a. |
Articulate goals and objectives which represent the IHS mission on behalf of AI/AN people with mental health problems.
|
b. |
Coordinate the formulation of policies and procedures for the professional/technical administration of mental health programs.
|
c. |
Seek resources necessary
to accomplish the mission of the IHS Mental Health Program on behalf of
the Areas, program offices, and tribal groups. Prepare, justify, and
submit to the Director, Division of Clinical and Preventive Services,
requests for necessary staff and budget. Develop and apply criteria which
will realistically guide the acquisition and
allocation of
resources, Advocate for
supplemental resources on behalf of AI/AN people from other governmental and private sources. Provide leadership and assistance in respect to recovering third party reimbursements. Review and recommend final IHS allocations of funds to Areas and special mental health projects.
|
d. |
Serve as a clearinghouse for information relevant to AI/AN mental ,health issues, needs, and services. Encourage a flow of information and communication between providers at all levels of AI/AN mental health programs. Conduct periodic Branch Chiefs and special interest meetings and workshops.
|
e. |
Assist in the recruitment and retention of competent staff committed to the goals and objectives of the IHS Mental Health Program. Serve as a source of information regarding position openings and prospective staff.
|
f. |
Provide
leadership in
assessing and
meeting the
training and continuing education requirements of staff. Maintain a Learning Resource Center
and procedures
for its
utilization. Perform
and/or coordinate training sessions.
|
g. |
Develop and maintain data reporting systems, compatible with IHS-wide plans and responsive to local requirements, services, and programs. Provide additional data necessary for good patient care and management of information. Monitor and interpret output data and systematically advise appropriate
decision makers of changes and trends. Make policy and program changes as needed based on information obtained.
|
h. |
Develop and promulgate standards for mental health services and program management, including standards and review procedures for P.L. 93-638 mental health programs. Conduct periodic management reviews of Area mental health programs with reports on findings distributed to appropriate Area and Headquarters personnel.
|
i. |
Provide Area Directors
and/or Area Chief Medical Officers assistance in recruitment, and
consultation regarding the qualifications, roles, and responsibilities of
the Area Mental Health Program Consultants. Area consultation is
encouraged by the Headquarters Mental Health Programs Branch, prior to the
selection of the Area Mental Health Program Consultants.
|
j. |
Advise IHS officials, including financial management and contracting offices, on technical and professional matters relating to AI/AN mental health issues. Serve as consultants to IHS, other Federal and State agencies, tribal organizations, professional associations, and private organizations in respect to issues and needs in AI/AN mental health programs.
|
k. |
Work closely with the Office of Planning, Evaluation and Legislation, Office of General Counsel, and other appropriate agencies in respect to legal issues involving the care and treatment of mentally disturbed patients and in other matters pertaining to the delivery of mental health services.
|
l. |
Through consultation, technical guidance, and program leadership assist Area mental health staff in planning and implementing the mental health program objectives and in carrying out established policies.
|
m. |
Assist the preparation of legislation as may be required. Prepare reports on proposed legislation which may affect the IHS Mental Health Program. Prepare proposed responses as
requested on behalf of the Director, IHS, to congressional, tribal, and other inquiries pertaining to AI/AN mental health issues and programs.
|
n. |
Revise and update policies, procedures, standards, etc., which reflect changes made by laws and policy decisions executed by the Director, IHS. Perform annual review of existing mental health standards and manual issuances.
|
o. |
Work with the Personnel Management Branch in developing personnel guidelines for mental health staff including duties, classification, performance evaluation requirements, selection criteria, etc.
|
p. |
Keep the Director, IHS and appropriate Headquarters staff informed on program operations, including accomplishments and problems. Submit an annual report and special issue papers or reports as requested or necessary.
|
q. |
Assure liaison and cooperatively work with other IHS programs including the alcoholism staff, social services staff, Maternal and Child Health staff and other clinical programs.
