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Quality management in health care : empirical studies in addiction treatment services alignedto the EFQM excellence model

Nabitz, U.W.

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Citation for published version (APA):Nabitz, U. W. (2006). Quality management in health care : empirical studies in addiction treatment servicesaligned to the EFQM excellence model.

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C H A P T E R I O

Evaluating treatment process redesign by applying the EFQM Excellence Model

Udo Nabitz, Mark Schramade, Gerard Schippers

Accepted for publication as: Nabitz, U., Schramade, M., & Schippers, G. (2006).

Evaluating treatment process redesign by applying the EFQM Excellence Model.

International Journal for Quality in Heath Care, 18, 336-345.

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CHAPTER 10

Abstract

O B J E C T I V E To evaluate a treatment process redesign programme implementing evidence-based treatment as part of a total quality management in a Dutch addic­tion treatment centre.

M E T H O D Quality management was monitored over a period of more than ten years in an addiction treatment centre with 550 professionals. Changes are evaluat­ed, comparing the scores on the nine criteria of the EFQM Excellence Model before and after a major redesign of treatment processes and ISO certification. RESULTS In the course often years, most intake, care, and cure processes were re­organized, the support processes were restructured and ISO certified, 29 evidence-based treatment protocols were developed and implemented, and patient follow-up measuring was established to make clinical outcomes transparent. Comparing the situation before and after the changes shows that the client satisfaction scores are stable, that the evaluation by personnel and society is inconsistent and that clinical, production, and financial outcomes are positive. The overall EFQM assessment by external assessors in 2004 shows much higher scores on the nine criteria than the as­sessment in 1994.

C O N C L U S I O N Evidence-based treatment can successfully be implemented in addiction treatment centres through treatment process redesign as part of a total quality management strategy.

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Evaluating treatment process redesign

Introduction

There is increasing evidence that proves that total quality management is a powerful strategy for profit organizations to make changes and be innovative. Literature re­views (Malorny, 1999), empirical studies (Easton &C Jarrell, 1998), and opinion lead­ers (Buelens, 2000; Garvin, 1991) show that total quality management is effective. However, these studies are limited to profit organizations, measuring only financial outcomes. In health care, there is also converging evidence that an overall quality-management strategy can be a successful way to be innovative (Shortell et al., 1995), but strong empirical evidence is lacking (Grol, 2001; Institute of Medicine, 2002; Moeller, 2001; Sanchez et al., 2005).

As part of a large, nation-wide innovation programme in the addiction field, one of the Dutch treatment centres adopted a total quality management strategy for sev­eral years. The centre had formulated an overall quality policy, implemented evi­dence-based treatment protocols by redesigning the primary processes, acquired the ISO certificate, and started to measure clinical outcome (Schippers, Es van, Mulder, & Dijk van, 2005; Schippers, Schramade, & Walburg, 2002; Walburg, 1997). The goal of the strategy was to reduce the gap between evidence and practice and to make the outcomes more transparent (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). This endeavour was evaluated by using the nine criteria of the Excellence Model of the European Foundation for Quality Management (EFQM Model) as a multidimensional framework. The research question of the study was whether this strategy is reflected in the quality improvement of the organization ap­plying the nine criteria from the EFQM Excellence Model before and after inter­vention.

Method

The method section is structured like a treatment effect study: setting, design, inter­vention and main outcome measures. It is a concise description limited to the main line omitting methodological considerations about the quasi-experimental design and the RADAR scoring matrix.

Setting The addiction treatment centre in this study is responsible for almost monopolisti-cally providing a wide range of free services for alcohol and drug dependent patients in the urban region of Amsterdam in the Netherlands. Annually, the centre treats approximately 3500 clients and approximately 5000 persons are supported by inter­net services. Next to cure and care, the centre provides a diversity of prevention,

217

CHAPTER IO

probation, dental, and laboratory services. The staff consists of 550 persons, and the annual budget is 32 million Euro. The centre has the reputation of being a leading-edge organization for quality management. In the 1980s, the first formal quality strategy was developed (The Jellinek Centre, 1994a; Walburg, 1990).

