Resource Tool for Non-government Drug and Alcohol Organisations

Resource Tool for Non-government Drug and Alcohol Organisations

EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: August 2009 ACHS Copyright 2

Introduction EQuIP and Non-government Drug and Alcohol Organisations The ACHS Evaluation and Quality Improvement Program (EQuIP) provides a framework that organisations can use to achieve excellence. It is a quality management tool that can help organisations develop and maintain a systematic way of operating which is monitored and evaluated on a continuous basis with a view to the organisation becoming the best of its type. The emphasis of EQuIP is on continuous improvement and the measurement and reporting of achievements and outcomes. The way in which this occurs is up to the individual organisation, and EQuIP enables each organisation to tailor its quality improvement activities to its own unique requirements. This Resource Tool for Non-government Drug and Alcohol Organisations has been developed in partnership between the Network of Alcohol and other Drug Agencies (NADA) and ACHS to assist non-government drug and alcohol organisations to apply the EQuIP standards and to address important areas that are relevant to the specialty of drug and alcohol service provision. NADA, as the peak body for non-government drug and alcohol organisations in NSW, supports agencies to reduce the alcohol and drug related harm to individuals, families and the community. A key role of NADA is to strengthen the non-government drug and alcohol sector by supporting agencies to engage in quality improvement programs. This Resource Tool targets those agencies that are new to formal quality improvement programs or those that are new to EQuIP. This resource tool is a living document and may be revised regularly. In this case, the version number and date in the footer will change. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: August 2009 ACHS Copyright 3

Feedback The ACHS and NADA welcome feedback on this resource tool. Should you have any comments / suggestions, please contact: Executive Director Development The Australian Council on Healthcare Standards (ACHS) 5 Macarthur Street ULTIMO NSW 2007 Phone: 61 2 9281 9955 Fax: 61 2 9211 9633 Email: achs@achs.org.au Web: www.achs.org.au Director Sector Development Network of Alcohol and Drug Agencies (NADA) PO Box 2345 STRAWBERRY HILLS NSW 2012 Phone: 61 2 9698 8669 Fax: 61 2 9690 0727 Email: admin@nada.org.au Web: www.nada.org.au Further Information For more information regarding ACHS accreditation (e.g. applicability of the criteria and the Self-Assessment) please contact: ACHS Customer Services Managers The Australian Council on Healthcare Standards (ACHS) 5 Macarthur Street ULTIMO NSW 2007 Phone: 61 2 9281 9955 Fax: 61 2 9211 9633 Email: Web: achs@achs.org.au www.achs.org.au EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: August 2009 ACHS Copyright 4

How to use this Resource Tool This resource tool should be used in conjunction with The ACHS EQuIP 4 Guide Part 1. The layout of this resource tool is as follows: The EQuIP standard is stated at the top of each page. Each EQuIP criterion is indicated in bold and may be supported by some additional points / examples for consideration by non-government drug and alcohol organisations. The mandatory criteria are identified throughout this document by italicised text. Self-Assessment examples have been provided in the format of the EQuIP 4 Self-Assessment Tool. At least one example of a Key Improvement and one example of Plans for Improvement are provided. The examples in these sections are not related to each other but provide suggestions for different activities to illustrate a result / outcome of an improvement and an action to improve. Please refer to The ACHS EQuIP 4 Guide Part 1 page 8, and The ACHS EQuIP 4 Guide - Part 4 pages 5 to 17 for information on Self-Assessments and the ACHS Electronic Assessment Tool (EAT). The table below shows an example of an organisation Key Improvement as it appears in the EQuIP Self-Assessment format in EAT. This table shows evidence to support the organisation s rating for each criterion. Organisations are required to document up to ten of the most significant results / outcomes with verifying data for each criterion which will give surveyors and EQuIP members an overview of achievement. The examples in this document are a guide only and should not be regarded as complete or as ACHS compulsory requirements. Key Improvement Example No Title of Key Improvements What did you change Result / Outcome 1 Discharge plan. The organisation developed a discharge planning form that client / admissions staff must complete prior to admission into the service. All clients entering the service have an individualised discharge plan so that they can be discharged safely from the service. Plans for Improvement Example Organisations are required to document up to ten organisational Plans for Improvement per criterion. The examples in this document are a guide only and are not intended to be regarded as complete or as ACHS compulsory requirements. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: August 2009 ACHS Copyright 5

