Quality Assurance

Quality Assurance

  1. The Board of Directors of Mid-Ohio Psychological Services, Inc. authorizes the Quality Assurance Committee to oversee the Quality Assurance (QA) procedures. The Quality Assurance Committee shall be comprised of a multi-disciplinary team including at minimum, the Operations Director, the Quality Assurance Coordinator, a representative of the support staff, and a clinical representative from each site. The Quality Assurance Committee will meet at least twelve times annually.
  2. The Quality Assurance Committee will be responsible for evaluating the Quality Assurance Plan. The quality assurance plan will be updated and approved annually by the Board of Directors during the September meeting. The Executive Director is responsible for integrating all quality assurance activities. The result of the Quality Assurance Review will be provided to the Board of Directors and the ADAMH Board at least on a quarterly basis. Monthly quality assurance meeting minutes will be distributed to all staff members and an opportunity will be made for staff members to provide feedback concerning the activities of the Quality Assurance Committee and the provision of services.
  3. The quality assurance plan is made up of four primary components: Clinical Accountability, Utilization Review, Professional Staff Organization (PSO), and the Safety and Infection Control.
  4. Although Mid-Ohio Psychological Services, Inc. does not currently contract with other agencies, the Quality Assurance Committee and the Executive Director will ensure that every effort will be made to incorporate quality assurance standards within such contracts.
  5. Efforts will be made to support a multi-disciplinary framework for all quality assurance reviews and activities. All disciplines currently working through Mid-Ohio Psychological Services, Inc. are to be represented in the quality assurance activities.
  6. Confidentiality will be maintained during all quality assurance activities as ensured in the Client Guidelines. To ensure confidentiality, only client ID numbers will be used in documenting issues germane to a particular client. All quality assurance minutes containing client specific information will be kept in a locked area accessible only to the Quality Assurance Committee. Information, which must be shared with outside agencies, such as the ADAMH Board, will not have client names or other information, which may identify any individual client. The majority of the data will be in aggregate form.
  7. When a conflict of interest occurs in the quality assurance procedures, every effort will be made within the organization to resolve the conflict. Usually this can be achieved by having the conflicting party simply remove themselves from the process and finding an appropriate replacement. If a conflict of interest cannot be resolved internally, the Board of Directors will develop a solution to the conflict. Service providers cannot review their own cases for quality assurance activities.
  8. All client rights complaints and grievances will be reviewed by the Quality Assurance Committee at their regular meetings and will recommend the Executive Director and/or Board of Directors to take appropriate action. Additionally, the Quality Assurance Committee will include a description of client grievances and complaints in their annual review report.
  9. In conducting all quality assurance activities, special emphasis shall be placed on those aspects of care with the greatest impact on the quality of services, including those of high volume, those known to be problematic, those offered to persons with multiple service needs, and aspects of care related to ethnic and minority populations.
  10. Each area of business/service shall have the opportunity to identify and review major aspects of care annually which may receive special emphasis. This review will be forwarded to the Quality Assurance Committee as part of the overall Quality Assurance Procedures. The results of this annual review will be forwarded to the Board of Directors and the ADAMH Board for appropriate action.
  11. All quality assurance reports will be maintained for at least five years.
  12. Core quality assurance activities (such as annual review of agency policies and procedures, client satisfaction survey, etc.) will be conducted on a scheduled basis as clarified on the Quality Assurance Activity Schedule.

rev 1/18/2018



Quality Assurance Committee (QA Committee)

The purpose of the QA Committee is to oversee and carry out the Quality Assurance Plan.  The QA Committee shall review information from the Clinical Accountability/Utilization Review/Professional Staff Organization/and the Safety and Infection Control.  The QA Committee reports to the Executive Director and the Board of Directors.  The QA Committee will be responsible for compiling the Annual Quality Assurance Review.  The QA Committee is responsible for ensuring that the overall quality assurance needs are met.  If a trend and/or other clinical issue is identified, the QA Committee will do a “focused review” and recommend corrective action to be carried out by the Operations Director and/or the Executive Director.

