2Clinic Quality Improvement Initiative A Partnership Between Clinic Providers and OMH to Improve the Outcome of Our Services
3As the first decades of the 21st Century unfold, what changes do you expect in the provision of mental health services?
4Our Evolving Environment We expect far more definitive research on what is effective in the treatment and rehabilitation of mental disordersProviders will need to be able to accomplish the transition from research to practiceProviders will need to use objective tools to assess client needs as well as the process and outcome of care
5OMH Vision: A Transformed System Actively combats stigmaValues qualityContinuously improvesMeasures success by measuring individual recoveryAdopts evidence based practicesTailors evidence based practice combinations to the needs of individual clientsStresses adequate housing, employment and social integration
6An Overview of the Workshop What is Quality ImprovementOverview of the MOACompletion of the QI PlanThree Examples of Quality Improvement Initiatives
8What is Continuous Quality Improvement? A quality management model whereby healthcare is seen as a series of processes and a system leading to an outcome. QI strives to make changes in the structural and process components of care to achieve better outcomes.Talk about structure, process, outcomes
9How Quality Improvement Began Shewhart and Bell LabsDeming and the Japanese Auto IndustryIndustry in the 1980’sHealthcare in the 1990’sThe Enduring PrinciplesMethod: Plan, Do, Check, ActCollaboration with those who do the workFocus on understanding our workCommitment to improvementCommitment to using objective data
10Quality Improvement and Healthcare Added element of the clientPassive vs. active: Individuals are empoweredMedical ErrorsOutcome of CareBasing Practice on EvidencePassive versus active patient: empowerment
11Variations on the Approach CQI Continuous Quality ImprovementTQM Total Quality ManagementSix Sigma Engineering OriginsPDCA Plan-Do-Check-Act cycleBSC Balanced Scorecard
12The Shared Elements of Continuous Quality Improvement Approaches
13Quality Improvement is an Orientation and Attitude We understand our work as processes and systems.We are committed to continuous improvement of processes and systems
14Core Principles of Continuous Quality Improvement Customer FocusRecovery OrientedEmployee EmpowermentLeadership InvolvementData Informed PracticeUsing Statistical ToolsPrevention over CorrectionContinuous ImprovementParticipation and Communication at all levelsCustomer Focus. High quality organizations focus on their internal and external customers and on meeting or exceeding customers’ needs.Employee Empowerment. Effective programs involve people at all levels of the organization in improving quality.Leadership Involvement. Strong leadership, direction and support of QI activities by the governing body and CEO are key to performance improvement. This involvement of organizational leadership assures that QI initiatives are consistent with provider mission and/or strategic plan.Data Informed Practice. Data is necessary to inform practice and measure results. Fact based decisions are likely to be correct decisions.Statistical Tools. Effective QI organizations use a defined set of analytic tools to turn data into information.Prevention over Correction. QI entities seek to design good processes to achieve excellent outcomes rather than fix processes after the fact.Continuous Improvement. Processes must be continually reviewed and improved. Small incremental changes do make an impact, and providers can almost always find an opportunity to make things better
15Overview of a CQI Program Essential Program AspectsProvide a structure through which the core organization functions are evaluated and improvedCore functions will be defined by the Mission, Vision, and Values of the organizationExamples of core functionsOutcomes: client safety, clinical outcomes, client satisfactionProcess: client flow, fiscal issuesCore functions operationalized for data collection purposesExamples of operationalized functionsOutcomes: med errors, suicide attempts, satisfaction survey dataProcess: wait list latency, no show rates, medication costsEvaluation of the functions achieved through analysis of collected dataImprovements accomplished through projects/initiatives
16Overview of a CQI Program Where do projects and initiatives come from?InternalUnacceptable variation in key indicatorsManagement initiativesClient complaintsIncidentsExternalLiterature, e.g., Evidenced Based PracticesBenchmarking – comparing organizations’ results to other, like organizationsRegulatory agencies, changes in law/standards
17Overview of a CQI Program Internal and external factors will be reviewed by QI Committee (and others – Board of Directors, etc)Projects/initiatives will be started based on results of prioritization process
18Setting PrioritiesAlways more improvement opportunities than can be effectively addressedSet Priorities based on:Relevance to missionClinical Importance: High volume, high risk, problem-proneExpected impact on outcome of careAvailable resources and cost
19What is a Project or Initiative? A planned activity, often involving a group of people, with a specific goal or expected outcomeQuality improvement is about doing something based on our prioritiesRequires a planned and systematic approach
20Shared Core Method of Quality Improvement Approaches PlanDoCheckActSingle approach employed throughout the facility.
