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Johnson shaha improving quality



Early article on the benefits of seeking routine feedback in psychotherapy

Early article on the benefits of seeking routine feedback in psychotherapy



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Johnson shaha improving quality Document Transcript

  • 1. Psychotherapy Volume 33/Summer 1996/Number 2 IMPROVING QUALITY IN PSYCHOTHERAPY LYNN D. JOHNSON STEVE SHAHA Brief Therapy Center QPAR Consulting Salt Lake City, Utah Draper, Utah Quality improvement in psychotherapy is has been used to eliminate outpatient a timely endeavor. The often maligned managed care. managed care movement may have the effect of stimulating higher quality The challenge posed by managed care may yet outpatient care. Quality Improvement turn to our advantage as psychotherapists. As the and quality assurance should be market for managed care has matured, the initial contrasted: Quality assurance is argued focus on saving money is declining in importance and the issue of quality is paramount (Eckert, to be counterproductive and inefficient, 1994). In any mature market, if prices are roughly quality improvement is relevant and the same for the service, quality is the key vari- useful. Quality improvement may able to determine purchase preferences. If man- stimulate better compliance with aged care providers are to maintain or increase treatment protocols. Academic clinical market share, they must demonstrate quality. psychology has produced treatment In the vociferous debate on the pros and cons of protocols and indicators of good outpatient managed care it's clear that managing inpatient care can yield important savings. This psychotherapy but these are widely is because inpatient care has been responsible for ignored by the practicing psychotherapist the increase in mental health costs (cf., Bak & as unwieldy and impractical. Continuous Weiner, 1993; Bak, Weiner, & Jackson, I992a,b). Quality Improvement is a behavioral However, one important fact has been over- data-driven technology that can be looked: it appears there is no savings to be had from outpatient management (Johnson, 1995). applied to mental health services. The present article gives an example of non- Outpatient Care and Illusory Savings adversarial data-driven process and There are several reasons for the inability of outcome improvements. A shift of managed care organizations (MCOs) to save paradigm toward feedback loops in money through managing outpatient (OP) care. psychotherapy, collecting data of First, outpatient mental health services account therapeutic change and patient for only 3-4% of the total health care bill and this satisfaction at each session, guides percentage has remained stable for the last fifteen years (Ackly, 1993). This suggests there is mini- therapy. Data collected cannot only help mal savings to be had, even if waste were present. guide the individual sessions and can be Second, the expense of reviewing OP MH cer- collected to establish a dose-effect tainly exceeds any savings, and it seems likely relationship for a particular therapist, or those savings would only come at the cost of for a clinic or group. Such information denying needed services. Outpatient care reviews cost as much as inpatient reviews, but the costs of the service itself is much lower. This means the cost-benefit ratio for outpatient review is much Correspondence regarding this article should be addressed higher and financially less justifiable. to Lynn Johnson, BriefTherapy Center, 166 East 5900 South, Third, outpatient care is largely self-policing. Ste. B-108, Salt Lake City, UT 84107. Patients tend to remain in therapy an average of 225
  • 2. L. D. Johnson & S. Shaha six sessions, and only through draconian efforts mark" and thus stifles innovation which might can that average be lowered through concurrent result in more efficient and effective treatment. management. So such outpatient management QA emphasizes uniformity, Continuous Quality must be sold to customers not as a money-saving Improvement (CQI) emphasizes development, re- measure (as MCOs originally intended) but as ducing costs while improving outcome. It is inevi- a quality assurance tool (Johnson, 1995). The table that QA will tend to emphasize some stan- customer is sold on OP reviews based on the need dards of care which evolving practice makes to assure high quality of service. irrelevant. A classic example is the requirement in public mental health centers that cases be MCOs and Quality "closed." While closing an Inpatient case makes Is MCO OP review a contributor to high quality sense (there being a definite date on which the care? Many MCOs try to measure OP quality patient leaves the hospital), closing an Outpatient through primary source verification of degrees, case makes no sense at all, since outpatient cases licenses, malpractice insurance, and so on. Such are better conceived of as ongoing relationships data only speak to a clinician's compliance with than as discrete events. By requiring closing sum- basic minimums for practice and do not address maries, the "quality assurance" model actually the issue of quality of service. It is unreasonable promotes less efficient use of therapist time. for managed care organization to try to measure Some therapist have been known to encourage a therapeutic quality, since such efforts are too far patient to come in every three months, just to removed from the therapeutic hour to assess qual- avoid case closing work! To reiterate, QA encour- ity. Inevitably certification of "quality" will tend ages game playing and evasion. toward irrelevant aspects such as whether the ther- apist has noted the name of a primary care physi- QA Versus CQI