|
r. |
Assure liaison and
cooperatively work with the National Institute of Mental Health, Bureau of
Indian Affairs (BIA), and other relevant State and Federal agencies whose
programs and resources could impact on AI/AN mental health needs and
programs. In support of and in cooperation with appropriate Directors of
Mental Health Program Branches in the Areas, facilitate cooperative
linkages with the BIA, State, and regional office authorities.
|
s. |
Facilitate and
monitor special
extramural
research projects which will have practical benefits on behalf of the AI/AN
service populations. Provide critical reviews for proposed research projects. Identify areas of needed research for AI/AN research organizations and others seeking such information. Conduct and assist in intramural research projects.
|
t. |
Assist the
cultural sensitivity
process of
health care providers and program administrators responsible for delivery of services to individuals and communities with cultural differences and needs. Identify culturally sensitive issues and problems. Provide consultation, workshops, and other means to address key community issues and problems.
|
u. |
Conduct special
mental health
related projects
and perform other tasks at the request of the Director, IHS, or other appropriate authorities.
|
a. |
Articulate Area specific goals and objectives consistent with the IHS Mental Health Program goals and objectives.
|
b. |
Formulate policies and procedures for the professional/technical administration of mental health programs at the Area level, revising and updating them as needed or directed. Such policies must be consistent with the IHS policy manuals.
|
c. |
Develop plans for the mental health services in the Area.
|
d. |
Coordinate mental health services, policies, procedures, and programs with those of other IHS Area activities including the Contract Health Care staff and the Financial Management Branch.
|
e. |
In accordance with IHS
and Headquarters Mental Health Programs Branch policies and agreements,
develop and maintain cooperative relationships with other Federal, tribal,
State, and local agencies.
|
f. |
Provide consultation to the Area Director, Area Chief Medical Officer, and other officials on technical and professional issues. When requested, represent the Area at public and other meetings.
|
g. |
Keep the Area Director, Area Chief Medical Officer, Headquarters Mental Health Programs Branch Chief, and Service Unit/tribal mental health staff informed about program operations, problems, and accomplishments.
|
h. |
Serve as a resource for training and technical assistance to Area and Service Unit staff as well as to tribes on programs, services and issues in the field of mental health. Establish close liaison and working relationship with Area alcoholism, social service and other human service program staffs.
|
i. |
Provide technical guidance and consultation to directors of Service Unit mental health programs and others charged with mental health program responsibility in order to assure comprehensive care and maintain conformity with established policies, standards, and procedures.
|
j. |
Provide Service Unit Directors or administrators assistance in recruitment and consultation regarding the qualifications, roles, and responsibilities of Service Unit mental health program staff. Develop position statements about the needs for mental health providers with specific expertise and the identification of human resource shortages in various professional
disciplines.
Perform
reviews of
annual
performance evaluations of the Service Unit mental health staff as necessary. The Area Mental Health Program Consultant should be consulted regarding all mental health personnel and contractors prior to their selection.
|
k. |
Perform program reviews, at least annually, of each Service Unit and Tribal 638 Program. Such reviews involve monitoring and evaluating program operations according to IHS Mental Health Program standards. Provide consultation and technical support to Service Units or Tribal 638 Programs with respect to quality of care.
|
l. |
Prepare an annual Area
mental health budget in appropriate format to include staffing requirements,
contracts, and other operational expenses and submit a copy to the Headquarters
Mental Health Programs
Branch. Provide allocation of categorical mental health funds to the Service
Units and/or tribal mental health program contractors. Because they are
categorical, mental health positions and funds shall not be used for non-mental
health program
services. Work
closely with
the Area
Financial
Management Branch in
administering the mental health program. Seek supplemental funding from other
sources in order to strengthen Service Unit/tribal mental health programs.
|
m. |
Serve as a resource and clearinghouse for information relevant to Area specific mental health issues, needs, and services. Encourage appropriate flow of communication between providers within the Area. Develop and conduct periodic staff meetings and workshops on mental health issues for the various health care disciplines.
|
n. |
Work with the Area Office of Personnel Management and the Service Unit staff in developing appropriate position descriptions, classification, selection criteria, vacancy announcements, etc., with respect to mental health personnel.