The QA Committee will review and annually assess the effectiveness of the Quality Assurance Plan.  Specifically, this annual review will include a review of:

1) Achievement of plan’s overall goals and objectives

2) Achievement of accepted professional standards of practice

3) Resolution of identified problems

4) Assessment of the efficacy of quality assurance activities and the adequacy of corrective actions

5) Improvement of service delivery systems

6) Communication of the findings to the agency staff, the agency’s Board of Directors, and the local ADAMH board

This will be completed by reviewing the QA Committee findings and reviewing the overall quality assurance process as it interfaces with the Board of Directors and the ADAMH Board.

The QA Committee meets at least 12 times a year. Clinical representatives from each site, representing the range of clinical disciplines practicing within the agency, the Director of Operations, and other staff when appropriate.  The purpose of the Committee and meetings is to encompass the entire QA process, as our agency size does not allow for separate committees to be developed for each area of QA.

During the monthly meeting, the current status of QA activities is given.  This includes an update on what reports are being worked on and corrections being made from previous months.  The Committee addresses any areas of concern. All client rights complaints and grievances will be reviewed by the QA Committee, and the Committee will recommend the Executive Director and/or Board of Directors take appropriate action.  The focused area of review is addressed.  Ideas will be sought and action plans decided upon to meet the QA activities schedule requirements.  This may entail surveys, running statistical reports, or conducting chart reviews.  Responses to the previous month’s focus review are made based on the information collected during the review process.

Monthly data is collected, reviewed and analyzed to track clinician Continuing Education Units (CEU’s) for PSO purposes, community agency referrals, and referrals to and from hospital facilities.

Client rights and grievance issues are reviewed and analyzed for the monthly QA report.  Any needs for corrective action and re-education are facilitated through the agency’s supervision process.

The QA Committee also reviews and analyzes Clinical Accountability, Utilization Review, Professional Staff Organization, and the Safety and Infection Control documents.

QA Goals and Objectives

Goal: Monitor agency and staff’s compliance with state requirements and internal policies and procedures

Objectives: Clinicians and other agency staff as applicable must consistently complete documentation that is required by this agency, the State and the accrediting agencies that this agency is associated with.


Goal: Monitor continuing education and training

Objectives: Clinicians and other agency staff must continue to meet the standards of the State toward maintaining their licensure, developing competencies, and improving the quality of care for our clients.


Goal: Ensure clinical accountability

Objectives: QA staff will work with clinicians to make sure that they are providing a thorough assessment, accurate diagnoses, and services that are consistent with the philosophies and standards of this agency and the State of Ohio through the peer review process.


Goal: Provide feedback about utilization of services

Objectives: QA staff will develop an understanding of what services are sought at this agency, how these services are accessed, if these services meet the needs of our clients, what other services are needed, are we attempting to meet the needs of our clients when we don’t have the available service (if so how?), and what external services are we as an agency utilizing and what external services are our clients utilizing.


Goal: Ensure a safe environment free of hazards for staff and clients

Objectives: QA staff will conduct monthly health and safety inspections, quarterly fire drills, and other emergency drills. The QA staff will monitor MUIs to provide re-education or preventative training to avoid future incidents.


Quality Assurance Activity Schedule

Monthly Activities

The QA Committee will review the reports/areas listed below to cover the 4 primary QA components. At any time, the Committee members may decide to add other reports to the meeting when appropriate.

Clinical Accountability: The QA Committee will review data regarding the report of abuse and neglect, clients’ hospitalization, internal and external referrals, clients’ involuntary termination, treatment outcomes, and peer review (records review and clinical care).

Utilization Review: The QA Committee will review data regarding production, utilization of services, waiting time to receive services, waiting list, scheduling issues, and clinician’s retention of clients.

Professional Staff Organization: The QA Committee will review data regarding staff trainings, professional development, and licensure/credentials issues.

Safety and Infection Control: The QA Committee will review data regarding health and safety, emergency drills, fire inspections, clients’ rights and grievances, review of services under contract, and major unusual incidents (MUIs).

Annual Report

The QA Annual Report should present a summary of the reports reviewed during the monthly QA meetings during the respective fiscal year. Additionally, the annual report should provide an overview of the agency including the demographics of the clientele, a review of the QA activities, clients’ and staff surveys, any focused reviews, and any other issues that needed to be monitored due to possible impact in the quality of the services delivered by this agency.