cian or whether the progress notes are signed. The A Continuous Quality Improvement (Scher- MCO pursuit of quality must necessarily focus on kenbach, 1988; Walton, 1986) model, in contrast what can be controlled at that level of review, for with traditional QA, empowers therapists. In example, primary verification of credentials and CQI, the aim is to improve quality, not exclude chart reviews. A potential approach to quality for and blame. One can measure quality in a way the MCO would be to contact patients about their that promotes growth and improvement on the reactions to the therapy they have received, but part of the clinician (Shaha & Fonnesbeck, 1993, even that implies a judgmental process instead 1994), but to do that, the quality improvement of collaborative. Furthermore, such measurement must originate with and benefit the clinician, not must necessarily be retrospective and thus too far an MCO. True CQI, Berwick (1989) suggests, is removed from the event to improve practitioner about growing better apples rather than weeding quality of service. out bad apples. Practitioner groups and mental MCOs are not doing quality improvement, health organizations have an interest in coopera- therefore, but Quality Assurance (QA), a process tive efforts to improve overall outcome data; imposed on the profession from without and usu- MCOs have an interest in reducing the number ally seen by the unwilling participants as busy of practitioners to whom they refer. Quality is work not related to actual care (Chowanec, 1994). not improved by ejecting practitioners but by giv- The danger of just measuring quality is that it ing them tools and techniques for improving their misses the essential element of improvement. In outcomes. Only by continuous measurement of other words, one can measure something called process and outcome can quality be achieved. "quality" in a vacuum, which means the MCO Continuous Quality Improvement and Total becomes a judgmental entity. This relationship is Quality Management arise from a general theory based on an avoidance of pain model (the thera- for quality in any organized endeavor. Deming pist wanting to avoid being singled out at defec- (1986) and Juran (1989) have helped organize tive or inferior) would inevitably promote evasion quality improvement in Japanese and American and game-playing with the MCO. industry, with the well-known results. While the In fact, one can argue that quality assurance basis for Deming's work was statistical process makes quality improvement impossible. Since control, measurement of the process and out- QA tends to emphasize minimum acceptable stan- comes of the manufacturing process, the impor- dards of care, it forces the practitioner to "toe the tance of customer satisfaction became central. In 226
  • 3. Quality Improvement other words, there is a convergence between do- seen in treatment, not the length of time by the ing well according to the engineers and according calendar) and outcome data are in an excellent to the customer. In psychotherapy, following position to obtain referrals on a case rate or capi- treatment models and protocols (e.g., Barlow, tated basis. Because of quality improvement data, 1993; Klerman, Weissman, Rounsaville, & large groups of insured lives might be covered Chevron, 1984) accurately and skillfully is analo- on a "case-rate" basis. This means the therapists gous to production quality; therapeutic alliance at that agency will not longer be managed by the (e.g., Burns & Nolen-Hoeksema, 1992) is analo- MCO. Instead, based on the past performance gous to customer satisfaction. (in terms of length of treatment and outcome), There has been some discussion in the literature referrals will be made and the therapist will man- about the need for quality improvement in mental age the case with the current data collection health services. Hoyt (1995) gives suggestions procedures. and examples of seeking quality within the HMO The term "case rate" means the MCO agrees staff model, and Eckert (1994) suggests that to pay for each patient based on the average cost through quality improvement psychotherapy can of treating that diagnostic category on an outpa- reduce costs and enhance outcome. Chowanec tient basis. For example, major depressive disor- (1994, 1996) specifically addresses the CQI der is the most common diagnosis, and a treat- model and discusses the application of CQI to ment course of 12-16 sessions is common in a state mental hospital. However, a systematic resolving the complaints. Resolution might be de- approach to CQI in outpatient mental health has fined as, among other criteria, the patient scaling not been presented. the depression as < 9 on the Beck Depression Inventory across several weeks (Frank, Prien, Jar- Improving Quality in Psychotherapy rett, Keller, Kupfer, Lavori, Rush, & Weissman, The time is optimal for psychotherapists to cre- 1991). Major depression can be treated briefly ate and develop means for personal and organiza- and effectively (Johnson & Miller, 1994), and if tional quality improvement. Such efforts would a group can achieve the criteria for resolution have personal and professional advantages: (such as >50% of treated patients with stable ONE: At a personal level, therapists can take Beck ratings >9) in less than 12 sessions in at professional pride in improving skills. To achieve least half of the patients, the ALOT case rate this, therapists must have useful and easily ad- results in a mutually advantageous outcome. ministered and scored instruments which have The MCO is satisfied because outcome data clinical utility. Such instruments must focus on demonstrate the patient is being treated effec- two aspects: clinical outcome and therapy rela- tively, that is, until