Plans for Improvement example No Intended Improvement Responsibility Timeframe 1 Intake / admissions policy updated to include discharge planning for all residents and process involved in developing plan. Admissions Coordinator. March 2010. Clinical Indicators The use of clinical indicators (CIs) by healthcare organisations continues to be an important component of the Evaluation and Quality Improvement Program (EQuIP). The collection of specific Australian Council on Healthcare Standards (ACHS) indicators is not mandatory and organisations may choose to develop their own indicators or use other indicators. Indicators assist healthcare organisations to identify areas which may benefit from continuous monitoring of clinical activity and performance and to improve the quality of care being delivered. Detailed information about the specific clinical indicator sets and the Comparative Report Service can be downloaded by EQuIP members from the ACHS website www.achs.org.au or by contacting the ACHS Performance and Outcomes Service, email pos@achs.org.au. Performance Indicators Performance indicators are one source which informs an evaluation process and may help to identify or flag further issues or questions. To assist healthcare organisations in the measurement and evaluation of their performance, the ACHS has compiled a list of performance indicators. A range of performance indicators has been suggested for each criterion in Part 3 of the ACHS EQuIP 4 Guide - Suggestions for measuring performance. The indicators are SUGGESTIONS ONLY. Organisations may continue to collect their own suite of performance indicators. There is no expectation that an organisation will collect any of the suggested performance indicators. While many of the indicators will be applicable to non-government drug and alcohol organisations, others may need to be modified or will not be relevant. The introduction to Part 3 explains how an organisation may modify the performance indicators to suit their needs. The indicators suggested in Part 3 are not the only ones available, nor are the lists of indicators all inclusive. The suggestions are designed to provide assistance to organisations. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: August 2009 ACHS Copyright 6

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. CLINICAL FUNCTION STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Criterion 1.1.1 The assessment system ensures current and ongoing needs of the consumer / patient are identified. These guidelines should be read in conjunction with criterion 1.1.3 consent process and criterion 1.6.3 cultural and special needs. The intent of this criterion is to ensure that the assessment system meets all the requirements of the client and the organisation. LA (a) Guidelines are made available for staff to assess physical, psychological and social needs, including the identification of at risk consumers / patients. The organisation has guidelines available for staff to assist them in assessing the physical, psychological and social needs of clients, including clients who are identified as at risk. (b) There is a policy for planning for separation at the time of the initial episode of care. The organisation has an Intake / Admissions Policy that requires staff to start planning for separation before the client begins treatment. When considering separation / exit planning from a residential facility, the services should plan for a worst case scenario e.g. when a client may be discharged during the night. Where appropriate, a carer or support person should be involved in the exit planning process and written consent obtained. The following are important factors to consider when formulating a discharge plan: travel distance and cost of travel home homelessness and the need for immediate accommodation needs (including costs) upon discharge high psychological needs age of client (under 18) or clients being discharged with children in their care who should be contacted after discharge or emergency contact. Assessment Policy Access to resources Intake / Admissions policy Exit plan form and guidelines Client exit package EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 7

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Discharge planning should also include a basic exit package with referral pathways to other organisations and support information e.g. free telephone numbers. (c) Referral systems to other relevant service providers exist. Referrals folder Referral numbers on discharge paperwork SA (a) Assessment is documented and where appropriate is multidisciplinary. Assessments are documented and filed in the client s file. Assessments are completed by appropriately qualified staff. In addition to this, self report assessments may also be included. Where appropriate, assessments are multidisciplinary. (b) Comprehensive assessment guidelines, based on professional standards and evidence are used. The organisation utilises comprehensive assessment guidelines that comply with professional standards and evidence. (c) The assessment system identifies the physical, psychological and social needs of the consumer / patient. (d) The needs of at risk consumers / patients are identified and managed. The assessment system identifies clients who are at risk and systems are in place to manage these clients. Risk is defined as the chance of something happening that will impact on objectives. To identify clients at risk specific assessments may be required, such as: mental health assessment domestic violence assessment suicide / self harm assessment Assessment forms located in client files Position descriptions Assessment Policy Assessment Policy NSW Health Drug and Alcohol Psychosocial Interventions NSW Health Drug and Alcohol Treatment Guidelines for Residential Settings Assessment Policy Client assessments Client Management Policy Assessment Policy Client contracts Treatment management plans Discharge plans Communication Policy Client file Aggression Policy EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 8

