Quality Improvement Plan Template Page 11
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16Section 6
Evaluation
An evaluation is completed at the end of each calendar year. The annual evaluation is
conducted by the Facility’s Name and kept on file in the Facility’s Name, along with the
Quality Improvement Plan. These documents will be reviewed by the Office of Mental
Health as part of the Facility’s Name certification process.
The evaluation summarizes the goals and objectives of the Facility’s Name’s Quality
Improvement Plan, the quality improvement activities conducted during the past year,
including the targeted process, systems and outcomes, the performance indicators utilized,
the findings of the measurement, data aggregation, assessment and analysis processes,
and the quality improvement initiatives taken in response to the findings.
# Summarize the progress towards meeting the Annual Goals/Objectives.
# For each of the goals, include a brief summary of progress including progress in
relation to training goal(s).
# Provide a brief summary of the findings for each of the indicators you used during the
year. These summaries should include both the outcomes of the measurement
process and the conclusions and actions taken in response to these outcomes.
Summarize your progress in relation to your Quality Initiative(s). For each initiative,
provide a brief description of what activities took place including the results on your
indicator. What are the next steps? How will you “hold the gains.” Describe any
implications of the quality improvement process for actions to be taken regarding
outcomes, systems or outcomes at your program in the coming year.)
# Recommendations: Based upon the evaluation, state the actions you see as
necessary to improve the effectiveness of the QI Plan.
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Parent category: Business