N.J. Admin. Code § 10:37G-2.6

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:37G-2.6 - Continuous quality improvement

(a) STCF staff shall conduct continuous quality improvement to monitor efforts toward incorporating patients' recovery and wellness goals in assessment and treatment planning activities. These activities shall address the following areas:

1. STCF staff shall monitor the quality and appropriateness of clinical performance;

i. Clinical interventions shall have empirical support either as evidence-based, promising or preferred practices (for example, medication algorithms, motivation-based interviewing) and be disorder-specific and relevant to the patient population being served (for example, dialectical behavior therapy for persons with Borderline Personality Disorder, Cognitive Behavioral Therapy for psychosis, etc.).

2. STCF staff shall identify areas for routine monitoring;

3. The STCF manager shall participate on the STCF quality assurance committee to ensure that STCF quality assurance findings are referred to the hospital-wide quality assurance committee;

4. The STCF manager shall ensure that persistent problems are addressed;

5. The STCF manager shall complete the Systems Review Committee (SRC) STCF form and shall submit it to the Division and the SRC monthly, noting, at a minimum, the number and/or kind of:

i. Admissions;

ii. Admission sources;

iii. Non-admissions (include reason - for example, eligible, but no bed available);

iv. Discharges;

v. Discharge destination;

vi. Transfer;

vii. Occupancy rate; and

viii. Length of stay on the STCF;

6. The STCF manager shall utilize various sources of data on acute hospital in-patient care and review statistics from comparable STCFs to identify areas for special review in order to evaluate performance; and

7. The STCF manager shall report any unusual incidents in accordance with the requirements of 10:37-6.108.

N.J. Admin. Code § 10:37G-2.6

Amended by R.2002 d.221, effective 7/15/2002.
See: 33 N.J.R. 3887(a), 34 N.J.R. 2451(a).
Rewrote the section.
Amended by R.2008 d.19, effective 1/22/2008.
See: 39 N.J.R. 2434(a), 40 N.J.R. 716(a).
Section was "Quality assurance activities". Rewrote the introductory paragraph of (a); added (a)1i; in (a)5, inserted "(SRC)" following "Committee" and substituted "SRC" for "systems review committee (SRC)" preceding "monthly"; and in (a)5iii, inserted "include reason - for example,".