there is a resolution of the tionship, since the later correlates most strongly depression symptoms; the clinician is satisfied with the eventual outcome (Hill, 1989). It is pos- because there is no need for narrative reports sible that a revised compensation system could to case managers. financially reward groups of therapists with high THREE: Finally, at a profession-wide level, quality, or in other words, both low dose-response developing quality improvement models allows ratios (the number of sessions needed to achieve a professional psychology to undo the disastrous stable remission of symptoms) and good customer mistakes of the past of opposing managed care satisfaction. Such teamwork can and should be (psychology's opposition to managed care only recognized and rewarded. Thus the therapist with marginalized the profession and certainly did not excellent skills has the personal satisfaction of contribute to any resolution of the problems with knowing his/her contribution to the group is managed care). Continuous Quality Improvement valued. will promote effective treatment options based TWO: At a group professional level, practice on results of treatment. After all, if there is a groups which can demonstrate good quality and significant difference in quality of services, those customer satisfaction will be able to directly bid which are somewhat more expensive but measur- for contracts which circumvent managed care ably better in quality will always find a market, through carve-outs, capitated care, and other in- just as quality in automobiles has been a selling novative reimbursement plans. Practice groups point. Desires by clients for quality insures there that collect Average Length of Treatment (ALOT, is always a significant market segment for expen- meaning the total number of hours a patient was sive, high quality transportation. 227
  • 4. L. D. Johnson & S. Shaha Total Quality Management and Continuous services. They include the BTC therapists, clients Quality Improvement asking for help in resolving problems with rela- TQM and CQI are generally conceived of as tionships, family conflict, interpersonal conflicts; a single process, with TQM being achieved by with symptoms of emotional or physical disease continually improving quality. The process for appropriate for psychotherapy interventions; or maximizing improvement consists of 11 steps problems with productivity social fit; organiza- which proceed in four conceptual stages (see Ta- tions including insurance companies and MCOs; ble 1). business organizations that contract for EAP ser- The TQM model requires the organization de- vices, executive coaching, critical incident de- velop a mission statement which defines the pur- briefing and crisis intervention, outplacement pose of the organization. The mission statement coaching and counseling. should capture in as few words as possible the In the circular process of defining the vision organization's purpose. The Brief Therapy Cen- and mission of the organization, we discovered a ter's (BTC) purpose is "The Brief Therapy Center vital customer whose needs were being ignored, offers the most effective and efficient psychologi- namely the Managed Care Organization. As a cal services possible." We are accountable to result of the mission statement and vision state- those who hire our services and offer timely and ment, the first author realized that global reports relevant reports on our work. of outcome to MCOs were insufficient. There The vision statement delineates (a) the values are two reasons why the pre-test/post-test model of the organization, (b) the customers and stake- is inadequate. holders, those who have a stake in the organiza- First, as Chowanec (1994, p. 791) stated, "(In tional mission. The BTC values statement is: "We CQI) (w)ork procedures are monitored so that treat all stakeholders in every situation with re- they can be corrected before defects in products spect and strive to create positive outcomes for occur. Feedback mechanisms are build into work all stakeholders in every intervention." The stake- procedures to collect that information needed to holders include not only all those who contract understand and then to improve the procedures." for our services and those who offer those ser- This article reports on a first attempt by BTC to vices, but also those who are affected by our measure and report on outcomes via continuous monitoring of processes. The first author, as di- rector of the center, was the test subject for the CQI efforts. Since then, other therapists at the TABLE 1. Components of Continuous Quality Improvement center are collecting their own data. A. The Reason for Existence (two interdependent and Second, the therapist does not know what spe- circular processes) cific interventions are promoting particular out- 1. Define Customers and Stakeholders: The Vision comes. Thus, with pre-post measures, therapists Statement. were unable to report to MCOs just what they 2. Draft the Mission Statement and Define were doing to solve certain problems and how Organizationval Values. those efforts were received. The first author pro- B. The Voices of the Customer and the Process posed more detailed feedback to certain MCOs 3. Identify Customers' Needs and Expectations. that refer patients to the BTC. Generally this was 4. Prioritize Customers' Needs and Expectations. met with reactions from MCOs ranging from con- 5. Select of Create Assessment Methods. fusion to enthusiasm. United Behavioral Systems' C. Process Improvement 6. Analyze the Current Process. Regional Vice President Tim Phillippe (personal 7. Revising or Redesigning the Process. communication, March 26, 1996) reported that What can be changed? they are actively seeking high quality providers What can be eliminated? to be Key Providers. This would mean that pro- What must be added? viders whose quality can be counted on would be 8. Implement and Test the New Process. exempt from the managed care process, saving 9. Assess the Effectiveness of the New Process. therapist's and MCO time and efforts. However, D. Continuously Learn and Improve the way by which a provider's quality can be 10. Refine the New Process. assured has not been well established. The present 11. Continuously improve. article proposes the therapist can provide reliable 228
