Purpose and governance
Define the goals of the CQI program, who oversees it, which committees or leaders review performance, and how decisions are documented.
Sources of quality information
Identify the data that can trigger improvement work: CCBHC quality measures, internal KPIs, access data, incidents, grievances, client experience, equity findings, audits, utilization, and evaluation results.
Priority-setting method
Explain how the organization decides which problems deserve formal CQI attention. Consider magnitude, risk, disparity, strategic importance, feasibility, and persistence.
Problem definition and root-cause analysis
Require teams to define the gap using evidence before choosing a solution. Use process mapping, stratification, record review, staff input, or other methods appropriate to the problem.
Improvement method
Describe the organization's approach to testing changes, such as PDSA cycles. Specify intervention owners, implementation dates, measures, and expected effects.
Monitoring and follow-through
Define how often active projects are reviewed, what counts as improvement, what happens when an intervention fails, and when a change is considered sustained.
Communication and learning
Specify how findings and lessons are shared with leadership, staff, clients, governing bodies, or partners as appropriate.
Annual evaluation of the CQI program
Review whether the CQI process itself is working: Are projects completed? Are improvements sustained? Are priorities tied to meaningful data? Are recurring problems being resolved?
CCBHC requirements can vary by program, state, grant, payer, measurement year, and measure steward. Use current SAMHSA, CMS, state, grant, and technical specifications for official reporting decisions.