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. potential for violence assessment risk to children assessment discharge planning and separation assessment. To assist in the management of at risk clients the organisation has: behaviour / self harm / aggression contracts treatment management plans discharge plans clear communication between staff. (e) The assessment system avoids duplication by multiple providers. The assessment system avoids duplication by ensuring that the information that is collected is relevant and in a standardised form. Assessments are located in the clients file so other staff can access the information without the need to re-assess. The organisation keeps the clients file for a minimum of seven years and all treatment episodes for clients are kept in the one location. (f) A support person / carer is involved in the assessment system where appropriate. When appropriate, and with the client s informed consent, a support person / carer is involved in the assessment. The organisation may also gather assessment information through consultation with other services involved with the client s care. (g) Information is provided to the consumer / patient on their health status. Information on a client s health status is provided to them by appropriately qualified professionals. In some organisations this may be facilitated by external service providers e.g. GP, counsellor, psychiatrist. (h) Reassessment of the consumer / patient occurs when there is a change in health or functional status. The organisation has systems in place to ensure that the client is reassessed when there is a change in health or functional status. On occasion this requires assessment by external service providers including doctors, psychiatrists and other medical professionals. Suicide / Self-harm Policy Shift handover Assessment Policy Standardised assessments Staff access to client files File Management Policy Electronic client database Assessment Policy outlining sources of assessment information Family Policy Privacy / Confidentiality / Consent Policy Health information sheets Position descriptions Appropriately qualified staff Relationships with external providers Assessment Policy Staff review of clients and recording of client status in files External Partnerships Policy Treatment management plans EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 9

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. (i) Planning for discharge / transfer commences at assessment, is multidisciplinary when appropriate, and coordinated. Planning for discharge / transfer begins at assessment and a plan is in place before the client commences treatment with the service. Assessments are multidisciplinary and conducted by trained staff. Assessment Policy Dates on discharge plan Qualifications of staff contributing to assessment / discharge plan MA (a) The assessment process is evaluated and improved, as required. CQI policy review plan Evidence of improvements (b) Referral systems are evaluated and improved, as required. Case Management Policy referencing Referrals Feedback from referral points (c) Processes for assessing and managing at risk consumers / patients are evaluated Intake / Admissions Policy and improved as required. Client Management Policy Review of assessment processes (d) Planning for discharge / transfer is evaluated to ensure it: File audit with completed discharge (i) consistently occurs plans (ii) is multidisciplinary if appropriate Feedback from client / consumer / (iii) meets consumer / patient and carer needs. carer The following guidelines specifically reference information that may be useful for this standard. NSW Health Drug and Alcohol Treatment Guidelines for Residential Settings NSW Health Drug and Alcohol Psychosocial Interventions 4.1 Assessing the needs of people seeking treatment, page 11 3.3.1 Intake and screening, page 18 7.1 Assessing progress during treatment, page 18 3.3.2 Comprehensive assessment, page 19 7.2 Common/consistent assessment forms and outcome measures, page 18 4.1.1 Assessment, page 25 8 Completion of treatment and continuing care, page 19 8.1 Continuing care and support programs, page 19 EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 10

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Part 1 of the ACHS EQuIP 4 Guide provides guidelines to support this criterion. In addition this Resource Tool lists examples of how drug and alcohol organisations may provide evidence of achievement in this criterion. Performance measures The performance measures that are related to this criterion can be reviewed on page 14 of Part 3 of the ACHS EQuIP 4 Guide. Key Improvements No Title of Key Improvements What did you change Result / Outcome Discharge plan The organisation developed a discharge 100% of clients entering service have an 1 planning form that client / admissions staff individualised discharge plan so that they can complete prior to admission into the service. be discharged safely and appropriately from the service. Assessment Policy. Assessment Policy was updated to include a domestic violence assessment. 100% of clients were asked questions on their experience of domestic violence. Of these, 57% did not require referral numbers, 27% accepted the referral and 16% declined referral 2 numbers. By adding the domestic violence assessment, the organisation has increased the comprehensiveness of the assessment and been able to provide additional referrals and support for the clients. Plans for Improvement No Intended Improvement Responsibility Timeframe 1 Intake / Admissions Policy updated to include discharge planning for all residents and process involved in developing plan. Admissions coordinator. March 2010. 2 Discharge Policy updated to include references Clinical staff. March 2010. to client s discharge plan. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 11

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. 3 Domestic Violence information pamphlets to be placed in client area so those clients who declined referral from staff can access numbers at any time. Case manager. August 2009. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 12

