Intensive Outpatient Treatment for Alcohol and Other Drug Abuse
Treatment Improvement Protocol (TIP) Series 8

A Brief Look at TQM

TQM is a focused management philosophy for providing the leadership, training, and motivation to continuously improve an organization's management and operations (Walton, 1990). The TQM approach includes several strategies and assumptions that are easily adaptable to IOT programs. These strategies include:

• Recognition of quality as the presence of value rather than the mere absence of defect
• Focusing on prevention of problems rather than merely eliminating late-stage problems
• Creation of a working environment where all employees seek continuous improvement
• Emphasizing significant cross-training and teamwork
• Focusing on the services being delivered as well as the process of providing services
• Forging a provider-customer partnership to work on improvements.

There are several key principles that are intrinsic to TQM. These include a focus on the customer, continual process improvement, communication, strategic quality planning, quality leadership, quality skills training, and quality measures. The heart and soul of TQM are the principles of continued focus on the customer and continual improvement of the process involved in providing customer products and services. These key principles can be understood as steps that form the basis of an ongoing cycle of change and improvement. When one phase of the cycle is completed, the cycle begins anew.

• Customer focus -- Irrespective of funding or setting, AOD programs provide services to various customers. Thoughtful consideration must be given to the idea of what constitutes a customer for an AOD treatment program. Indeed, it is critical to identify all the customers in the system. While patients are one obvious type of customer, there are others, including referral sources, family members, employers, funding sources, and other providers. Central to the TQM approach is a constant emphasis on satisfying the needs of the customer and identifying ways that can best meet those needs. Importantly, there should be an understanding of the strengths and weaknesses in the system from the customer's perspective, and involvement of the customer in problem solving.
• Continuous process improvement -- Service delivery involves products and processes. Products are the things that are provided to a client, including treatment services. Processes include everything that is done to provide the client with the products and services. Programs that are actively involved with making quality improvements must focus on both products and processes and continual improvements. The emphasis is on improvement, not compliance with existing structures. The goal is to reduce chronic waste of time, labor, material, and funds. Often this involves the identification and analysis of critical processes and the simplification and removal of variation.
• Communication -- The TQM approach recognizes that the individuals who are actually performing certain jobs are the best sources for identifying improvement opportunities for those job functions. Thus, to encourage program-wide participation, all staff, including administrators, must share information and experiences continually. This can be accomplished through newsletters, suggestion boxes, teamwork days, meetings, and other events.
• Strategic quality planning -- Critical to TQM is having a vision or mental image of a future state where the quality of service delivery always elicits satisfaction. A goal is a statement of attainable achievement that can be proposed and accomplished with sustained effort and energy over a given length of time. Specific vision statements help program staff to identify the kind of future that is preferred for the program. Setting quality goals helps motivate employees and promotes teamwork. In order to achieve quality goals, programs must be committed and must communicate that commitment to all staff members. An initial step is to formalize the organizational planning process. Quality plans include such elements as mission, goals, measurable objectives, vision, customer identification, quality policies, management principles, benefits, expectations, external and internal measures, role of quality assurance, and productivity initiatives. Through employee committees, documentation, and constant communication, the plan becomes a part of the day-to-day operations and the culture of the organization.
• Quality leadership -- Program leaders (both administrators and program staff) have critical roles in the development of quality within their programs. They help provide a focus on the patient. They can support and encourage all staff to participate in quality improvement and install structures, such as task forces and steering committees, and allocate resources. They become role models and nonverbally communicate their commitment to quality by directing their attention to promotion of quality. As previously mentioned, employees who perform certain tasks are often the best sources for identifying improvement opportunities for those tasks. Since such staff members may not have great stature in the formal hierarchy, it is essential that staff members become empowered by administrators and management. In this way, anyone can assume leadership roles within the program.
• Quality skills training -- TQM involves a plan for providing training about quality in order for employees to achieve quality goals and objectives. Ultimately, all staff should be trained in the tools and techniques of TQM. Staff training should include such topics as quality principles and concepts, continuous process involvement, problem solving, setting measurable objectives (benchmarking), working in teams, managing in a participative environment, evaluating outcomes, and communications.
• Quality measures -- In order to identify opportunities for quality improvement, programs must assess where their strengths lie. This can be done through regular assessment processes that check for compliance with Federal or State laws or accreditation requirements. This can also be accomplished through patient feedback, questionnaires, focus groups, and other practices. But the focus of TQM is on the utilization of quality measures. Measures may be utilized throughout an organization to provide feedback on a regular basis regarding the degree to which the program is meeting its quality goals, objectives, and standards. An array of methods may be used to simplify data collection and statistical analysis and develop useful, reliable information that serves as a real-world scorecard. These may include client surveys, benchmarking, statistical process control, work flow analysis, and cost of quality measures.

