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Lynn Mercurio, CEO

September 6, 2012



The FY 2013 Performance Improvement Plan began in July 2012 and ended in June 2013.  This is the first report that reviews an entire year of a Performance Improvement Plan based on a fiscal year.  The concept of continuous improvement is seen in the development of this plan, and will be a continuous theme in the Performance Improvement Plans of the future.


Attached is an easy to read chart that tracked the results of the FY 13 Performance Improvement Plan.  Below is a summary of the four areas that evaluate both business and clinical outcomes:  Access, Effectiveness, Efficiency, and Satisfaction.





Two goals were discontinued due to the continuous successful results: maintaining consumer population in each office and reducing the number of calls that went to voicemail during business hours.  One goal was discontinued due to acquiring steps with handrails to access CHS vans.


Saturday PSR groups in Hannibal showed the great vacillation in quarterly results, having no Saturday groups in the second and third quarter and achieving at 166.67% in the fourth quarter.  This will be addressed in the FY14 PIP.


Consumers access to services were measured to exceed expectations in CHS crisis services (100%), IDDT services at intake (100%), and accessing psychiatric services.


Providing staff with timely access to benefits is an important service to our employees; this activity was measured at 100% in providing information on medical and 401K benefits to CHS staff.


Progress was made in providing a shared file to Hannibal and Fulton staff, however access is still somewhat cumbersome and the goal is for all staff to be able to access a shared file directly.  This goal will continue.





Only one goal on effectiveness was completed this fiscal year despite several goals that achieved at 100% each quarter. The one goal that was completed was the one recommended by CARF. CARF recommended the development of a committee to develop a policy addressing the safety of staff in the community setting.  An ad hoc committee led by the Lead QMHP did develop a policy that was approved and implemented.  Goals that achieved at 100% that will continue include a goal having to do with the financial stability of the organization.  Both objectives, the random review of billing matched to service and the monitoring of billing to assure 100% use of the DMH allocation objectives were determined to be at 100%, however due to the importance of these measures, this goal and its two objectives will continue.


One area that continues to be difficult to meet the DMH standards is the contact and follow-up after a consumer has been psychiatrically hospitalized by the Case Manager.  The positive is that follow up with the CHS psychiatrist meets the DMH standard at 100%.   Continued efforts will be made to address this issue.


Tracking meaningful activities of our consumers shows an “up and down” pattern throughout the year in both offices, vacillating by 23% among the quarters in Hannibal and 14% in Fulton. 


Efforts to improve PSR quality in the Hannibal office led to exceeding the expectation is breaking the group into two or more smaller groups by 25% (expectation was 50% of the time, and results were this was done 75% of the time).  And while the expectation was not reached in staff meeting with consumers one week prior to the consumer presentation, the frequency did increase from 49% to 76.5%.


This was the first year DMH did an IDDT fidelity review at Comprehensive Health Systems.  Areas to improve were identified and an improvement plan was accepted by DMH and implemented.  There was a rather large discrepancy between the score of 4.2 identified by CHS IDDT staff when conducting a fidelity review and the DMH score of 3.1.  This discrepancy is due to DMH citing services that are not available in our geographic location, but are part of the fidelity review, as well as the fidelity review and DMH looking for primary dual diagnosis treatment that CHS does not offer due to our CPR status.  This will continue to be monitored.


Other areas of effectiveness that met expectations include goals on competent and trained staff, medication errors, and consumers reviewing and understanding their rights and the treatment plan process.





Hannibal’s PSR efforts to have consumers at the CHS building by 9:00 am proved to be untenable due to circumstances beyond the CHS staff control—if an RCF was running late, traffic issues, road condition issues, etc.  Some changes are anticipated for the FY14 PIP in this area. However the Hannibal PSR was very successful in increasing the number of meals that they—with consumer participation—prepare, thus reducing dependence on the Nutrition Center.  Numerous benefits including reducing cost, providing opportunities for consumers to increase their daily living skills, and improving the nutritional value of the meals has resulted from this objective.


Making use of the limited psychiatric service time CHS has in each office efficiently, as well as addressing the satisfaction of our consumers in timely doctor appointments, was measured by looking at consumer’s meeting with the doctor within 15 minutes of their scheduled appointment.  While Hannibal exceeded the goal in three of the four quarters—and barely missed the goal in the fourth quarter, Fulton significantly improved their timeliness over the year.


Other areas that were measured and met the expectation were completing the Healthcare Home annual health assessments, arranging for transportation for Fulton consumers to come to Dr. appointments, and the IDDT team reviewing recent ASI’s and updating treatment plans as needed.





Comprehensive Health Systems traditionally has scored high on satisfaction surveys from all areas—referral sources, consumers, and staff.  However an effort to assess satisfaction from new consumers entering our services and those who have been discharged has resulted in few satisfaction surveys being returned, and thus incomplete results.  Even adding the offering of a Walmart gift card if discharged consumers would return a satisfaction survey did not result in increased numbers; in fact, not one discharge survey was returned in the fourth quarter.


The only area that did not meet expectations in the satisfaction category was consumers reporting that they were satisfied with their current medication regime; the goal was 90% in the Hannibal office, however the results varied from 100% the first quarter, then 60% the second quarter, and stabilized at 80% and 83% respectively for the third and fourth quarter.


Click here to download ACCESS

Click here to download EFFECTIVENESS

Click here to download EFFICIENCY

Click here to download SATISFACTION