processes and outcomes as ways of assuring
quality.^208
Accreditation of health care facilities tends to
focus on structural measures (e.g., physical plant
adequacy, nursing ratios, certification of
providers, availability of certain services).
While patient outcomes (e.g., survival, function,
quality of life) are in many ways the most
important variables, they are difficult to collect
and analyze. Patient outcomes may be affected
by factors independent of the quality of a
specific health care service delivered, including
co-occurring conditions, patient compliance and
lifestyle. Outcome data also are subjective and
vary according to the setting and the particular
instruments used to measure them. Given these
barriers, quality assurance efforts tend to focus
on the process of care, which examines the
frequency with which interventions known to
correlate with positive outcomes are
performed.^209
State Quality Assurance Requirements. State
quality assurance requirements for addiction
treatment programs and facilities are highly
variable and focus mainly on process. For
example, a program that is run efficiently and
maintains good records would be considered a
quality program regardless of patient outcomes.
CASA Columbia’s state-by-state analysis of
regulations and statutes found that 45 states have
some type of quality assurance requirements for
addiction treatment facilities and programs,
although this may take the form of simply
requiring the establishment of a quality
improvement plan. Fewer than half of these
states (21 states) have explicit requirements that
patient outcome data be collected but, even for
those that do, the types of data required rarely
are specified. Four of the states that require the
collection of patient outcome data have
explicitly-defined categories of such data, but
these categories focus primarily on reductions in
specific types of substance use or its
consequences--such as reduction or elimination
of the use of illicit drugs, reduction or
elimination of associated criminal activities or
improvement of quality of life. The absence of
other indicators linked to improved health and
function or effective disease management is
noticeably absent.CASA Columbia’s review found little evidence
that states impose sanctions on facilities that fail
to meet the outcome reporting requirements and,
for those that do, the penalties are minor (e.g., a
$100 fine).Federal Quality Assurance Requirements.
Federal quality assurance requirements vary by
program. Federal Medicare/Medicaid conditions
of participation address quality assurance issues
by requiring utilization review committees to
assure compliance with written procedures for
evaluating admissions, continued care and
discharges; linking treatment plans to
established goals; clinical record keeping; and
requiring that the group of professionals within
the program or facility that develops patient care
policies review and act upon recommendations
from the utilization review committee.^210The federal regulations for opioid maintenance
therapy programs require continual quality
assurance measures which must include ongoing
assessment of patient outcomes (not specified)
and annual review of program policies and
procedures.^211All federal agencies that operate programs or
provide funds related to addiction treatment are
required to report on the performance of those
programs in accordance with the Government
Performance Results Act (GPRA) of 1993. In
order to fulfill their requirements under the Act,
each federal agency must develop a strategic
plan (including annual performance targets)
covering each of their programs, conduct
evaluations to assess how well a program is
working and why particular outcomes have (or
have not) been achieved and produce program
performance reports based on analyses of
program effectiveness.^212SAMHSA is the leading federal agency that
funds addiction treatment; it administers the
Substance Abuse Prevention and Treatment
Block Grant (SAPTBG), a federal grant that
funds state prevention, treatment, recovery