|
o. |
Assist in the sensitization process of health care providers and program administrators to Area mental health issues and problems, including culturally sensitive matters. Provide consultation, workshops, and other ways to deal with identified mental health needs and issues.
|
p. |
Assure the provision of continuing education and training opportunities for mental health staff within the Area. Advocate for access to Area training funds for mental health training.
|
q. |
Assure the use of authorized patient care and activities reporting system by all mental health providers and consultants within the Area. Carefully monitor, review, and interpret outcome information, providing relevant information to
decision makers and care givers. Gather, study, and report other pieces of useful information, including specialized patient care reports which may impact on program services and management.
|
r. |
Provide strong advocacy on behalf of Area direct service providers and Service Unit mental health staff with respect to the importance of architectural and environmental concerns. Emphasize the recognition that therapeutic outcomes of mental health services are influenced by facility design and arrangement. (See Policy on Architecture and Environment section 3-14.5B(2) on page 60.1
|
s. |
Serve as technical project officers on P.L. 93-638 grants and contracts and other contracts pertaining to mental health services within the Area, if requested and if the project officer function does not compromise the competent execution of mental health duties. Participate in the development of scopes of work and selection of contracting procedures to be used for any mental health functions to be contracted.
|
t. |
Maintain close communication and working relationships with Headquarters Mental Health Programs Branch. Attend IHS Mental Health Program Branch Chiefs meetings.
|
u. |
Prepare and submit an annual mental health program report to the Area Director and the Headquarters Mental Health Programs Branch, including preparation of other routine and special reports as needed. Respond in timely
manner to special requests for information from the Area Director or the Headquarters Mental Health Programs Branch.
|
v. |
Conduct special mental health related assignments and perform other tasks at the request of the Area Director or other appropriate authorities. Consultation is encouraged with the Headquarters Mental Health Programs Branch for any non-mental health related details of TDY assignments of Area mental health staff.
|
w. |
Provide advocacy
for prioritizing
Contract
Health Care Services (CHS) funds for mental health needs. Each Area mental health program shall develop a prioritization of CHS mental health services.
|
x. |
Develop and update goals and objectives for the Area health promotion/disease prevention activities in relation to IHS national objectives.
|
d. |
Through joint planning, coordinate mental health services with activities of other Service Unit programs, tribal programs, BIA, schools, state agencies, and other providers to the service population. Establish
close liaison
and working
relationships with local alcoholism, social service, and other human service programs. Through these relationships, help assure a high standard of service delivery and continuity of patient care.
|
e. |
Serve as a clearinghouse for information relevant to Service Unit specific mental health issues, needs, and services.
|
f. |
Develop long term plans for mental health service delivery based on an assessment of local needs and resources and tribal specific health
plans. Based on the long term plan and any special emphasis objectives, an annual program plan should be developed. Make recommendations on program requirements, e.g., personnel and operating costs, for use in preparing budget and position requests.
|
g. |
Select program staff with concurrence of the Service Unit/Facility Director and in consultation with the Area Mental Program Consultant.
|
h. |
If requested, serve as
technical project officer for tribal or other mental health related
projects. Assist in the development of scopes of work for any mental
health functions to be contracted.
|
i. |
Consistently utilize authorized patient care and activities reporting system. Document patient
contracts in the health record. Assure the confidentiality of all patient
information. Analyze and utilize data output for clinical case
management and program planning.
|
j. |
Inform the Clinical Director, Service Unit Director, and Area Mental Health Program Consultant about program operations, accomplishments ..and needs. Prepare and submit monthly program narratives, annual program reports, and other routine or special reports to the Area Mental Health Program Consultant in a timely manner.
|
k. |
Adhere to mental health program standards of care for direct and indirect services.
|
l. |
Assure that appropriate professional supervision is provided for all staff and that accurate position
descriptions, standards of performance, evaluations, training, or continuing education plans are developed and updated.
|
m. |
Assure that a local quality assurance process to evaluate patient/client services is consistent with the IHS Mental Health Program policy.
