Assertive Community Treatment (ACT) Provider Perspectives and Experiences on Continuous Quality Improvement

Purpose: Continuous quality improvement (CQI) is an important approach to advance consumer outcomes and healthcare system performance. Emphasizing a data-driven decision-making process, CQI requires the active participation of all healthcare providers. In this study, we focused on providers of Assertive Community Treatment (ACT), a well-established intervention for people with severe mental illness, and aimed to understand their perspective of QI and experience of collecting and using consumer data.

Methods:  The study used a mixed-methods approach. To understand provider perceptions of four dimensions central to the success of CQI, an anonymous online survey that consisted of background information questions (roles on the ACT team, professional licenses, and length of service) and a 15-item scale derived from the CQI Climate Survey (Dana, 2004; overall Cronbach’s α = .90) was distributed to a comprehensive list of 708 ACT providers in New York State. To explore data practice among ACT providers, and facilitators and challenges ACT teams have encountered in data use, we invited ACT team leaders (TLs) to participate in semi-structured focus groups. Those who could not attend the focus group were interviewed individually.

Results: The survey was completed by 177 providers (response rate 25.1%). Close to 80% of providers indicate that they comprehend the relationship between the quality of their work and the management of work processes (77.2%), and believe they have a good understanding of quality improvement (77.3%). Over two-thirds (68.4%) agree that their agency has used data to support quality improvement and decision-making. Interestingly, linear regression analysis shows that the longer the providers have worked in the mental health field, the less they have a common understanding of quality and customer needs (B = -.16, p < .05), and the less they are certain about their agency leader’s capacity to conduct CQI projects (B = -.18, p < .05).

Eighteen TLs participated in either focus groups or individual interviews. Results from thematic analysis suggest that while acknowledging the importance of collecting consumer data, TLs feel that multiple reporting systems are cumbersome and take time away from caring for clients. All TLs raise the issue of the repetitiveness of data submissions, and suggest having a central, integrated database to decrease the reporting burden on providers. As well, TLs perceive data reporting as meeting auditing requirements by the regulatory bodies, and as a vehicle for punitive measures, rather than a useful CQI process. TLs have concerns about data accuracy, and consider the interval of data submission (e.g. 1 year) too long. Most of TLs do not use data they entered in the state-implemented information systems to evaluate their practice. Rather, they rely on their knowledge of consumers gathered from clinical encounters and morning meeting discussions to track consumer progress.

Implications: Despite an understanding of the significance and concepts of CQI, ACT providers experience multiple barriers to the uptake of a data-driven process that can ultimately lead to meaningful CQI. Strategies to address these impediments and promote a data-centric culture are multi-faceted and require attention at the state, municipal, agency, and provider levels.