These measures are not limited to providing care, but can also be applied with regard to such problems as waiting lists. From the perspective of TQM, waiting lists relate to customer satisfaction issues: patient discontent based on the inaccessibility of treatment services. Thus, TQM would approach the subject of waiting lists in an ongoing, revolving cycle of improvement, in this case, continually making improvements that result in shorter waiting lists.

Quality improvement is an essential aspect of IOT programming. TQM practices can be easily adapted to the IOT program environment and can have a tremendous impact with regard to improving AOD treatment. TQM projects have been used in the IOT setting for such purposes as the following:

• Analyzing treatment planning and continuity of care issues that arise in IOT from the widespread use of outside agencies to address a range of medical, psychiatric, and psychosocial issues of program clients
• Examining defined interdisciplinary problems and issues and establishing problem-solving groups across the different disciplines when integrated services are delivered within the IOT setting.

Permanent Program Mechanisms for Quality Improvement

All IOT programs should adhere to the following quality improvement guidelines.

• Staff should continually look for opportunities for improvement within the service delivery area, focusing on defining the breadth of customers served by the program. While the patient is the most obvious customer, staff should consider referral sources, funding sources, ancillary care providers, employers, and family members as customers to whom services are provided.
• IOT staff should measure the effectiveness of the IOT program based on such program variables as the length of client retention, the level of patient participation, and the frequency and patterns of attendance. Also, they should monitor patient information, including discharge status and program completion, patient relapse, and return to treatment.

For some evening IOT programs, involvement in quality improvement efforts can be challenging regarding the issue of using part-time contract staff as group therapists. Such staff may be present in the program only during hours when full-time, permanent staff are not available, creating potential communication problems between the two groups. One strategy for involving part-time staff in the quality improvement process is to have them cofacilitate therapy groups with a member of the full-time core staff and/or establish a regular channel for communication and feedback, such as regularly scheduled meetings, phone calls, or written communication logs.

• Programs should conduct customer surveys to obtain direct feedback on program strengths and weaknesses and recommendations for improvement from clients, referral sources, family members, funding sources, and other programs.
• Programs should gather data to help State programs accurately determine what variables will help predict whether an AOD abuser will stay in IOT care or will progress therapeutically. For example, programs can compare baseline assessments of clients who complete treatment with the assessments of clients who do not complete treatment.
• In IOT outcome evaluations, it is important to include all program participants, including those who have dropped out of treatment. Also, in a State system, which has many types of treatment programs, cross-program comparisons can be made when it is impossible to make random assignment.
• The examination of administrative issues should not be avoided when IOT practices are evaluated. There should be adequate resources allocated to administrative needs, including continuous quality improvement.

Outcome Measures

Evaluation of program outcome is a very effective way of obtaining the information needed to improve some aspects of the quality of the program. IOT programs can incorporate outcome evaluations in relation to ongoing clinical work and patient improvement. IOT programs must establish and clarify program goals and objectives in order to conduct an outcome analysis, and to know the meaningful outcome indicators.

Moreover, outcome data should be used not only to determine whether the IOT program is doing a "good" or "bad" job, but also to interpret the nuances. For instance, when looking at AOD use among clients, a complete picture of the overall program impact on the client is needed, including general psychosocial and quality-of-life indicators. A considerable amount of data can be examined without sophisticated statistical analysis. For instance, IOT programs should be able to examine program attendance and patient outcome data and be able to readily apply findings to the program evaluation processes. An appropriate management information system should be implemented to ensure rapid and complete access to outcome data.

A variety of outcome measures are needed, including staff and administrative measures, special population measures, general treatment population measures, and treatment services.

Staff and administrative measures. Staff and administrative measures clarify outcomes by holding staff responsible for particular program components and by making them active participants in the ongoing processes of the program. Using program evaluations, staff turnover rates should be examined in different IOT programs as a measure of the level of staff satisfaction. However, when making a decision regarding program philosophy, caution should be used regarding how the staffing satisfaction data are used. Occasionally, program changes that foster superior client care can precipitate initial discomfort and resistance among program staff.

Special population measures. It is important to emphasize that program and patient outcome indicators will be different for different treatment groups. For instance, clients with dual disorders may have a different threshold for attendance than AOD patients without dual disorders. Additional outcomes that are meaningful with this group include medication compliance, psychiatric symptom improvement, and rehospitalization. Similarly, special outcome indicators may be appropriate for pregnant IOT clients including delivery complications and birth outcomes for infants.

