Quality assurance (QA) procedures are employed by drug treatment programs to maintain or improve the level of care provided to patients and to control costs. These procedures ensure that the many components of a program work smoothly together and provide opportunities for representatives of all staff to come together to discuss interrelated issues. Deficiencies in program staffing, policy, function, and equipment are detected and corrected.
Quality assurance is best accomplished through an interdisciplinary team approach. This team approach is put into practice by a QA committee composed of representatives from each of the disciplines present in the treatment program. Committee membership will vary based on the composition and size of the treatment program. Membership may include a program manager, medical director, counseling supervisor, clerical supervisor, and others.
Once a QA committee is constituted, review criteria must be identified for all aspects of the treatment program. These criteria permit an objective review of the quality of program services. Each criterion should have these characteristics:
Be stated as a procedure or goal.
Identify the individual/team of individuals who are responsible for its execution or completion.
Indicate a standard, that is, the number of times the criterion is expected to be met.
Identify exceptions that justify nonconformance.
The QA committee should develop and follow a quality assurance protocol. This protocol establishes the goals of the QA program, the frequency of committee meetings, and approved methods to conduct investigations, analyze findings, and deliver recommendations.
In addition, a mechanism should be established to receive and manage patient complaints about program services. Such a mechanism must accommodate significant patient feedback and provide for the thorough consideration and evaluation of each complaint.
Experience has demonstrated that patients entering drug treatment programs need and benefit from a wide range of supportive services. Screening for infectious diseases is one of a number of critically needed services that can lead to enhanced overall health, a rejuvenated self-concept, and improved prospects for recovery from drug use. To provide comprehensive, high quality care, treatment staff are encouraged to carry out quality assurance monitoring.
A regular audit of patient records must be conducted. These audits should assess patient charts against established criteria to determine the appropriateness of diagnoses and treatment regimens, and the completeness of all documentation. Also, nonclinical aspects of treatment programs should be reviewed and assessed by QA committee members.
The discussion below highlights major clinical and nonclinical areas for QA focus and provides the basis for criteria that are especially relevant to screening for infectious diseases. These, as well as other areas and criteria, can be added to existing quality assurance efforts or modified to meet individual program priorities and community circumstances.
A complete and comprehensive history of the patient is essential. The process should produce information covering the patient's medical, drug use, psychosocial, and sexual history. This information sets the stage for the physical examination and followup care. Examples of quality assurance monitoring criteria include
All histories are completed.
Previous sexually transmitted disease, HIV, tuberculosis, hepatitis, and other infectious diseases test results and dates are documented.
Pregnancy, or the likelihood of pregnancy, is documented.
Allergies, and medications that are contraindicated, are documented.
A thorough physical examination is needed to confirm information gathered from the patient and to reveal additional medical and service needs. The examination must assess the patient's immediate health status and provide the basis for prevention and treatment of infectious diseases. Examples of quality assurance monitoring criteria include
Physical examination is completed.
Laboratory tests are ordered.
Appropriate tuberculosis skin test is offered. (Testing is required for the methadone-maintained patient.)
HIV-screening test is offered.
Serologic test for syphilis is offered. (Testing is required for the methadone-maintained patient.)
Appropriate screening for viral hepatitis is offered when appropriate.
Testing for hepatitis A and D is offered to appropriate patients.
Testing for sexually transmitted diseases is offered when appropriate.
The Centers for Disease Control and Prevention suggests that for those programs that provide laboratory services, the quality of the procedures can be monitored regularly through the use of control studies. For example, a study of Gram stain versus culture correlation of male urethral discharges can be conducted.
Laboratory services should be provided by an approved laboratory that meets State certification requirements.
Drug treatment programs offer a range of services in a variety of settings. A treatment plan is prepared for each patient and guides patient care. Screening for and treatment of infectious diseases should be part of the patient's treatment plan. Such services may be part of a treatment program's existing service capability, or provided through the use of community-based referral networks. Examples of quality assurance monitoring criteria include
Treatment plan is prepared and signed by appropriate staff.
Patient chart is signed by clinician.
Diagnosis correlates with laboratory and clinical findings.
Patient counseling and educational services motivate patients to accept infectious disease testing, encourage follow through on prescribed treatment regimens, and support prevention initiatives. Patients learn how infectious diseases may threaten their recovery and are supported in their management of these diseases. Examples of quality assurance monitoring criteria include
Pre- and post-test counseling is offered.
Contact tracing and partner notification is facilitated and/or conducted.
Risk-reduction counseling is provided.
Retention in treatment interventions are implemented.
Case management and followup services are offered.
Confidentiality regulations and reporting requirements are discussed.
A key function of a QA program is to monitor the process of referral. Most treatment programs provide patients with referrals to other service organizations. Experience shows that merely making referrals for patients neither ensures that services are received nor guarantees the quality of the services that are delivered. Examples of quality assurance monitoring criteria are as follows:
Referrals are documented, including reasons for the referrals and problems to be addressed.
Results of referrals are documented, including patient evaluations, agreed-upon services, rejections and reasons for rejections, and evidence of other steps taken to provide services.
Progress or termination of services, and the reason services were terminated, are documented.
Treatment programs that screen for infectious diseases play a particularly important role in surveillance reporting of infectious diseases. Diseases mandated reportable by State laws and regulations include many of those diagnosed in treatment populations. Treatment staff must be knowledgeable about and prepared to provide required data that is needed to safeguard public health. An example of quality assurance monitoring criteria is
Required reporting of infectious diseases is done in accordance with State and local regulations.
Each treatment program must ensure that internal policies and procedures comply with both Federal and State confidentiality and reporting regulations. Once compliance is ensured through the development of policies and staff training, a process of quality assurance monitoring should be developed to routinely review a sample of all program records. Examples of quality assurance monitoring criteria include
The patient is informed of his or her right to confidentiality by program and referral agency staff.