21Quality Improvement: Plan Select the projectUnderstand and clarify the processDataFlowchartingBrainstormingFishbone DiagramDevelop a Plan of Action
22Quality Improvement: Plan Plan the actionPlan the pilot test of the actionInclude in the plan a measure of performance
23What is a Performance Indicator? A quantitative tool that provides information about the performance of a processQuantitative tool - means variablein relation to an outcome recognizing that some outcome measures relate to an entire host of processes? For example, recovery or symptom improvement or improvement in functional status.
24Quality Improvement: Do Collect dataAnalyze and prioritizeDetermine most likely solutionsTest whether our action really works before we make it a routine part of our daily operations
25Quality Improvement: Check At the end of the pilot period, determine whether the action has had the desired effect.Is the modified process stable?Did the process improve?
26Quality Improvement: Act If the action works:Make it part of routine operationsContinue to gather data to make sure you are holding the gains
27Quality Improvement: Act If the action does not work:Return to the Plan stageUse the test to plan a better action
28PDCA is a CycleIt is not about one single dramatic action, but about trying things to see if they work.Remember, life is a series of experiments.
29Evidence Based Practice A special QI method: Systematically copying a process or system that works betterCare of psychiatric disorders is an increasingly research based activityThe Challenge: Transfer of knowledgeA formal rather than informal activityApproach fidelity.Objective assessment.
30Our Partnership for Quality Memorandum of Agreement
31Key DatesNovember 30, 2005: MOA due to OMH in order to receive increase retroactive toJanuary 15, 2006: CQI Plan due to OMHFebruary 1, 2007: First Annual Evaluation due to OMHFebruary 1, 2008: Second Annual Evaluation due to OMH
32Key Dates New York CityNovember 30, 2005: MOA due to OMH in order to receive increase retroactive toJanuary 15, 2006: CQI Plan due to OMHApril 30, 2007: First annual evaluation due to OMHApril 30, 2008: Second annual evaluation due to OMH
33Highlights of MOADoes not require providers to adopt one particular frameworkDoes require that certain key principles guide any QI effortRequires participation in the implementation of Child and Adult Integrated Reporting System (CAIRS)Creates measurement opportunitiesOMH’s Center for Information Technology and Evaluation Research (CITER) will be coordinating a statewide implementation of CAIRS for clinics in the next several months.
34First YearEducate Leadership and Staff on principles of QI, Performance Measurement and Evidenced-Based Practices (EBP)Create an Administrative structure to perform QI activities through the designation of a Quality Improvement CommitteeDevelop a Quality Improvement PlanImplement at least one measure of the process or outcome of careHandouts in the packet, on the CD enclosed and on the OMH and SAMHSA website re EBPs.Samhsa phone # re: EBP – 1(800)Tony Salerno – (518)Integrated treatment for co-occurring mental and substance use disordersStandardized pharmacological treatmentAssertive Community Treatment (ACT)Illness management and recovery skillsFamily psychoeducationSupported employment
35Second Year Include QI Plan in new employee orientation Develop and use a second performance indicatorDocument use of data from indicators in decision-makingSurvey individuals served, families and staff about their perceptions of careComplete an annual QI Evaluation
36Third YearCollaboration with OMH on an evidence-based practice in the area of medication therapy to be determined.