Highlighted Areas of Review


  • PSO activities: Review the accuracy of clinicians’ scope of practice


  • Fire Drill
  • Review of trends and patterns of service offered by the agency, highlighting trends in service
  • Training Survey


  • Review of AOD Services
  • Director Performance Survey


  • Tornado Drill
  • Review accessibility, availability, and appropriateness of services for persons who speak a language other than English, or have a handicapping condition
  • Accessibility Survey


  • Fire Drill
  • Review of changes in any agency’s Policy and Procedure Manuals
  • Client Satisfaction Survey


  • Bomb Threat Drill
  • Review Case Manager/TMP Focused Reviews
  • Employee Satisfaction Survey


  • Power Failure Drill
  • Review of QA Activities: Review achievement of goals and objectives, review QA Policy and Procedures, assess efficiency of QA activities, review resolution of identified problems and corrective actions, review areas for improvement
  • Referral Source Survey


  • Fire Drill
  • Complete Annual QA Report and communicate findings to all agency staff, the Board of Directors, and other outside entities


  • Violent Situation Drill
  • Review of clinical pertinence and appropriateness of services rendered


  • Review of service evaluation activities and identify services to be evaluated (pick one service area)


  • Fire Drill
  • Review/Update the Notebook/Drill Log


  • Medical Emergency Drill
  • Conduct a Consumer Needs Survey




The QA Committee will monitor clinical accountability though the peer review of clients’ charts to evaluate clinical care and compliance with record maintenance. Both clinical care and record compliance will be evaluated through the completion of the Case Compliance Checklist which will separately score clinicians’ performance in clinical care and record compliance review. Record compliance may be assessed separately from time to time as determined necessary by the QA committee.  The Case Compliance Checklist addresses the appropriateness of the therapeutic intervention, the diagnosis, treatment plan, that services were related to the treatment plan goals and objectives, and that documentation accurately reflects the services provided. The QA Committee will review the Case Compliance Checklist at least annually to ensure that the form is updated with any pertinent changes in policies and procedures.

The purpose of reviewing clinical care is to evaluate the quality and therapeutic outcomes of the services provided to the client.  It is to assess the relationship of the diagnosis to the treatment plan, how the treatment is implemented, how the therapeutic process develops, and reviews the clinician’s therapeutic responsibilities for the quality of care given the client.  The ultimate purpose is to ensure high quality client care is provided that is clinically pertinent and appropriate. The purpose of reviewing client’s records is to ensure the adequacy and completeness of the information contained in the client record.  It is to ensure that pertinent, timely, appropriate, and legible information is contained in client records.  Completeness shall refer to the specified uniformity in the record keeping.


The QA Coordinator will randomly choose client names from the active clients list and the termination query list for every clinician each month. The list of charts to be reviewed (Peer Review List) will be available online to all staff and will be updated by the QA Coordinator at least monthly. The review will be conducted by trained staff who will complete the Case Compliance Checklist. Upon completion, the reviewer scores the checklist and will note any deficiencies on the Case Compliance Checklist. The reviewer then will scan the Case Compliance Checklist to QA, leaving the original for the clinician responsible for the case to make the appropriate corrections. After the corrections are completed, the Case Compliance Checklist is to be reviewed and signed by the clinician’s supervisor. The clinician will then scan the Case Compliance Checklist to QA again with the appropriate corrections and signatures. It is the clinician’s responsibility to take appropriate action to either bring the case into compliance with accepted standards or offer a written explanation which addresses the noted deficiency by means of clarifying and explaining the nature of the deficiency. If the clinician chooses to appeal the findings of the reviewer, he/she may do so by filing a written appeal to the QA Coordinator whose responsibility it is to then accept the clinician’s explanation or enforce the findings of the reviewer within five working days of the receipt of the appeal. The QA Committee targets to have at least 10% of all active charts reviewed in a period of 12 months. Besides active charts, at least 10% of the Peer Review list should include closed charts. This random selection of records shall represent at least one record from each clinician, one representation of each of the services provided including at least; one AOD client, one youthful client record, one adult record, and one record representing an ethnic or racial minority group as available within the agency. The records of AOD Program clients will be included in this review and the reviewer will have a documented AOD scope of practice.  During this process, the clinical staff member responsible for any case under review is excluded from the Peer Review of his/her client’s case record.

The entire chart should be reviewed. The threshold to pass is 90% compliance. The QA Coordinator shall review 5% of all charts reviewed to check for signatures and corrections. If corrections are necessary but are not made, the QA Coordinator shall bring this to the attention of the clinician’s supervisor.

