  2. UR shall be part of the Organizational Provider’s QI Program and under the umbrella of the QIC.