39The Wide Variety of Possibilities (Three Examples) Improving Engagement of Youth and FamiliesReducing the Wait ListIntegrated Treatment (An Evidence Based Practice)
40Example 1: Relevance to Mission and Clinical Importance Improving the Engagement of Youth and Families in Clinic ServicesTwo thirds of children in need of mental health services do not receive services. (US Public Health Service, 1999, 2001)Only 20% of all children in a study sample of clinics in New York State completed the episode of care in which they were enrolled. (Lyons, 1999)No show rates can be as high as 50%. (Lerman and Pottick, 1995)What I would like to do now is walk you through a QI example using engagement.So where did they start? In the planning stage thinking about priorities they uncovered that:2/3rds of children with mental health problems do not receive any type of mental health services. Furthermore, among those who receive some services, no-show rates for appointments may be as high as 50% and premature terminations are common.John Lyons found that in NY only 20% of all children in a sample of clinics completed care. No show rates can be extremely high.• From 2004 to 2005, OMH, the Citizens’ Committee for Children, the New York City Department of Health and Mental Hygiene (DOHMH), and the Mount Sinai School of Medicine implemented the 9-month quality improvement project the “Learning Collaborative to Improve Engagement and Retention of Children and Families in Treatment.” You are going to hear more about this tomorrow because Dr. McKay is on the agenda. The Collaborative, with input from a workgroup of local stakeholders (community providers, family and youth advocates, OMH staff, and DOHMH staff), found that evidence-based engagement interventions and quality improvement methods were effective in improving rates of initial engagement of children in outpatient mental health clinic services
41What were the indicators ? #1 The show rate for the first intake appointment for all new evaluations of children and adolescents:# who kept first intake appointments#scheduled appointments#2 Attendance at any scheduled clinic appointments subsequent to the first kept intake appointment for all new evaluations:# of attended clinic appointments (excluding first kept intake appt.)#scheduled clinic appt. (excluding the first kept intake appt)
42North Shore Child and Family Guidance Center Baseline Data 91% of children and families keep intake appointments66% of children and families attend clinic appointments subsequent to the first intake appointment
43What was the desired result? By implementing an evidence based training program related to improving the engagement rates for clients, the clinic would treat and retain more children for the duration of their episodes of care.
44ObjectivesImprove the show rate for the first intake appointment for all new evaluations of children and adolescentsImprove attendance at any scheduled clinic appointments subsequent to the first kept intake appointment for all new evaluationsThere were four indicators for this project, we will just focus on 2 for the purpose of this presentation.
45What is Engagement?A process that begins with an individual being identified as experiencing mental health difficulties and ending with that individual receiving mental health care (Laitinen-Krispiijin et al, 1999, Zawaanswijk et al, 2003)Has been divided into 2 specific steps: initial attendance and ongoing engagement (McKay et al 1996, 1997, 1998). Rates of service engagement can differ at each and warrant specific consideration.References are from “Engagement of Youth and their Families in Child Mental Health Care Summary” Prepared by Mary McKay, Ph.D. and William Bannon, MSW Mt. Sinai School of Medicine and New York State Office of Mental Health. Not in packet, but available from Marcia Fazio and will send to them if they want.
46Evidence Based Engagement Interventions Reminders reduced missed appointments by as much as 32% (Kourany et al, 1990, McLean et al 1989, Shivack et al, 1989 and Sullivan)Intensive family-focused telephone engagement intervention associated with 50% increase in initial show rates and a 24% decrease in premature terminations (Szapocznik, 1988, 1997)
47Empirically Supported Telephone Engagement Strategy Focus during the initial telephone intake or appointment callRelies on an understanding of child, family, community and system level barriers to mental health careFamily-Focused Telephone Engagement Intervention:1. Clarify the need for mental health care2. Increase caregiver investment and efficacy3. Identify attitudes about previous experiences with mental health care and institutions4. Problem Solve, Problem Solve, around concrete obstacles to care
48How Was it Assessed?Staff received training in EBP engagement techniques Oct 04In Nov 04, agency began collecting data on indicators 1 and 2Data was tracked for 9 monthsResults compared pre (business as usual in Oct 04) and post (following the engagement intervention)
49PlanAgency received training in the evidence based engagement intervention (Oct 04)Following the training, agency identified a quality improvement team, developed a plan to incorporate the EBP into their operations, and a plan to track the effectiveness of the intervention over nine months using the indicators agreed upon
50DoIn November 2004, agency implemented the engagement strategy and began collecting dataData was collected each month for nine months and analyzed for trends and patterns
51CheckCourse corrections were made when it appeared that the results did not support the original intentNorth Shore reviewed data and discussed findings in monthly conference calls and quarterly meetings with other clinics participating
52North Shore Child and Family Guidance Center Performance Indicator #1
54North Shore’s Experience Fewer issues with dropout (Indicator #1). They started high (91%) and maintained that rate over allThe real success came with Indicator #2. They retained a significantly higher rate of clients after the collaborative than beforeMoved from 66 to 84 percent
55Act Revised process was fully implemented Data collection continues to ensure that the positive results are maintained over timeStaff learned from each other
56Lessons and Challenges Collect only the data that is tied to the improvement you want to make. (example of what was collected for this in your packets)Keep it simple and Non-Burdensome. (Most clinics collected data by hand)Make sure the findings are communicated and that leadership knows about the QI project. It is part of the overall agency management framework.Don’t take shortcuts. Don’t skip the PDCA.Call your colleagues.Compare results across sites in an agency.
