Area
|
Objective
|
Measure
|
Target
|
Average
|
Access
|
Ensure that individuals have access to all appropriate services in routine, urgent and emergency situations
|
Responsiveness to initial request for service.
|
0-2 Business Days – For initial referral to scheduled Initial Assessment
|
1.52 days
|
Access
|
Ensure that individuals have access to all appropriate services in routine, urgent and emergency situations
|
Responsiveness to initial request for service.
|
0-5 Business Days - Intake to scheduled appointment for Treatment
|
5 days
|
Access
|
Ensure that individuals have access to all appropriate services in routine, urgent and emergency situations
|
Responsiveness to initial request for service.
|
0-14 Business Days – From intake to First scheduled MD appointment
|
8 Days
|
Access
|
Ensure that individuals have access to all appropriate services in routine, urgent and emergency situations
|
Responsiveness to initial request for service. %
|
Appointment Canceled by Staff is less than 5%
|
0.74%
|
Access
COVID Impact
|
Service provided in natural community settings
|
BH Services provided in home, school or community %
|
70%
|
20%
|
Engagement into Treatment
|
Appointments Kept at Initial Assessments
|
Show Rate %
|
80%
|
80%
|
Engagement into Treatment
|
Initial Psychiatric Appointments Kept
|
Show Rate %
|
80%
|
92%
|
Substance Use Disorders
Child & Adolescent
|
Evidence of outpatient substance abuse treatment services & programming available
|
Hours Available
|
5 hours
|
10 hours
|
Substance Use Disorders
Child & Adolescent
|
Evidence of individuals with co-occurring SUD diagnosis receive group counseling to addresses SUD issues
|
% Individuals Receiving Group Services
|
80%
|
70%
|
Effectiveness
|
Improved Community Functioning
|
% of clients with no reentry into crisis stabilization units and/or long-term psychiatric facilities.
|
70%
|
75%
|
Individual Satisfaction
|
Satisfaction with services provided
|
maintain a total score of 90% customer satisfaction (Agree/Strongly Agree)
|
76%
|
50-94%
|
Family Satisfaction
|
Satisfaction with services provided
|
maintain a total score of 90% family satisfaction (Agree/Strongly Agree)
|
97%
|
84-100%
Mode=100
(n=11/24)
|
Stakeholder Satisfaction
|
Satisfaction with services provided
|
maintain a total score of 90% stakeholder satisfaction
|
90%
|
91%
|
Risk/Corporate Compliance
|
Reduce Risk
|
Conformance with HIPPA/Corporate Compliance %
|
100%
|
100%
|
Risk/Corporate Compliance
|
Reduce Risk
|
Number Worker Comp Injuries
|
1
|
0.025%
(n=1/40)
|
Risk/Corporate Compliance
|
Reduce Risk
|
# avoidable accidents
|
0
|
0
|
Human Resources
|
|
Maintain “0” Staff Grievances
|
0
|
0
|
Human Resources
|
Train Clinical Staff in Best Practice
|
% Staff ESFT Trained
(Clinical Director/Consulting withDr Steve Simms, Phd.))
|
100%
|
100%
|
Health/Safety
|
Reduce Risk/Increase Staff/Customer Safety
|
Compliance with scheduled drills %
|
100%
|
100%
|
External Audits
|
Compliance with DBHDDF/DCH Billing Standards
|
ASO/CMO Score %
|
90%
|
81%
|
External Audits
|
Compliance with DBHDD Documentation Standards
|
ASO Score %
|
90%
|
94%
|
Peer Review Clinical Documentation
|
Compliance with DCH/ DBHDD & DII Standards
|
% Compliance
|
100%
|
90%
|