Design The centre's total quality management strategy was initiated in 1994 and the treat­ment process redesign programme's major changes were introduced in the period 1997-2003. An evaluation was made possible by comparing a report on the state of the centre in 1994 with a similar report in 2004, which can be seen as a pre-post quasi experimental design (Cook, & Campbell, 1979).

Intervention The interventions are only briefly described but there is ample Dutch documenta­tion available about the policy of total quality management, the development of ev­idence-based protocols and the project management of the process redesign pro­gramme.

Total quality management

Total quality management is a structured, systematic approach for creating continu­ous quality improvements of all processes by all people of an organization. This means applying methods such as multilevel self-assessment, auditing, improvement projects, plan-do-check-act cycles, certification, result and customer orientation, permanent education, and process redesign (Joint Commission Mission, 1998).

After conducting several improvement projects, the treatment centre introduced total quality management (Nabitz, Klazinga, & Walburg, 2000) in the early 1990s including the development of a quality management system which became ISO cer­tified (Bouwens, 2001). In the subsequent phase, the attention switched from sup­port processes to treatment processes, including evidence-based protocols, and re­designing the processes. Related to the process redesign was the measurement of clinical outcome at follow-up, to make them more transparent and to stimulate cli­nicians to learn from feedback (Mugford, Banfield, & O'Hanlon, 1991).

Evidence-based treatment of addiction

Evidence-based treatment of addiction means that the research findings on the ef­fectiveness of treatment modalities are used and translated into clinical practice (Joint Commission Mission, 1998). Although addiction treatment has quite a re­search tradition, the first reviews on the effectiveness of treatments for alcohol and drug addiction were published in the 1980s and 1990s (Miller, Andrews, Wilbourne, & Bennet, 1986). The university research institute related to the treatment centre

218

Evaluating treatment process redesign

used the reviews and evaluated the actual treatment modalities of the centre which led to the conclusion that hardly any of the treatment modalities were evidence based. This initiated a radical redesign of the treatment processes. The research in­stitute suggested combining the effective treatment modalities with the concepts of the disease model of alcoholism and stepped care for treatment planning (Brink, 1996; Institute of Medicine, 1990; Sobel & Sobel, 1995).

Treatment process redesign programme

Treatment process redesign or re-engineering is the application of Business Process Redesign in health care organizations. It means that treatment processes are funda­mentally reviewed and radically redesigned to achieve dramatic improvements in performance measures (Hammer & Champy, 1993; Johansson, Mchuch, Pendle-bury, Wheeler, & Bate, 1993). Process redesign, customer orientation, case manage­ment, and the use of information technology are the focus of the approach (Wal­burg, 1997).

The process redesign programme was brought into practice by a steering group under the leadership of a dedicated, determined and transformation-oriented direc­torate. The group met every two weeks and directed the programme for the whole period and discussed and decided on the protocols, the trajectory model, the reor­ganization of the centre, the new housing facilities, and the technical infrastructure such as an electronic patient file.

A department for Quality and Innovation was established and equipped with fresh staff, external advisors, and a quality manager. In close cooperation with the research institute and within the realms of a national innovation programme (Schippers, Schramade, & Walburg, 2002) a formal design method in six steps was developed (Dijk, Schramade, Walburg, & Wildt, 1999). Furthermore, all personnel of the centre were engaged in diverse quality projects. Middle management partici­pated in monthly conferences, where progress was presented and a broad communi­cation strategy was developed to inform, motivate, and stimulate clinicians, with emphasis on measuring and learning (Dijk, Schramade, Walburg, & Zwijnenburg, 2 0 0 0 ) .

Main outcome measures The main outcome measures are the nine criteria of the EFQM Excellence Model as they are used for quality assessment. The first five criteria, which are the Enablers are assessed on the base of written documentation. The four Result criteria have to be grounded on facts and figures in terms of perception measures and performance indicators.

219

C H A P T E R I O

The EFQM quality assessment

The nine EFQM criteria are a well-known and frequently applied framework for evaluating the quality level of a health care organization (Brandt, 2001). The criteria were originally developed to identify the European quality award winners, but are now used to identify the quality level of many organizations (Blount, 2006). The criteria are detailed in 32 criteria parts, which are scored by assessors using the RADAR scoring matrix distinguishing five quality levels on a scale from 0% to 100% (European Foundation for Quality Management, 2003).