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Criterion 1.1.2 Care is planned and delivered in partnership with the consumer / patient and when relevant, the carer, to achieve the best possible outcomes. These guidelines should be read in conjunction with criteria 1.3.1 appropriateness, 1.4.1 effectiveness, 1.6.1 consumer input, 1.6.2 rights and responsibilities and 1.6.3 cultural and special needs. The intent of this criterion is to ensure that care planning and delivery promote a consultative, collaborative approach that actively involves the client. This will ensure the best possible outcomes for the client. LA (a) Evidence-based practice guidelines on care planning and delivery are available. NSW Health Drug and Alcohol (b) Care is provided in response to consumer / patient needs in a timely manner in accordance with established policy and procedures. (c) A comfortable and caring environment is provided for consumers / patients. Treatment occurs in a comfortable and caring environment for clients. The organisation ensures through various policy and procedures that: the environment complies with OH&S requirements the environment is clean and well maintained consideration is given to replacement of furniture / fittings / equipment etc as appropriate. Psychosocial Interventions Drug and Alcohol Treatment Guidelines for Residential Settings EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 13 Resource library Diagnosis Policy Treatment Policy Access to peer review journals and other reference material Review of client files with completed treatment plans Assessment Policy Case Management Policy Counselling Policy OH&S policies and procedures Cleaning roster Maintenance committee Maintenance record Design and layout of premises

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. SA (a) Care planning and delivery are based on the assessment of the consumer / patient needs and with the consumer / patient and, when relevant, their carer. Treatment planning and delivery are based on the assessment of client needs and in collaboration with the client and their carer (where relevant). (b) All care planning, decisions, actions and changes are documented in the consumer / patient health record. (c) Care is delivered by skilled and trained individuals within a competent multidisciplinary team with an identified team leader. (d) A system exists for the effective identification and management of a deteriorating consumer / patient. Clients of the service are reviewed regularly and changes recorded in their file. Staff attend various meetings (changeover, staff, clinical, case management) where there is an opportunity to discuss clients who may be deteriorating and interventions are put in place to assist them. (e) Consumers / patients and carers, when appropriate are given information that allows them to understand their care. This may be done both prior to, during and after treatment. Assessment Policy Case Management Policy Treatment Policy Family Policy Case management notes in client file Counselling notes in client file Treatment management plans Client file File Management Policy Communications Policy Position descriptions Personnel files Staff profile Organisational structure Training register Staff training budget Supervision Policy Client file Client identified goals within file Changeover meeting record Minutes of meetings Client management policies Case conferencing At risk alert on client file Service information via brochure / website Booking letter EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 14

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. (f) There is evidence that the consumer / patient has been provided with information on care delivery options. Clients of the organisation are provided with information about the treatment they will receive. They are required to sign and agree that they understand the treatment they will be involved in and their personal responsibilities if they are to remain in treatment. Client responsibilities Carers package Group / program schedule Client orientation manual Signed client consent forms / contract in client file Client rights and responsibilities MA (a) The care planning and delivery processes are evaluated and improved as required. Individual treatment plans are reviewed in clinical meetings and supervision. Policies associated with treatment are reviewed regularly via the CQI policy review plan or as required. The client provides the organisation with feedback on their treatment through evaluation forms. (b) Policies and procedures for care delivery are evaluated against evidence, professional guidelines, codes of practice and medico-legal requirements. Part of the review process for policies and procedures is to ensure that the policy is in line with, and referenced to relevant requirements. (c) Multidisciplinary team processes for care delivery are evaluated and improved as required. Staff of the organisation meet regularly to discuss the treatment needs of clients, outcomes achieved and what could be done differently to better assist the client. (d) The environment in which care is provided is evaluated and improved as required. The organisation conducts regular evaluations on the environment in terms of OH&S, Clinical meeting minutes CQI policy review plan Evaluation Policy / forms Results of client satisfaction with treatment NSW Health Drug and Alcohol Psychosocial Interventions Drug and Alcohol Treatment Guidelines for Residential Settings Psychologists Code of Conduct Case presentations Clinical meetings Group and / or individual supervision Staff meetings Minutes of meetings Monthly environment checks EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 15

