Quality Improvement Program

SPC maintains a comprehensive Quality Improvement Program in order to facilitate continuous quality improvement in the delivery of behavioral healthcare services. The QI Program Description and Workplan serve as a guide to the completion of all activities within the Program and to the establishment and functioning of the QI Committee. The QI Committee is composed of members of all programs and services, reviews all improvement activities, and ensures that all agency, state, federal, and stakeholder regulatory standards are met and/or exceeded.  All major services, operations, and programs have effectiveness, efficiency, and satisfaction outcome measures that are utilized to ensure that only high quality behavioral healthcare services are provided to our clients. The QI Program is audited by our major funding sources and CARF--The Commission on Accreditation of Rehabilitation Facilities.

Quality Improvement Program Executive Summary
September, 2007
Prepared by Tony Floda, PhD, CPHQ 
PDF format

• Served 11,730 non-duplicated clients, with 5,890 of these being outpatient, 5,706 being crisis clients, and 412 being sexual assault (THS) clients
• Majority of clients were young adults, closely followed by adolescents, then by middle-aged adults. Less than 3% of clients were children or older adults. There was a fairly equal balance between male and female clients, with most clients being White. Hispanics accounted for the next highest population (23%)
• 100% of referrals met the 7 day standard
• Treatment services were highly effective. EMPACT clients were less likely to commit suicide than even the general Arizona and US populations in spite of their greatly increased risk
• There was a 42% reduction in formal client complaints from FY 06 to FY 07
• A formal Adverse Events Committee was formed and investigated 4 Adverse Events. In all cases the investigation demonstrated that EMPACT staff exhibited  excellent  quality of care. These findings were confirmed by external investigatory agencies (eg. RBHA, ADHS)
• ICS Performance Premium eligible staff exceeded the highest productivity levels by 24%
• Outpatient clients reported high levels of satisfaction in all but one category (Easy to schedule 1^st appointment)
• Counseling only and med only clients were both satisfied with services, with counseling only clients being slightly more satisfied on 3 indicators
• Counseling only and clients who received multiple services (ie. usually counseling and medication) were both highly satisfied with services
• Clients who received multiple services and medication only clients were both satisfied with services, with multiple service clients rating statistically higher on 2 indicators
• Clients reported the same high levels of satisfaction as was reported in FY 06
• Both adults and adolescents reported statistically improved functional and symptomatic outcomes during treatment according to the Outcome Rating Scale. The results were significantly better than reported in FY 06.
• “No Show” rates were reduced by 28%, as shown by an analysis of 2 three months time periods in FY 07
• External and internal medical record audits demonstrated that adults achieved functional and symptomatic improvement during treatment. However, there are still many opportunities for growth in adequately documenting client progress  
• An Hispanic Focus Group was conducted in order to clarify client needs and to modify service delivery to meet these needs  
• Trauma Healing Services clients reported high levels of satisfaction with services and improvement after receiving services  
• Trauma Healing Hotline clients reported high levels of satisfaction with services and improvement after receiving services  
• Crisis Teams exceeded stabilization goals  
• Prevention participants reported high levels of satisfaction and increased knowledge after receiving presentations

• CARF--The Commission on Accreditation - http://www.cphq.org
• The National Association for Healthcare Quality - http://www.nahq.org
• Healthcare Quality Certification Board - http://www.cphq.org