CCHP-MH
Clinical Autonomy - ✔️✔️Clinical decisions and actions regarding MH care provided to
inmates meet their serious MH needs are solely the responsibility of qualified mental
health professionals
Monthly MH Statistical Reports - ✔️✔️Service Volume such as number of inmates on
SW, meds, etc. Deaths, Emergent services provided, F/U services for acute patients
such as those on SW.
Access to Care - ✔️✔️The foundation on which all NCCHC standards are based.
Access to Care - ✔️✔️The mental health authority is on site at least twice weekly.
QMHP - ✔️✔️Include psychiatrists, psychologists, psychiatric social workers, LPC's,
Psych nurses, and others by virtue of their education and experience are permitted by
law.
Clinical Autonomy - ✔️✔️The intent of this standard is to ensure that clinical decisions
are made for clinical purposes and without interference from other personnel.
Administrative Meetings and Reports - ✔️✔️Administrative Meetings are held at least
quarterly. Minutes are made and shared with all attendees.
Mental Health Staff Meetings - ✔️✔️Occur at least monthly
MH Statistical Reports - ✔️✔️Are made at least monthly.
Policies and Proceedures - ✔️✔️There must be a manual. Each policy is reviewed
annually. Ensure all staff have available access. It is recommended that each policy be
cross referenced with the relevant NCCHC standard.
Policy - ✔️✔️The facility's official position on a particular issue related to its operations.
Procedure - ✔️✔️Describes in detail, sometimes in sequence, how a policy is to be
carried out.
Continuous Quality Improvement Program - ✔️✔️Monitors and improves mental health
care delivered in the facility. Committee meets at least quarterly.
, Quality improvement committee - ✔️✔️Meets at least quarterly.
CQI Program - ✔️✔️The CQI committee completes an annual review of the
effectiveness of the CQI program.
CQI Annual Review - ✔️✔️An annual review of of deaths and serious incidents
involving inmates with mental illness is conducted to identify trends and needed
corrective actions.
Outcome quality improvement studies - ✔️✔️Examine whether expected outcomes of
patient care were achieved by: Identification of the problem, Conduct baseline study,
develop and implement corrective action plan, restudying, Assessing whether the plans
were sufficient, determine if the frequency of follow up was sufficient.
NCCHC recommends use of the following quality performance measures in evaluating
programs: - ✔️✔️Accessibility, appropriateness of clinical decision making, continuity,
timeliness, effectiveness, efficiency, quality of clinician-patient interaction, safety.
CQI programs should use one or more of the following quality performance measures: -
✔️✔️Intake processing, primary care, medication service, MH services, Intrasystem
transfer services, scheduled-off site services, unscheduled on-site and off-site services,
ancillary services (lab), infirmary services.
Primary Care - ✔️✔️The time between the sick-call request being picked up and the
QMHP's face-to-face sick-call encounter. Time between order of psych meds and
receipt by patient. Time between patient emergency and arrival of emergency services.
Emergency Response Plan - ✔️✔️Full-time MH staff are provided with an annual
opportunity to practice their roles in the event of an emergency or disaster. When the
facility conducts emergency drills critiques are shared with MH staff.
Emergency Plan - ✔️✔️Should be practiced and critiqued at least annually. Staff
members review and initial the written critiques.
Communication on Patients' Mental Health Needs - ✔️✔️MH staff and custody staff
communicate about inmates with special needs: Chronic MH illness, Suicidal inmates,
Intellectual/Developmental disability, significant substance abuse histories, victims of
physical/sexual abuse, other serious MH problems.
Procedure in the Event of an Inmate Death - ✔️✔️All deaths of MH patients and
suicides are reviewed within 30 days.
A death review includes: - ✔️✔️A administrative review, a clinical mortality review, a
psychological autopsy if death is by suicide.
Clinical Autonomy - ✔️✔️Clinical decisions and actions regarding MH care provided to
inmates meet their serious MH needs are solely the responsibility of qualified mental
health professionals
Monthly MH Statistical Reports - ✔️✔️Service Volume such as number of inmates on
SW, meds, etc. Deaths, Emergent services provided, F/U services for acute patients
such as those on SW.
Access to Care - ✔️✔️The foundation on which all NCCHC standards are based.
Access to Care - ✔️✔️The mental health authority is on site at least twice weekly.
QMHP - ✔️✔️Include psychiatrists, psychologists, psychiatric social workers, LPC's,
Psych nurses, and others by virtue of their education and experience are permitted by
law.
Clinical Autonomy - ✔️✔️The intent of this standard is to ensure that clinical decisions
are made for clinical purposes and without interference from other personnel.
Administrative Meetings and Reports - ✔️✔️Administrative Meetings are held at least
quarterly. Minutes are made and shared with all attendees.
Mental Health Staff Meetings - ✔️✔️Occur at least monthly
MH Statistical Reports - ✔️✔️Are made at least monthly.
Policies and Proceedures - ✔️✔️There must be a manual. Each policy is reviewed
annually. Ensure all staff have available access. It is recommended that each policy be
cross referenced with the relevant NCCHC standard.
Policy - ✔️✔️The facility's official position on a particular issue related to its operations.
Procedure - ✔️✔️Describes in detail, sometimes in sequence, how a policy is to be
carried out.
Continuous Quality Improvement Program - ✔️✔️Monitors and improves mental health
care delivered in the facility. Committee meets at least quarterly.
, Quality improvement committee - ✔️✔️Meets at least quarterly.
CQI Program - ✔️✔️The CQI committee completes an annual review of the
effectiveness of the CQI program.
CQI Annual Review - ✔️✔️An annual review of of deaths and serious incidents
involving inmates with mental illness is conducted to identify trends and needed
corrective actions.
Outcome quality improvement studies - ✔️✔️Examine whether expected outcomes of
patient care were achieved by: Identification of the problem, Conduct baseline study,
develop and implement corrective action plan, restudying, Assessing whether the plans
were sufficient, determine if the frequency of follow up was sufficient.
NCCHC recommends use of the following quality performance measures in evaluating
programs: - ✔️✔️Accessibility, appropriateness of clinical decision making, continuity,
timeliness, effectiveness, efficiency, quality of clinician-patient interaction, safety.
CQI programs should use one or more of the following quality performance measures: -
✔️✔️Intake processing, primary care, medication service, MH services, Intrasystem
transfer services, scheduled-off site services, unscheduled on-site and off-site services,
ancillary services (lab), infirmary services.
Primary Care - ✔️✔️The time between the sick-call request being picked up and the
QMHP's face-to-face sick-call encounter. Time between order of psych meds and
receipt by patient. Time between patient emergency and arrival of emergency services.
Emergency Response Plan - ✔️✔️Full-time MH staff are provided with an annual
opportunity to practice their roles in the event of an emergency or disaster. When the
facility conducts emergency drills critiques are shared with MH staff.
Emergency Plan - ✔️✔️Should be practiced and critiqued at least annually. Staff
members review and initial the written critiques.
Communication on Patients' Mental Health Needs - ✔️✔️MH staff and custody staff
communicate about inmates with special needs: Chronic MH illness, Suicidal inmates,
Intellectual/Developmental disability, significant substance abuse histories, victims of
physical/sexual abuse, other serious MH problems.
Procedure in the Event of an Inmate Death - ✔️✔️All deaths of MH patients and
suicides are reviewed within 30 days.
A death review includes: - ✔️✔️A administrative review, a clinical mortality review, a
psychological autopsy if death is by suicide.