Comparing two assessments

In 1994, a submission report of the treatment centre was composed based on docu­ments with quantitative and qualitative data from various sources (The Jellinek Centre, 1994b). Three independent Dutch quality assessors evaluated the report and the material, visited the centre and reached a consensus on the final scores of the nine EFQM criteria (The Jellinek Centre, 1994a). These scores represent the status of the centre before the intervention and are seen for this study as the pre-assess-ment. In 1996, Dutch quality assessors evaluated the progress and the centre re­ceived the Dutch Quality Prize for the improvements. In the following years a series of internal self-assessments were conducted.

In 2004, a new EFQM submission report was composed, which reflected the sit­uation of the centre in 2004 (Schramade, Nabitz, Osseman, & Visser, 2004). Seven­teen members of the European EFQM Health Sector Group, among whom were nine EFQM assessors, studied the report, used the RADAR scoring matrix and de­termined the final scores of the nine EFQM criteria in a consensus meeting. The findings of the group represent the status of the centre in 2004 and are seen as the post-assessment.

Comparison in the radar graph

The nine criteria of the EFQM Model and the assessment procedure remained con­sistent over the years, although the scoring system changed in 1999. In 1994, a sim­ple scoring matrix was used for 28 criteria parts. In 2004, a complex RADAR scor­ing matrix was introduced for the 32 criterion parts. Among the EFQM assessors, there is consensus that the old scoring system is an over-estimation of the quality level of about one level (20%). For the purpose of this study, and after consulting two independent assessors who are experienced with the scoring systems, the scores of the nine criteria were adjusted. The 1994 scores were reduced by 10% and the 2004 scores enhanced by 10%. These adjustments allow a fair and methodologically relatively sound comparison of the 1994 and 2004 assessments in the typical radar graph.

220

Evaluating treatment process redesign

Results

The results illustrate the situation of the treatment centre in 1994 and in 2004 along the nine EFQM criteria. Tables ia and ib provide an impression of the innovations and changes in the centre and allow a qualitative comparison. The radar graph of Figure 2 is based on the judgement of the assessors and allows a quantitative com­parison.

Organizational improvements: EFQM criteria I to 4 Tables ia and ib show the most important changes. These are the restructuring of the organization into three treatment circuits (intake, intensive cure, and complex care), the use of an annual planning cycle, an extensive schooling programme, a tra­jectory management, new housing, and an advanced technical infrastructure.

Table l a : EFQM criteria 1 to 2 : Status 1994 and 2004

Situation 1994 Situation 2004

1. Lê3dêrshin

1. Mission statement: Aims, vision and vstues of the organization were not expiicitly formulated but determined by regulatory bodies. A first attempt for a mission statement was made in the quality policy document of 1990.

2. Organizational structure: The treatment departments had grown over the years. In 1994, the social welfare departments for addiction of the region merged with the centre. In total, there were 28 programmes grouped into three divisions. The programmes operated quite independently.

3. Quality management: Quality projects were carried out by project leaders. A steering group coordinated the projects and had a budget to stimulate improvements. The first EFQM assessment was carried out.

221

1. Mission statement: There is a concise mission statement: ''The centre is a leading and innovative organization dedicated to the clients, the social network of the clients and the society, and delivers prevention, treatment, rehabilitation and care for persons with addiction problems and addiction related iife-styies". The mission is used in many documents for decision making and planning.

2. Organizational structure: The structure is modified following the trajectory mode! of the treatment process redesign programme. There are three divisions: intake, intensive cure, and complex care headed by dual management (administrative and clinicai).

3. Quality management: Quality, costs and stakeholder orientation are top items for management. The implementation of evidence-based treatment modules is the hrst task. The management is enrolled in EFQM self-assessments and runs an improvement register.

CHAPTER 10

Table l b : EFQM criteria 3 to 4: Status 1994 and 2004

Situation 1994 Situat ion 2004

2. Policy and Strategy

I. Epidemiological research: There are some national epidemiological figures available on use, misuse and abuse. The first systematic population survey "Antenna" was conducted delivering specific and detailed regional figures.

