Quality Service Reviews Technical Support
Information and resources for the Quality Services Reviews process
To evaluate the quality of the mental health services and supports provided by NH Community Mental Health Centers (CMHCs) as outlined in the Community Mental Health Agreement (CMHA), NH DHHS employs a structured assessment using qualitative and quantitative data from individual interviews, staff interviews, clinical record reviews, and DHHS databases.
This Quality Services Review (QSR) process measures the CMHCs’ achievement of 18 quality indicators and 66 performance measures that represent best practices regarding the substantive provisions of the CMHA and includes a number of tasks performed by DHHS and Community Mental Health Staff (CMHC) staff within a prescribed timeframe. The various tasks involve communication, logistics, IT, data entry, data analytics, scheduling, transportation, training, orientation, interviewing, and scoring.
Quality Service Review (QSR)
For the first two to three days of the annual QSR at the CMHC, DHHS QSR reviewers focus on a clinical record review. The final three days of the annual QSR at the CMHC consist of interviews with individuals and interviews with CMHC staff.
During the clinical record review, daily contact occurs with QSR reviewers to ensure consistent practice and inter-rater reliability, and assistance is sought from the CMHC staff if needed. If a reviewer is unable to locate adequate evidence in the CMHC’s clinical record, the reviewer documents that instance as “no evidence” and CMHC staff are given the opportunity to locate documentation within its clinical record system.
Quality Improvement Plan (QIP) and Progress Reports (PRs)
During the post on-site period, follow-up tasks required of the CMHC are completed and DHHS commences scoring. The QSR data is analyzed and the CMHC’s QSR Report is written and provided to the CMHC identifying any areas in need of improvement. If needed, the CMHC submits a Quality Improvement Plan (QIP) to DHHS for approval. Progress reports submitted to DHHS by the CMHC are monitored and technical assistance is provided to the CMHC if needed. The next QSR cycle serves to validate progress made toward achievement of the improvement target(s).
- Instructions for Completing the QIP and Progress Reports
- Developing SMART Action Steps
- Guide for Action Step Development for QI 13
- Institute for Healthcare Improvement
- PICK Chart
- Fishbone Diagram
- Five Whys Template
- Root Cause Analysis
- Sampling Type Overview (transferrable information from the EPA)
- Fishbone Diagram Examples- GoLeanSixSigma
- Community Mental Health Agreement
When is my QIP Due?
The first tab in your QIP template entitled “Due Dates” will tell you exactly when your QIP is due. It is due 30 days from the date of the Final QSR Report.
When are my Progress Reports Due?
The first tab in your QIP template entitled “Due Dates” will tell you exactly when your Progress Reports are due for the entire year. Your 1st Quarter Progress Report is due 90 days from your QIP due date, your 2nd Quarter Progress Report is due 90 days from the due date of the 1st Quarterly, your 3rd Quarter Progress Report is due 90 days from the due date of 2nd Quarterly, and your 4th Quarter Progress Report is due 90 days from the due date of 3rd Quarterly.
What happens if the due date falls on a weekend or holiday?
If a due date falls on a Saturday, Sunday, or Holiday, submit the required document on the second business day following the Saturday, Sunday, or Holiday.
I see the QIP tabs, but where are the Progress Report tabs in the template?
DHHS will provide you with a template in which all tabs are unhidden. However, if you cannot find a progress report tab, it is likely “hidden.” To view all tabs, simply right-click on any tab in the QIP template and select "Unhide" from the drop-down menu. Highlight the tab you would like to view, and then click "OK." To hide the tab again, simply right click on the tab and select "Hide."
I received feedback on my QIP that my action step must be specific and measurable. What does this mean?
Your action steps must be SMART: specific, measurable, achievable, relevant, and time bound. Each action step must answer Who, What, and How. Who needs to be involved in the action step and to whom does it apply. What are you trying to achieve? How does this action step achieve the “what” and “why” of your action step and how will this action step be accomplished? How does this action step increase the percentage of individuals who need X (QI in need of improvement)? Finally, what metrics are you going to use to determine if you’ve made progress?
Where might I find ideas on developing SMART action steps?
In the Quick Links above, there is a Guide or Action Step Development for Q1 13. Until further guides are developed and posted, this Guide may be used for all your action steps to help spark ideas. Another resource is the Institute for Healthcare Improvement which offers many quality improvement tips and resources that are transferrable to the mental health field.