CCBHC Compliance & CQI

Your CQI Data Is Only as Strong as the Voices Behind It

Pulse For Good delivers the independent, anonymous feedback infrastructure that CCBHCs need to meet SAMHSA's certification criteria for quality improvement, client satisfaction, and equity reporting.

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hello@pulseforgood.com | (435) 770-6209
The Challenge

Most client feedback systems
weren't built for this.

CCBHCs operate under SAMHSA's 2023 Certification Criteria, which require robust systems for Continuous Quality Improvement (CQI), client satisfaction measurement, and health equity tracking. These requirements are concentrated in Program Requirement 5 (Quality and Other Reporting) and Program Requirement 6 (Organizational Authority, Governance, and Accreditation).


Meeting these on paper is one thing. Meeting them with data that holds up under scrutiny is another.

Criteria Mapping

How Pulse Maps to CCBHC
Certification Criteria

Every claim below aligns with the SAMHSA 2023 CCBHC Certification Criteria (Program Requirements 5 & 6), updated March 2023.

CCBHC CriteriaHow Pulse For Good HelpsWhat You Get
Criteria 5.A
Data Collection, Reporting & Tracking
Anonymous kiosks, QR codes, and tablet surveys capture candid, timestamped feedback across all programs and service sites, completely independent of your EHR. Data flows automatically into dashboards with no manual entry.Audit-ready data exports. Evidence of independent, ongoing client experience tracking as required by SAMHSA.
Criteria 5.B
Continuous Quality Improvement
Trend reports deliver both quantitative satisfaction scores and qualitative open-text themes directly into Plan-Do-Study-Act (PDSA) cycles. Dashboards are designed for monthly or quarterly CQI committee review.Documented, data-driven CQI. Board-ready visualizations that demonstrate evidence-based quality improvement.
Criteria 5.B.3
Data-Driven CQI with Health Equity Focus
The 2023 criteria require CQI plans to use quantitative and qualitative data with an explicit focus on populations experiencing health disparities. Pulse's demographic tagging (age, race, ethnicity, gender, program) enables disaggregated outcome analysis.Disaggregated data for populations facing health inequities. Defensible disparity detection that satisfies federal equity expectations.
Client Satisfaction Measurement
within Criteria 5.B
Tracks access, respect, safety, cultural responsiveness, effectiveness, and overall satisfaction, aligned with SAMHSA quality domains. Responses are collected continuously, not just at intake or annual intervals.Subjective experience converted into measurable, trendable metrics. Ongoing data rather than periodic survey snapshots.
Criteria 6.B
Governance & Accountability
Real-time dashboards simplify reporting to governing boards, CQI committees, funders, and SAMHSA. "You Said - We Did" summaries demonstrate that client input directly informs organizational decisions.Transparent governance reporting at every level. Documented evidence that client voice shapes improvement.
Early Risk DetectionAggregate trend analysis exposes patterns of dissatisfaction around safety, access, respect, or environment before they escalate into formal grievances, complaints, or critical incidents.Fewer escalations and grievances. Proactive support for trauma-informed service environments.
What Pulse Measures

Six domains tied to
CCBHC quality reporting

Every response is timestamped, aggregated by site and program, and trended automatically.

Access

"It's easy to get help when I need it."

Captures whether clients can reach services when they need them, including wait times and appointment availability.

Respect & Dignity

"Staff treat me with respect."

Measures the interpersonal quality of interactions between clients and staff at every touchpoint.

Safety

"I feel safe here."

Tracks physical and emotional safety within the clinical environment. Critical for trauma-informed care.

Cultural Responsiveness

"Staff understand my background."

Assesses whether care delivery meets cultural and linguistic needs, aligned with the National CLAS Standards.

Effectiveness

"I'm getting the help I need."

Gauges perceived clinical effectiveness. A leading indicator for treatment engagement and retention.

Overall Satisfaction

"I'd recommend this program."

A composite indicator that correlates with client retention, engagement, and program reputation.

CQI Workflow

The 5-step CQI cycle
with Pulse

Pulse integrates directly into the Plan-Do-Study-Act cycle that forms the backbone of CCBHC quality improvement.

1

Collect

Gather feedback via kiosk, QR code, or tablet at every service site. Pulse captures responses anonymously and continuously. Clients can respond in under 60 seconds.

2

Review

Use pre-built dashboards in monthly or quarterly CQI meetings. See satisfaction trends, demographic breakdowns, and qualitative themes with no data analyst required.

3

Identify

Spot trends in satisfaction, access barriers, environment concerns, or equity gaps. Filter by site, program, demographic group, or time period.

4

Implement

Adjust processes, staffing, outreach, or facility conditions based on what clients are actually reporting. Document the rationale using Pulse data as your evidence base.

5

Re-measure & Report

Demonstrate measurable improvement to SAMHSA, state certifiers, or funders. Export timestamped data for compliance documentation or use dashboards for board presentations.

2M+

Anonymous responses collected

10+ Years

Serving vulnerable populations

Zero

IT integration required

Why Pulse

Built for behavioral health.
Built for scrutiny.

Anonymous Honesty

Clients speak freely when they trust the process. No login, no name, no identifying information. No fear of retaliation means more honest data, and honest data is the only kind worth building CQI plans around.

Equity Visibility

Compare experiences across race, ethnicity, age, gender, and program. Pulse surfaces the disparities that aggregated satisfaction scores hide, giving your CQI team actionable, disaggregated data aligned with SAMHSA's explicit equity requirements.

Plug-and-Play Simplicity

Deploy in days, not months. No EHR integration, no IT infrastructure changes, and no additional staff training. Kiosks arrive pre-configured and QR codes can be printed and posted in minutes.

Audit-Resilient Data

Every response is timestamped and exportable. Pulse produces the kind of independent, documented evidence that state reviewers, SAMHSA auditors, and funders expect, without scrambling before a compliance deadline.

Built for Scrutiny

Pulse provides an independent client voice that exists outside your EHR and clinical workflow. This separation strengthens the credibility of your CQI story. It's not just another internal metric; it's what clients are actually saying.

See How Pulse Fits
Your CQI Plan

Request a CQI readiness walkthrough, a sample audit-ready report, or a live demo.

Get Started
pulseforgood.com  |  hello@pulseforgood.com  |  (435) 770-6209