|
n. |
In consultation with the Service Unit Director and appropriate staff, assure that the architecture and environment where mental health services are provided are conducive to therapeutic outcomes (see Policy on Architecture and Environment on page 60).
|
o. |
Develop a local directory of Federal, state, tribal, and other. resources useful for making referrals, gathering information, and consultation.
|
p. |
Based on their training, qualifications, and experience, professional staff should apply for and obtain appropriate clinical privileges in accordance with the bylaws of the Service Unit medical staff and the State law of the state in which the Service Unit is located.
|
q. |
Work cooperatively with the Service Unit Contract Health Care and third party reimbursement programs to assure that mental health services are included. Each local mental health program should define mental health Contract Health Care priority categories.
|
r. |
Conduct special mental health related assignments and perform other tasks at the request of the Service Unit Director, Area Mental Health Program Consultant, or other appropriate authorities. Consultation by the Service Unit administration with the Area Mental Health Program Consultant is encouraged for non-mental health related details.
|
s. |
Develop Health Promotion/Disease Prevention services and related mental health priorities and objectives. Assume responsibility for the Service Units Health Promotion/Disease Prevention activities.
|
t. |
Advocate for the development of and participate in the maintenance of an up-to-date suicide register. The register should contain information on suicide gestures, attempts and completions.
|
a. |
A written plan is to be established at each Service Unit or facility indicating resources to be utilized in providing emergency mental health services, contact persons, and means of contact including available telephone numbers.
|
b. |
The plan should include a roster indicating 24-hour, seven days a week mental health emergency coverage. The roster is to be posted and made available to staff providing emergency medical and other emergency services (i.e., police). The roster should indicate levels of available consultation (e.g., paraprofessional or professional).
|
c. |
Information on emergency mental health services available locally is to be updated on at least an annual basis for IHS or tribal staff providing emergency medical and other emergency services.
|
d. |
Selective training on the identification and handling of patients in psychiatric emergency situation will be provided to health care and social service staff, police, and others. New staff will be fully oriented to emergency service policies and procedures.
|
e. |
The Service Unit/tribal mental health programs will have a written policy and procedure for the assessment and management of suicidal, homicidal and other violent patients, including use of restraint
such policies will be consistent with other Service Unit or facility policies, and Joint Commission on Accreditation of Healthcare Organization (JCAHO) and Medicare standards.
|
f. |
The
Service Unit/tribal
mental health
programs
shall develop and maintain an up-to-date suicide register. The register is to identify suicide gestures, attempts and completions. This should include information from emergency room rosters, police, courts, coroner and state data collection agencies. Procedures for avoiding duplication of reports should be employed to the extent possible. Efforts to reach out to significant others will be made and recorded in all cases of completed suicides.
Training in recognition of persons who are potentially suicidal and appropriate intervention will be provided annually be all staff and be available to all interested persons and relevant agencies. Separate psychological autopsies should be completed for all mental health patients who have been under treatment and who are dead on arrival. All register data should be coded in such a way as to protect patient confidentially and should be maintained in locked files. Composite statistical information may be used to establish baseline rates of suicides, attempts and gestures and to assist tribes/IHS in developing specific interventions and measuring their effectiveness. Any data used for research or publication should have prior tribal clearance and be screened through appropriate IHS Area research committees.
|
g. |
Locally specific program procedures will be developed and implemented for written referral for mental health services, of persons who have made suicide attempts.
|
a. |
The Service Unit/tribal mental health program will provide or arrange for the full range of outpatient assessment, diagnostic, treatment, crisis intervention and referral service. Diagnostic services shall include differential diagnoses of neurological, infectious, toxic and other medical conditions which produce psychiatric symptoms.
|
b. |
Persons who request mental health services will be contacted by a mental health provider within 72 hours.
|
c. |
The program will provide or arrange for a wide range of treatment modalities appropriate to meet the needs of its clients with special attention to the treatment needs of special populations.
|
d. |
Medical consultation will be sought when
indicated. Appropriate
referral to
physicians
will be made for medical problems.
