Using QI to Address a Citywide Need for Improving How Bostonians Affected by Substance Abuse Disorders Seek Treatment and Other Recovery Support Services

The team participated in the following activities: brainstorming, developing a sub-aim, process-mapping, and completing several Plan, Do, Study, Act (PDSA) cycles to increase by 25% the percentage of PAATHS clients connected to their primary service needs within 4 days of intake. The team used the nominal group technique (NGT) to identify a question to pose and engage the team in identifying problems to address. The staff members were asked to answer the following question: What is/are the biggest barriers for you to be able to connect your clients to the resources they request in a timely manner? The NGT activity was completed as follows: 1. Team members were instructed to silently respond to the question and record their answers on a sheet of paper. 2. When everyone was finished, each person took a turn and shared one answer at a time. 3. Answers were recorded on a flip chart, and everyone had an opportunity to vote as a team to agree on which problems they felt were most important to address. 4. The team developed sub-aims and mapped the process from July 1, 2012 to December 14, 2012, when the clients arrived until the time they left. 5. The team discussed and identified problem areas such as redundant/unnecessary paperwork and bottlenecks, and they agreed on areas for improvement or change. As a result of the brainstorming sessions, the team agreed to implement changes through PDSA cycles. The team planned the PDSA cycles by identifying problem areas on process maps and by discussing the following questions: 1. Why do we do it this way? 2. Is there a better way to do it? 3. What will it look like (i.e., who will do it and when)? 4. What steps do we need to take to get there? 5. How will we know that it works? Next, the team discussed how it would implement changes and pilot them for 3 weeks and how it would assess whether the changes were working by reviewing predetermined measures and input from staff. To conclude based on findings from the study period (3 weeks), the team agreed to further tweak and re-pilot cycles to adopt, abandon, or adapt changes. A total of 7 PDSA cycles were completed from December 17, 2012 to July 22, 2013, and a total of 1,160 clients and 7 employees were exposed to these QI efforts. PAATHS serves approximately 2,500 clients per year and will continue all QI efforts in Year 2 of implementation.

The team evaluated the QI initiative's impact in the following ways: • recorded time of arrival and the time that the case manager/public health advocate received the chart after clients registered with the program assistant or began making phone calls to detoxification (detox) or other programs for clients; • used treatment care plans, daily admission logs, Microsoft Excel files, and client logs; • used staff and client questionnaires; and • used site visits and thank you cards. 1. During the first PDSA cycle, the team updated all the registration and intake forms and developed a treatment care plan. The updated intake forms collected the necessary information for the service clients requested, and staff used the treatment plan to summarize what happened during intake and to document when placement had occurred. The team also began to record two different sets of time to identify how long clients had to wait before meeting with a case manager/public health advocate. When PAATHS clients checked in, the program assistant recorded the time of arrival on the daily admission log, and each case manager/public health advocate began recording the time that he or she received the chart after clients registered with the program assistant or began making phone calls to detox or other programs for clients. For this first cycle, the team agreed to record the time on the updated intake forms. 2. At the end of the 3-week pilot, the change team leader, Yailka Cardenas, developed a questionnaire that allowed staff the opportunity to provide feedback on all the changes. The questionnaires revealed that staff often forgot to record the time of arrival or the time the case manager/public health advocate called the clients because the time was being recorded on multiple forms. The surveys also indicated that clients were highly satisfied with the treatment plans because at the end of the visit, they received a copy of the form that summarized their visit. The form included the client’s short- and long-term goals and documented when staff and/or the client needed to complete follow-up. The feedback on the questionnaires was reviewed during a change team meeting, and the team agreed to begin recording the time clients were meeting with a case manager/public health advocate on the client service log. The client service log is the first form that staff see and is located inside everyone's chart. Furthermore, the time of arrival and the time staff record on the client service log, as well as basic client demographic information, were entered into an Excel file daily. The change team used these Excel files to demonstrate positive and negative outcomes during the change projects. For example, the team developed tables and graphs using the data on the Excel file to demonstrate growth within the program and to see how long clients were sitting in the waiting room. These tables and graphs were a great way to obtain buy-in from the entire team, to see what worked and did not work, and to continue the project's momentum. In the near future, the Excel file will be replaced with an internal database or medical record. 3. PAATHS serves high-risk priority populations including intravenous drug users, homeless individuals, pregnant women, uninsured adults, and individuals with chronic medical diagnoses looking for acute and short-term structured environments. The team at PAATHS provides outreach, education, case management, crisis intervention, and advocacy by providing level-of-care assessments; facilitating referrals and linkages to substance abuse–related treatment and other recovery support services. As part of the referral process, each program required the case manager/public health advocates to complete different multipage referral forms when trying to locate one appropriate placement for each client served. Unfortunately, these forms were often incomplete, which left several applications without being reviewed and not many clients placed into post-detox programs. Another barrier for PAATHS was the lack of medical staff and/or medical equipment that most detox centers have to verify an individual's length of sobriety. Thus, as part of one of the PDSA cycles, PAATHS adopted a new standardized referral form developed by MDPH in an effort to reduce the administrative burden on staff in agencies to which PAATHS refers clients. By adopting this standardized referral form, PAATHS formalized the new referral process and reduced the number of incomplete applications. The program also decided to purchase 12-panel urine quick cups and to evaluate this effort in combination with the standardized referral form. These accurate, easy-to-use kits test for 12 substances. PAATHS staff provided the verification programs needed from clients reporting at least 5 days of sobriety. These results were tracked on the daily admission log and treatment care plans. 4. To ensure that the numbers of incomplete applications were kept minimal, the QI coach suggested developing a checklist for staff and a system for chart auditing and quality assurance. The checklist outlined the new forms, held staff accountable to the new intake process, and helped the case manager/public health advocates keep track of what forms needed to be filled out. The checklist was reviewed during group and individual supervision while the team implemented the PDSA cycle. The change team leader, Yailka Cardenas, also began a chart auditing and quality assurance process to track whether staff were committed to all the changes, to identify staff who struggled with some of the changes, and to identify additional training needs. 5. As part of the program’s expansion and QI efforts, the team agreed to increase outreach efforts by visiting detox centers and post-detox programs to make personal contacts to improve program placements within key agencies. The site visits helped develop a better understanding of what services programs offered and increased the network of agencies that took referrals from PAATHS. The program kept a log of the agencies the team visited and sent follow-up thank you cards to most of these agencies. The team did not send thank you cards to all the programs because some are in Long Island/Boston Harbor and had incomplete mailing addresses. 6. Last, one of the case manager/public health advocates developed a client questionnaire. The program assistant asked clients to fill out the questionnaire when they arrived at the front desk. A total of 15 clients agreed to complete the survey. The goal of this survey was to get a better understanding of what services clients were looking for, what the program could look into including in the near future (e.g., food, brochures), and feedback on the program’s QI efforts. The surveys indicated that more than half of the participants would like to engage in relapse prevention and health-related groups. Participants would also like to see the program offer snacks and brochures while they wait. This QI effort did not help with any of the current aims but will help during future projects in Year 2 of implementation.