Patient-Based Quality Improvement Indicators

The specific indicators of quality shown in Exhibit 5-1 are of particular importance. Staff can perform chart reviews to verify the quality improvement indicators. Routine weekly reviews of charts of 25 percent of the patients seen, with followup of any problems discussed in weekly case conferences, is a standard recommended by JCAHO (Joint Commission on Accreditation of Healthcare Organizations, 1993). Treatment staff should complete and document each of the following steps in the patient's record. If a step has not been performed, a reason for the omission should be included.

1. Admission procedures

   • Document the level of withdrawal; take previous medical history and drug use history; conduct physical examination; address legal issues; obtain patient consent for treatment
   • Develop an individualized treatment plan
   • Develop and initiate a plan for discharge and aftercare
   • Conduct formal assessment.
2. Primary services

   • Evaluate the patient's physical and psychological status (must include a medical history and physical examination within 24 hours, if these were not performed at admission)
   • Develop a plan documenting the anticipated course of medical and social management
   • Develop a plan for continuing care (involving the patient's family or significant others in treatment, when possible)
   • Perform routine drug screens
   • Flag files to indicate (1) previously treated patients and (2) patients with special medical problems, such as insulin-dependent diabetes, a history of seizures, drug sensitivities, or psychiatric comorbidity
   • Consult previous admission data and treatment plans, if available.
3. Financial information

   • Obtain at admission; seek reauthorizations as required
   • Provide assistance in obtaining entitlements such as Medicaid.
4. Discharge and aftercare

   • Identify patient's continuing needs for medical care, housing, legal assistance, food stamps, child care, or other services
   • Address legal problems (e.g., for court-referred patients)
   • Comply with legal mandates and reporting requirements.

Program-Based Quality Improvement Indicators

The programs' internal management information system should include clinical reports, incident reports, followup reports from referral resources, insurance and accreditation reports, and public health and other Government inspection reports. In addition, any other quality-improvement reports that have been generated to analyze trend data drawn from patient charts should be included. Every treatment program should have such a system in place to capture and compile these data so that program administrators can take a step back from reviewing the charts of individual patients to look at the entire patient population. The following indicators should be documented:

• Patient demographic data
• Primary and secondary drugs used at admission
• Sources of referral into the program, plus any changes in referral patterns
• Accuracy and timeliness of intake assessments (e.g., significant problems not identified at initial assessment, changes in the treatment plan, indications that clinical care was not appropriately individualized)
• Admissions processed within designated time frames
• Number of people interviewed who were not admitted (where they went and why)
• Number of individuals on the waiting list for admission and the average length of time on the waiting list (with note made of any changes cyclically and over time)
• Ratio of planned discharges versus the number of patients who left against advice (the case manager's unscheduled discharge report is a key document for this indicator)
• Staff data on training completed, turnover rates, internal promotion and transfer rates, staff complement (overall and by specialized unit), staff credentials, and training relative to job responsibilities and program licensure requirements
• Safety, security, sanitation, and insurance inspection reports
• Financial performance (e.g., evidence that reimbursements are billed accurately and promptly, all eligible funds are applied for, appropriate financial procedures are in place, financial records are in order and independently audited on a regular schedule).

The National Institute on Drug Abuse has published a technology transfer package to help program administrators and staff who have no previous experience or formal training in evaluation to plan and conduct evaluations of their programs. The package is titled How Good Is Your Drug Abuse Treatment Program? and includes an overview and case study manual, an evaluation guide, a resource manual, and looseleaf worksheets and agendas. The procedures and steps discussed in the guide conform to the standards of JCAHO. It is available free of charge from the National Clearinghouse for Alcohol and Drug Information at (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired) at (800) 487-4889.