Quality assurance: where's the proof?

by Kyle China

The behavioral health services industry has historically suffered from a lack of rigorous quality assurance procedures. This trend has been changing for the past few decades, with the industry frequently seeming to be dragged, kicking and screaming, forward. Many other industries, such as food service and automobile sales, have extensive quality assurance procedures and rigorous testing standards; however the behavioral health service delivery field continues to lag far behind. Would you eat a piece of food that wasn’t inspected or drive a car that wasn’t safety tested? From a consumer’s perspective, why pay for behavioral health services if there is little or no evidence of their quality, efficacy or value?

This trend is accelerating quickly, with state agencies, managed care organizations and insurance providers increasingly rewarding measureable quality. The Affordable Care Act will apply pressure to service providers to increase the quality of their human services, and funding sources will continue to increasingly tie reimbursement to demonstrably effective treatment outcomes. In this environment, service providers need to quantify treatment outcomes, measure the integrity of their service delivery systems for efficiency and effectiveness and generalize effective methodologies across their programs, all in a cost-effective manner.

Many workers in this industry are trained to provide compassionate and therapeutic care to those they serve, and they do not come from a business or industrial background where measuring quality is paramount, and frequently the driving principle. In these more industrial settings, quality assurance typically has a sterile, mathematical and analytical flavor. To many behavioral health providers, the thought of measuring the efficacy of human services using these highly analytical quality assurance methods is anxiety provoking and philosophically threatening, because of the morally repugnant danger of reducing human relationships to numbers.

From a service provider’s perspective, it is a time to react to these changes in creative and responsible ways. One way to address the concerns of many professionals in this field is to simply apply a different quality assurance methodology. Many behavioral health professionals are educated and trained in basic program evaluation, which is derived from experimental design in the social sciences and focuses on measuring socially significant qualitative and quantitative factors. The Centers for Disease Control and Prevention (CDC) provides guidelines for program evaluation that are intended for research-related ends, however they are too rigorous and expensive to carry out for the vast majority of service providers. The answer lies in an efficient, doable and scalable Applied Program Evaluation methodology.

Such a methodology would have to include at least three main components. First, the integrity of service delivery systems must be measured frequently and systematically to ensure there is little to no drift from standard operating procedures. Second, socially valid treatment outcomes must be measured to determine the impact of service delivery systems. These measures might include specific symptom reduction; direct behavioral measures; factors such as “resiliency” that make up constructs; general customer satisfaction measures; and, possibly most important for funding sources, the future utilization of services. Third, this data must be analyzed and communicated in clear, simple and meaningful terms.

When these conditions are met, service providers can collect evidence about their services and make a more informed decision about if the service is valuable or wasteful. This allows providers to simultaneously compete on quality and eliminate waste, thus providing better care more efficiently. To truly have a transformative effect on the industry, service providers must collaborate better with families, guardians and funding sources in their areas, to determine equitable and meaningful socially valid outcomes for their communities and the entire behavioral health industry.|

Kyle China is a Board Certified Behavior Analyst (BCBA) with 12 years experience in the Behavioral Health field. His experience ranges from directly treating behavioral disorders across inpatient, outpatient and community settings to designing, developing and managing performance improvement initiatives and increasing safety and streamlining processes. Kyle received a master’s degree in clinical psychology from LaSalle University in 2007. He has received recognition from the Senate and House of Representatives of the Commonwealth of Pennsylvania for outstanding work with children affected by developmental disabilities.