Peer Review Policy & Procedure
Alameda County Behavioral Health Care Services (ACBHCS) will require each provider site or other contracted Community Based Organization (CBO) to follow policy and procedure in accordance with the Peer Review Plan described below. The primary mission of the Peer Review Plan is to facilitate ongoing quality improvement in delivery of services to consumers at the program level. The process used is intended to be a vehicle for program transformation rather than individual clinician review.
Each provider will have latitude to choose a programmatic topic for ongoing exploration which they identify as an avenue to improve quality of care to consumers. To aid the process of topic selection, ACBHCS encourages the use of brainstorming sessions and staff focus groups. In keeping with the current shifts in our system priorities toward empowerment, resilience and wellness and recovery, the topic selection process should enhance staff involvement and buy-in to the process and outcomes.
It is important to decide whether the programâ€™s focus will be on a specific topic or on an issue identified as a current problem, as explained below. Both approaches are equally valid and useful but carry different implications and mind-sets. Program choice of Topic vs. Problem as an approach may initially have more to do with ensuring staff buy-in than the actual subject matter, as staff resistance can be higher when focusing on an established problem.
Topics: Topics can be generated from staff interest, changes in program emphasis, population served, etc. Topics do not imply the need for correction or that an error has occurred, they only imply a desire for potential ongoing change and improvement.
Problems: Problem identification is usually the result of a negative outcome. It is crucial for the health of any organization, its staff and its consumers to be able to examine problems and identify creative solutions. Indicators of problems in service delivery can include:
Peer Review Committee (PRC)
A Peer Review Committee (PRC) will be established by the Center Director/Executive Director/designee at each provider site or program. Agencies with multiple programs may complete a separate PRC and topic for each site.
Participation in the PRC will be open to all program staff, including clinical and administrative. At least one of the committee participants must be a licensed Mental Health Practitioner. The Center Director/Executive Director shall assure that the PRC has sufficient resources and authority to carry out its responsibilities as set forth in this plan.
Committee Documentation: Compliance and Administrative Reporting
By July 1st of each year, the Center Director/Executive Director will submit to the BHCS Quality Assurance Administrator, a report of Committee activities, findings and recommendations, using the PRC report guideline. Adherence to these guidelines is essential to maintain consistency in reporting across programs to give the county useful data that can be shared.
The QA Representative will formulate a county-wide summary report of findings. This report will be made available to the BHCS Training Committee where it will be used to assess needs for specific training programs. Training will be provided through BHCS to meet broad-based provider needs. In addition, the findings will be made available to all providers via the BHCS website and an annual conference.
All reports required by this Plan shall be kept separate from consumer clinical records and shall be stored in a locked file. Peer review reports taken off-site shall not include names or demographic information which could be used to identify individual consumers. Peer review reports produced within the provider site shall not identify a consumer by name. Peer review reports and proceedings are subject to all confidentiality requirements as is other information kept in personnel and clinical records. Participation in the PRC is subject to the same confidentiality requirements as applied to any other form of collaboration and/or consultation among staff.
Overview of the Peer Review Plan
Small Agency Adjustment
Any agency serving 10 or less distinct clients in one fiscal year is not required to do a full Peer Review. Instead, the Agency will submit to the QA Office an annual letter reflecting what their program has done during the fiscal year to improve clinical care during the fiscal year. This letter is due on the same cycle as all other Peer Reviews, on July 1st of each year. If an agency feels they qualify for this exception, they must notify the QA office in writing, no later than October 1st of the beginning of the fiscal year.