57More Information Contact: Mary McKay, Ph.D. Professor of Social Work Mt. Sinai School of Medicine, Dept. of PsychiatryMarcia Fazio, Director, External Review UnitNew York State Office of Mental HealthOffice of Quality Management
58More Contact InformationNorth Shore Child and Family Guidance CenterRegina Barros, Director of Clinical ServicesAndrew Malekoff, Associate Director480 Old Westbury Rd.Roslyn Heights, NY 11577ext. 330
59Example 2: Mission Relevance and Clinical Importance Reducing the Wait ListRensselaer County Mental Health Department determined that individuals were unable to access its clinic services in a timely manner. (Problem prone and high risk)There was no way to differentiate people who needed counseling from those who needed other types of services. (Mission relevance)Information gathered during the intake call was often inaccurate. (Problem prone)The result was that consumers were waiting 2-3 months for a clinic appointment. (Problem prone, high risk)
60What were the indicators? Number of calls receivedNumber of appointments madeNumber of individuals who did not show for treatmentWait timeCost per appointment
61Rensselaer County Baseline Data 760 calls received760 appointments made14 no shows each month2-3 month wait time$133,000 cost for 760 appointments
62What was the desired result? The county wanted to reduce the wait list, improve the response time and provide services based on what its customers really needed.
63What was the model?A team of senior clinicians was formed. They have the confidence to make decisions.Clinicians were trained to ask the right questions. Who is bothered? What is bothering them? How much and in what way? Client, Referral Source, Clinician?Individuals who called the clinic for help received a call back from a senior clinician immediately.Clinicians spent as much time as necessary over the telephone to determine what the caller needed.Clinicians were prepared to make multiple calls to referral sources if necessary.Clinicians were careful about the language that they used. Instead of saying “What do you expect to get out of treatment”? They asked “Why did you call?”Callers were called back in 2 weeks to ensure that the suggestions they were given were helpful.
64PlanThe county decided that the wait time for clinic services was not acceptableSenior staff implemented a model for answering the phone differently when consumers call for services that had proved successful in another part of the county’s organizationThe model developers were adamant that this model had been replicated from another part of the organization. The clinic did not invent it. so that’s what I was getting at above..
65DoSenior Clinicians were trained in the model, assigned days of the week and answered all calls for their particular dayCalls were tracked on a monthly basis and outcomes were monitored for the year to ensure that the intervention was having the desired effect
66Data Before Calls received= 760 # Appts made= 760 (100%) No-Show Rate= 14/moWait time to appt= 2-3 moCost 175. for 760 appts= $133,000.AfterCalls received= 760#Appts made= 427 (56%)No-show Rate= 4/moWait time to appt= 0 creeping to 1.5 moCost $175. for 427 appts= $74,725. Savings to county= $58,275.
67Examples of what services people received other than outpatient therapy TransportationRespite servicesParenting ClassesFlexible Funds to pay for basic needs: clothing, phoneSpecialty Services: Bereavement, Sexual Offender TreatmentAdviceEducation of the Referral Source (person doesn’t need therapy, they need some other service)
68CheckCourse corrections were implemented when problems were identified. (e.g., Team members were replaced when it appeared their practices were inconsistent with the model.)
69Act Successful strategies were reinforced during staff meetings Adherence to new protocols monitored over time
70Lessons LearnedNot everyone who calls a clinic needs outpatient therapy. 43% of the callers in this county needed basic problems solved.Not all clinicians were cut out for this model and some were removed from the team.It was important to use Sr. Clinicians who were confident making decisions on the spot, speaking to judges, etc. Sr. Clinicians had a 30% appointment rate vs. 60% appointment rate for less experienced staff.Any person who really wanted to come in for therapy was provided an appointment even if the clinician had assessed that it was not necessary.
