Quality/Performance Improvement Framework

Quality/performance improvement (QI/PI) frameworks are used to establish and evaluate processes in practice. The most common models for such a framework are Plan-Do-Study-Act (PDSA) and Six Sigma Define, Measure, Analyze, Improve, Control (DMAIC). The purpose of this assessment is to use key information from your project charter to develop a QI/PI framework from which you will begin developing a project implementation plan and logic model in the next assessment.

Develop a quality/performance improvement (QI/PI) framework for your project, aligned with your project charter. Choose a model for your framework, using the PDCA or DMAIC model, a model used in your organization, or another familiar reputable model that is suitable for your project. PDCA or DMAIC model information and examples are included in Resources.

Provide a succinct, scholarly narrative that reflects the content of your model and addresses the key points outlined below:

Graded Requirements

Each of the main tasks corresponds to scoring guide criteria. Read the performance-level descriptions in the scoring guide for each criterion to see how your work will be assessed.

• Describe the current practice needing improvement.What is the problem and its root cause?What is the gap between what is and what should be?What evidence supports your assertions and conclusions?
• Describes a QI/QP framework that will support and guide the project.What do you need to accomplish to meet the project objectives and outcomes?What formative assessments will help you ensure that the project is on course?Which framework will assist you in guiding the entire project?
• Explain how QI/PI data will be collected and analyzed.What data is needed?How will you record and organize collected data?What are appropriate data analysis methods for the type of data you will be collecting?
• Describe proposed QI/PI changes and expected outcomes.What are appropriate measures for determining actual improvement?How feasible are the proposed changes and what are the relevant contextual factors that can affect expected outcomes?
• Explain how changes in quality or performance will be evaluated.What evaluation tools or methods will you use?What criteria will you use to evaluate outcomes?
• Write clearly and concisely in a logically coherent and appropriate form and style.Write with a specific purpose and audience in mind.Adhere to scholarly and disciplinary writing standards.Proofread your writing to minimize errors that could distract readers and make it difficult for them to focus on the substance of your introduction.
• Apply APA style and formatting to scholarly writing.

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Align the project charter with a continuous improvement model.Describe the current practice needing improvement.Explain how QI/PI data will be collected and analyzed.Describe the proposed QI/PI changes and expected outcomes.Explain how changes in quality or performance will be evaluated.
• Competency 6: Address assessment purpose in a well-organized text, incorporating appropriate evidence and tone in grammatically sound sentences.Write clearly and concisely in a logically coherent and appropriate form and style.Apply APA style and formatting to scholarly writing.