|
e. |
Patients receiving psychotropic medication will be reviewed by a physician, preferably a psychiatrist, every 30 days and more often if indicated.
|
f. |
Patients receiving major
tranquilizing medications should have their status evaluated by a physician, preferably a psychiatrist for tardive dyskinesia and other drug side effects at least every six months, and more often if indicated.
|
g. |
The Service Unit/tribal mental health program will offer to provide or arrange for training of other care providers who may be involved in following patients on psychotropic medications.
|
h. |
Mental health program staff shall participate, when appropriate,- in inter- and intra-agency meetings and case staffings in order to provide referral, continuity of care, liaison, and networking services for the client/patient.
|
i. |
Mental health staff will be authorized to provide only the services for which they are appropriately trained, credentialed, supervised, and/or licensed.
|
j. |
A disposition note should be placed in the patient record to document plans for direct or referral services. The note should include documentation of discussion and understanding of the plans by the patient or his/her legal representative.
|
k. |
Hours of service should be posted in clear view at the service program and be related to the needs of the service population. Provisions must be made for alternate service delivery during hours when a facility is closed.
|
a. |
Inpatient care for mentally ill persons in an IHS general hospital must be provided according to established JCAHO, Health Care Finance Administration (HCFA) and hospital medical staff by laws.
|
b. |
Procedures will be developed and implemented for referring persons for outpatient follow-up.
|
c. |
With approval
of the
attending physician,
mental
health staff may provide verbal and written assessments; make provisional diagnosis, develop or assist in developing goals of hospitalization and treatment plans, visit patients daily to provided therapy, consult with staff on patient management, provide or arrange for appropriate referrals and otherwise assist with patient management issues.
|
d. |
The discharge plan should be developed soon after the patients admission, involve
the patient's admission, involve patient,
family, and
other providers
as
appropriate, and be
consistent with goals set in the individual treatment plan.
|
e. |
The mental health program should provide or arrange for training for staff regarding the management of psychiatric patients in a general-medical hospital setting.
|
a. |
Mental health providers will respond to requests from other health care providers on the hospital/clinic staff for consultation regarding diagnosis, planning, management, referrals and follow-up of individual patients.
|
b. |
Mental health providers will establish professional relationships with other health care providers and community agencies in the community in order to assure assistance for their patients, and to increase their awareness of local mental health issues and the services that are available to clients.
|
c. |
Mental health providers should participate in hospital/clinic activities and have input in the program and administrative planning of health services and treatment policies.
|
d. |
Each mental health program will develop and maintain a local/regional resource directory.
|
e. |
Mental health staff shall participate in the interagency Child Protection Team (CPT).
|
f. |
Mental health staff should contribute to the development and maintenance of child abuse/neglect and handicapped child registers.
|
g. |
Mental health staff should participate in the establishment of Area/Service Unit level multidisciplinary teams/committees to address mental health care needs of children and other underserved populations.
|
a. |
Formal assessment:
Policies and procedures should provide for timely formal assessment of behavior and level of functioning to be performed on every individual patient, couple or family accepted into treatment.
|
b. |
Content of patient assessment:
The assessment process should include evaluation of strengths and weaknesses in the context of the patients environment from a multi-faceted point of view including cognitive, emotional, developmental, psycho-social, and physical functioning.
|
c. |
Review of records:
All pertinent records which may include medical records, school records, and legal status are to be obtained and reviewed. Required releases of information will be obtained.
|
d. |
Content of the patient interview:
Initial assessment interview shall include a review of presenting problems, chief complaint, recent and past history, social and family history, significant medical history, and use of drugs and medications. A mental status examination will be performed on patients accepted into
treatment. Family members and/or
significant others will
be interviewed when appropriate. The initial assessment will be documented
in the patient record.
|
e. |
Additional assessment procedures:
When additional assessment is required to understand a. patients condition and to make a diagnosis, it is the providers responsibility, with consultation if necessary, to perform the additional assessment or to make an appropriate referral. Additional assessment procedures can include physical examination, specialized neurological or other examinations, laboratory tests, radiological examinations, and psychological testing.