  • 5. Quality Improvement and valid data to establish that quality and create a the patient in easily administered, easily scored, mutually beneficial relationship with the managed and interpreted instruments. Second, the informa- care organization. tion should be in units of single sessions and pa- tient responses to sessions and even to interven- Continuous Quality Improvement tions. Pragmatically, it seems likely the single The goal of providing continuous measures of session is the most convenient unit of measure- improvement to our target customers was adopted ment. Such an assessment must be brief yet rele- by the BTC. Specific levels of improvement, tar- vant to client concerns. Both client satisfaction geted to the complaints of the patient, should also and clinical improvement can be measured via be measured regularly, and after every session if objective rating methods. possible. CQI implies an ongoing improvement Brickey and Enright (1995) reported on an out- effort. That meant we had to have a measure- come measure which assessed current functioning ment system. of clients seen only one time. The outcome was Measurement of outcome must be valid, reli- measured simply by asking the clients to rate their able, and feasible. Feasibility implies measure- functioning on a 1-9 scale, with 1 = much worse, ment that is simple and inexpensive. Academic S = same, and 9 = much better. The clients measures tend to be expert-judgement driven, and rated their functioning on eight areas: Problem given the current reimbursement patterns in ther- Status, Outlook, Social Functioning, Thinking/ apy, it is unlikely at best that agencies will use problem solving, anxiety/depression level, them. For example, using the Hamilton Rating health, support from friends, family and others, Scale for Depression (HRSD) is difficult since and Sense of control over your life. It is not clear it should be administered by a therapist via a which of those categories contribute the most to structured interview. There are two main reasons the outcome satisfaction, and which might be rep- that this is unworkable. etitious, but such an easy measurement approach First, since we are working within the require- certainly has useful aspects. It is simple, easily ment to be efficient (using not one session more understood, and easy to collect. than is necessary), to use up a session on assess- Many simple survey and questionnaire instru- ment has a poor cost-benefit ratio, for the MCO ments exist to assess a variety of complaints, from (having to pay for an extra session), the therapist the familiar (Beck Depression Inventory) to the (spending a session in assessment that has no less known but useful (cf., Fischer & Corcoran, therapeutic value) and the patient (having to sit 1994a,fc). Seligman (1995) demonstrates how through the measurement process, gaining neither brief symptom-oriented questionnaires help a cli- understanding nor useful skills). Instead, self- ent who is reading a self-help book. Question- report devices such as the Beck Depression Inven- naires help a reader distinguish between a simple tory might track improvement effectively and problem and a more severe one, such as a de- efficiently. pressive state which may respond to self-help ver- Second, for the assessment to be objective, a sus a serious depression which requires a profes- therapist other than the treating therapist should sional assessment and intervention. administer the Hamilton. Obtaining an indepen- dent rater is not a reasonable requirement for an Selection of the OQ-45 agency in which fees for service support the CQI Perhaps the ideal method of measurement efforts. Instead the agency must use a combina- would be to administer specific instruments for tion of self-report process measures and outcome specific complaints. For example, patients com- measures. The process measures the patient's sat- plaining of anxiety and panic would respond to isfaction with the therapy session, and the out- a panic rating scale after each session, patients come measures symptom relief and improvement with a depression diagnosis would respond to a in functioning. Achieving ideal levels of validity depression inventory. For this project such an and reliability cannot outweigh feasibility for a ideal system was judged too complicated, requi- technology to be practical and helpful. ring difficult data transformation to obtain dose- Schlosser (199S) has pointed out that quality response curves (i.e., learning how quickly improvement requires several elements. First, in- patients generally respond to treatment at formation must be focused on the functioning of BTC). 229