1. Epidemiological research: An annual regional epidemiological survey is conducted. The use, misuse and abuse of substances is monitored. The findings show a stable pattern of substance use but also a treatment gap. About 80% of persons with addiction problems do not go to the centre for professional help.

2. Stakeholder demands: The stakeholders of the centre were not identified. There was an hierarchical relation with the regulatory bodies of the community and the Ministry of Health.

2. Stakeholder demands: The demands of the stakeholders a-e studied and evaluated using a focus group methodology. Strategic partnerships, treatment chain and outcome orientation proved to be the most important demands of the stakeholders and are leading for the policy development.

3. Annual planning cycle: The programmes contributed to an annual report but there was no annual planning. Annual budgeting was initiated.

3. Annual planning cycle: The annual planning cyde is well established. The nine EFQM criteria form the structure. A Goaifinder procedure is applied. There is a management review every four months.

3. People

I. Personnei management system: The personnel department had delivered the first handbook with all regulations for the staff of the centre.

l . Personnei management system: A computerized information system is Introduced to document the 119 functions and the reimbursement system of ail personnel members in order to increase consistency, transparency and flexibility. The function, trajectory manager, is formalized and introduced. The personnel handbook is available on the intranet.

2. In-service training: New personnel receives training. Schooling is mainly external. There is an international summer school on addiction treatment for two weeks.

2. Schooling system: Along with the development of protocols, a broad schooling and training system is set up. In 20 newly developed training courses the evidence-based treatment protocols are introduced. More than 350 professionals are trained every year. High report card grades 3TQ given for the training by the participants.

3. Safety and risk prevention: First incidences of aggression are signalled. Sick leave and early retirement cases increase.

3. Safety and risk prevention: Safety personnel officers are trained and appointed for each location. Personnel follows training courses to handle aggression. Regular risk inventory on the workplaces are conducted.

4 . Partnership and Resources

1. Housing and workplaces: The programmes of the centre were scattered over 20 locations. AH housing facilities, except one clinic, had very low standards. The housing was poorly adapted to the demands of addiction treatment. There were serious safety and technical problems.

1. Housing and workplaces: The planning of new housing followed the priorities of the treatment process redesign programme. After elaborate negotiations, one central intake unit was established, one central clinic for complex care was built and the second clinic for intensive cure was renovated. Other locations were also renovated. All teams and departments had changed location. In 2004, the housing met the highest standards of allocation of space, infrastructure, inventory and communication means.

2. Information technology: An information strategy plan was available which gave directions for the information structure, the information systems, software and hardware. A financial, an administrative, and a central registration system were introduced. A broad training programme for personal computer use was carried out.

2. Information technology: The computer and information facilities of the centre are advanced- The information strategy plan is aligned with the demands of the trajectory model. A complex but efficient technical infrastructure with several local networks and a central server system of 400 computers supports trajectory management and the electronic patient file. More than 30 informatics projects were planned, carried out and evaluated.

3. Research and knowledge management: The existing department for research, medical informatics and computer facilities was split into medical administration and information systems and a new research institute was founded.

3. Research and knowledge management: The research institute had a leading role in the treatment process redesign programme. The method to develop protocols was introduced by the institute. A call centre to carry out systematic foilow-up interviews was installed. New research projects about craving, personality disorders, evidence-based treatment and randomized clinical trials were started. The research activity were evaluated annually and were reviewed in 2003 and 20Ö4.

2 2 2

Evaluating treatment process redesign

Process improvements: EFQM Criteria 5 In 1994, the work-instructions, documentation, and protocols of all departments within the treatment centre were collected. This amounted to several hundred doc­uments of which only a few were related to care and cure processes. The documents had no systematic structure, were incomplete, fragmented, limited, and not author­ized. The protocols were neither evidence based nor met the standards required for ISO certification (Ong, Geerlings, & Nabitz, 1995).

