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Alameda County Behavioral Health Care Services (ACBHCS) will require
each provider site or other contracted Community Based Organization (CBO)
to follow policy and procedure in accordance with the Peer Review Plan
described below. The primary mission of the Peer Review Plan is
to facilitate ongoing quality improvement in delivery of services to
consumers at the program level. The process used is
intended to be a vehicle for program transformation rather than
individual clinician review.
Topic Selection
Each provider will have latitude to choose a programmatic topic for
ongoing exploration which they identify as an avenue to improve quality
of care to consumers. To aid the process of topic selection,
ACBHCS encourages the use of brainstorming sessions and staff focus
groups. In keeping with the current shifts in our system priorities
toward empowerment, resilience and wellness and recovery, the topic
selection process should enhance staff involvement and buy-in to the
process and outcomes.
It is important to decide whether the program’s focus will be on a
specific topic or on an issue identified as a current problem, as
explained below. Both approaches are equally valid and useful but
carry different implications and mind-sets. Program choice of
Topic vs. Problem as an approach may initially have more to do
with ensuring staff buy-in than the actual subject matter, as staff
resistance can be higher when focusing on an established problem.
Topics: Topics can be generated from staff interest,
changes in program emphasis, population served, etc. Topics do not imply
the need for correction or that an error has occurred, they only imply a
desire for potential ongoing change and improvement.
Problems: Problem identification is usually the result
of a negative outcome. It is crucial for the health of any organization,
its staff and its consumers to be able to examine problems and identify
creative solutions. Indicators of problems in service delivery can
include:
- Single/sentinel events of major impact
- Collective events or patterns: problems that together are of
concern
- Trends giving reason for concern over time
- Issues raised by multiple sources
Peer Review Committee (PRC)
A Peer Review Committee (PRC) will be established by the Center
Director/Executive Director/designee at each provider site or program.
Agencies with multiple programs may complete a separate PRC and topic
for each site.
Participation in the PRC will be open to all program staff, including
clinical and administrative. At least one of the committee participants
must be a licensed Mental Health Practitioner. The Center
Director/Executive Director shall assure that the PRC has sufficient
resources and authority to carry out its responsibilities as set forth
in this plan.
- The PRC will review, over the course of one fiscal year, at
least eight clinical cases, as they relate to the chosen program
topic or problem. Larger programs are encouraged to look
at a larger sample to increase the reliability of the data.
- The PRC will protect the confidentiality of the consumer(s)
according to HIPAA guidelines, as delineated below.
- The PRC will analyze review findings and make recommendations,
including staff training needs, changes to program and service
delivery.
- The PRC will perform at least twice yearly self-appraisal of
their Peer Review process to assess effectiveness and make necessary
improvements.
- Minutes and summary reports of the PRC activities will be
maintained by the provider site.
- Other functions and responsibilities may be assigned, as
determined by ACBHCS.
Committee Documentation: Compliance and Administrative
Reporting
By July 1st of each year, the Center Director/Executive Director will
submit to the BHCS Quality Assurance Administrator, a report of
Committee activities, findings and recommendations, using the PRC report
guideline. Adherence to these guidelines is essential to maintain
consistency in reporting across programs to give the county useful data
that can be shared.
The QA Representative will formulate a county-wide summary report of
findings. This report will be made available to the BHCS Training
Committee where it will be used to assess needs for specific training
programs. Training will be provided through BHCS to meet
broad-based provider needs. In addition, the findings will be made
available to all providers via the BHCS website and an annual
conference.
All reports required by this Plan shall be kept separate from
consumer clinical records and shall be stored in a locked file.
Peer review reports taken off-site shall not include names or
demographic information which could be used to identify individual
consumers. Peer review reports produced within the provider site
shall not identify a consumer by name. Peer review reports and
proceedings are subject to all confidentiality requirements as is other
information kept in personnel and clinical records. Participation
in the PRC is subject to the same confidentiality requirements as
applied to any other form of collaboration and/or consultation among
staff.
Overview of the Peer Review Plan
- Topic Selection
- Plan a change and implement
- Peer Review
- Analyze results and draw conclusions
- Report
Small Agency Adjustment
Any agency serving 10 or less distinct clients in one fiscal
year is not required to do a full Peer Review. Instead, the Agency
will submit to the QA Office an annual letter reflecting what their
program has done during the fiscal year to improve clinical care during
the fiscal year. This letter is due on the same cycle as all other
Peer Reviews, on July 1st of each year. If an agency feels
they qualify for this exception, they must notify the QA office in
writing, no later than October 1st
of the beginning of the fiscal year.
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