3521 West Broward Blvd., Suite 206,

Lauderhill, FL 33312

(954) 622-8121



Continuous Quality Improvement (CQI)

Continuous Quality Improvement (CQI) is a progressive incremental improvement of processes, safety, and the care of persons served. The CQI team is responsible for conducting Contract Accountability Reviews for all Network Providers. In addition, the CQI team oversees Community Persons Served Satisfaction Surveys, Incident Reporting, Secret Shopper, Civil Rights compliance, Complaints and Grievances, ROSC implementation, Cultural and Linguistic Competency compliance, conformance to CARF standards, and ensures BBHC policies and procedures are updated annually.

The goal of the BBHC CQI department is to improve outcomes, systems processes, and ensure regulatory compliance. The BBHC CQI department aims for excellence and to quantify and document accomplishments, and improvement begins with a culture of improving outcomes. CQI is a philosophy that encourages organizations to continuously ask:

How are we doing? Can we do better?

Can we do things more efficiently?

Can we be more effective?

The BBHC CQI team is available to provide support and technical assistance for Network Provider. The CQI team can be reached via email at [email protected]

Community Person Served Satisfaction Survey

Broward Behavioral Health Coalition, Inc., (BBHC) has implemented the Community Person Served Satisfaction Survey (CPSS) requirement and adopts this policy to ensure provider compliance with the administration of the CPSSS pursuant to guidelines set forth by the Florida Department of Children and Families (the Department). BBHC shall ensure that subcontracted providers disseminate and collect the information obtained by the Community Persons Served Satisfaction Survey as required by the Department.

All BBHC contracted agencies, providers, and programs, except those who are expressly exempt from this requirement as set forth below must disseminate and/or administer and report to DCF the data collected from the CPSSS via the DCF electronic link: https://floridadcf.iad1.qualtrics.com/jfe/form/SV_eyYJyIzOiUmRnfg


The categories are as follows:

  • Adult Mental Health
  • Children Mental Health
  • Adult Substance Abuse
  • Children Substance Abuse


Performance Measures 

A Performance Outcome Measure (POM) record includes the following information about an individual: socio-demographic and clinical characteristics including level of care; level of functioning; and diagnosis. This information must be recorded and submitted during each treatment episode. It is required for analyzing and reporting to various entities responsible for the oversight and improvement of a statewide system of care for the prevention, treatment, and recovery of individuals with serious mental health or substance use disorders.

Over the course of a treatment episode, POM data will be submitted many times. There must always be at least one POM record associated with the admission and discharge. However, during treatment, POM’s must be updated every 90 days following the admission and can be associated directly with the admission or directly with the discharge.

BBHC reviews network POMs on a weekly basis to ensure that the BBHC  Network meets or exceeds target performance goals. Network Providers are encouraged to regularly review their performance measures to ensure data is being transmitted correctly. CQI staff can provide technical assistance for Providers when needed.

Performance Measures as of 7.5.2023


Incident Reporting Analysis System

The Incident Reporting and Analysis System (IRAS) is an online incident reporting tool that enables the Department to collect and analyze information about critical incidents that occur in all licensed substance abuse providers and contracted mental health treatment providers. Each provider is required to have at least two IRAS reporters, who are located in Broward County and able to enter IRAS reports within the required timeframes.

BBHC Incident Reporting Training

Secret Shopper 

The Secret Shopper Initiative is to ensure that front door staff receptionists and generally those who answer phone calls of individuals seeking services and information about services are knowledgeable about what services are available, provide a welcoming and encouraging environment, and do not discourage services based on ability to pay or other factors. Additionally, this initiative is to ensure provider agencies have implemented a “No Wrong Door Policy” which is the model for service delivery to persons served who have mental health or substance use disorders, or both, regardless of the point entry to the behavioral health care system, as referenced in the Florida Statutes (FS 394.4573(1)(d).

CQI staff will tabulate, analyze, and trend the information obtained both by provider and the overall system, and compile into a summary report. Provider agencies will receive an annual summary report for their agency. In addition, any accompanying recommendations will be included on the report for quality improvement activity.