Written informed consent is on file whenever there are discussions concerning the patient with individuals or organizations outside the treatment facility.
Written informed consent is time-limited, content-specific, person-to-person, signed, and witnessed.
Reviews of patient records reveal the quality of care being offered to individual patients and determine if treatment protocols are being followed and are adequate. Quality assurance activities must also address the nonclinical aspects of treatment programs that are critical for an effective infectious diseases screening component. Key nonclinical aspects for QA monitoring include interagency agreements, patient/staff interactions, environmental safety, and staff and community development.
Many treatment programs rely on community- based medical facilities and laboratories to provide infectious diseases screening services and/or followup medical care. Patients may require other support services as well, such as legal, social, and financial assistance provided by organizations in the local community and by State and Federal organizations.
The referral process that connects the patient in treatment to needed services in the wider community requires good interagency collaboration and linkage. In order for interagency collaboration and linkage to be successful, there should be a written document that clearly delineates the responsibilities of the cooperating agencies. Interagency agreements, at a minimum, must have these characteristics:
Describe the services to be provided by each agency.
Describe the referral process to be used and the documentation requirements of each agency.
Establish a time frame for the review and possible revision of the agreement.
Examples of quality assurance monitoring criteria are as follows.
The program referral conforms to all conditions of the appropriate interagency referral agreement.
The referral agency adheres to all conditions of the interagency referral agreement.
Agreed-upon services are provided in a timely manner.
Staff interactions with patients should be observed regularly - at least every 6 months. Monitoring of these interactions can identify staffing and workflow issues, communication problems, and other impediments to effective and comprehensive care needed by patients in treatment. Examples of quality assurance monitoring criteria include
Number of patients seen by staff member meets program standards.
Patient waiting times are within program standards.
Staff skills are appropriate to patient needs.
Staff demonstrate a nonjudgmental and culturally/ethnically sensitive manner when interacting with patients.
Semiannual safety audits are recommended by the Centers for Disease Control and Prevention for sexually transmitted disease clinics. Such regular audits can be beneficial for treatment programs as well. Criteria are needed to assess the effectiveness of procedures designed to ensure the safety of patients, staff, and the community. Examples of quality assurance monitoring criteria include
Active cases of tuberculosis are isolated.
Procedures are followed for the appropriate use of electrical equipment, including medical apparatus, heating and air conditioning units, lighting, and food preparation equipment.
Chemicals, such as oxygen and cleaning solvents, and controlled substances, including methadone, are properly stored and secured.
Evacuation procedures are in place in case of fire, civil disturbance, or natural disaster.
Environmental security measures, such as proper ventilation, are in place to prevent contamination or the spread of infectious disease.
Treatment staff implement treatment protocols and link the program to the broader community. As a result, staff must be knowledgeable about the origin, manifestations, prevention, and treatment of a number of infectious diseases common to the populations they serve. The following are examples of quality assurance monitoring criteria:
Staff are offered training to enhance their cultural and ethnic competency.
Staff are offered educational opportunities with respect to infectious diseases.
Because treatment staff may be exposed to infectious diseases, they should be offered screening and treatment for specific infectious diseases. The following tests and precautions should be made available to treatment staff.
Annual tuberculosis skin test; appropriate followup if indicated is recommended
Hepatitis B test offered to direct-care medical staff
Hepatitis B vaccine provided to direct-care medical staff with negative test results
Preventive therapy offered to staff exposed to blood or body fluids from a patient infected with HIV
A QA program to maintain and improve the quality of care provided by a treatment program is essentially an ongoing process. Establishing a QA committee begins the cycle and key elements of the process are summarized as follows:
The QA committee selects review criteria that permit an objective review of the quality of patient services. Criteria are precise and have the four qualities that are identified above. The criteria are compiled into a QA plan for the program. Figure 1 provides an example of a format for such a plan.
A random sample of patient records is selected to ensure a true representation of program activities. Charts should be representative of the treatment population. A sample large enough to provide significant amounts of information about program operations is needed.
QA committee members review the randomly selected charts and compare them to review criteria. Findings are noted on a quality assurance report form. A sample report form is presented by figure 2.
The QA committee meets regularly and members present any variations from the established standards that are found for each respective patient chart. Justification for any variation must be established by the QA committee or corrective action taken.
The QA committee addresses each deficiency and determines the appropriate corrective action. Each deficiency is addressed and corrected by the responsible staff official (into whose area of responsibility the variation falls). The treatment program director has overall responsibility to ensure that corrective action is implemented. Followup action is recorded on a QA followup action form. An example of such a form as represented by figure 3.
Deficiencies and corrective actions can be in the areas of knowledge, environment, or feedback. Deficiencies in knowledge may require further education of staff, such as in-service programs, further orientations, or demonstrations. Deficiencies in environment may require a restructuring to reduce interference, rearrangement of tasks or program flow, or provision of needed tools. Deficiencies in feedback may require discussions to clarify a function or task.
The QA committee determines if the corrective action successfully solved the problem that produced the variation. Scrutiny of patient records during an established timeframe is required and results are discussed at subsequent QA committee meetings. If similar problems are noted, the committee must reevaluate the situation and new corrective action should be taken.
QA committee findings may be presented in quarterly or other scheduled reports to agency boards, commissions, or other entities as directed.
The QA process can be facilitated by computerized recordkeeping and use of management information systems. Computer capability can simplify the process and reduce the time required to gather, review, and analyze data and findings. For example, once review criteria and the key elements of each criterion are determined, computer printouts of relevant data from computerized records can be generated. Management information systems can correlate these data efficiently for subsequent analysis by committee members.
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