Project Charter
School of Nursing and Health Sciences, Capella University
NURS-FPX9100 Defining Nursing Doc Project
January, 2024
1
Project Charter
Part 1
Project Charter Information
Project Name
Project Site
Contact at site
Enhancing Medication-Assisted Treatment (MAT) Referral Rates through the Implementation of
Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) Tools
The project site is at Banyan Health System, a community mental health center in Miami, Florida.
Name with credentials:
Organizational Email:
Phone Number:
Name with credentials: : Dr M. Trujillo, MD, MBA – Chief Medical Officer – Senior Vice President
Preceptor
Email: mtrujillo@banyanhealth.org
Phone Number:
The Executive Sponsor for this project holds the position of Chief Medical Officer and Senior
Vice President at Banyan Health System. This individual was selected for their significant role in
Executive Sponsor
overseeing and guiding the medical aspects of the organization. As a key decision-maker and leader
within the healthcare system, their involvement ensures alignment with organizational goals and
enhances the project’s credibility and support.
2
The current practice at Banyan Health System reveals a gap in addressing alcohol misuse among
individuals seeking mental health services. Currently, there is no established process for promptly
screening and referring patients to the Medication-Assisted Treatment (MAT) program, particularly
for co-occurring substance use disorders, notably alcohol misuse. The absence of a streamlined
protocol for screening and referral exacerbates the difficulty in connecting individuals with the MAT
program promptly.
Identifying this gap stems from an in-depth analysis of national and internal data. Nationally,
studies such as those by Babor et al. (2023) and Karno et al. (2021) emphasize the importance of
Screening, Brief Intervention, and Referral to Treatment (SBIRT) tools in addressing substance abuse.
Internally, data from Banyan Health System indicates a suboptimal referral rate to the MAT program,
Gap Analysis
signifying a clear need for improvement.
The desired condition involves implementing routine Alcohol Screening, Brief Intervention, and
Referral to Treatment (SBIRT) tools into standard care protocols. This proactive approach aims to
enhance the identification and referral of individuals with alcohol-related concerns to the MAT
program, ultimately improving patient outcomes.
The Gap Analysis tool employed for this project is the Fishbone diagram, which visually
represents the cause-and-effect relationships contributing to the identified gap. The Fishbone diagram
provides a comprehensive overview of the various factors influencing the current state and aids in
developing targeted interventions for improvement. The appendix includes the detailed Fishbone
diagram for reference (Appendix 1).
3
The proposed project is grounded in a compelling need to address barriers hindering individuals
with co-occurring substance use and mental health disorders from accessing optimal treatment.
Substantiating this need, Agterberg et al. (2020) delve into the examination of treatment barriers with
a focus on gender differences. The study sheds light on the challenges faced by women, revealing
higher barriers related to family responsibilities, relational factors, and mental health when compared
to men. These findings emphasize the unique obstacles encountered by women seeking substance use
treatment, providing a clear rationale for the development of gender-responsive services (Agterberg et
al., 2020).
Recent research underscores the significant prevalence and impact of Alcohol Use Disorders
Evidence to Support the
Need
(AUDs) on individual health and public healthcare systems. Yeo et al. (2022) reported in “JAMA
Network” a notable increase in alcohol use, related disorders, and a rise in mortality rates among
younger individuals, especially in the context of the COVID-19 pandemic. Concurrently, the
effectiveness of Medication-Assisted Treatment (MAT) in treating AUDs has been increasingly
recognized. Arms and colleagues (2022) conducted a comprehensive review, highlighting MAT’s
efficacy in reducing alcohol-related harm and relapse rates. Despite MAT’s proven effectiveness, its
utilization remains limited. Snell-Rood et al. (2021) identified barriers such as lack of awareness,
stigma, and insufficient referral rates in “The Psychiatric Service Journal.”
In the past decade, there has been a 16% increase in alcohol use and a 58% increase in high-risk
drinking among women. High-risk drinking is defined as consuming more than three drinks in a day
or more than seven drinks in a week. This trend is particularly concerning due to the unique and
severe consequences it poses for women. Women experience a faster progression to alcohol-related
4
problems and alcohol use disorders (AUD) compared to men. Pregnant women risk exposing the fetus
to alcohol. SBIRT is a public health strategy to address risky alcohol use in women. The article
provides guidance for healthcare providers on best practices for preventing and treating alcoholrelated risks in women of all ages (Hammock et al., 2020).
The role of Screening, Brief Intervention, and Referral to Treatment (SBIRT) in enhancing MAT
referrals is gaining attention. Thoele et al. (2021) demonstrated that SBIRT implementation in primary
care settings significantly increases MAT referrals. Further, integrating SBIRT into routine healthcare
practices has been shown to streamline the identification of individuals with AUDs and their referral
to MAT. Babor et al. (2023) suggested that healthcare systems incorporating SBIRT experienced
higher rates of successful MAT referrals. Lastly, the cost-effectiveness and societal benefits of SBIRT
implementation are notable. Green et al. (2022) in “Health Economics” found that every dollar spent
