Question: My organization collects data on several performance measures such as length-of-stay and where individuals are discharged (e.g., to home, a group home or foster care). Several of these measures are contractually required by our funders and the state. Would these measures demonstrate compliance with LD.04.04.01? Do they comply with CTS.03.01.09?
Answer: The Joint Commission BHC News has this to say, “Yes, these measures comply with standard LD.04.04.01— Leaders establish priorities for performance improvement — because they are priorities for your organization. However they do not comply with CTS.03.01.09 — The organization assesses the outcomes of care, treatment or service provided to the individual served — because they measure processes and not outcomes.
“Examples of outcomes measures include sobriety rates for organizations providing treatment to individuals with alcohol use issues; reading and math achievement levels for students at therapeutic schools; employment rates for individuals provided treatment in community mental health centers; and permanency rates for children in foster care. Your organization should monitor not only the outcomes for each individual served, but also the aggregate data for your organization. Then it is important to analyze the data. Analysis identifies trends, patterns and performance levels that suggest opportunities for improvement.”
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