71Contact InformationRensselaer County Department of Mental HealthKatherine Maciol, CommissionerAaron Hoorwitz, Ph.D. Chief PsychologistNed Pattison Government CenterTroy, NY 12180
72Information on the Model Developers:Rensselaer CountyDepartment of Mental HealthAaron HoorowitzChief PsychologistDonna BradburyPrincipal Court Consultation SpecialistSara ThiellCourt Consultation Specialist
73Example 3: Mission Relevance and Clinical Importance Integrated Dual Disorder Treatment: The OpportunityA clinic found that a significant percent of their clients were experiencing alcohol / substance use problems along with mental illness. (High volume/Problem prone)Among this group were the most difficult to treat effectively. (Problem Prone)Staff varied in their approach to these clients with no consensus on what was most effective. (High Risk)“Why is my client not getting better?” (Problem prone)OMH identified Integrated Treatment as an “evidence-based practice” with resources available. (Mission relevant)Back to our hypothetical illustration -
74IndicatorsThe number of dually diagnosed individuals assessed initially and at 6 and 12 month intervalsThe number of dually diagnosed individuals progressing through treatment
75Desired ResultA significantly improved treatment outcome for dual disorder (mental illness and substance use) clients as measured by changes in stage.Note this is an example of a project focusing on clinical outcome.A simple desired result but also an ambitious one.We must do some consistent measurement and assessment to determine whether we are reaching our desired result.
76Plan: The ModelTreatment is most effective if the same clinician or team helps the client with both substance abuse and mental illnessPeople who recover from substance abuse disorder go through a stepwise process that can be described in stagesAt different stages, different types of treatment are helpfulLet’s talk a little bit about the evidence based practice that the clinic is deciding to adopt. There is a very large research literature supporting this practice. A bibliography is available on the OMH web site. We will not make any attempt to summarize that research here. We will just provide enough information about IDDT so that it can be used as a hypothetical example. I am also not really an IDDT expert, so I will keep us focused on this as an example of adopting an EBP rather than on IDDT itself, its merits or shortcomings.But here are the core principles of IDDT. They are quite straight forward.(Read the principles)
77Stages of Recovery Change Treatment Precontemplation Contemplation PreparationActionMaintenanceTreatmentEngagementPersuasionActive TreatmentRelapse PreventionThis is a well developed practice with many training materials and other resources available to assist practitioners who want to adopt the practice.Here are the actual stages of change or recovery as defined within the IDDT approach. For each stage, there is a particular focus of treatment associated with specific therapeutic interventions and practitioner skills.In your handouts, is a brief chapter from the IDDT Workbook. Show them the notebook. This is one of the most useful basic resources for this approach. It is available from the Department of Health and Human Services.Briefly illustrate this slide with information from the handout about a particular stage (Chapter 6).There is a wide variety of other written resources available.OMH: Jeff Gleba, resource person in OMH. Willing to come out and consult.Variety of resources available regionally. Provide Field Office Resource person if there is one.
78Substance Abuse Treatment Scale Pre-EngagementEngagementEarly PersuasionLate PersuasionEarly Active TreatmentLate Active TreatmentRelapse PreventionIn Remission or RecoveryOne of the things that makes this a particularly attractive EBP is that it comes with a very simple but effective assessment tool. It is an eight point rating scale based on the stages of recovery. A copy of the scale is in your handout.Each category on the scale is briefly described, for example…This scale has a number of real positives:Can be done instantly by clinicians who are knowledgeable of IDDT and who know their clients.It has a lot of what is called “face validity.” It has clear and obvious meaning in relation to the approach.Since it was developed directly in relationship with the IDDT approach, it has what is called “construct validity.” What it measures has real meaning in relation to how you understand you clients and what you are trying to accomplish with them.It gives you a single number that can readily be used in a number of ways to guide what you are doing and assess your success with this approach. We will be talking more about this.
79Four Basic Skills of Clinicians Knowledge of substances of abuse and how they affect mental illnessesAbility to assess substance abuseMotivational counseling for those not ready to acknowledge substance abuseIntegrated substance abuse counseling for those motivated to address their problemsAs you can see in your handout, this is a highly prescriptive approach. At each stage, the therapist focuses on certain types of interventions. It requires a specific set of skills of practitioners. These are summarized on this slide.
