PURPOSE: This rule describes requirements for quality improvement activities in Alcohol and Drug Abuse Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Compulsive Gambling Treatment Programs, Substance Abuse Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Psychiatric Outpatient Programs.

1. (1) The organization develops and implements a written plan for a systematic quality assessment and improvement process that is accountable to the governing body and addresses those programs and services certified by the department.

   1. (A) An individual or committee is designated as responsible for coordinating and implementing the quality improvement plan.
   2. (B) Direct service staff and consumers are involved in the planning, design, implementation and review of the organization’s quality improvement activities.
   3. (C) Records and reports of quality improvement activities are maintained.
   4. (D) The organization updates its plan for quality assessment and improvement at least annually.

2. (2) Data are collected to assess quality, monitor service delivery processes and outcomes, identify opportunities for improvement, and monitor improvement efforts.

   1. (A) Data collection shall reflect priority areas identified in the plan.
   2. (B) Consumer satisfaction data shall be included as part of the organization’s quality assessment and improvement process. Such data must be collected in a manner that promotes participation by all consumers.
   3. (C) Data are systematically aggregated and analyzed on an ongoing basis.
   4. (D) Data collection analyses are performed using valid, reliable processes.
   5. (E) The organization compares its performance over time and with other sources of information.
   6. (F) Undesirable patterns in performance and sentinel events are intensively analyzed.

3. (3) The organization develops and implements strategies for service improvement, based on the data analysis.

   1. (A) The organization evaluates the effectiveness of those strategies in achieving improved services delivery and outcomes.
   2. (B) If improved service delivery and outcomes have not been achieved, the organization revises and implements new strategies.
4. (4) The department may require, at its option, the use of designated measures or instruments in the quality assessment and improvement process, in order to promote consistency in data collection, analysis, and applicability. The required use of particular measures or instruments shall be applicable only to those programs or services funded by the department or provided through a service network authorized by the department.

AUTHORITY: sections 630.050 and 630.055, RSMo 2000.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. *Original authority: 630.050, RSMo 1980, amended 1993, 1995 and 630.055, RSMo 1980.