Table 2a : EFQM cr i ter ia 5: T r e a t m e n t p ro toco ls in 2 0 0 4

Nr. Name of the treatment protocol I * E*

V* V

V

A. Protocol for internet support and treatment 1. Support for clients with substance misuse: "Chat module" 2. Self-help protocol for substance abuse, smoking and

gambling 3. Structured treatment protocol for clients with alcohol

problems B. Protocol for Cognitive Behaviour Therapy

4. Lifestyle training for individuals and groups 5. Lifestyle training for partner and family 6. Lifestyle training for probation clients

C. Specia l ized in te rven t ions 7. Crisis intervention 8. I n - and outpatient detoxification 9. Guidelines Inpatient Motivation Centre 10. Guidelines 12 step approach 11 . Guidelines for partners and family of clients in clinical setting 12. Guidelines for families coping with addiction 13- Guidelines daily skills

14. Guidelines day routines 15. Addiction and schizophrenia 16. Addiction and borderline 17. Addiction and depression 18. Guidelines for chronic drug users: "Spiral up" 19. Social skills training 20. Personal effectiveness 2 1 . Cognitive and social skills "Brenner manual"

D. Medical treatments 22. Medical treatment alcohol problems 23. Medical treatment opiate problems 24. Medical treatment nicotine problems

E. Case m a n a g e m e n t 25. Guidelines for indication and trajectory decision

26. Intensive case management 27. Guidelines aftercare 28. Guidelines trajectory evaluation 29. Telephone-based trajectory evaluation

V V' V

V

V V V V V V V V V V V V

V v-

V V V

V V V v

V

V -V

V V -V -V --V'

v'

V V V V

V

V V V

V -V -V

V --

V -------V -V

V ---

V

-V

V -V -V

D' Developed, I * Implemented, E* Evaluated

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C H A P T E R IO

Table 2b : EFQM cr i ter ia 5: ISO procedures in 2004

Nr. Name of the ISO certified procedures 1 * 2 * 3 *

A. Procedure group policy development and regulations V V V Such as policy documents of the divisions, including dentistry and laboratory. Regulations concerning privacy, judicial questions for admissions and complaint management.

B. Procedure group for the quality management system V V V The structure of the quality management system, including procedures for the internal documentation, the internal and external auditing system and improvement register.

C. Procedure g roup for p lann ing and cont ro l V V V

Such as the scheduling and the structuring of the annual plan and the decision making, including performance indicators, budgets, internal control and reporting systematically.

D. Procedure g roup for p reven t ion and p ro jec t m a n a g e m e n t V V V

The general procedure for project management for the centre and the specific procedures for prevention such as development of leaflets, coaching of schools, test services and monitoring systems.

E. Procedure group to support treatment modules V V V Process documentation for treatment modules such as intake, lifestyle, crisis intervention, clinical treatment, aftercare and evaluation.

F. Procedure group medical responsibilities and treatment V V V Protocols concerning medications, methadone, blood testing, delirium insults, overdoses, suicide and death. Monitors for incidents and accidents and external reporting systems for calamities.

G. Procedure g roup personnel and resources V V V

Procedures such as recruiting and selecting personnel, staff education, job evaluation and career planning. Including safety procedures, fire drills and aggression management

H. Procedure g roup qual i ty assessment and i m p r o v e m e n t V V V

Procedures to monitor and measure results, feedback procedures, instrument development and data management

1* Certified January 1999, 2* Certified January 2001, 3* Certified January 2004

In 2004, two types of protocols had been introduced in the treatment centre. Twenty-nine evidence-based treatment protocols were developed, 21 were imple­mented, and 11 were evaluated, see Table 2a. A quality management system with eight groups of ISO certified procedures was established covering over 100 struc­tured, authorized, and certified documents, see Table 2b.

Based on the idea of stepped care a logical structure for the treatment protocols was developed, distinguishing eight trajectories, and a self-help internet path, see Figure 1.