80PlanCommitment: We are serious about doing this and will stick with itLeadership and staffLearning, measuring and assessingFidelity to the practice: We want to do this rightStrategyA starting point and 12 month objectivesOur hypothetical clinic has a close knit staff of a nurse, two social workers, a part time psychologist and a part time psychiatrist. One of the social workers also serves as the Director of the clinic.In their ongoing discussions, clinic staff have struggled with the issue of how to serve their clients with both mental illness and substance use disorders. Some members of the staff have been exposed to IDDT and have been favorably impressed. In their weekly staff meeting, the Director proposed that they consider adopting an integrated treatment approach. In their discussion, there was a discussion that a willy-nilly approach would not work. This will need to be a longer term commitment with a carefully planned and executed process, a strategy.Invited Jeff G. from OMH who shared the OMH perspective and other service providers. He also shared the idea of the stages of treatment as a practical starting point.Clinic staff met and decided to do it. All clinicians would make a commitment to learning and treating their clients with this approach.The Director developed a brief written strategy in close consultation with staff. Since this was to be a longer term project, they wanted to formulated some short term (12 month) objectives to focus their efforts. Note relevance to QI Plan.Director presented the strategy to the Board and they were highly supportive.
81What is a Strategy? Avoiding the Britney Spears wedding The larger pictureA set of related and planned actions which make a coherent whole designed to accomplish a major goalLet’s talk a little bit about what it means to develop a strategy.It’s easy to fall in love and do something impulsive. Sometimes we regret this later. Often it does not work out. One benefit of making our strategy explicit is that it lets us know who, or in this case what, we are marrying. It is the rational basis for a long term commitment.A strategy is the larger picture. The term strategy comes from military parlance. It is the science of planning and directing large scale military operations.Read the definition.
82The Clinic’s StrategyObtain and maintain leadership and staff commitmentAll clinic staff will become competent in the skills of IDDTClinical staff will carefully review all their clients, further assessing and making a substance use disorder diagnosis as appropriateClinical staff will rate the stage of treatment of all clients with a substance diagnosis every six monthsRatings will be used to assess individual progress and aggregated to guide staff training and assess outcomeStaff will complete a self-rating of fidelity to the IDDT approach every six monthsSo what does the clinic’s strategy look like. (Review) What do you think of this as a strategy?Note:The importance of leadership. This is an ongoing activity. How is commitment maintained. Deming – “constancy of purpose”This is the big picture, the major elements. In all cases there is another level of detail which may change over time. For example, in the are of staff training: Initially, staff committed themselves to use the IDDT Workbook and devote a hour of staff time each week to learning and practicing. The Board agreed to a budget for consultants to focus on specific learning issues and challenges.Fidelity rating scale is in the handout. Discuss the value of this. Note that this is a second measure and the OMH agreement requires only a single measure this year.Let’s look at the certain parts of this strategy in a little more detail.
83Strategy: Learning and Practicing Staff meet for an hour weekly using the “Integrated Dual Disorders Treatment Workbook” as a resourceFocus on developing skills most relevant to the stage of recovery of most clientsLater, as indicated by the data, focus on the most difficult stage transitionsBring in outside training resources to focus on treatment challengesThis spells out the part of the strategy having to do with the development of staff competence in a little more detail. Note the relationship between the use of data and the staff training strategy.
84DoClassify all clients who meet criteria for substance abuse or dependence on the Substance Abuse Treatment ScaleDevelop a profile of clients on the ScaleClassify clients at the time of each treatment plan reviewTrack and evaluate progress of individual clients and dual disorder clients as a groupThis is their strategy in the area of measurement of assessment and measurement.Understanding where their clients are in relation to the stages of treatment is also their critical starting point. It is an initial action which opens the door into the entire project.
85Do: Starting Point: Assessment Two StagesIdentify clients who meet the criteria for substance abuse and dependenceClassify clients on the Substance Abuse Treatment Scale
86Do: Initial Rating Database We are assuming a small clinic with a minimum of resources but plenty of motivation. Since we are assuming that most clinics have a copy of Microsoft Excel available to them, we will use that tool in our example. In this regard, we should mention a number of points.We will use Excel as an illustration, but we will not be training you how to use Excel for this purpose. Our illustration is a simple one, however, and should be well within the capabilities of anyone who has a modicum of ability in using computers and has had introductory training in Excel.This is a basic application. There are certainly many more sophisticated tools out there for this and similar purposes. If you are using one of these tools, we offer our encouragement to continue. We are not endorsing Excel as the optimal data analytic strategy.The data are made up, but the Excel application is real. We designed it to be as simple as possible. If you would like me to mail you a copy, give me your address after the session.Here is the really basic database. The fields are:Number: A unique number to identity the patient.Date: The date when the patient was assessed.Measure: This is interesting. This indicates the measurement point for the patient. 1 indicates the first time the patient was assess; two the second time, etc. According to our plan all of these measurement points will be six months apart. This illustrates the first point for all the patients.Rating: This is the actual rating for each patient on the 8 point scale.