The QA Coordinator will monitor patterns of low scores and inform the clinician’s supervisor when there is a pattern of scores below 80%. If a particular clinician is found to have consistent inadequacies in documenting clinical activities, reeducation and/or disciplinary action may be initiated through the supervision structure.  The results of the chart review, including clinical care and client’s records review will be reported in the monthly QA meeting by recording each site’s and agency’s overall performance.  Each client record within the framework shall be organized in a manner consistent with the policies and procedures and the model record on file at the agency.  The general organization of the client record shall be the responsibility of the support staff.

Client Involvement

All clients/families of clients will be given the opportunity to complete an anonymous Quality of Service Survey/Client Satisfaction Survey (MHSIP), which will be made available to them annually.  All surveys will be collected when completed.  Clients will be surveyed in the following areas:

  • Appropriateness (Responsiveness to client needs)
  • Cultural Competency (of staff providing services)
  • Recommendation of services to others
  • Overall satisfaction


Additionally, the local ADAMH board will share the results of the community wide mental health service survey (Referral Source Satisfaction Survey) and this data will be integrated into the Utilization Review to determine areas of service to be developed.  Finally, persons served, and their families or significant others will be invited to participate in the planning, implementing and evaluating all mental health education services through the Community Service Plan.

Referral Source Surveys

The agency will conduct a Referral Source Survey annually.  Referral sources will be surveyed in the following areas:

  • Access (ease of referral)
  • Program Information (general information about program)
  • Client information (feedback about clients)
  • Overall satisfaction

All surveys will be collected when completed, and the information will be compiled and reported in the Annual QA Report.  The results of the survey will be incorporated into Utilization Review to determine areas of service to be developed.



The purpose of the Utilization Review is to assess and ensure that high quality client care is provided through an effective and efficient utilization of the program’s resources and services.  This entails review of clinical time utilization, scheduling, space allocation, hours of operation, service modalities, and budgeting.  The Utilization Review determines if and what agency resources are underutilized or over utilized, and if these resources are being inefficiently scheduled. It further makes recommendations to address any findings.  The Utilization Review examines length of stay, discharge, and continuation of care criteria, as well as if and when referrals to other resources are appropriate.


The QA Coordinator will conduct Utilization Review.  The QA Coordinator reviews reports related to utilization, active clients, and staff productivity to create the Utilization Review table that records the number of clients assigned to each clinician, the number of clients the clinician saw in that month, and the average number of contacts is calculated. In addition, the percentage of agency dollars billed per clinician and the proficiency of scheduling and production by clinical staff is calculated for the monthly QA report.  In the event that there is a client wait list, it will be reviewed. Payer source information will be evaluated using specific reports, and shared at least once a year in the QA Annual Report. All other findings will be reported in the monthly QA report and any areas of concern will be discussed in the QA Committee Meeting.

Client Record

Utilization Review is also conducted as part of the Case Compliance Checklist.  The QA Committee will concern itself with reviewing the general nature of the services delivery system provided to the client.  Utilization Review will ascertain that service providers are providing only authorized services. The QA Committee assumes the task of assuring that the service is most appropriate to the needs of the client and that the length of involvement is appropriate to those needs.  Additionally, all clients involuntarily terminated will be reviewed.

The QA Committee will review client records to assure coordination of assessment, treatment and termination of services.  This Committee will assure sufficient availability of consultation with one another as well as all staff should any questions arise.  Finally, the QA Committee will monitor and review continuity of services to those discharged from psychiatric inpatient hospitals through Monthly Summary forms completed by clinicians.  The Monthly Summary forms are reviewed and the hospital discharge date is recorded along with the date the client was seen following discharge.  These dates are reviewed to make sure the client received a follow-up session with their clinician within 14 days of discharge.

Scheduling and Monthly Reports

The QA Committee reviews reports pertaining to service delivery.  The QA Committee compares trends in the agency’s historical information and is to identify services that are being under-utilized, over-utilized, or inefficiently scheduled.  Corrective action will be directed through the Executive Director toward specific issues related to direct clinical care and will be forwarded to the Board of Directors for issues which must be addressed at a more global level.

Correction of Problems

It is the responsibility of the Executive Director to ensure the correction of all deficiencies identified by the QA Committee within a time frame agreed upon by the Board of Directors.