|
f. |
Diagnosis:
The assessment process
leads to a formal diagnosis. The DSM-III-R diagnostic criteria
or
the current equivalent
with its five (5) axes as appropriate should be utilized. In utilization of
DSM-III-R, providers should allow for flexible interpretation given local
cultural and social values. The DSM-III-R is a three volume psychiatric
diagnostic classification system used frequently by mental health providers. The
results of the assessment process shall be documented in the patient record.
|
a. |
The treatment planning
process will be initiated following screening and assessment for all mental
health treatment provided directly by the staff. When
patients are
referred to
outside
consultations or treatment facilities and are anticipated to return for treatment, a copy of the treatment plan is to be sent to the referral mental health program.
|
b. |
A mental health contact consisting of a onetime service appointment does not require a formal plan.
For patients
requiring ongoing care, an initial treatment plan shall be r.: developed by the clinician by the third
visit.
The treatment plan shall be based on the diagnostic assessment data including cultural values. The treatment plan should include services to be provided by mental health staff directly, referrals, frequency of services, expected length of treatment and the name of the staff member assigned to work with the patient. Progress notes and/or discharge summary are required.
|
c. |
The treatment plan shall contain objectives, methods for achieving them, measurable and appropriate outcome, and a plan for periodic review. Timeframes for periodic review for complex and long term problems and for situations involving lack of progress should be established.
|
d. |
Appropriate therapeutic efforts may begin before a fully developed treatment plan is finalized and should consider spiritual/cultural orientation, the patients presenting problems, physical health, emotional status, and behavioral status. The Subjective/Objective Assessment Plan (SOAP) format will be utilized to document patient contacts. The SOAP format is referenced in the IHS Medical Records Manual.
|
e. |
Each mental health program shall use a systematic, multidisciplinary treatment planning process with patients who have complex problems. Complex situations may include difficult differential diagnosis, involvement of multiple agencies or multiple problems, and the need for long-term ongoing treatment. The multidisciplinary team may include other health care providers, traditional practitioners, school personnel, outside consultations, other mental health disciplines or other agencies depending upon the needs of the patient and the
facility staffing pattern.
|
f. |
Treatment planning may
involve the patient and, as appropriate, the patient�s family, extended
family, school, or significant others.
|
(i) |
crisis intervention;
|
(ii) |
supportive therapy utilizing ventilation, active listening, reflection,
problem redefinition, and others;
|
(iii) |
insight oriented therapy utilizing, in general terms, ventilation,
clarification, enhancement of self esteem and examination of alternative
coping strategies, motivational techniques, dream analysis, education and
others;
|
(iv) |
psychodynamically oriented therapy utilizing elements of various
treatment philosophies such as, Gestalt Therapy, Psychoanalysis,
Transactional Analysis, Rational Emotive Therapy, Reality Therapy,
Psychodrama and others;
|
(v) |
behavior modification utilizing progressive relaxation, cognitive
therapy, hypnotherapy, desensitization, biofeedback, stress management,
and some forms of adverse conditioning; and
|
(vi) |
Pharmacotherapy (see item in this standards section).
|
a. |
The local mental health program is supervised by an individual designated by the administration of the Service Unit in consultation with the Area Mental
Health Program
Consultant. Local
mental health program directors are responsible for overall development and implementation of mental health programs, professional supervision of mental health providers, and for articulating the mental health program to others in the service delivery system and outside agencies within the community.
|
b. |
To assure delivery of optimal services, job descriptions will detail the skills needed by the mental health care provider.
|
c. |
Standards of performance
shall be based on the job description.
|
d. |
Construction of performance standards will be according to-the requirements of the Office of Personnel Management (OPM), including processes for performance evaluation of individuals.
|
e. |
Qualifications and demonstrated competencies should be consistent with those required by the Federal Service.
|
f. |
All paraprofessional level mental health staff should function with adequate supervision by a mental health professional.
|
g. |
Policies and procedures setting forth roles, responsibilities , and supervision of trainees and volunteers should be established.