  • 6. L. D. Johnson & S. Shaha In the present investigation, a simple outcome The treatment guidelines followed in the pres- device developed by Lambert, Lunnen, Umphress, ent investigation have been described previously Hansen, and Burlingame (1994) was used to as- (Johnson & Miller, 1994) as Solution-Focused sess individual outcome and response curves in Brief Therapy. A thought-stopping technique was a brief therapy oriented private practice. This in- used with Case 1 that is borrowed from Psychol- strument is the OQ-45, a 45-item Likert-scale ogy of Mind (Carlson, 1994). checklist.1 The OQ-45 samples three domains: Symptom Distress (the degree to which the patient Clinical Improvement Tracked with the OQ-45 feels bothered by symptoms of depression, anxi- The results collected were utilized in two ways: ety, cognitive problems, and the like); Interper- First, each patient's progress was tracked from sonal Relations (the degree of dissatisfaction the session to session, and was sometimes discussed patient has with relationships); and Social Role with the patient. For example, the following two (the degree to which the patient feels unable to profiles were helpful in improving the patient's perform or function at work or school). The in- course of treatment: strument also contains Critical Items pertaining to dangerousness to self or others and substance Case Example 1: A.C. abuse. The author tracked thirty-eight consecutive A.C. is a 36-year-old female complaining of difficulty in adult admissions to his outpatient practice (a concentrating, lapses of memory, emotional swings, and low youth and adolescent version is under develop- self-esteem. She gave a history of being sexually abused by ment but was not available at that time), adminis- a stepfather from ages 13 to 16, at which time she moved out and the abuse ceased. She was seeking help in stabilizing her tering the OQ-45 to each patient at each visit. moods, helping her be more productive at work, and coping Since the instrument takes only five minutes to with her history of abuse. administer and three to score, the requirement for The therapist emphasized "active coping." The patient was patients to fill it out and the results to be entered encouraged to discuss times when she coped unusually well in charts was modest. A "cutoff' score indicates with the symptoms, or times when the symptoms were less intrusive. Several themes were isolated (e.g., staying busy, the top of a normal range of scores. A patient focusing on helping other people, not thinking about the falling below the cutoff is significantly more abuse). Her homework assignment was to do more coping likely to be like a normal reference group than activities, including those she already did plus mastery and like a clinical group. The usefulness of the cutting pleasure activities she negotiated with the therapist. She was score is as a rule of thumb indicating reasonable taught a variation of thought-stopping to deal with the intru- sive images. Shereportedthe thought stopping technique was (not ideal) adjustment. Scores below the cutting gentle, satisfying, and easy to use.2 score, if stable, suggest (at the BTC) a break from On the third visit she was functioning well. She asked if therapy, or less frequent sessions, be pursued. the therapist could help herremembermore about what had Other therapists may not agree with this practice happened to her during the sexual abuse. He recommended guideline, and may believe it is necessary to keep against it, but she insisted, and he presented a hypnotic strat- egy for recovering memories. patients in treatment to consolidate gains. On the fourth visit she was much worse, and the session Patient satisfaction ratings were sometimes col- was spend analyzing the pros and cons of active coping treat- ment versus recovery of memory treatment. She decided to lected, using the Session Rating form (Johnson, continue the active coping, again made some progress, but on 1995). We were influenced by Burns and Nolen- the sixth session again requested talk about the abuse history. Hoeksema (1992) in including a satisfaction mea- Again the therapist recommended against it but complied. On sure in addition to an outcome measure. This 10- the seventh session her symptoms hadreturned,and together the therapist and the patient examined the results of thinking item form asks the patient to rate the therapy about the abuse versus increasing her coping skills. She re- relationship, the degree of agreement between turned to the active coping, and on the eighth visit she had therapist and patient on goals and tasks of ther- returned to a good mood andreportedshe was very productive apy, the depth and smoothness of the session, and and happy at work and at home. Unfortunately the therapist global ratings of helpfulness and how hopeful the failed to obtain an OQ-45 at the last visit. The patient took a break from therapy with the understanding that she would patient felt at the end of the session. call if more help was needed. Telephone follow up indicated 1 The OQ-45 is available from American Professional Cre- 2 dentialling, 10421 Stevenson Road, Box 346, Stevenson, MD A description of this technique is available from the 21153-0346. A child/adolescent version is in development. first author. 230
  • 7. Quality Improvement she has had no mote complaints, that she and her husband ploring the past might be helpful, to explore the future would are very happy and compatible, that she is happy at work, be even more helpful, and oriented the patient toward solu- and has not sought any other therapy since the last contact tions and outcomes instead of problems and origins of those with the BTC. problems (Johnson & Miller, 1994). P.R. cooperated, al- Her OQ-45 Symptom Distress scores illustrate how tracking though with some trepidation, thinking perhaps he was miss- objective measures of her functioning helped to inform and ing something vital by not exploring the past. guide the treatment (see Figure 1). It is worm noting that her P.R. presented with complaints of underachievement and Social Role scores illustrated the fact that she was able to dyssynchnny, wishing he had been able to achieve more than work well throughout the treatment, and that she did not let he was achieving. As an assistant