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. maintenance and equipment required. These are conducted using checklists, audit tools, specific committees, consumer / staff feedback. (e) The system for the effective identification and management of a deteriorating patient is evaluated and improved as required. Clients identified as being at risk have flags within their file. File audits are utilised to ensure that this system is being utilised and improvements / staff training are initiated as required. Quarterly OHS inspections and action plan Client satisfaction surveys House maintenance committee OHS / equipment required standard agenda item at staff meetings File audits of utilisation of at risk flags The following guidelines specifically reference information that may be useful for this Standard NSW Health Drug and Alcohol Treatment Guidelines for Residential Settings NSW Health Drug and Alcohol Psychosocial Interventions 3.2 Principles for effective treatment, pages 8-10 3.3 Common treatment processes in psychosocial interventions, page 18 6.1 Best practice, page 15 3.3.3 Feedback to client, page 19 9.5 Case management, page 22 3.3.4 The treatment plan, page 20 4.1.9 Continuing care, pages 39-40 6 Care co-ordination and case management, pages 53-56 Part 1 of The ACHS EQuIP 4 Guide provides guidelines to support this criterion. In addition this Resource Tool lists examples of how drug and alcohol organisations may provide evidence of achievement in this criterion. Performance measures The performance measures that are related to this criterion can be reviewed on page 15 of Part 3 of The ACHS EQuIP 4 Guide. Key Improvements No Title of Key Improvements What did you change Result / Outcome 1 At risk checklist on admission. An admissions check list was developed to Improved communication of clients identified EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 16

No Title of Key Improvements What did you change Result / Outcome ensure client assessments are reviewed and at risk flags are being indicated in client file. STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. as being at risk and early identification of changes in risk factors Plans for Improvement No Intended Improvement Responsibility Timeframe At risk clients to be reviewed as standard agenda item at clinical meetings. Clinical Director. November 2009. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 17

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Criterion 1.1.3 Consumers / patients are informed of the consent process, understand and provide consent for their health care. These guidelines should be read in conjunction with criterion 1.6.2 rights and responsibilities. The intent of this criterion is to ensure that the process of consent is managed appropriately. LA (a) Consumers / patients are provided with comprehensive and accessible information on recommended investigations, treatment or procedures and costs prior to providing consent for that health care. The organisation provides information to clients and discusses with them, information about the treatment the service can provide and its associated costs prior to the client receiving treatment. (b) The investigations, treatment and procedures that require consumer / patient consent are clearly defined. The client is required to sign a consent form. This form defines all treatment and procedures that the client is consenting to and may include financial, procedural, treatment, ethics and research consent. (c) There is a policy on consent that is consistent with state and federal legislative requirements. The organisation has a policy that refers to the procedure for gaining client consent. This may be part of an Intake Policy. Requirements for consent are in line with state, federal or any other associated guidelines. The policy should address the following: The procedure used to obtain consent Aspects of the service provided that require clients consent Documentation of consent in client file Sharing of consent between other service providers. (d) Healthcare providers are advised of the policy. The organisation s Confidentiality / Consent policy can be provided to external service providers Service brochure Website Admissions letter Client rights and responsibilities Intake checklist Group / program structure Consent form in client file Referenced in Intake / Admissions Policy Confidentiality / Consent Policy Release of information EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 18

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. on request. If an external provider requests information about a client of the service they are informed of the policy and no information is exchanged without authority to do so from the client. Communication Policy Consent form Confidentiality agreement SA (a) Consent is obtained for all investigations, treatment or procedures and costs in accordance with the organisation s policy. A signed consent form is located in each client file. This form may include consent for any: invasive procedure which is performed on the client e.g. supervised urinalysis, breath testing material risks inherent in the treatment e.g. risks involved in detoxification, or through the emergence of negative emotions / sleep difficulties as a result of an intervention collection of health information and to any use of that information and / or disclosure by the organisation to third parties e.g. consent obtained to create a client file, release information to third parties, use data for research / statistics financial responsibilities of the client e.g. fee paying, signing over of Centrelink authority. (b) There is a process to manage consent where it is unable to be given at the time of entry into the health service. In the case where a client is unable to give signed consent e.g. when doing a telephone assessment, paperwork exists to enable the recording of verbal consent. Signed consent form Release of information form Centrelink nomination forms Confidentiality agreement Phone assessment paperwork Assessment Policy Privacy / Confidentiality / Consent Policy MA (a) The consent process is evaluated and improved as required. (b) Compliance with the consent process is evaluated and strategies for improvement are implemented as required. The organisation completes file audits to ensure that signed consent forms are located in the client file. CQI policy review plan EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 19 File audit paperwork Results of file audits Staff meeting minutes reflecting associated follow up