|
(i) |
familiarize with facility, tribes and communities;
|
(ii) |
cultural orientation;
|
(iii) |
relationships and referrals to other agencies;
|
(vi) |
legal issues (legal status of patients, requirements for patient
consent, confidentiality and Privacy Act information, release of
information;
|
(v) |
organizational structure;
|
(vi) |
job description and performance plan;
|
(vii) |
supervising and consultative relationship;
|
(viii) |
recordkeeping requirements, including the Problem Oriented Medical
Record (POMR), informed consent forms, mental health forms;
|
(ix) |
data reporting systems requirements;
|
(x) |
review of policies, procedures, and protocols relating to local service
delivery (standards of care), mental health standards of care, IHS manual
sections pertinent to duties;
|
(xi) |
professional and ethical standards which include at a minimum,
relationships with patients and co-workers, clinical practice issues, and
confidentiality of patient information;
|
(xii) |
office procedures (phone, travel, filing, etc.);
|
(xiii) |
information on Federal personnel policies and procedures including
employee rights and responsibilities; and
|
(xiv) |
any other related materials deemed important.
|
(i) |
A
process for
delineation of
privileges
for all individuals who are permitted by law and by a facility to provide patient care services independently in a facility whether or not they are members of the medical staff. Consistent with local practice, clinical privileges are recommended for mental health technicians, mental health counselors, and psychiatric nurses. The process for granting privileges should be based on verified information regarding the individuals licensure, specific training, experience, and current competence.
|
(ii) |
Provisions for measurement of initial and continued demonstrated clinical competence in order to assure that patients will receive quality care.
|
(iii) |
Relevant findings from Quality Assurance activities are considered part
of the mechanisms used to appraise that competence of all those
individuals who practice independently or under supervision.
|
(vi) |
Peer recommendations should be in part the basis of the development of
recommendations for individual clinical privileges.
|
(v) |
A mechanism to assure that all individuals with clinical privileges
provide services within the scope of privileges granted.
|
(vi) |
Provision for review of privileges granted according to a specified
interval of time, but no longer than two years.
|
(vii) |
Process for denial, limitation, or changes in clinical privileges
granted and a process for appeal.
|
a. |
Quality assurance programs at all program levels (Headquarters, Area, Service Unit) shall include activities which are designed to objectively and systematically monitor and evaluate the quality of the process and outcome of clinical services, pursue opportunities to improve patient care and resolve identified problems with the patient treatment process.
|
b. |
The Headquarters Mental Health Programs Branch is responsible for encouraging an effective quality assurance program in all mental health programs. Headquarters is to provide consultation and technical assistance in the development of a quality assurance system and to periodically review the effectiveness of the system.
|
c. |
Area Mental Health Program Consultants provide technical advice required to implement the Area mental health quality assurance program at the local program units consistent with the services provided locally. An Area-wide quality assurance plan should be developed and maintained and should be based on the IHS Mental Health Program Services program standards.
|
d. |
All mental health program directors should develop a quality assurance plan according to services provided locally and implement a quality assurance system which systematically monitors and evaluates the quality of patient care services, identifies problems, and develops and documents corrective action taken to resolve problems.
|
e. |
Mental health providers should participate in the development, implementation, and maintenance of the local mental health quality assurance plan. The participation of the provider includes recordkeeping and data collection, and may include organization of data, interpretation of data and recommendations for corrective actions based on assigned periodic quality assurance activities.
|
f. |
All mental health program quality assurance plans should be consistent with the overall facility/Service Unit quality assurance plan. The Service Unit quality assurance plans must include the ongoing monitoring of a minimum of one quality assurance indicator for each of the services provided. Recommended quality assurance monitors are identified for each patient care activity described in the IHS Mental Health program services standards and have been included in
Appendix 3-14-C.
|
g. |
All mental health quality assurance plans must also include provision for determination of patient satisfaction with mental health services through some form of annual survey. Annual surveys should include data collection, interpretation, and documentation of corrective improve patient satisfaction action taken to with
services.
|