on SBIRT implementation yielded significant returns regarding reduced healthcare costs and
improved societal outcomes, emphasizing these interventions’ economic and social value.
A study by Uong et al., (2021) evaluated the screening practices for excessive alcohol
consumption among emergency department (ED) physicians. The study found that out of the 347
surveyed ED physicians, only about 16% consistently screened adult patients for excessive alcohol
use. Less than 20% of physicians used a recommended screening tool. The study identified limited
time and insufficient treatment options for patients with drinking problems as significant barriers to
screening. The research indicates a low frequency of screening for excessive drinking.
The study conducted by Williams and Fish (2020) addresses the need for improvement in mental
health and substance abuse treatment accessibility for the LGBTQ+ population. Their research reveals
a concerning gap in the availability of culturally competent services, despite the documented need
5
within this community. The findings underscore the importance of targeted interventions to address
disparities in access to care for LGBTQ+ individuals, advocating for initiatives that enhance
inclusivity and cater to the specific needs of this demographic (Williams & Fish, 2020).
Ressel et al. (2020) contribute valuable insights by conducting a systematic review of the risk
and protective factors associated with substance use in individuals with autism spectrum disorders.
The review highlights a shift in understanding, challenging the initial belief that symptoms
characteristic of autism protect individuals from substance abuse. Instead, it identifies a substantial cooccurrence of substance abuse in this population, necessitating a nuanced understanding of risk and
protective factors. This study emphasizes the need for tailored interventions and heightened awareness
among service providers to effectively address the unique challenges faced by individuals with autism
spectrum disorders and substance abuse concerns (Ressel et al., 2020).
Together, these studies underscore the critical need for the proposed project, providing empirical
evidence supporting the urgency to enhance Medication-Assisted Treatment (MAT) referral rates
through implementing Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT)
tools. By addressing the identified barriers, the project aims to improve access to comprehensive care
for individuals with co-occurring disorders, aligning to optimize treatment outcomes and promote
inclusive healthcare practices.
6
For the community mental health center providers (P), how does the required per-visit
implementation of the Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) tools
PICOT
(I) compared to current practice (C) affect the referral rate to Medication-Assisted-Treatment (MAT)
program (O) over 12 weeks (T)?
7
The project’s overarching aim is to enhance Medication-Assisted Treatment (MAT) referral rates
at Banyan Health System through implementing Alcohol Screening, Brief Intervention, and Referral
to Treatment (SBIRT) tools. The primary goal is to establish a standardized and effective process for
identifying and referring individuals with alcohol-related concerns to the MAT program within the
community mental health center.
The anticipated impact of the current project focuses on three key areas. Firstly, there is an
expectation of improved patient outcomes. By increasing the referral rate to Medication-Assisted
Treatment (MAT) services, the project aims to enhance treatment engagement and retention rates,
ultimately boosting the overall recovery success for individuals with co-occurring substance use
disorders, especially those involving alcohol misuse. This approach is grounded in the belief that more
Project Aim
effective referrals can lead to better patient support and recovery pathways.
Secondly, the project anticipates streamlined healthcare delivery. Implementing Screening, Brief
Intervention, and Referral to Treatment (SBIRT) tools is expected to enhance the efficiency of
healthcare providers. This improvement will be particularly evident in their ability to identify and
address alcohol-related concerns. Such efficiency is about faster care and more effective and focused
delivery, ensuring patients receive the proper care at the right time.
Lastly, the project focuses on cost savings. It aims to evaluate the impact on healthcare resources
and expenses, emphasizing potential cost savings. This aspect underscores the importance of efficient
and targeted interventions in optimizing resource utilization. By improving the way healthcare
resources are used, especially in the context of substance use disorders, the project hopes to
8
demonstrate that well-planned and implemented interventions can lead to significant economic
benefits alongside the primary goal of enhanced patient care.
The importance of addressing this issue is underscored by the pressing need to improve the
current practice at Banyan Health System, where the lack of a systematic process for alcohol
screening and referral poses challenges to effective MAT services. Co-occurring substance use
disorders, particularly alcohol misuse, represent a significant barrier to successful treatment outcomes,
necessitating a targeted intervention to bridge this gap.
Historically, the challenges in identifying and referring individuals with alcohol-related concerns
to MAT services have been recognized within the broader healthcare landscape. National studies, such
as those by Babor et al. (2023) and Karno et al. (2021), have emphasized the effectiveness of SBIRT
tools in addressing substance abuse. Banyan Health System’s historical data, coupled with national
evidence, further supports the imperative to implement a standardized approach for alcohol screening
and referral to enhance the overall quality of care provided to the community.