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Evaluating treatment process redesign

Figure 1: Tra jectory mode l 2004

Internet self-help (0)

Intake (1) evaluation (I)

Intake (2) snort

Outpatient Treatment

evaluation (2)

Intake (3)

Intake (4)

Intake (5)

Outpatient Detoxification

Inpatient Detoxification

- *

Outpatient Treatment

Outpatient Daycare

Inpatient Treatment

Outpatient Aftercare

Inpatient Aftercare

•

evaluation (3)

evaluation (4)

evaluation (5)

Intake (6) Re- and pro-active treatment and care for Doubei diagnoses clients

evaluation (6)

Intake (7) Re- en pro-active treatment and care for Stabilised cfients

evaluation (7)

Short crisis treatment (S)

0) Internet support

1) Minimal treatment

2) Short outpatient treatment

Trajectory names

3) Outpatient treatment

4) Day treatment

5) Inpatient treatment

6) Doubele diagnoses treatment

7) Long-term care

8) Crisis intervention

Outcome indicators: EFQM Criteria 6 to 9 The outcome indicators of the EFQM Excellence Model are seen as a multi-dimen­sional indicator framework covering client, people and society satisfaction and in­cluding clinical, administrative and financial indicators. This way a broad, balanced overview of the relevant results of the addiction treatment centre is assured.

Client satisfaction: EFQM Criteria 6

In 1994, the centre participated in the first national mental health organizations sat­isfaction survey, 156 outpatient and 94 inpatient clients participated in the exit in­terviews. This was about 10% of all treated clients. The results show that there was high satisfaction concerning the professionals and low satisfaction concerning hous­ing and some types of treatment (Jongerius, Hull, & Derks, 1994). In 2004, the

225

CHAPTER 10

in-house call-centre continuously collects the treatment outcome of approximately

1200 clients per year concerning three validated clinical scales, including the report

card score. The findings show, per trajectory, the percentage of clients who were sat­

isfied with three aspects of the treatment. O n all but one of the scales more than

50% percent are satisfied. The most positive rating shows that 91% were happy with

the decision making in the day treatment. The report card figure ranges from 6.7

{satisfactory) to 7.9 {good). For the trajectory Internet self-help, which was evaluat­

ed in 2004 by 522 clients, 50% were satisfied with the information, decision making,

and outcome, and 75% stated that the internet help can be recommended to other

people. The report card score was a 6 {passed) (Blankers, 2005).

Personnel satisfaction: EFQM Criteria 7

In 1994, the first ad hoc personnel satisfaction measurement was conducted among

34 outpatient service personnel. There was a high satisfaction rate (85% and higher)

signalling meaningful, pleasant, useful, and interesting work. A low satisfaction rat­

ing was given to career possibilities, schooling, and work stress (lower 59%) (Voet

van der, 1995). During the process redesign programme, two systematic surveys

among the relevant teams were conducted to measure work satisfaction. The results

of the first survey among more than 300 personnel showed high scores on the scales

autonomy, responsibility, support by colleagues, and the meaningfulness of the

work. However, the personnel negatively rated internal structure, workflow, and the

work stress. Teams that participated in the process redesign programme scored un­

favourably. The second survey in 2004 was part of the national work stress monitor­

ing programme. The scores show high work pleasure and strong commitment of the

majority of the staff, but about half of the personnel indicate that they need time for

recovery. The personnel still see the structuring of the work processes, the mental

and emotional burden and the limited career and learning possibilities as negative

points. However, the ratio of personnel on sick leave had decreased over the preced­

ing three years and was lower than the national benchmark (Schramade & Nabitz,

2005) .

Society satisfaction: EFQM Criteria 8

In 1994, there was only a vague impression available of society's appreciation of the

addiction centre's achievements. Society as a whole was not yet seen as a stakeholder

of the centre, and facts about their opinion were not available. Since 1996, a national

population survey is conducted every three years. The image of the centre, meas­

ured with 13 items, is positive overall, but items such as innovation, costs, and flexi­

bility are rated lower than the average and there are signs of a negative trend (Nabitz,

Vis, &C Brink van den, 2001).

2 2 6

Evaluating treatment process redesign

Table 3: EFQM criteria 9: Clinical outcome abstinence rate 2004

Percentages foilow-up

Abs* U. c. Not u . c * Total

Tra jec tory 1 : Minimal intervention (N = 194)

TNTAKF A b s t i n e n t

Consumption under control Consum. not under control Totaa!