87Do: Initial Rating of Clinic Patients This is the first thing the clinic did with their data. It is based on all clients first measurement point. They aggregated the initial ratings of clinic patients. What does this tell us? This revealed that most of their patients fell into the stages from engagement to early active treatment. This allowed them to focus their training efforts on the staff skills relevant to these stages.
88CheckAggregate an initial, 6 month and 12 month rating of all IDDT clientsComplete staff training using the IDDT WorkbookAnalyze stage of treatment of IDDT clients to help focus training needs and issuesAnalyze progress of IDDT clients as a groupAnalyze difficult stage transitionsThese are the 12 month objectives that are incorporated into the QI Plan. We will now look at some hypothetical data to illustrated how the data related objectives were met.
89Check: Example of a Client’s Progress Clinic staff continue to rate their patients every 6 months and put the numbers into their data base. This is an example of a specific patient’s progress over a year and a half. It could be made a part of the treatment plan review process for this group of patients.
90Check: Progress of IDDT Clients This graph depicts the average progress of all patients during their first 18 months of integrated treatment. Note that patients would start treatment as different points in time. It would be very difficult to aggregate this information using so many different dates. Putting in the numerical measurement points makes this analysis quite simple.
91Check: Percent of Clients Progressing Through Each Stage As the clinic gathered more data over time, they were able to do this interesting analysis. It asks the question: How successfully are clients moving through each stage of recovery.For each stage at each measurement point across clients, we calculated the percentage of clients who were at a higher stage at the time of the next measurement.Note: Stage 8 is not included because a client cannot progress any further.Let’s look at the data:Overall it looks like the program is pretty successful. Patients are progressing. Isn’t this helpful to know.Good success in moving clients on from the pre-engagement stage. But, note that we only counted two cases. We wouldn’t want to draw any conclusions from this.Look at stage 4. Our biggest barrier seems to be moving clients on from Late Persuasion to Early Active Treatment. This is where we want to focus our case review and staff development efforts. Perhaps consult an expert.To some extent, this also seems to be true of the movement from Relapse Prevention to the final stage, In Remission or Recovery, as well.
92Act Actions were based on the initial assessment of clients Since most of the patients fell into the stages from engagement to active treatment, training efforts focused on the staff skills relevant to these stages
93The Quality Improvement Plan Note required elements of the plan in the MOA.
94Quality Improvement Plan Template Meets the requirements of the MOAOptionalSections to be completedMission, Vision and Scope of servicesLeadership and QI committeeGoals and objectivesSelection and description of indicatorAssessment strategiesApproach or model to be usedDesigned to meet the requirements of the MOA.
95Mission/Vision: Scope of Services Section 1 of the Plan Describe program philosophyProvide basic descriptive information including:Description of individuals servedCatchment areaType of servicesSize of the organization
96Leadership and QI Committee Section 2 of the Plan The Quality Improvement CommitteeMembership issuesResponsibilitiesMeeting frequencyCritical role of leadership supportSharing of findings with stakeholdersSuggested Materials for use in educating leaders:
97Goals and Objectives Section 3 of the Plan Long term core goals of any quality improvement programObjectivesRelated to selected goalsSpecific to the clinicMeasurableExpected completion within 12 monthsA basis for the annual evaluationObjectivesDo not need an objective under every goalProvide a couple of specific examples of objectives
98Things to Consider in Selecting a Performance Indicator Section 4 of the Plan Mission of the ClinicClinical importance: High Volume, High Risk, Problem ProneOutcomeAvailable resources and cost
99Description of Performance Indicator Section 4 of the Plan A quantitative tool that provides information about the performance of a clinic’s processes, services, functions or outcomesData collectionAssessment frequency
100Assessment Strategies Section 4 of the Plan Describe assessment methods and tools to turn data into informationSee Appendix AMemory Jogger in packet
101Approach or Model Used Section 5 of the Plan Various models existPDCA is described
102Contact InformationCentral and Western New YorkThomas CheneyLong IslandJames MastersonNew York City and Hudson RiverAlan McCollom and Ellen Smith