Behavioral Health Standard 1.N – Performance Improvement

1.N.1.a-c

A written analysis is completed:

  1. At least annually.
  2. That analyzes performance indicators in relation to performance targets, including:
    1. Business functions.
    2. Service delivery of each program seeking accreditation, including:
      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.
    3. Extenuating or influencing factors.
  3. That:
    1. Identifies areas needing performance improvement.
    2. Results in an action plan to address the improvements needed to reach established or revised performance targets.
    3. Outlines actions taken or changes made to improve performance.
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1.N.2.a-d

The analysis of performance indicators are used to:

  1. Review the implementation of:
    1. The mission of the organization.
    2. The core values of the organization.
  2. Improve the quality of programs and services.
  3. Facilitate organizational decision making.
  4. Review or update the organization’s strategic plan.
  • ???

1.N.3.a-c

The organization communicates performance information

  1. To:
    1. Persons served.
    2. Personnel.
    3. Other stakeholders.
  2. According to the needs of the specific group, including:
    1. The format of the information communicated.
    2. The content of the information communicated.
    3. The timeliness of the information communicated.
  3. That is accurate.
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