PURPOSE: This rule describes requirements for performance improvement activities in Opioid Treatment Programs, Substance Use Disorder Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs, Institutional Treatment Programs, Recovery Support Programs, Substance Awareness Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Outpatient Mental Health Treatment Programs.

1. (1) Performance Improvement. The organization shall develop, implement, and maintain an effective, ongoing, agency-wide and data-driven performance measurement and performance improvement program/process. These activities allow the organization to objectively review how well it is accomplishing its mission, and develop and initiate performance improvement changes.

   1. (A) The performance measurement and performance improvement program encompasses the organization’s full array of clinical services and focuses on indicators related to improved behavioral health or other healthcare outcomes for individuals served.
   2. (B) Direct service staff and medical staff shall be actively involved in performance measurement and improvement activities including, but not limited to, clinical care issues and practices related to the use of medications.

   3. (C) Components of the organization’s performance measurement and performance improvement program includes, but is not limited to:

      1. 1. A description of its purpose, priorities, policies, and

goals;

1. 2. A description of the measurement analysis and how it

will help define future performance improvement activities;

1. 3. A description of evaluation and quality assurance

activities that will be utilized to determine the effectiveness of the performance improvement plan;

1. 4. A description of the organizational systems needed

to implement the plan including the functions, descriptions of accountability, and roles and responsibilities of staff or performance improvement committee; and

1. 5. A plan for communicating planned activities and

processes to staff and the governing body on a regular basis.

1. (2) Performance Improvement Plan. The organization shall develop and implement an annual performance improvement plan. The plan is updated on an ongoing basis to reflect changes, corrections, and other modifications and reviewed annually with the organization’s governing body.

   1. (A) Direct service staff, individuals served, and family members/natural supports are involved in the planning, design, implementation and review of the organization’s performance improvement activities.

   2. (B) The performance improvement plan shall include, but is not limited to:

      1. 1. A process for obtaining satisfaction and other feedback

related to service delivery from individuals served, family members/natural supports, and other stakeholders;

1. 2. A process to measure outcomes for individuals served;
2. 3. A review of clinical records to ensure all required

documentation is thorough, timely and complete;

1. 4. A process to evaluate whether services are effective,

appropriate, and relate to treatment goals;

1. 5. Activities to improve access and retention in services;
2. 6. Review of clinical staff training and competencies;
3. 7. Review of critical/sentinal events, grievances, and

complaints; and

1. 8. A process for monitoring compliance of subcontractors.

1. (3) Performance Measurement and Analysis. Performance measurement is a process by which an organization monitors important aspects of its programs, systems, and care processes. Qualitative and quantitative data is collected, systematically aggregated, and analyzed on an ongoing basis to assist organizational leadership in evaluating whether the adequate structure and correct processes are in place to achieve the organization’s desired results.

   1. (A) Properly trained staff shall use valid, reliable processes to collect and analyze data. The data may be used to—

      1. 1. Distinguish between expected behavioral health

outcomes and actual outcomes in areas such as employment/ return to school, stable housing, decreased involvement in the justice system, improved physical health and wellness, and increased engagement in services;

1. 2. Establish baseline measures before improvements are

made;

1. 3. Make decisions based on solid evidence;
2. 4. Allow performance comparisons across sites;
3. 5. Monitor process changes to ensure improvements are

sustained over time;

1. 6. Recognize improved performance;
2. 7. Determine the effectiveness of evidence-based and/or

best practices provided;

1. 8. Monitor and continually improve management, clinical

services, and support services; and

1. 9. Address undesirable patterns in performance and

sentinel events.

1. (B) Results of the performance analysis are available to individuals served, family members/natural supports, other stakeholders, and the department.

1. (4) The department may require, at its option, the use of designated measures or instruments in the performance measurement and improvement process in order to promote consistency in data collection, analysis, and applicability. The required use of particular measures or instruments applies to programs or services funded by the department.

2. (5) Documentation. The organization shall maintain documentation of its performance measurement and performance improvement program and be able to demonstrate its operation to staff of the department, accrediting body, or other interested parties.

   1. (A) Documentation shall include, but is not limited to, the following types of information:

      1. 1. Management reports;
      2. 2. Strategic plans;
      3. 3. Budgets;
      4. 4. Accessibility plans;
      5. 5. Technology plans and analysis;
      6. 6. Risk analysis reports and information;
      7. 7. Environmental health and safety reports;
      8. 8. Financial reports;
      9. 9. Quality assurance reports including review of clinical

records to ensure documentation requirements are being met;

1. 10. Data collected;
2. 11. Demographic information of individuals served; and
3. 12. Satisfaction data of individuals, family members/

natural supports, and other stakeholders.

AUTHORITY: sections 630.050 and 630.055, RSMo 2016.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Amended: Filed Nov. 5, 2018, effective June 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980.