General treatment population measures. A useful outcome measurement tool is the Addiction Severity Index (ASI) (McLellan et al., 1980; 1985; 1992a). The ASI can be administered at IOT intake and discharge by trained assessment staff members. Used at intake, it leads logically to treatment planning. At discharge, it yields specific outcome data in seven key areas of the client's life, including recent AOD use and legal, occupational, medical, family/social, and psychiatric status.

The ASI provides IOT programs with:

• A subjective patient evaluation and an interviewer evaluation of problem severity, both of which can provide an indication of patient treatment priorities.
• An easy monitoring tool for clinical supervision since severity scores in each domain can be quickly checked to ensure adequate treatment planning in problem areas.
• The capability to monitor outcomes of discharged clients through community followup. (Patients can be located and reevaluated using the ASI followup interview.)
• A research tool structured to derive objective and subjective measures of need and improvement.
• A rich database by which such issues as the relationship between client characteristics and outcome data can be examined.
• A standardized assessment instrument that permits comparisons across programs and levels of care.

Treatment Services Review. The Treatment Services Review was developed to complement the ASI and corresponds directly to ASI categories (McLellan et al., 1992). This instrument provides a structured way of measuring patient perception of the quantity of services received in each of the seven ASI areas. That is, it yields a perceived services-delivered rating. Other important measures of patient-level service delivery include: number of individual counseling sessions, number of group counseling sessions, number of urine tests and Breathalyzer checks, and length of stay.

Other measures. IOT programs also should conduct client satisfaction surveys as an evaluation tool. Self-help group involvement is another way of measuring continued sobriety and determination to retain or regain any short-term loss of sobriety.

One measure of particular relevance to the IOT setting is the successful transfer and retention of clients in long-term standard outpatient services following completion of the IOT program. Patient follow-through with the transition plan should be automatic. A primary goal of IOT services should be to motivate clients to remain in ongoing recovery programs.

External Evaluation Processes

A number of institutionalized review processes provide useful feedback for IOT programs, including:

• Accreditation organizations -- Often, State accreditation processes, such as licensing or certification divisions, as well as national accreditation bodies, such as the Joint Commission on Accreditation of Healthcare Organizations, or the Commission on Accreditation of Rehabilitation Facilities, provide a readily available, and often mandated, source of quality improvement.
• Consultants -- IOT administrators may find it helpful to seek professional assistance in defining and clarifying their program mission. Consultants can be particularly helpful with respect to program development, preparing mission statements, stating program philosophies, and translating all of these into procedural policy. Consultants can not only help programs establish and plan TQM programs, they can also "sell" the importance of the TQM process to staff members by conducting staff presentations on TQM.
• Governing board -- Whether by choice or because of State regulations, many IOT programs have advisory and/or governing bodies that oversee the development and operations of the program. Members of such governing bodies should have familiarity with AOD treatment and should have ample time to be actively involved. Governing board members should see their role as working in a complementary relationship with the program staff with the common goal of overall success of the program.

A clear mission statement helps make the program direction explicit and realistic. It also helps decrease the tendency of programs to overextend themselves by offering services or treating client populations that are outside their intended mission.

Therapeutic Setting

The appearance of the facility sends a powerful message to IOT clients about dignity and respect. The appearance of the facility can have an impact on patients' assessment of program quality. IOT programs should consider the following recommendations:

• Plan ahead for flexibility regarding treatment team and group space. Maximize the flexibility of available space. When designing a new facility, first evolve an understanding of space needs in order to custom-design the space for most efficient use.
• Keep furniture and facility resources in good working order. The physical surroundings should be clean and tidy.
• Design a space for clients to get away from the therapy rooms during breaks in treatment. Clients need a physical break from the intensive sessions. Space itself can be therapeutic.
• Many IOT programs will want to provide refreshments, and a dining room or cafeteria area is ideal. At the least, a snack machine and coffee should be available.
• For some treatment groups, particularly large urban programs serving a homeless population, shower and laundry facilities will make the IOT program more attractive.
• Certain literature and didactic information should be available. Updated self-help meeting schedules should be present in high-traffic areas such as the clinic lobby.
• Bathrooms should be conveniently located near group therapy rooms and recreational space. Also, the bathrooms should be designed with the need for collection of urine samples for drug screening in mind. Alternatives include one-way mirrors, space for direct observation, and the ability to temporarily turn off the water supply.
• Whenever possible, IOT programs -- especially those with extended hours -- should have a recreation room for patients. These areas should be designed to promote client socialization.
• Each IOT program has to thoughtfully address its smoking policy. This is both a facility and a program philosophy issue. If smoking is allowed internally, make sure the rights of nonsmokers are protected.
• A centralized entrance for client registration may be useful, depending on the particular client groups and setting. This has the added benefit of monitoring who is coming in and out of the program.
• The neighborhood setting is important. While programs should be located in the areas where the target patients reside, the program also should be in a safe location, and be secure. Patients and staff should feel safe participating in treatment, especially in evening programs. Consideration should be given to the level of acceptance that the neighborhood has for the program. Efforts should be made to ensure as cooperative and supportive arrangements as possible.

