SOP 508.11: Mental Health Continuous Quality Improvement

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|
|Policy Number: 508.11|Effective Date: 12/16/2021|Page Number: 1 of 6|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

I. Introduction and Summary:

It is the policy of the Georgia Department of Corrections (GDC) to establish a
Continuous Quality Improvement (CQI) program to monitor the accessibility,
timeliness, effectiveness, continuity, and efficiency of mental health services. This
procedure is applicable to all state institutions providing mental health services.

II. Authority:

A. NCCHC Standards for Health Services in Prisons;

B. NCCHC Standards for Health Services in Juvenile Detention and Confinement

Facilities;

C. GDC Standard Operating Procedures (SOPs): 508.03, Death Notification and

Investigation and 507.01.12, Continuous Quality Improvement and Peer Review;
and

D. ACA Standards: 2-CO-4E-01, 5-ACI-6D-02 (ref. 4-4410, Mandatory), and 5-ACI
6D-03 (ref. 4-4411, Mandatory).

III. Definitions:

A. Continuous Quality Improvement (CQI) - A program designed to objectively

and systematically monitor and evaluate the quality and appropriateness of mental
health services, pursue opportunities to improve care and correct identified
problems.

B. Statewide Mental Health CQI Committee - A comprehensive team of central

office staff focused on the continuous improvement of the quality of mental health
care. Members include but are not limited to:

1. Statewide mental health director/designee;

2. Chief psychiatrist representing state and/or vendor;

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|
|Policy Number: 508.11|Effective Date: 12/16/2021|Page Number: 2 of 6|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

3. Chief psychologist/designee;

4. Mental health program consultants;

5. Representatives from all vendors;

6. Representative(s) from physical health;

7. Representative(s) from security; and

8. Representative(s) from information technologies, as needed.

C. Facility Mental Health CQI Committee - A comprehensive team of mental

health facility staff focused on the continuous improvement of the quality of
mental health care. Members include, but are not limited to:

1. Mental health unit manager(s);

2. Psychiatrist/advanced practice registered nurse (APRN);

3. Clinical director/psychologist;

4. Mental health counselor(s);

5. Activity therapist(s);

6. Mental health nurse(s);

7. Warden/designee;

8. Pharmacist;

9. Health services administrator (hsa)/designee; and

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|
|Policy Number: 508.11|Effective Date: 12/16/2021|Page Number: 3 of 6|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

10. Security.

IV. Statement of Policy and Applicable Procedures:

A. Development of a CQI Program:

1. Central office mental health services will coordinate the development and

implementation of a CQI program for mental health services. The statewide
mental health CQI Committee will meet at least quarterly.

2. Each mental health facility’s CQI Program will be monitored under the

auspices of the statewide mental health CQI Committee.

3. Each facility will send an annual CQI plan to central office by January 31 [st] .

The plan will include mandatory quarterly CQI topics of:

a. Restraints;

b. Crisis Stabilization Unit (CSU)/Acute Care Unit (ACU) admissions;

c. Mental health precipitated hospitalization (emergency room visits/visits

that convert to admission);

d. Emergency forced medications;

e. Involuntary medication;

f. Psychotropic medication non-adherence statistics;

g. Self-injurious and assaultive behavior;

h. Facility mortality reviews resulting from suicides;

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|
|Policy Number: 508.11|Effective Date: 12/16/2021|Page Number: 4 of 6|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

i. Suicide prevention committee meetings;

j. 10 - 12-hour assessment of offenders placed in restrictive housing post
discharge from stabilization unit (ACU/CSU) treatment; and

k. Offender medical file problem list (an upper-level provider has

documented the primary mental health diagnosis).

4. The facility mental health CQI Committee will choose additional CQI studies

as needed and/or recommended.

5. The facility mental health CQI quarterly studies will consist of one

comprehensive audit, one self-audit, and two quarters as identified in above
referenced topics.

6. Completed reports with data and associated minutes shall be forwarded to

central office on a quarterly basis, using the Continuous Quality Improvement
Summary (Attachment 1). The due dates for submission are:

a. 1 [st] Quarter: April 30 [th;] ;

b. 2 [nd] Quarter: July 31 [st;] ;

c. 3 [rd] Quarter: October 31 [st;] ; and

d. 4 [th] Quarter: January 31 [st] .

7. The facility mental health unit manager will coordinate or delegate

coordination of the CQI process. In the event, that a mental health unit manager
is not assigned to a facility, the statewide CQI Committee will determine the
responsible party.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|
|Policy Number: 508.11|Effective Date: 12/16/2021|Page Number: 5 of 6|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

8. The facility mental health CQI Committee will meet at least quarterly. The

purpose of this meeting will be to:

a. Discuss the CQI plan;

b. Present data collected for topics of studies;

c. Problem solve; and

d. Plan actions with clear accountability.

9. If a level of compliance is met continuously for several audits, the CQI aspect

of care may be dropped, excluding the mandatory topics. If a new aspect of
care is identified, it may be added. If a new aspect of care is added, a
monitoring process will be designed and a percent (threshold) for reasonable
expectation of compliance will be decided.

10. The mental health unit manager/designee may assign various staff members to

conduct the self-audit and mandatory studies.

11. Any mental health nursing-related studies will be shared with nursing services

and reported through the medical CQI Committee, as well as the mental health
CQI Committee.

B. Peer Review:

1. Peer Review is conducted annually by the mental health vendor and applies to

all doctoral level providers and APRNs.

2. Verification of the peer review that is conducted will be placed in individual

credentialing files.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|Policy Name: Mental Health Continuous Quality Improvement|
|Policy Number: 508.11|Effective Date: 12/16/2021|Page Number: 6 of 6|
|Authority:
Commissioner
|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

3. Any documentation regarding peer review data should be stamped “Peer

Review” and filed in secure places, with no unauthorized copies circulating.

V. Attachments:

Attachment 1: Continuous Quality Improvement Summary

VI. Record Retention of Forms Relevant to this Policy:

Upon completion, Attachment 1 will be sent to central office (original) and a copy
given to the onsite CQI Coordinator. This form shall be maintained in the mental
health area for 10 years.