Quality Department

Welcome to the Quality Department at MCCMH!

Our goal is to track and trend data to identify successes and deficiencies so we can highlight the great things happening at MCCMH, and also what we need to work on.

We accomplish this through internal and external audits throughout the year where standards are set through the State of Michigan, CARF, NCQA, and other governing bodies.

What is the purpose of the Audit?

To identify providers and subsidiaries are exceeding or meeting all standards to provide consistent excellent Mental Health Care to our Persons Served.If deficiencies are found our talented audit team will consult with your agency on how to problem solve to reach compliance.If at any time throughout the year there is a change to a standard and expectation, our Quality Team will communicate in writing all adjustments to the audit tool. We want each Provider to be successful, and if we can assist you in obtaining that status, we are more than happy to help! Updated audit tools are available upon request, please email [email protected].

Satisfaction Surveys

The MCCMH person served and provider satisfaction surveys both highlight areas where the organization is performing at or above expectations as well as areas for improvement. MCCMH operationalizes this in a question/answer format. The organization then implements process improvement plans to correct indicators below the percentage standard.


The purpose of this report is to analyze goals and objectives identified by the organization to secure excellence in service provision. The goal of the Quality Assurance Performance Improvement Program (QAPIP) is to assess the system, determine areas for change and continuously enhance the network processes. The QAPIP provides a road map for the organization to promote data-driven decisions that move the network forward in delivering high-quality services. Click to view the QAPIP documents:

QAPIP Workplan/CCBHC Workplan
FY19/20 QAPIP Evaluation Final


Between October 22-23, 2020, MCCMH completed the Commission on Accreditation of Rehabilitation Facilities (CARF) survey for accreditation and was awarded a three-year accreditation which will extend through 6/23/2023. MCCMH is proud to continue to provide top-quality care to individuals served as recognized by the CARF accreditation. MCCMH will continue to strive for excellence in service provision. View the CARF Accreditation Letter.


The Michigan Mission-Based Performance Indicator System, also known as the Key Performance Indicators (KPI), was first implemented in fiscal year 1997 and is contractually required of all PIHPs and CMHSPs. Since 1997, the system has undergone changes based on feedback from consumers, families, advocates and mental health professionals. These indicators include measures on timeliness of service in emergent and non-emergent situations, service following discharge from an inpatient facility, and percentage of readmissions to inpatient facilities. All indicators are continually monitored and reported on a quarterly basis.

CMHSP Q4. Draft Performance Indicators 2020
PIHP Q4. Draft Performance Indicators 2020


If you are experiencing any barriers to getting services, please let us know so we can assist you by emailing [email protected].

Important Upcoming Events for Quality

Provider Quality Meeting - June 11, 2021

The Provider Quality Meetings are open to all network providers and persons receiving services through MCCMH. Quality and Network Operations provide current reports, updates, and initiatives throughout the Prepaid Inpatient Health Plans. Meetings are held quarterly. Input from all stakeholders is encouraged. For more information or to join the meeting, please email [email protected].