Indices and Thresholds

Each clinician is expected to maintain at least a fifty percent face-to-face contact ratio and 90% Peer Review Compliance.

Wait List Management

The agency only uses a wait list when services cannot be provided on a first come, first serve basis and are scheduled with the appropriate clinician at the first available appointment time.

The following procedures would be followed if a wait list became necessary for AOD clients:

An intake would be made. The support staff member taking the intake will then notify the referral source by telephone that the client has been put on a wait list and given the expected length of wait time and then ask the referral source to contact the office weekly if they need an updated wait list status.

  1. Intake usually begins when a client calls with a presenting problem.  Support staff is to complete an Initial Telephone Contact form and the client is assigned to a clinician for intake according to established guidelines.  During the initial phone intake, every effort will be made to determine the existence of any special needs including assistance with language, physical challenges or the potential impediments to the provision of treatment and every effort will be made to address these concerns at no cost to the client. The client would then be categorized to into one of the following groups based on the intake information
    1. Pregnant women
    2. Intravenous drug user
    3. Clients with medical and/or psychiatric emergencies
    4. Non-emergency status clients
  2. The client will be contacted on a weekly basis to notify them of any changes in their wait list status and to verify that there has not been a change in the client’s needs.
  3. Clients will be removed from the wait list when a clinician becomes available, by order of importance with clients with medical and/or psychiatric emergencies and pregnant women being removed first, then intravenous drug users, and lastly non-emergency status clients.
  4. The QA Committee will verify with the Operations Director each quarter whether there is or has been a wait list in effect, and if there is they will check to make sure that clients are being managed according to this policy.



The QA Committee will conduct the activities of the Professional Staff Organization (PSO) to assure the highest degree of professionalism, ethics, and conduct within the scope of the resources available to the agency.  The Operations Director will be responsible for the verification and maintenance of staff members credentialing and licensing.  The QA Committee will be responsible for the quality of all clinical care, verifying that staff are practicing within the scope of practice, and clinical privileges.  The QA Committee will also review the professional disclosure statements of the clinical staff. The QA Committee will ensure that all clinical staff are qualified by training or continuing education to serve persons of culturally diverse backgrounds. These qualifications should include:  the effects on ethnic minority persons of psychiatric interventions, including psychotropic medications; issues related to differential diagnosis of ethnic minority persons; and vernacular language patterns of ethnic minority persons.  The QA Committee will work closely with the Training Director and Training Committee to ensure that staff are appropriately trained to perform the requirements of their jobs and to ensure that they are able to maintain appropriate credentialing.


The members of the QA Committee will conduct all PSO activities.  Information regarding clinician’s CEU obtainment will be collected from the Monthly Summary Report (trainings completed outside the agency) and reports from Eventbrite (trainings completed at MOPS).  Any professional needs within the agency, professional status concerns, and listings of professional staff persons will be reported to the Committee for review and action.  The clinical supervisors are responsible for all diagnoses and treatment of clients whose services are not performed by an independently licensed practitioner.


Designated staff will conduct the safety and infection control activities at each site and report the findings to the QA Coordinator. The Operations Director is responsible for seeing that the agency is in compliance with all Federal, State, and local requirements for health, safety, and accessibility.  All findings will be reported to the QA Committee and the Operations Director who will take corrective action.


Safety and Infection Control activities include monitoring, assessing, identifying, resolving, and evaluating potentially dangerous situations to clients, staff, and the general community within the agency and its satellites.  Areas of concern include, but are not limited to:  Physical Plant, Disaster Evacuation, Hazardous Waste, Electrical Cords, Fire Safety, Handicapped Access, Incident Reporting and Infection Control.

Please see the agency’s risk management policies and procedures for detailed information.


Each month a designated staff member will complete a Quality Assurance Safety and Infection Control form. Any issues discovered will be brought to the attention of the QA Committee and reported in the QA report. The other areas of concern to the S&IC are address in the agency’s Risk Management and Incident Reporting policies and procedures.

Major and Unusual Incident Reporting

All Major, Unusual Incidents (MUI’s) will be reviewed monthly by the Operations Director, Executive Director and brought to the attention of the QA Committee and the Board of Directors.  Specific attention to patterns, trends, and risks that may be identified will be reported on in the QA report. The agency’s policies and procedures for reporting MUI’s are listed under Incident Reporting.


rev 2/2018