Suggestions for Providers

• Providers should create and maintain a database related to services that the various payers will reimburse. This database should include: payers (insurer's name, phone number, address, contact people) and information regarding deductibles, copayments, daily rates, capitation (maximum payments), and billing procedures. A tracking mechanism should be included to specify recertification requirements when they exist.
• Providers should meet in person with the reviewers and decisionmakers who approve admissions. By so doing, the provider and payer can have a clear understanding of each other's expectations, practices, and policies. For example, there should be a clear understanding regarding what constitutes a treatment day and how nontreatment days are to be considered.
• Providers should obtain written copies of payers' policies and guidelines for billing and payment, and not rely solely on phone conversations.
• In situations where payers will not furnish providers with written policies and procedures, the provider should send a confirming followup letter or fax memorandum that summarizes the content of a conversation or phone call. Written documentation of informal understandings and agreements can save much money, time, and frustration.
• Payers are increasingly requiring outcome data for reimbursable treatment services. Thus, providers should collect outcome data, so that they can demonstrate quality treatment and quality improvement. Often such data can be gathered at little or no cost by using graduate students or trained support staff to collect followup client information.
• Providers should inform payers that research suggests that for some patients, IOT provides a level of care equivalent to inpatient treatment. This is not true for nonintensive outpatient treatment (Fink et al., 1985). Therefore, careful patient-treatment matching is needed to ensure that clients are placed in the least restrictive and most cost-effective type of treatment program, based on the severity of their presenting AOD use problem, medical and psychiatric status, and psychosocial conditions. Providers should provide payers with admission criteria that distinguish IOT patients from patients that can be served by lower intensity outpatient services. Further, IOT programs should ensure that the level of care offered is clearly distinct from that available in nonintensive outpatient programs?
• Providers should inform payers that IOT has an important place in continuing care, since the longer clients remain in outpatient treatment, the higher is the likelihood of a more stable recovery (McCaul and Svikis, 1991).
• When communicating with payers, providers should clearly and carefully describe the specific types, intensity, range, and levels of IOT services that are provided to help payers make informed and educated decisions.
• Providers should establish assertive, close, and ongoing linkages to social service organizations and health care programs that offer other types and levels of care with the greatest cost effectiveness, if services are not provided inhouse.
• During the intake phase of IOT treatment, it is useful to identify whether the client may have additional reimbursement coverage through a spouse's or other family member's insurance policy. Sometimes, despite a client's own exhausted benefits, coverage may be obtained through a secondary payer.

Some payers may regard IOT as an add-on or optional service. It is the responsibility of IOT treatment providers to educate payers that IOT is a specific level of care that can provide a level of treatment intensity that approaches medically monitored inpatient treatment but is achieved in an outpatient setting. Importantly, payers should understand that IOT is a vital part of the continuum of care that includes: 1) medically managed inpatient treatment, 2) medically monitored inpatient treatment, 3) intensive outpatient treatment, and 4) outpatient treatment. Payers should also be educated that IOT is a level of care, not a specific type or model of program. For example, payers should be taught that IOT can be adapted to several models such as day treatment, evening treatment, weekend treatment, partial hospitalization, and treatment in combination with housing such as apartments, dormitories, or other forms of resident housing.

Providers and payers should understand that moving clients from one level of care to a less intense level of care (such as from inpatient care to IOT) will utilize the continuum of care, decrease daily treatment costs, and make it possible to provide prolonged episodes of treatment. However, it is imperative for providers to remind payers that the decisions to move clients from one level of care to another should always be based on the individual client's treatment needs.

In some cases, where payers do not yet have a policy regarding insurance policy conversion from inpatient to outpatient treatment, they may not be able to guarantee this service. However, individual insurance company staff may be able to informally provide such a conversion. In any case, informed agreements should be in writing to avoid misunderstandings that may occur later. There is an increased likelihood for such flexibility when effective, proactive, and ongoing communication and collaboration exists between providers and payers.

There is a need for IOT programs to collaborate with one another in lobbying efforts. Organized National, State, and local institutions can help educate legislators, as well as payers, regarding the benefits of IOT and demonstrate their support for particular payer reimbursement strategies. Professionals from employee assistance programs can work with benefits departments to explain the utility of IOT programs