SOP_NUMBER: 508.11
TITLE: Mental Health Continuous Quality Improvement
REFERENCE_CODE: VG25-0001
DIVISION: Health Services Division (Mental Health)
TOPIC_AREA: 508 Policy - MH Administration/Staff/Certification
EFFECTIVE_DATE: 2021-12-16
WORD_COUNT: 1162
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/106273
URL: https://gps.press/sop-data/508.11/
SUMMARY:
This policy establishes a Continuous Quality Improvement (CQI) program for mental health services across all GDC state institutions. The program monitors the accessibility, timeliness, effectiveness, continuity, and efficiency of mental health care through statewide and facility-level CQI committees that conduct quarterly audits on mandatory topics including restraints, crisis stabilization admissions, emergency medications, and suicide prevention. All facilities must submit annual CQI plans and quarterly reports to central office documenting data, findings, and corrective actions.
KEY_TOPICS: continuous quality improvement, mental health services, CQI program, quality improvement, mental health monitoring, restraints, crisis stabilization unit, acute care unit, emergency medications, involuntary medication, self-injurious behavior, suicide prevention, facility audits, compliance monitoring, mental health audits, performance metrics, peer review
ATTACHMENTS:
1. Continuous Quality Improvement (CQI) Summary Form
URL: https://gps.press/sop-data/508.11-att-1/
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FULL TEXT:
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|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.