restaurant manager, he felt her symptoms reduce her functioning (see Figure 2). That fact he was under utilized and had not pursued opportunities. He influenced the therapist to discourage exploration of that past. asked for help in exploring his past to determine why he was It was thought that if the patient could respond to solution- unable to make decisions, to enjoy relationships, felt guilty, focused interventions, there was nothing to be gained from a and was unable to complete tasks and projects. He had been discussion of the problems, and this apparently turned out to married three times, and the last divorce precipitated his call- be the case. It is recognized that in other cases, discussion ing the therapist. of the past is necessary. Following protocols for Solution-Focused Brief Therapy (Johnson & Miller, 1994), the patient began to increase behav- Case Example 2: P.R. iors mat seemed to correlate with exceptions, and "as if" homework designed to bring about the enactment of the "mira- P.R., a 44-year-old male, changed his initial focus from cle question." As soon as the OQ-45 indicated his Symptom exploring the past to a focus on die present and future. He Distress scores were at and below the cutoff (after the third wanted to understand the origins of what he called "self- meeting), sessions were spaced every three to four weeks. As defeating behavior." The therapist suggested that while ex- can be seen, his adjustment in the normal range of functioning was stable and persistent over several months. Both Interpersonal Relations and Social Distress scores de- clined (showing improved functioning in personal relation- ships and at work). He reported setting better limits with people who had been taking advantage of him, and that he felt more productive and efficient at work. The Symptom Distress and Social Distress scores are shown infigures3 and 4. He made useful and realistic vocational plans and began to work on them. He resolved a long-standing conflict with the restaurant manager which resulted in a reduction of stress for both of them. He reported he was happy and satisfied with his life, and thought that psychotherapy had been somewhat helpful in creating positive changes in his life. Profiling the Therapist's Dose-Response Curve The results also yielded a dose-response curve for a single therapist. Thirty-eight patients began this project, and the data are shown in Figures 5 Figure 1. Symptom Distress: A.C. through 8. These data are preliminary but do sug- 10/3 10/17 10/31 11/14 12/6 12/27 2/27 3/11 • Score + Cutoff • Score + Cutoff Figure 2. Social Role: A.C. Figure 3. Symptom Distress: P.R. 231
  • 8. L. D. Johnson & S. Shaha 10/3 10/17 10/31 11/14 12/6 12/27 2/27 3/11 1 2 3 4 5 6 7 8 D Score + Cutoff o Means + Cutoff Figure 4. Social Role: P.R. Figure 5. Dose Response Curve: Symptom Distress gest that by the sixth session, patient or client patient rated the session at "2" on a 0-4 scale. In asking him complaints are well on the way to resolution.3 about those items, be replied he wasn't sure how therapy was supposed to help, and didn't know what he was supposed to Please note that the data are not perfect. Three hope for. On the other hand, his mother, who was viewed as patients continued in therapy but due to failure a "customer" rated the sessions as "4" on the same items, on the therapist's part did not take the OQ-45. suggesting she knew very well what to hope for and found Nevertheless, the ALOT is less than six sessions her son was making good progress toward the goals. To her the sessions were helpful. Nevertheless, in subsequent ses- for a mixed group of patients and diagnoses. sions, more attention was paid to the identified patient and Tracking outcomes for each session helped focus his hopes. This improved his cooperation with the family the therapist's attention and efforts. Incorporating sessions and he did become active in therapeutic homework. Session Rating data (Johnson, 199S) was also Using the Session Rating form helped the therapist maintain helpful, since the Session Rating form focused a good relationship with the family members, focusing on what would be of most use to each of them. Mr. S. seemed on the therapy relationship, giving complimentary to benefit mostly from positive refraining of his complaints information when compared with the OQ-45. while mother benefitted from goal-directed structural change of the family contingencies (Alexander & Parsons, 1982). It Client Satisfaction can be argued that such information is informally available to the therapist anyway, and indeed mis is true, but the Session Case Example 3: J.S. Rating form serves to point the therapist's attention to main- taining good relationships, a vital component to therapy. J.S. is a 15-year-old male referred for shoplifting and re- fusal to attend school. He has a history school problems, learning problems, attention complaints, and of positive re- Discussion sponse to stimulant medication. Herefusesto take the medica- There is no representation made that the forego- tion, protesting it makes him feel different. Following the ing is excellent research. Its purpose was strictly Customer Status evaluation (Johnson, 1995), the therapist viewed hisrelationshipwith Mr. S. as a "complainant" rela- to allow the first author to track with objective tionship, in that he did acknowledge he had problems but did data the results of his therapy efforts with a broad not agree to work hard to solve them. This is analogous to range of patients. Originally there was no inten- Prochaska's Contemplation category (Prochaska, DiClem- tion of publishing the results, and only because ente, & Norcross, 1992). The distinction between Contempla- of the kind invitation by the guest editor of this