A significant topic of interest at the annual TJC Behavioral Healthcare Conference in Chicago this month was the new requirements going into effect in January 2018 related to outcomes measurement. These requirements apply to organizations and programs surveyed under the Behavioral Healthcare Accreditation Manual. The relevant standard is CTS.03.01.09 in the BH manual and the revisions to this standard require the following:

  • Use of a standardized tool or instrument to monitor the individual’s progress in achieving the identified goals. The tool can be focused on a population or diagnostic category (e.g. depression) or have a more global focus (such as functional status or quality of life.)
  • Analyzing this outcome data (for that individual) and using the results to revise the goals and objectives on the individual’s care/treatment/service plan based on progress or lack of progress.
  • Aggregating and analyzing the data (across the population) and evaluating the outcomes of care/treatment/services provided to that population

It was emphasized during the conference presentations that the new requirements are intended to promote the use of measurement based care. Measurement based care is a process of using objective data as feedback during the course of services in order to monitor progress toward the desired outcome. This data is then used for two purposes: to inform care for the individual served and to support quality improvement efforts for the organization

SAMHSA has recognized measurement based care as an evidence based practice. Several significant studies in recent years have shown that outcomes were significantly improved across a wide variety of mental health disorders when measurement based care was used. It has also been shown that one of the main contributors to poor outcomes is the lack of systematic measurement to determine whether individuals are responding to treatment.

It was also informative to hear at the conference what is considered NOT to be measurement based care:

  • A measure that assesses the use of evidence‐based care or clinical practice guidelines
  • A perception of care questionnaire or patient satisfaction survey
  • A measure of medication/treatment compliance
  • An assessment of outcome after the completion of service, even if it compares a baseline score to a subsequent point of measurement (e.g., intake/termination, admission/discharge)

So, how will surveyors be reviewing compliance with the new requirements? Essentially, there are three areas that surveyors will be evaluating to determine compliance:

Has the organization/program selected an outcomes measurement instrument? Key questions here will be how leadership was involved in the decision and whether clinicians and supervisors can explain how and why the instrument is being used.

Is the instrument being used consistently and in the manner in which it was intended to be used? Surveyors will want to know what training was provided to staff and how is their competency being assessed. Also, is the instrument being administered at the recommended frequency? Surveyors will utilize tracers and record reviews to determine if the instrument was appropriately administered and if results were discussed with the client. Surveyors may also ask clients about how the instrument is used and if results are discussed with them.

Is the treatment team and supervision activity informed by the data? Surveyors will evaluate whether results of the data are being used by the treatment team to consider changes to the treatment plan.

While surveyors will not be expecting full blown implementation and extensive aggregate data as of January 1st, they will expect to see that the essential components of your outcomes measurement process (as outlined above) have been put in place.


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