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Feedback from clients on consent management The following guidelines specifically reference information that may be useful for this Standard NSW Health Drug and Alcohol Treatment Guidelines for Residential Settings NSW Health Drug and Alcohol Psychosocial Interventions 6.1 Best practice, page 15 2.4 Confidentiality, page 14 Part 1 of The ACHS EQuIP 4 Guide provides guidelines to support this criterion. In addition this Resource Tool lists examples of how drug and alcohol organisations may provide evidence of achievement in this criterion. Performance measures The performance measures that are related to this criterion can be reviewed on page 16 of Part 3 of The ACHS EQuIP 4 Guide. Key Improvements No Title of Key Improvements What did you change Result / Outcome 1 Information provided to clients about the service pre-treatment was reviewed. Client information sheet was developed to mail to client prior to intake into the service. Clients receive detailed information about the service and service requirements prior to intake. This gives the client an opportunity to contact the service with any questions or concerns they may have. Reviewed procedure for discussing the limits of Confidentiality agreement developed outlining Clients discuss, sign and are given a copy of 2 confidentiality. the limits of confidentiality and use of client the confidentiality agreement. The signed data for research. agreement is located in the client file as a legal record. Plans for Improvement No Intended Improvement Responsibility Timeframe 1 Development of website for the provision of Service manager. August 2009. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 20

No Intended Improvement Responsibility Timeframe information to clients. STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 21

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Criterion 1.1.4 Care is evaluated by health care providers and when appropriate with the consumer/patient and carer. These guidelines should be read in conjunction with criteria 1.3.1 appropriateness and 1.4.1 effectiveness. The intent of this criterion is to ensure that organisations evaluate the care and services they provide. LA (a) Consumers / patients are encouraged to provide feedback on the care provided. Clients of the service are encouraged to give feedback on the care the service has provided. This is encouraged through both informal and formal mechanisms. Client feedback form Client complaints form Client suggestion form Group evaluation forms Client satisfaction surveys Client meetings with staff Focus groups Evaluation Policy SA (a) Formal processes are in place across the organisation for the review of clinical care. Group and individual supervision Case conferencing File audits of treatment plans Clinical meetings Client satisfaction surveys (b) Prior to discharge, healthcare providers discuss the outcomes of care with the consumer / patient and when relevant, the carer, and this is documented. Prior to program completion, the client has an opportunity to discuss treatment outcomes with the staff providing treatment. This is in line with treatment guidelines and recorded in the client file. Case Management Policy Treatment Policy Clinical meetings Documentation in client file Evaluation Policy / forms EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 22

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. MA (a) Individual and group consumer / patient care is evaluated and improved as required. The organisation has an Evaluation Policy that outlines when and what is evaluated. Evaluation forms exist for group and individual treatment as well as overall satisfaction with all aspects of treatment. Evaluation forms are reviewed on an individual basis as the client completes the service. Individual forms are entered into a database to allow for group analysis. Evaluation forms Evaluation Policy Evaluation database Results of evaluation and associated actions (b) Consumers / patients, and when relevant carers participate in the evaluation of the care. Evaluation forms Evaluation Policy Family and carers feedback form (c) Care outcomes for consumers / patients including those identified as at risk are evaluated and improved as required. The organisation monitors treatment outcomes for clients via comparing pre- and postassessment results, completion rates and length of stay. The data collection is compared against funding agreements / indicators. (d) Indicators, adverse clinical events and mortality are reviewed and documented by relevant clinician groups to evaluate and improve care delivery. The organisation has a policy to ensure the reporting of any incident / accidents that occur. These instances are investigated and steps initiated to improve service. Data of number of accidents / incident that occur are collated as specified in Data Collection Policy. (e) Individual and aggregate consumer / patient data are collected and reviewed on care delivery and outcomes. Treatment outcomes for clients are evaluated and improved on. The organisation monitors treatment outcomes for clients via comparing pre and post assessment results, completion rates and length of stay. The data collection is compared against funding agreements/indicators. Assessment Policy Data Collection Policy Data base of treatment indicators Reports from electronic client database Annual reports Incident / accident reporting Staff meeting minutes where incidents / accidents have been discussed. Data Collection Policy Incident / accident collated report Assessment Policy Data Collection Policy Database of treatment indicators Reports from electronic client database Annual reports EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 23