tion and Complainant is in the attribution of responsibility: The complainant tends to see the problem as outside of the self. issue were the results written up. Good results Treatment emphasized family therapy and changing family with some challenging patients may have been contingencies to support positive behavior. J.S. rated the ses- obtained because the therapist and the patient's sions on the Session Rating form as "3" or "4" on all items efforts were more focused, perhaps partly due to except "Helpfulness" and "Hopefulness." On those items, the the accountability encouraged by the objective scales of outcome and satisfaction. Certainly there can be no suggestion made that 3 The seventh session with A.C. raised the mean of that this report proves that obtaining outcome and sat- session; without her data the mean would be considerably isfaction data after each session improves therapy. below the cutting scores. It does seem that there has been an improvement 232
  • 9. Quality Improvement 3 4 5 6 1 8 1 2 3 4 5 6 7 8 a Means + Cutoff • Means + Cutoff Figure 6. Dose Response Curve: Social Role Figure 8. Dose Response Curve: Total Score in outcomes since beginning the use of the Ses- ity for the resources spent on outpatient treatment. sion Rating and OQ-45. There seems to be a Substituting objective data for the verbal reports tendency for the therapist to think harder and de- now required would be a step in the right direc- velop better interventions and therapeutic home- tion. Wouldn't it be so much more simple for work when there is some way of tracking the objective test data and session satisfaction data results of each session. Furthermore, these data, to completely substitute for the verbal or written however sparse, incomplete, and scientifically reviews that are now required? There is certainly lacking, form a type of baseline against which no universal agreement on how one could judge future efforts can be compared. good therapy via written reports, and to imagine Continuous Quality Improvement appears to be that a case reviewer distant from the therapy ses- a useful and accessible technology. Psychologists sion can sift through artifact and artifice to distin- particularly should enjoy an ease of understand- guish, Solomon-like, which therapy should con- ing, given our training in statistics, research de- tinue and which should be denied, is to strain sign, and the scientific method. The data collected credibility to the limit. can be used to substitute for the kind of data Eliminating OP Review with Objective Data which are now demanded by managed care. At this time it is evident that intensive review of Sessions where the patient is in the normal outpatient psychotherapy is not cost-effective. range should automatically be spaced out and ter- However, the managed care organizations must minated. If the patient wishes to continue, the do something to address the need for accountabil- patient should pay for that, just as if a patient who once needed physical therapy wants to join a health club. After the need for the physical therapy is resolved, the insurance company would not pay for further treatment just to make the patient more and more fit. Sessions where the patient is showing eleva- tions but progress should automatically continue until the patient can achieve a criterion level of adjustment and behavior. This doesn't require an expensive OP MCO review. Only in a case where there is substantial dysfunction, measured by ob- jective data, and where there is no progress after several sessions should a review be necessary, 2 3 4 5 6 7 8 not for the purpose of denial, but for the purpose of consultation. • Means + Cutoff Using objective data can therefore reduce the Figure 7. Dose Response Curve: Interpersonal Relations number of OP reviews that must be done. Further 233
  • 10. L. D. Johnson & S. Shaha improvements can be achieved by eliminating re- health coverage. Using objective data in place of views altogether. This has been achieved in rela- verbal reports eliminates a source of "noise" in tion to one MCO at the BTC. As mentioned ear- the review process. Currently, reviews are done lier, an MCO was approached with the outcome via written or spoken reports by the therapist. data in this article and the proposal was made to Verbally skilled therapists are likely to obtain eliminate outpatient reviews with the outpatient more authorizations than therapists who may be reviewers. In place of those verbal reviews, OQ- skilled but inarticulate in dealing with reviewers. 45 and Session Rating data would be kept for Other advantages accrue to the MCOs with this each patient. Collapsed data would be reported model. As pointed out earlier, OP review is not each quarter, and individual data would be avail- cost-effective. While officially MCOs have not able for inspection. It was then agreed that the conceded that point, informally MCO officials patients would be seen on a case rate basis, mean- who reviewed an early version of this article did ing that each patient referred to BTC would be agree. We can assume MCOs would like to be paid at a flat rate, based on average costs for out of the OP review business. Developing con- outpatient treatment in the Salt Lake area. While tracts with groups demonstrating a CQI practice, not a large contract, such relief from intrusive the business of review devolves onto the prac- outpatient reviews is welcome. We are currently titioners, where is should have been all of the negotiating with a second MCO to provide service time. The MCO saves money by eliminating the on the same basis, saving therapist time (no re- loss leader of OP review, and can concentrate on porting and asking for continuing authorizations maintaining good IP review