Clinical Quality Assurances

Clinical quality assurances reinforce the commitment of a professional to providing the highest quality care to each client served. This is consistent with ethical practices expected of all mental health professionals. These assurances are structured to ensure there is a regular review process related to the quality of client care that helps address the difference between what is actually happening in services and what should be happening. The standard of utilizing clinical quality assurances applies to organizations, programs, and individual practitioners. Decisions related to quality client care are not made in a vacuum - the process of quality assurance is to be present throughout all aspects of service, whether in an organization or a private practice.

In order to have an effective system, the standards of quality to be monitored need to be defined in order to establish criteria for review. These standards are to be based on best practices and the professional norms of behavior. Policies and procedures must be in place that address the process to be used, the accountability involved, and who is responsible for components of the system. There are many options for review processes, including peer review, case studies, client satisfaction surveys, program evaluations and others. The processes selected by organizations, programs, and practitioners ultimately need to fit within the structure of services provided. The process for clinical quality assurance should be clearly documented and involve stakeholders including staff at all levels of an organization and clients.

Whatever system is implemented by an organization, program or practitioner, it should ensure that the following clinical quality assurances exist, are reviewed and are clearly documented:

  • Assessment: Initial assessments are completed regarding client appropriateness for services (often these are diagnostic in nature). Ongoing clinical assessments occur throughout services in order to best tailor interventions for client needs. 
  • Treatment Planning: Appropriate and effective treatment plans are to be developed with clients that indicate the frequency and duration of interventions for clearly identified problems. Treatment plans include who is responsible for components and discharge criteria. 
  • Clinical Documentation: Documentation is to be completed completely, professionally and in a timely manner. Documentation will likely include assessments, treatment plans, progress notes, and incident reports. It may also include medical forms, evaluations, or paperwork from other sources. 
  • Informed Consent: Practitioners are expected to communicate clearly and openly with clients about the risks and benefits of treatment options so clients can make informed decisions about the type of treatment they want to use. After being informed, the client has the option to consent to the treatment. This can become challenging with minor-aged clients, whose parents or guardians are legally in charge of providing consent or with involuntary clients who are mandated by courts to participate in treatment. Clients, even minor-aged clients, cannot legally be forced to participate in treatment unless they present an immediate risk of harm to themselves or others (as assessed by a licensed mental health practitioner) so they must give some level of consent in order to participate and cannot physically be forced to do so. Best practice is to inform clients completely about the risks and benefits of services and to gain their informed consent to participation in treatment. Any informed consent process should be documented in order to formalize the agreement and make it clear to both clients and professionals what is expected. 
  • Confidentiality: In providing AT, it is expected for organizations, programs and practitioners to inform clients about their level of confidentiality and the limits of confidentiality. In addition, processes for storage of client files and managing documentation are to adhere to industry standards in mental health practice. 
  • Client's Rights and Grievance Processes: A clear listing of client's rights should be provided to client's at the beginning of any treatment process as well as a description of the grievance process to be used if the client believes his or her rights have been violated. 
  • Program Evaluation: The effectiveness of services is evaluated in order to determine if the services are meeting designated goals. This process informs program development efforts aimed toward improving services to clients. 

In summary, the best practice is to have a clear, structured system in place for reviewing the quality of clinical care provided. The criteria developed for review are expected to be based on best practices, including professional norms, industry standards of practice, and the best research evidence available. This process should involve all layers of service in an organization and be clearly documented. Clinical quality assurance helps us to ensure we are providing safe, effective, and ethical services to our clients.