The following guidelines specifically reference information that may be useful for this Standard NSW Health Drug and Alcohol Treatment Guidelines for Residential Settings 7.1 Assessing progress during treatment, page 18 7.2 Common / consistent assessment forms and outcome measures, page 18 9.4 Evaluation of treatment programs, pages 21-22 NSW Health Drug and Alcohol Psychosocial Interventions 3.3.6 Outcome measurement, page 23 STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Part 1 of The ACHS EQuIP Guide 4 provides guidelines to support this criterion. In addition this Resource Tool lists examples of how drug and alcohol organisations may provide evidence of achievement in this criterion. Performance measures The performance measures that are related to this criterion can be reviewed on page 17 of Part 3 of The ACHS EQuIP 4 Guide. Key Improvements No Title of Key Improvements What did you change Result / Outcome Standard agenda for client meetings. A standard agenda was created for use in Client concerns are being addressed on a daily 1 client meetings to ensure clients have the basis. opportunity to discuss treatment concerns with staff on a daily basis. Plans for Improvement No Intended Improvement Responsibility Timeframe Evaluation data to be tabulated and presented Team leader. October 2009. 1 on quarterly basis in staff meetings. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 24

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Criterion 1.1.5 Processes for discharge / transfer address the needs of the consumer / patient for ongoing care. The intent of this criterion is to ensure that handover of care is effective and that organisations have processes in place to make certain that the client has a smooth and safe transition when an episode of care is completed. LA (a) Guidelines for discharge, transfer or separation are available. Staff have access to guidelines for client discharge from treatment. (b) Arrangements with other service providers are made with consumer / patient consent and input and confirmed prior to discharge or transfer. Clients are invited to sign a release of information to facilitate communication between service providers in the case of discharge or transfer from the service. Part of the discharge planning process includes input from the client, other service providers and carers when establishing the discharge plan. Discharge Policy NSW Health Drug and Alcohol Psychosocial Interventions NSW Health Drug and Alcohol Treatment Guidelines for Residential Settings Resources Referral Policy / Practices Release of information form in client files Exit planning form Records of conversations with other services on client file notes SA (a) An effective system for discharge / transfer is implemented throughout the organisation and ensures continuity of care between referrers and providers. The organisation has a discharge policy to ensure that the system is effective. This policy includes referral to other treatment providers to ensure continuity of care and outlines circumstances where mandatory reporting may be required. (b) Service providers receive timely notification about consumer / patient discharge to their care. Discharge Policy Feedback from referral agencies etc. Discharge paperwork Referral letters EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 25

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Part of the discharge process requires staff to follow up via phone or letter any other services involved in the client s care. (c) Results of investigations follow the consumer / patient through the referral system. Pertinent information regarding treatment is transferred through the referral system. When a client is discharged / transferred within the service, the client s file is also transferred facilitating continuity of care. If for example the client s medication changes during treatment, these changes are communicated back to the client s regular treatment provider. (d) Discharge information is discussed with the consumer / patient and a written discharge summary is provided. There are discussions with clients regarding their discharge; clients are provided with discharge information and a discharge report on request. (e) Formalised follow-up occurs for at risk consumers / patients. The organisation identifies clients who may be at risk and formal follow-up occurs to assist these clients. If a client is at risk for self harm / suicide, homelessness or violence, the police, ambulance, mental health or other relevant services are contacted. This will be recorded in the client s file. Client file notes Referral letter Shift hand-over meetings Discharge paperwork Discharge reports Discharge information package for all clients Discharge Policy Discharge paperwork Client file notes MA (a) The processes for discharge / transfer are evaluated and improved as required. File audits of discharge paperwork ensure discharge processes are evaluated and improved. Client discharges that do not proceed as planned are discussed at staff meetings and the Discharge Policy and procedures are updated as required. The policy is reviewed and updated according to the CQI policy review plan. (b) Information for consumers / patients, other services providers and the systems for providing the information are evaluated and improved as required. File audit of discharge paperwork Staff meeting minutes CQI policy review plan Feedback from clients CQI policy review plan EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 26

The following guidelines specifically reference information that may be useful for this standard NSW Health Drug and Alcohol Treatment Guidelines for Residential Settings NSW Health Drug and Alcohol Psychosocial Interventions 11.2.7 Discharge from program, page 31 3.3.8 Discharge and onward referral, pages 23 24 STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Part 1 of The ACHS EQuIP 4 Guide provides guidelines to support this criterion. In addition this Resource Tool lists examples of how drug and alcohol organisations may provide evidence of achievement in this criterion. Performance measures The performance measures that are related to this criterion can be reviewed on page 18 of Part 3 of The ACHS EQuIP 4 Guide. Key Improvements No Title of Key Improvements What did you change Result / Outcome Discharge of at risk clients. Discharge checklist developed to ensure that By completing the discharge checklist, the 1 risks for individual clients were considered. needs of at risk clients are considered and appropriate action taken to ensure client safety and satisfy duty-of-care requirements. Plans for Improvement No Intended Improvement Responsibility Timeframe 1 Discharge report for all clients on discharge. Clinical staff. November 2009. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 27