standards. for treatment) and eliminating the need for the MCO to pay a reviewer, a supervisor, and support Cooperating with Reluctant Therapists staff to manage the case. While measurement of each session is now part The question of unreliable results due to biased of every BTC therapist's work, such dedication administrations of outcome measures must be ad- is not automatic. Not all therapists in a system dressed. A therapist could conceivably influence welcome a Continuous Quality Improvement patients to rate their improvement as more than model. On the contrary, some will resist any such they actually felt. An unscrupulous therapist measure, claiming the resulting therapy is shallow could even fill out forms for the patient, in order or ineffective or will result in symptom substitu- to create a false impression of high quality. This tion. When the first author was presenting these can only be corrected by backup procedures such ideas to a group of HMO psychologists, one as measurement by third parties, audits via tele- claimed giving process (session satisfaction) and phone interviews, or mail out follow up surveys, outcome (clinical improvement) measures after but a discussion of bias correction procedures is each session would yield artifactual data, since beyond the scope of the present discussion. he expected patients (within a specific diagnostic group) to get worse before they got better. His Cooperating with MCOs resistance to the process is based on fears that his With therapists in charge of improving their model of treatment will be devalued and he will own quality, the MCO can shift to what it does not be seen as a valued provider. best, communicating with its customer, namely Clinical psychology already has models for en- the business entity that has contracted with the gaging resistant clients. For example, Szapocz- MCO. MCO leadership generally recognizes that nick, Perez-Vidal, Brickman, Foote, Santisteban, quality improvement must come at the level of Hervis, and Kurtines (1988), have outlined proto- the therapist, and welcome an opportunity to get cols for engaging resistant adolescents into family out of the case-review business. Cost savings in therapy programs. Can psychologists develop IP care can be communicated. The MCO can similar guidelines, based on understanding the combine the data from many therapists and show basis of that resistance, for engaging reluctant customers the results of treatment in terms of therapists into quality improvement efforts? improvements in symptoms, increased ability to As in the example above, one resistance may be work productively, and increased satisfaction based on a fear that all therapists will be forced to with relationships. Such outcome data allow the endorse a particular model of therapy. Cognitive- customer to understand what it is achieved from behavioral treatment appears to be preferred by the nervous and mental disorders coverage in its MCO reviewers because of ease of understanding 234
  • 11. Quality Improvement the interventions and rationale, and therapists to meet the needs and goals of the hospital staff may fear dynamic models will become anathema. was successful. Managed care overtook psycho- The truth is quite the opposite. therapy and we have been reacting ever since. Demands that all therapists adhere to a particu- Psychotherapy must be proactive, not reactive in lar model is an artifact of the QA oriented process improving services and increasing reliability and of concurrent OP review. If we substitute quality customer satisfaction. improvement for QA, and in-house documenta- tion of process and outcome for remote reviews, References therapists can follow any model that produces ACKLEY, D. C. (1993). Managed care and outpatient mental good process (client satisfaction) and outcome health: The hidden costs. The Independent Practitioner, 13, 155-159. CQI models generally allow or even encourage ALEXANDER, J. F. & PARSONS, B. V. (1982). Functional fam- "cheating" within the values of the organization. ily therapy. Caimel, CA: Brooks-Cole. Adherence to a theoretical model, whether BAK, J. S. & WEINER, R. H. (1993). Issues affecting psychol- cognitive-behavioral or object relations, is not re- ogists as health care service providers in the national insur- quired. Thus, a therapist who expects patients to ance debate. The Independent Practitioner, 13, 30-38. BAK, J. S., WEINER, R. H., & JACKSON, L. J. (1992a). Man- get worse before getting better is within the limits aged mental health care: Should independent practitioners of CQI, as long as the final outcomes are capitulate or mobilize? (Part 1). The Independent Prac- (1) effective, that is, result in resolution of the titioner, 12, 31-35. presenting complaint, and (2) efficient, that is, BAK, J. S., WEINER, R. H., & JACKSON, L. J. (1992fc). 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Conversely, if pa- BURNS, D. & NOLEN-HOEKSEMA, S. (1992). Therapeutic em- pathy and recovery from depression in cognitive-behavioral tients who do not show deterioration are less sta- therapy: Structural equation model. Journal of Consulting ble, then that step is presumably necessary and and Clinical Psychology, 60, 441-449. must be part of a critical therapeutic path for CHOWANEC, G. D. (1994). Continuous Quality Improvement: those patients. Conceptual foundations and application to mental health care. Hospital and Community Psychiatry, 45, 789-793. CHOWANEC, G. D. (1996). The fall and rise of TQM at a public Summary mental health hospital. Journal on Quality Improvement, CQI in OP psychotherapy offers many advan- 22(1), 19-26. tages. Within a group practice setting, the most DEMING, W. E. (1986). Out of the crisis. 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