DBHDS Quality Improvement Initiative

January 22, 2016

At the quarterly meeting of the DBHDS Quality Improvement Committee, Dr. Jack Barber, Interim Commissioner, described a significant step forward in the Department’s approach to building a comprehensive QI structure for the BH and ID/DD system of care in Virginia. Based on the growing capacity of the “data warehouse,” reports will be given by Licensing, Human Rights, Risk Management, Mortality Review, DOJ Implementation, etc. Each will focus on the eight domains outlined in the DOJ Settlement agreement –

  • safety and freedom from harm,

  • physical, mental and behavioral health and well being

  • avoiding crises

  • stability

  • choice and self-determination

  • community inclusion

  • access to services

  • provider capacity


While much of the activity is to meet the requirements of the DOJ Settlement, the eight domains are equally applicable to the Behavioral Health service system and the QIC will broaden its portfolio to include the Behavioral Health service system.

Each report will outline the trends in findings in the previous Quarter, with analysis, steps already taken and recommendations for additional action. For example, the report from the Office of Licensing might include the number of providers cited for a selected standard and how many of those had also been cited more than one in the previous 36 months. We will not be reporting the data here, but did receive a positive response to a request for information about major trends/findings to be summarized and shared with the provider community. We also contributed to the conversation about the need to place the data into context and to dive deep enough into the data to, for example, show separately citations for “water at inappropriate temperature” and the “environment shall be clean, dry, and free of foul odors” both of which fall under standard §280.

There is much yet to do to refine the process and the data, but it is clear that Dr. Barber will bring a new focus on the analysis and documentation of both the steps taken and the results of those actions. We welcome this approach as it will help us to recognize the quality of the provider community while allowing us to identify the weaknesses in the system.