3 Outcome Categories to Target for PDSA in 2021

Tristan Keelan
Jan 31, 2021 2:20:39 PM

Project management with gantt chartAs Quality Improvement Managers look for improvement project this year in Health and Human Services, there are a few categories that will dominate the landscape.  While there are a number of difference measures for each category, and a lot depends on the program in question. Described here are the general categories of outcomes that many Quality Improvement professionals will be targeting for PDSA improvement projects this year.

For a closer look at the calculations of specific measures click here.

1. Speed to Service

As I once heard Michael Flora of MTM Services say to a room full of people at NATCON; "Clients come to you for treatment, not for assessment."

Any program in Behavioral Health or other Human Services should be considering their customer journey as it relates to program entry and speed.  How long do certain processes take is a very important question to be asking right now.  If you are treating substance use disorders and someone reaches out to the agency for help, we know how important it is that their first appointment not be days or weeks away.  To combat this many clinics are moving to open access models that produces same day referral to treatment time frames. However, its important to remember that for many programs with assessment procedures its not a matter of how fast they are brought into the office, but how long does it take before they are in a meaningful therapeutic session.

Of course, lets not forget; treatment begins at intake, and assessment ends at discharge.  Nevertheless, agencies should be looking to shorten waitlist times and expedite enrollment procedures to get clients who want care, into care, fast.  For Residential services this means getting clients enrolled and safely within your facility.  For Foster Care programs this is getting kids into safe home environments.  For court ordered services this is establishing that client orientation to review the court menu and introduce the services to be received.

Whatever it is, a great place to look for PDSA improvement projects is processes that will promote the shortest possible time from establishment of need to delivery of services.  

Data Tips: Start with data that allows you calculate the days between your client awareness date (referral date) and your first date of service.  You can look to improve the average time lag, but you can also measure the frequency that a target time lag is achieved.  For example, what percentage of cases achieve a time to service under 5 days.

2. Appointment Attendance

The logic here is based on the simple principle that you can't make a difference for a client if you don't see the client.  

Attendance in therapeutic services is a measure that reflects a lot more than it initially leads on.  On the surface, a positive attendance rate suggests that clinicians are getting the face time (or screen time) that they need to make an impact.  However; attendance is also a reflection of client engagement in treatment.  The best way to truly affect show rates is to provide valuable services.  If clients feel they are getting value for their time, they will show up.  If they don't, they won't.  But, since you need clients to show up in order to demonstrate value to them, the two reasons for achieving good rates push back and forth on each other.

The two common rates to look at are boosting the show rate, while reducing the no-call no-show rate.  However, there is a third category that can tell us a lot and is worth planning around.  That is the client cancelled/rescheduled rate.  If your client cancellations and rescheduled appointments are getting lumped into your no-show rate, consider pulling them out.  A client who cancels or reschedules within your attendance policy timeframe is actually engaged enough in their care to take proactive action regarding their appointments.  You don't want these to count negatively from an engagement standpoint, but you also can't count them as an appointment attended.  Pulling them into their own category of consideration though is appropriate.

Data Tip:  Consider tagging each appointment as one of the following; Show, No-Show(no-call, no-show), Patient Cancel/Reschedule, Provider Cancel/Reschedule. You will be able to calculate a rate for each against the total number of scheduled appointments.

3. Assessment Delta's

The best way to numerically define the value an agency provides is to use an assessment instrument that allows you to calculate change in scores over time.  Some of the instruments out there include PHQ-9, DLA-20, Youth Connections Scale, Strengths and Difficulties Questionnaire, NCFAS, among many others.  When these tools are consistently used throughout an episode of care, you will be able to isolate a client's first score and their last score.  Once you have those two pieces, the calculated difference between them represents the amount of impact you made on that client during their time in your program.

Once you have calculated the delta for each client with your chosen instrument, you can average them out and look at how those averages change based on different criteria.  Are the deltas better or worse for certain diagnosis groups, or certain ages you serve, or different referral types.  This is such a good source of PDSA improvement effort because it allows you to narrow down the type of client you want to improve services to.  It would be a daunting task to say you could improve deltas for your whole average by a certain amount of points.  But to first narrow down the group you want to improve on creates realistic and precise action planning for a subset of clients, which should have a positive affect on overall measures as well.

Data Tip: It's important when calculating your scores that you understand your assessment.  Is lower or higher better for all questions? Or are some higher is better and some lower is better?.  If you have a mix then you need to parse them out for meaningful delta calculations. Another thing to consider is that total scores aren't always the most meaningful when assessment tools are broken down into concentrated domains.  It may be seeking improvement on a certain domain within an assessment that helps drive your PDSA planning.

Whether these are new ideas or old news, these three outcome areas should get you thinking about where to look for meaningful improvement areas to focus on for 2021 and beyond.

For more specific outcome calculations to help you measure and improve this year click here.