Behavioral Health Standard 1.M – Performance Measures


The organization has a written description of its performance measurement and management system that includes, at a minimum:

  1. Mission.
  2. Programs / Services seeking accreditation.
  3. Objectives of the programs / services seeking accreditation.
  4. Personnel responsibilities related to performance measurement and management.
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The organization demonstrates how its data collection system addressees the following:

  1. Reliability.
  2. Validity.
  3. Completeness.
  4. Accuracy.
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The data collected by the organization:

  1. Include:
    1. Financial information.
    2. Accessibility information.
    3. Resource allocation.
    4. Surveys, if applicable.
    5. Risk management.
    6. Governance reports, if applicable.
    7. Human resource activities.
    8. Technology.
    9. Health and safety reports.
    10. Strategic planning information.
    11. Field trends, including research findings, if applicable.
    12. Service delivery.
  2. Address:
    1. The needs of persons served.
    2. The needs of other stakeholders.
    3. The business needs of the organization.
  3. Allow for comparative analysis.
  4. Are used to set:
    1. Written business function:
      1. Objectives.
      2. Performance indicators.
      3. Performance targets.
    2. For each program seeking accreditation, written service delivery:
      1. Objectives.
      2. Performance indicators.
      3. Performance targets.
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The organization collects data about the characteristics of the persons served.

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The organization collects data about the persons served at:

  1. The beginning of services.
  2. Appropriate intervals during services.
  3. The end of services.
  4. Point(s) in time following services.
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The organization measures:

  1. Business function performance indicators.
  2. Service delivery performance indicators for each program / service seeking accreditation in each of the following areas:
    1. The effectiveness of services.
    2. The efficiency of services.
    3. Service access.
    4. Satisfaction and other feedback from:
      1. The persons served.
      2. Other stakeholders.
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For each delivery performance indicator, the organization determines:

  1. To whom the indicator will be applied.
  2. The person(s) responsible for collecting data.
  3. The source from which data will be collected.
  4. A performance target based on an industry benchmark, the organization’s performance history, or established by the organization or other stakeholder.
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