Managing Your CCBHC Transformation | Stage 5 Continuous Quality Improvement

Written by Mary Givens, CCBHC Program Manager

Stage 5 Continuous Quality Improvement Supporting the Five Stages of the CCBHC Experience 

Phase 5

Stage 5 Continuous Quality Improvement | Supporting the Five Stages of the CCBHC Experience 

Stage 5 is really the beginning of the ongoing Continuous Quality Improvement (CQI) process required for the existence, sustainment, and ongoing success of the CCBHC, as tracked by measurable outcomes. CQI, as defined by The National Library of Medicineis a progressive incremental improvement of processes, safety, and patient care. The goal of CQI may include improvement of operations, outcomes, systems processes, improved work environment, or regulatory compliance. Process improvement may be “gradual” or “breakthrough” in nature.” This is the definition we will work with as we further our discussion on CQI for the CCBHC in this article.  

Continuous Quality Improvement in Your CCBHC: As you know, the CQI process includes identifying the problem, benchmarking, setting a goal, then developing and executing iterative quality improvement initiatives. As noted in article two of this sixpart series, we recommend the use of Plan, Do, Study, Act Cycles (PDSA) cycles, also known as Deming CyclesThrough the iterative process of learning and repeating plans and actions, the changes and improvements you are developing are implemented, and their impacts are tracked, measured, and incorporated in your next round of progress and expanded success. The process should be repeated until the measure is mastered. Once mastered, new and more challenging outcomes can be introduced.  

The right EHR technology is critical for collecting care-delivery data and tied to tools and methods for tracking outcomes. The more efficient and streamlined the data collection process is, the more consistently the data will be collected and the more actionable it will be. The more robust and transparent the reporting and analytics tools of the EHR are the greater the visibility into your CCBHC’s performance on the outcome measures will be. High performance on your CCBHC outcomes will support its ability to maintain sustainability, support growth, while delivering profitability, decrease in cost of delivering services, and increased quality of care, with greater customer satisfaction — all goals of the triple aim and the value-based care model.  

Recommended CCBHC CQI initiatives focus on these areas: 

  • Preventive care-screening and follow up 
  • Continuum of care following an acute care event 
  • Decrease in cycle time – point of contact to comprehensive assessment 
  • Increased client satisfaction 
  • Decease in symptoms or remission  
  • Increased client safety  
  • Higher utilization of services  
  • Greater compliance with criteria 
  • Decrease in healthcare disparity 
  • Increase in diversion strategies 
  • Decrease in involvement with the judicial system 
  • Decrease in acute or emergent episodes of care 
  • Decrease in costs 

Annual Cost Report: The “Certified Community Behavioral health Clinic Cost Report” contains a great deal of information about your agency’s finances. Completing the cost report will take time and will probably require the efforts of people with a range of clinical and financial skills across your teams. Designation of the roles and responsibilities to leaders in your organization can support the success of this effort. The cost report may be used to determine the clinic-specific PPS rate and to annually report demonstration costs. According to this guide, the accrual basis of accounting is considered the most accurate method for determining costs during a period of time. 

The instructions for the cost report can be found here.   

  • The cost report template itself can be found here.

Ideally, each year you become more effective at identifying your true costs, using data from the previous year and your increased knowledge and skills 

There are many third-party firms who have experience completing CMS cost reports. Many CCBHCs choose to take advantage of these third-party firms because the cost report is so complex and so time consuming.  

Annual Budget: Your CCBHC will need to annually update its budget.  budget. Presumably you have been tracking your costs of delivering the CCBHC services carefully throughout the year so your budget can be your opportunity to make any adjustment to your findings.  

Annual Community Needs Assessment: SAMHSA has a webpage committed to supporting the process for a state that is ready to execute a Community Needs Assessment. Since each CCBHC must update the state’s community assessment annually, much of this content is continuously relevant.  The SAMHSA website includes information on “Key Steps in a Needs Assessment” as well as Implementing the Results of the Needs Assessments” which is key to the day-to-day delivery of services of your CCBHC.  

The criteria for the state include the following requirements related to conducting a needs assessment: 

  • Program Requirement: Staffing 
  • Program Requirement: Availability and Accessibility of Services
  • Program Requirement: Scope of Services 

These requirements now become those of the CCBHC for the annual update.  

Annual Customer Satisfaction Survey: The client or customer satisfaction survey is used to gather feedback regarding the quality of service and medical treatment provided by your CCBHC from the client’s perspective. The information provided in this feedback should be integrated into your service delivery strategy. A well-designed survey can help you improve the quality of services in your CCBHC.  

According to the AAFP, some key elements of a good customer satisfaction survey are  

  • Word questions carefully; brevity, clarity, and consistency 
  • Questions should cover quality, access to care, and interpersonal issues 
  • Use consistent scales 
  • Include an open-ended question 
  • Collect demographic data 
  • Strive for anonymity 

I hope you have enjoyed this six-part series on the CCBHC Experience. Please be sure to check out some of the resources linked throughout these articles. You can find other CCBHC articles and recorded webinars at 

If I can answer any questions or be of any assistance to you, please email me at Continued success to you and your CCBHC! 

Mary Givens 2022

Mary Givens, MRA
CCBHC Program Manager

Mary Givens has been with Qualifacts for 13 years. She has a Masters in Rehabilitation Administration from the University of San Francisco. Before coming to Qualifacts, Mary was the CEO of a non-profit organization that served IDD, she was the Director of Client Services and a Director of Supported Employment for people with SPMI. Since coming to Qualifacts, she has been a Project Manager for Implementation and a Program Manager of Meaningful Use, and is currently the CCBHC Program Manager.

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