Community Services Programs

Mental Health Agency Licensing Standards; Social Clubs Standards - Quality Management

Quality management is broadly defined as management philosophies and behavioral and statistical tools aimed at improving quality, customer satisfaction, and profitability. Although all effective quality management processes have distinct similarities, each agency must adopt quality management principles and practices that are sensitive to their organizational culture and effective in their particular setting. For this reason, the Department and the Division of Licensing does not espouse one particular model of quality management. Therefore, the standards in this section relate to an agency's ability to demonstrate that they have an ongoing and effective quality management process that is customer-focused and strives for customer satisfaction. 

The agency has a written plan that addresses how the organization currently monitors, evaluates and improves quality.

The agency can demonstrate that it identifies, monitors, and attempts to improve areas deemed to be critical to quality client care.

There is documented evidence that quality management activities are conducted on an ongoing and regular basis.

The effectiveness of quality management is assessed and documented at least annually and involves input from clients, family members, guardians, client representatives, staff, and referral sources.

The agency shall have, available for review, insurance policies citing professional and commercial liability coverage for the organization, staff, volunteers, and students.

The agency has a policy and procedure regarding the reporting and recording of adverse and potentially adverse occurrences, including the recording of complaints.

Interpretive Guideline for SC.62
Some examples of adverse or potentially adverse occurrences include, but are not necessarily limited to the following:
1. deaths;
2. injuries;
3. violations of agency policies; and
4. violations of client rights.