7% 8% 25% 40%

Tra jec tory 2 : Shor t ou tpa t ien t t r ea tmen t (Li festy le t ra in ing 1 , N = 199)

TMTAIT'F Abstinent Consumption under control Consumption not under cont. Total

T ra jec to ry 3 : Outpa t ien t t r ea tmen t (Li festy le t ra in ing 2, IM = 292)

TNTAKF Abstinent IN A K t consumption under control

Consumption not under cont. Total

T ra jec to ry 3 : Ou tpa t ien t t r e a t m e n t (no t o therwise spec i f ied, N = 124)

INTAKE A b s t i n e n t

' " I M - Consumption under control Consumption not under cont. Total

T ra jec to ry 4 : Day t r e a t m e n t (N = 14)

TNTAKF Abstinent Consumption under control Consumption not under cont. Total

T ra jec to ry 5: Inpa t ien t t r e a t m e n t (N =

TNTAKF Abstinent 1 A Consumption under control

Consumption not under cont. Total

T ra jec to ry 6 : Double d iagnoses pa r t - t ime t r e a t m e n t (IM = 24 )

TNTAKF Abstinent Consumption under control Consumption not under cont. Total

T ra jec to ry 6 : Double d iagnoses cl inical t r e a t m e n t (N = 48)

INTAKE Abstinent Consumption under control Consumption not under cont. Total

T ra jec to ry 7: Long - te rm care: There is

8% 6%

20% 34%

7% 5%

25% 37%

9% 6% 37% 52%

0% 7%

43% 50%

4 0 )

8% 10% 50% 68%

0% 4 % 29% 33%

2% 7%

22% 3 1 %

insufficie

3% 2% 13% 18%

1 % 2% 19% 22%

1 % 4 % 15% 20%

1 % 4 % 8% 13%

0% 7% 7% 14%

0% 0% 12% 12%

0% 4 % 9% 13%

0% 4 % 13% 17%

nt data avai lab le.

4 % 3%

35% 42%

1 % 39% 44%

1 % 1 %

4 1 % 43%

0% 1 %

34% 35%

0% 0%

36% 36%

0% 0%

20% 20%

0% 0% 54% 54%

0% 2%

50% 52%

14% 13% 73% 100%

13% 9%

78% 100%

9% 10% 8 1 % 100%

10% 1 1 % 79%

100%

0% 14% 86% 100%

8% 10% 82% 100%

0% 8%

92% 100%

2% 13% 85% 100%

Abs* a Abstinent, U. c * ** Consumption under control. Not u. c.x - Consumption not under control The criterion for abstinence is defined by the Addiction Severity Index (ASI) norms as no consumption of alcohol or drugs in the last 30 days. Controlled consumption is defined as iess than three glasses alcohol a day and less than 21 days in the iast months and less than 7 days of drugs use in the last month. There is a rest category for all remaining cases, which is called uncontrolled consumption.

Clinical, productivity and financial indicators: EFQM Criteria 9

In 1994, data on clinical outcome of the treatment programmes was not available.

Table 3 shows the clinical outcomes, assessed by the call-centre nine months after in­

take. In 2004, a total of 895 clients were interviewed and complete data of the six

227

CHAPTER 10

trajectories became available. This is a response rate of 50%. The abstinence rate varies between 31% and 68%. On average, about 50% of the

clients were abstinent nine months after intake, and about 20% controlled their consumption on an acceptable level. The table takes into account the situation of the client at intake.

In 1994, the available data on productivity were rather limited. 2044 clients en­tered the centre. Outpatient contacts exceeded 12 000 and the occupation of the beds was 98%. In 2004, data on the productivity can be segmented into input, throughput, and output figures. A total of 3812 clients had an intake in 2004. 5489 Clients logged in for internet support (input). 3283 Clients followed a treatment tra­jectory, of which 3044 finished the trajectory (throughput). In general the output figures meet the formulated goals for 2004 and show an increase over the last ten years.

The financial data for the whole centre show a gradual increase in total volume from 20 million Euro in 1994 to 32 million Euro in 2004. The balance has been pos­itive for most of the years, but there were years with small negative annual results. The reserves, which where generated during the preceding four years were more than 10% of the total turnover.