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Criterion 1.1.6 Systems for ongoing care of the consumer / patient are coordinated and effective. These guidelines should be read in conjunction with criteria 1.1.5 discharge and transfer and 2.4.1 population health. LA (a) There are processes for ongoing care by multiple service providers. Policy and procedures for ongoing care o Case Management Policy o Treatment Policy o Discharge Policy SA (a) There are documented arrangements for liaison between the organisation and other service providers that outline the coordination of ongoing care. Systems are in place to facilitate liaison with other service providers e.g. doctors, pharmacy, mental health, Centrelink, other drug & alcohol services, Department of Housing, Probation and Parole, MERIT, DoCS. (b) Case management or care coordination is available for appropriate consumers / patients. Clients of the service are able to access staff for case management. (c) Consumers/patients with chronic illness are educated in self-management. Clients are educated (where appropriate) on strategies to assist self-management. This is dependent on client need and the experience of staff, clients may be referred to an external service provider where appropriate. (d) Triage systems are available to prioritise the admission of consumers / patients with chronic illness when required. Case Management Policy Release of information documentation Case Management Policy Psycho-educational groups Guest speakers on health related topics Access/referral to external service providers Information provided using print and other media Not applicable EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 28

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. (e) Strategies are developed to reduce acute presentations and avoidable admissions of consumers/patients with chronic illness. Not applicable MA (a) The ongoing care process is evaluated and improvements are made to ensure better practice. The case management / treatment offered by the organisation is continually evaluated to ensure better practice. (b) The education system for consumers / patients requiring ongoing care is evaluated and improvements are made to ensure better practice. The educational needs of clients are continually assessed and psycho-educational groups developed and / or partnerships with external services are established to meet these needs. (c) The triage and readmission process for patients with chronic illness is evaluated and improvements are made to ensure better practice. Evaluation Policy CQI policy review plan Documentation of review activities and outcomes Development of groups Evaluation Policy Client feedback New relationships with external service providers. External Partnerships Policy Not applicable The following guidelines specifically reference information that may be useful for this standard NSW Health Drug and Alcohol Treatment Guidelines for Residential Settings NSW Health Drug and Alcohol Psychosocial Interventions 8 Completion of treatment and continuing care, page 19 3.3.7 Continuing care, page 23 8.1 Continuing care and support programs, pages 19-20 3.3.8 Discharge and onward referral, page 23 11.3.7 After treatment, page 34 4.1.9 Continuing care, page 39 EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 29

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Part 1 of The ACHS EQuIP 4 Guide provides guidelines to support this criterion. In addition this Resource Tool lists examples of how drug and alcohol organisations may provide evidence of achievement in this criterion. Performance measures The performance measures that are related to this criterion can be reviewed on page 20 of Part 3 of The ACHS EQuIP 4 Guide. Key Improvements No Title of Key Improvements What did you change Result / Outcome Referrals to other services. Templates developed to assist staff with File audit results indicate improvement in 1 referral letters. number of referral rates from 30% to by 58% Plans for Improvement No Intended Improvement Responsibility Timeframe Increase number of focus groups with clients to Team leader. Nov 2009. 1 ensure their ongoing needs are being met. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 30

STANDARD 1.1: CONTINUITY OF CARE Consumers / patients are provided with high quality care throughout the care delivery process. Criterion 1.1.7 Systems exist to ensure that the care of dying and deceased consumers / patients is managed with dignity and comfort. Due to the specific operational framework of drug and alcohol organisations this criterion has limited application. However, the organisation should have a policy for the management of a deteriorating consumer in accordance with criterion 1.1.2. The policy should outline the procedure for management of a consumer death in the organisation, including how the organisation would deal with a coronial case in the event of death. Drug and alcohol organisations should discuss the relevance of this criterion with their ACHS Customer Services Manager. EQuIP 4 Resource Tool for Non Government Drug and Alcohol Organisations: Version 4 ACHS Copyright 31