Quality assurance is monitored in a number of ways. First, an extensive protocol adherence method has been developed to assure providers are implementing Family Behavior Therapy (FBT) as intended. Second, clinic procedures, program charts and data management, are routinely evaluated following standardized protocols. A summary of these methods follows:
Integrity of FBT and Therapist Adherence/Competence
Several strategies are employed to ensure the integrity of FBT, including 1) utilization of intervention manuals and provider step-by-step protocol checklists during sessions, 2) written documentation by the provider of techniques used during the sessions in standardized progress notes, 3) ratings of clients/family participation by providers after each intervention, 4) ratings of interventions by clients after each intervention, 5) audio taping of all sessions, 6) on-going clinical supervision of intervention sessions, 7) random on-going review of audiotapes, including corrective feedback and scores reflecting the percentage of intervention steps performed for each intervention delivered, 8) provider use of protocol checklists that indicate materials needed for each session, specific tasks to be completed, and the order in which treatment tasks will be completed, providers review their own session audio-tapes and provide one another with their corrective feedback to assure future protocol adherence and scores reflecting the percentage of intervention steps performed for each intervention delivered. These checklists assist in determining the providers’ adherence and competence. The agency head should assure there is a licensed professional employed by the agency to assure all case records and all reviews of intervention delivery are implemented in a manner that is consistent with State and federal laws.
In understanding the value of protocol checklists, during FBT sessions providers indicate on each prescribed intervention protocol checklist whether each therapy task was performed. Independent raters (the national trainer(s), supervisor, other providers) then listen to the audio- tapes, and indicate on a separate protocol checklist the extent to which the therapy tasks have been completed. The provider’s, and rater’s lists are compared, and a reliability estimate is computed. The validity estimate for each intervention component during each session is based only upon the lists completed by the national trainer, and is calculated by dividing the number of tasks completed by the total number of possible tasks for the respective intervention, and multiplying the dividend by 100. Reliability is calculated by dividing the total number of agreements (between the trainer and provider) by the total number of agreements (between the trainer and provider) plus disagreements (between the trainer and provider), and multiplying the resulting dividend by l00. This method of protocol adherence has been utilized in controlled treatment studies funded by NIH (most recently Azrin, Donohue et al., 2001) and formally reviewed (Sheidow et al., 2008). Eighty percent adherence is customarily required for providers to be judged satisfactorily competent in the administration of FBT protocol. The agency head should assure the transmission of case information between supervisors, providers and trainers are implemented in a manner that is consistent with State and federal laws.
Quality assurance for case records is typically maintained by monitoring approximately 5 to 10% of client charts of therapists, as well as various clinic procedures, on a random basis. To assist in this process, a chart has been developed to record all necessary quality assurance data that closely corresponds with the detailed step-by-step protocol checklists. All forms are standardized, so the process is relatively quick (less than a couple of minutes per chart). Providers who evidence errors are required to fix all problems, and the issues are brought to the attention of supervisors. The charts of these therapists are also examined more frequently in future reviews. This procedure has been demonstrated to be psychometrically validated (see Bradshaw et al., 2016). The agency head should assure all quality assurance procedures are implemented in a manner that is consistent with State and federal laws.