Continuous Quality Improvement
Performance Enhancement in State Substance Abuse Treatment Systems
in the late 1990s, DeltaMetrics began advancing this central focus
beyond one-time measurement and evaluation.
Through its carefully developed understanding of how treatment
systems are organized and an appreciation of the important clinical
aspects of treatment, it became clear that by using treatment process
data, patient demographic and historical data, financial data,
outcomes data and other quantitative measurements, DeltaMetrics could
assist its clients in establishing programs of Continuous Quality
Improvement (CQI) consisting of a series of “Performance
Enhancement” (PE) initiatives.
program of CQI is essentially one that transforms an organization into
a learning organization by creating a framework for continuous
comparison of experiences against internal and external standards.
(at discharge and follow-up)
a CQI strategy that relies on recurring assessment of patient outcomes
at follow-up as a primary data source is ideal, but very expensive,
DeltaMetrics is employing less costly approaches to CQI that can be
just as effective. One
such approach uses performance indicators (PIs), or data elements
routinely collected within the system for which there is evidence of
some value in predicting patient outcomes.
For example, there is substantial evidence to suggest that
retention in substance abuse treatment is a good predictor of patient
the percentage of patients retained in treatment for the intended
period of time (e.g., 1 month) may be employed as one PI.
It is important to monitor and reevaluate PIs from time to time
to make certain that they retain value as surrogates for patient
outcomes. Small, focused,
and more intensive studies on selected samples of patients can serve
that purpose, aid in the interpretation of PIs and more accurately
define the impact of systems changes on outcomes.
The simple table below illustrates how data
generated under a CQI system can be used to develop
performance-enhancing treatment interventions in a substance abuse
One intervention suggested by the data in this example
is a hands-on training program for clinicians to improve employment
status outcomes at six months post discharge.
Such a training program could draw upon empirically-based
treatment protocols, such as those that are available at no cost from
the Center for Substance Abuse Treatment and other federal agencies,
or from the research community.
another form of intervention may be suggested if the question is asked
"What does this data tell us about who is our best provider from
the point of view of achieving good employment status outcomes at 6
months post discharge for the lowest cost?"
If we get the same result consistently, then that provider may
have something to offer by way of training to the other providers that
might enhance across-the-board performance on this measure.
must be emphasized, however, that differences at baseline make
comparisons between different groups of patients in a system difficult to interpret. Thus, in the above example,
as in any PE intervention, case
mix adjustment strategies must be used to control for biases that
may exist in the analyses because of initial patient differences.
Case-mix adjusted outcomes data can also be used to identify targets
for performance improvement through qualitative analytic strategies,
such as benchmarking. As
illustrated in the above example, providers that perform in the top
and bottom quintiles on an outcomes dimension can be identified and
their practices and characteristics compared through in-depth
semi-structured interviews. Differences
between the two groups of performers can reveal programmatic elements
or clinical practices that would serve as a model for those who may
need to modify their practices in order to improve patient outcomes.
Initiate a continuous feedback process so that each intervention
helps to modify or inform subsequent plans, actions and data
design, a CQI strategy is an ongoing and dynamic enterprise. The
approach is to define the appropriate measures, monitor them on a
continuous basis, and evaluate them for changes over time, and whether
the changes are process- or content-based.
In the previous example, an intervention consisting of
peer-directed, best practices workshops on improving employment
outcomes might be pilot tested with a subset of clinicians and the
results measured through a targeted outcomes evaluation.
Empirical-based modifications to the intervention might then be
applied system-wide and be periodically evaluated.
The application of one intervention may also yield additional targets for improvement. Application of an intervention to improve employment outcomes, for example, may yield data showing that the skill sets of clinicians differ from the needs of their clients. For example, a provider organization that has experienced a recent increase in users of a particular substance might not be trained in the most current empirical-based therapeutic strategies for treating its abuse. Similarly, other changes in client characteristics might be better addressed with new skills. Consequently, after identifying the skills of providers and the characteristics of clients, the need for more appropriate clinical interventions could be identified and strategies disseminated.
learn more about CQI programs for your systems of care, contact
Richard Weiss, DeltaMetrics Director of Research and Evaluation, at
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