West Quality Improvement Award Winner: Measuring the seven `Rs`

JAMES W. WEST, MD, QUALITY IMPROVEMENT AWARD WINNER

CRC Health Group, headquartered in Cupertino, California, has 145 behavioral healthcare facilities in 29 states, with more than 5,000 employees serving more than 29,000 people every day. CRC's Quality Management and Clinical Services (QM/CS) Team directly assists each treatment facility within CRC's Recovery Division. The QM/CS Team develops, implements, monitors, and trends quality improvement activities for 62 comprehensive treatment clinics (CTCs) in 18 states, and team members realized in 2003 that they needed a standardized evaluation tool to meet their goals.

Thus, the QM/CS team developed the Quality Management Rating Audit Instrument (RAI), which allows the team to accomplish seven “R” factors: review, report, rate, respond, react, reassess, and resolve. These R factors allow for an ongoing, complete, comprehensive, full-circle, standardized quality management performance review of each facility. The RAI has ten distinct performance measurement categories:

• Quantitative Documentation and Treatment Continuity/Randomly Selected Patient Records

• Quality of Treatment and Documentation/Randomly Selected Patient Records

• Quality of Treatment and Documentation/Special Patient Records

• Administrative Oversight

• Human Resources/Staffing

• Customer Satisfaction/Services

• Marketing/Public Relations

• Regulatory Compliance

• Staff Development/Training

• Special Services

CTCs receive two on-site audits per year, during which the QM/CS Team auditor collects data using the following sources:

• Inspection/review of patient files (active and inactive)

• Inspection/review of human resources and personnel files

• Inspection/review of administrative files

• Walk-through(s) of the program facility

• Interviews with staff members

• Review of other survey/audit reports, outcomes, and plans of correction

In addition, the auditor collects narrative information for each RAI category, identifying areas of strength or those needing improvement as well as offering other comments (e.g., training needs). The reviewer scores each performance measurement area on a 1 to 10 Likert scale:

• 1 to 4—nonconformance. A plan of action is required within 7 days to initiate movement toward conformance.

• 5 to 7—moderate conformance. A plan of action within 90 days would be appropriate.

• 8 to 10—commendable conformance. A minor plan of action might be needed over six months.

Once each of the ten RAI scores is calculated, the scores are totaled to yield a mean score for the facility. The auditor presents the facility with preliminary results, focusing on the most deficient areas. This immediate feedback allows the facility to commence its plan of action.

Cumulative data for two consecutive six-month reporting periods are shown in the table, which exhibits overall mean scores from all active, operating clinics within each six-month range. CTCs have demonstrated either ongoing improvement or stability in each of the ten performance measurement areas.

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Table. Overall RAI mean scores for CTCs

Performance Measurement Indicator	December 2006 All Clinic Mean*	June 2007 All Clinic Mean**	Percentage Change
* Representative of mean scores for June to December 2006 for 55 CTC programs; ** representative of mean scores for January to June 2007 for 58 CTC programs.
Quantitative Documentation and Treatment Continuity/Randomly Selected Patient Records	6.7	7.1	+0.4%
Quality of Treatment and Documentation/Randomly Selected Patient Records	7.1	7.4	+0.3%
Quality of Treatment and Documentation/Special Patient Records	6.8	7.1	+0.3%
Administrative Oversight	7.8	8.0	+0.2%
Human Resources/Staffing	7.5	7.5	0.0%
Customer Satisfaction/Services	7.7	7.8	+0.1%
Marketing/Public Relations	7.8	8.2	+0.4%
Regulatory Compliance	8.3	8.3	0.0%
Staff Development/Training	7.3	7.7	+0.4%
Special Services	6.6	7.6	+1.0%

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Based on feedback from the CTCs' leadership and direct-service staff, improvements or stability in the performance measurement categories can be attributed to the following factors:

Policy and procedure manual revisions. These have been developed to incorporate and model best-practice standards. It appears that direct-service staff are more apt to embrace policies that reflect best-practice standards and are subsequently more apt to incorporate best-practice criteria into clinical practice and associated clinical documentation.

Revisions to clinical documentation forms. These were made to clarify, reduce redundancy and, in some instances, simplify forms. It appears that direct-service staff have embraced this initiative, resulting in more comprehensive and enhanced clinical documentation. Another benefit appears to be more direct-contact time available for direct services, which also positively impacts care and results in comprehensive clinical documentation.

Ongoing enhanced staff development and training opportunities and initiatives. These have been instrumental to overall improvement seen in the clinical treatment and documentation areas. Ongoing structured and enhanced clinical supervision and quality records-review processes that incorporate feedback have been instrumental to improvements seen in these areas.

Staff stability and retention. Stability and retention, particularly at the facility leadership and direct-service levels, have been a positive factor in overall administrative oversight, community relations and marketing, customer satisfaction, and regulatory/accreditation compliance.

Delegation and assignment of additional responsibilities among key staff members (e.g., health and safety officer, HIPAA privacy officer, and risk management officer). These changes have been directly attributed to improved conformance in administrative oversight, community relations and marketing, customer satisfaction, and regulatory/accreditation compliance.

While we are still in the process of analyzing the 2007 quality improvement factors in each area, the goal for 2008 is to realize an additional 0.3 to 0.6% improvement in each area.

The authors are with CRC Health Group's QM/CS Team: Celeste N. Jupinko is Vice-President of Quality Management and Clinical Services; Fred Pottle, Director of Quality Management; Michele Solomon, Director of Policy Management; Emily Jennings, Director of Staff Development and Training; Nancy Casillas, Lead, Quality Management Coordinator; Lillian Gonzales, Quality Management Coordinator; Nathaniel Lunn, QM/CS Administrative Support Specialist; and Nancy Good, Vice-President of Corporate Compliance.

For information about CRC Health Group, visit https://www.crchealth.com. For information about this article, e-mail cjupinko@crchealth.com.