12AS 9249 W. Lake City Road
Houghton Lake, MI 48629 / Authorization & Approval:

Darrell E. Milner, Executive Director

Title: MidMichigan Health Services Behavioral Health
Continuous Quality Improvement & Peer
Review Policy

Brian Gedeon, MD, SBHC Advisor

Stacey Gedeon, PsyD, Behavioral Health Director

Effective Date:
7/27/2011 / Reviewed:
7/27/2011 / Supercedes:
N/A

I. Policy Statement:

MidMichigan Health Services (MHS) & School-Based Health Center (SBHC) Behavioral Health Providers will participate in the MHS Continuous Quality Improvement Plan and a Peer Review Process consistent with credential requirements and employee performance evaluation of MHS.

II. Policy Purpose:

To define peer review and Continuous Quality Improvement plan (CQI)

process.

III. Definitions:

Continuous Quality Improvement (CQI)- Consisting of or including peer/chart review, case consultation, journal review/update of new evidence-based practices, presentations, and other activities relating to best-practice in the field.

IV. Policy Standards

  1. Behavioral Health Providers will participate in the MHS CQI program as one entity.
  1. CQI is an ongoing element of the Behavioral Health Consultation Group’s meetings.
  1. Oversight of CQI plan is assigned to MHS’s Quality Improvement

Coordinator who may designate duties to others as appropriate.

  1. All records, data and knowledge collected for a quality management functions are confidential.
  1. Behavioral Health Providers participate in a peer review process based on

MHS requirements.

  1. All Behavioral Health Providers will participate in a peer review

process of quality care provided which includes chart review and professional discussion.

a. Process includes management for corrective actions.

b. Individual peer review performance results are placed in the Behavioral Health Director’s office suite.

2. Random audits of client assessments and treatment notes may also

be conducted by the Behavioral Health Director and/or designeeand

maybe used inthe employee’s annual performance evaluation.

  1. The Behavioral Health Team implements a quarterly review of 5 charts per

provider.

  1. Behavioral Health Providers utilize the standard “Behavioral Health

Chart Review Tool” to conduct quarterly reviews. (See Attached)

  1. Review and signature of peer review forms indicating understanding of necessary corrective actions will take place within 2 weeks of receipt of reviewer’s comments.

Behavioral Health CQI

Corrective Action Agreement

I have received and understand the reviewer’s comments and plan to implement corrective action as noted below in subsequent “eClinical” patient notes.

Summary of Identified Corrective Action Needed:

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Plan for implementation and/or rationale for continuing similar practice:

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Provider NameDate

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Signature

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Stacey Gedeon, PsyD, DirectorDate

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CQI CoordinatorDate