EFQM assessment: Criteria I to 9 In Figure 2, the scoring of the two EFQM assessor groups of 1994 and 2004 are graphically represented (Dorren, Stevens, & Wiersema, 1994; Schramade et al., 2004). The dotted line of 1994 shows low quality (level one or lower than 20%) for the EFQM criteria: Processes (5), Customer Results (6) and People Results (7).

The line representing 2004 illustrates that the assessors are much more positive about the quality of the centre. All criteria are at level two or higher (above 40%). Based on the judgement of the assessors, four EFQM criteria have improved more than one level (20%): Processes (5), Partnerships and Resources (4), People (3) and Customer Results (6). Leadership (1) remained the same. Policy and Strategy (2) and the results criteria People Results (7), Key Performance Results (9), Society Re­sults (8) only show some improvement.

Discussion and conclusion

This study demonstrates that over a ten-year period substantive and positive changes had been achieved by applying a total quality management strategy with the focus on treatment process redesign. A trajectory model, which constitutes the framework for intake, cure, and care has been established, evidence-based treatment protocols have been introduced, the quality management system has been certified, and follow-up treatment outcomes have been constantly evaluated by an in-house

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Evaluating treatment process redesign

Figure 2: Radar graph of the 9 EFQM criteria in 1994 and 2004

Criteria 5: Processes

Criteria 1: Leadership

Criteria 4: Partnership &

Resources

Criteria 2: Policy and Strategy

Criteria 3: People

Criteria 7: People Results

Criteria 9: Key Performance

Results

Criteria 8: Society Results

Assessment 1994: The submission report 1994 was assessed by three Dutch assessors.

Assessment 2004: The submission report 2004 was assessed by the members of the EFQM Health Sector Group.

call-centre. Many additional innovations such as the housing, technical infrastruc­ture, and in-service training that did not exist in 1994 were introduced by 2004. Consequently, the EFQM assessors testify a higher quality level of the treatment centre, visualised in the radar graph.

There are only a few publications about similar projects in health care organiza­tions. In the Basque Country in Spain all 32 health care services used a total quality management approach and report positive results concerning all nine EFQM crite­ria (Sanchez et al., 2005). The findings of Sanchez et al. also show that the personnel satisfaction radically improved, which shows that innovations can also lead to high­er personnel satisfaction, which was not achieved in this study of the addiction treatment centre. A publication about a dental clinic in Switzerland with a staff of

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C H A P T E R I O

about 20 professionals also shows very positive results. The clinic worked with a to­tal quality management strategy and carried out a large variety of creative improve­ment projects, and was honoured with the European Quality Award (Harr, 2001). Both studies prove that a total quality management strategy takes time before sus­tainable effects become visible. The well-known study of Hendricks and Singhal in which more than 800 profit organizations were compared using an experimental design shows that it took at least six years before the experimental group, which had followed a total quality management strategy proved to be superior to the control group (Hendricks & Singhal, 1997).

The goal of the addiction treatment centre used in this study was to reduce the gap between scientific evidence and everyday practice and to make the results of the centre more transparent. It can be concluded that this goal has been achieved. How­ever, the implementation of the evidence protocols is still ongoing and the dramatic improvement in performance, as predicted by Hammer and Champy (Hammer et al., 1993; The Jellinek Centre, 1994a) has not been demonstrated. The client satisfac­tion and the clinical results are not better than in other studies (Kiifner & Feurlein, 1989). People Results (7) and Society Results (8) show no clear improvement. It is very likely that only new effective treatment modalities in combination with a total quality management strategy can lead to a real breakthrough in the performance of addiction treatment.

Acknowledgements

The treatment process redesign programme was carried out in the Jellinek Centre in Amsterdam, The Netherlands. In 2004, the Board of Directors were Petra van Dam and Christian Krappel. The innovation programme was initiated by Jan Walburg then CEO of the centre. During the programme the Board of Directors comprised of Jan Walburg, Astrid van Dijk and Petra van Dam. This study was supported by the Amsterdam Institute for Addiction Research of the Academic Medical Centre Amsterdam. The treatment process redesign programme was funded by the Zorgkantoor AGIS Amersfoort, and the Ministry of Health, Welfare and Sports, The Hague.

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