9
Part II
Stakeholders
The identified stakeholders encompass pivotal roles within the project, including Dr. M. Trujillo
the Chief Medical Officer, influencing organizational direction; T. Aguila, RN, a Registered Nurse
crucial for direct patient interaction and intervention implementation; J. Reid, the Director of
Employee Development and Compliance, ensuring staff training and integration into routine practice;
Stakeholder
and Y. Mendez, the MAT Program Manager, offering insights into MAT program dynamics and
contributing to seamless referral processes. Their diverse roles collectively contribute to the project’s
success, addressing challenges from leadership direction to hands-on implementation within the
Banyan Health System.
Initials or fictitious
Title, Role, or
Connection to
name
Affiliation.
the project.
Oversight of
Dr. M. Trujillo
Chief Medical
Officer
medical
operations at
Banyan Health
System
Potential
Contribution
impact (how
to the
affected).
project.
Influencing the
Crucial for
overall culture of
successful
care, Ensuring
implementatio change: Ensuring buy-in
alignment with
n: Leadership
from the medical
organizational
and strategic
leadership team
goals
direction
Barriers or anticipated
challenges, if any
Potential resistance to
10
Directly
involved in
T. Aguila, RN
Registered Nurse
Active
implementing
healthcare staff
SBIRT tools and
engaged in
influencing the
patient care
referral process
to MAT
programs
Ensuring
J. Reid
Director of
Oversees
Employee
training and
Development
development of
and Compliance
healthcare staff
providers receive
adequate training
on SBIRT tools
is essential for
integration into
routine practice
Critical for
the
effectiveness
Resistance to new
of the
practices; Time
intervention:
constraints for training
Direct patient
interaction
Essential for
integration
into routine
Ensuring consistent and
practice:
effective training; Time
Competence
constraints for staff
and
development
preparedness
of providers
11
Crucial for
Aligning the
Directly
Y. Mendez
MAT Program
involved in the
Manager
MAT referral
process
project with the
existing MAT
program,
Ensuring a
seamless referral
process
successful
integration:
Insights into
challenges
and
opportunities
Coordination with existing
MAT processes; Clear
communication channels
within the
MAT
program
12
S. Adams, the Director of Quality Improvement, has been selected to lead the team due to her
extensive experience and role overseeing quality improvement initiatives at Banyan Health System.
Her familiarity with the organizational culture and in-depth knowledge of quality improvement
processes position her as an ideal leader for this project. Sarah’s leadership qualities include strong
emotional intelligence, effective communication skills, and collaborative attributes, all of which
contribute to her success in fostering a positive and inclusive environment within the team.
In addressing ethical practices, diversity, equity, and inclusion, Ms. Adams prioritizes
adherence to ethical guidelines throughout the project. She actively promotes a culture of diversity
and inclusion, recognizing the value of different perspectives in contributing to the project’s success
(Stahl et al., 2021). Ms. Adams ensures equitable practices, providing all team members with equal
Team Leader
opportunities for involvement and contribution.
Ms. Adams ‘s leadership style is participative, emphasizing collaboration and input from team
members. This approach aligns with the nature of quality improvement initiatives, where diverse
perspectives and expertise contribute to successful outcomes (Wang et et al., 2022). To leverage her
leadership role effectively, Ms. Adams employs two distinct leadership approaches. Firstly, she
adopts a transformational leadership approach, inspiring and motivating the team to exceed
expectations and fostering a culture of continuous improvement and innovation. This approach is
particularly effective when initiating new phases of the quality improvement project, encouraging a
shared vision and commitment to excellence.
Ms. Adams employs a servant leadership approach, prioritizing the well-being and
development of team members. This fosters a sense of community and shared purpose within the
team, contributing to enhanced cohesion and individual motivation. In practice, Ms. Adams actively
13
listens to team members’ concerns or challenges. She provides personalized support, such as
additional resources or training, to ensure each member feels valued and supported in their role. By
combining these leadership approaches, Ms. Adams creates a dynamic and supportive environment
that fosters both innovation and individual well-being within the team, ultimately contributing to the
success of the quality improvement effort.
The team members for this project bring diverse qualifications and roles to the table. A. Patel,
a Quality Improvement Specialist, leverages expertise in methodologies like Lean Six Sigma to
ensure the project adheres to industry best practices. J. Rodriguez, a Substance Abuse Counselor,
provides a vital perspective on alcohol-related concerns, ensuring patient-centered interventions. As a
data analyst, M. Nguyen contributes analytical skills and health informatics expertise for effective
data-driven decision-making. Dr P. Borrego, a Physician, offers a clinical viewpoint to align the
project with medical best practices. S. Kim, the Cultural Competency Trainer, ensures an inclusive
Team Members
approach, considering diverse perspectives. Finally, T. Jackson, the Community Outreach
Coordinator, focuses on community needs, facilitating successful project implementation and
acceptance.
14
Team Member
Title
Department or
Credentials or
Affiliation
Qualifications
Rationale for
selection/Contribution to
the project
A. Patel brings expertise in
quality improvement
A. Patel
Quality Improvement
Quality Improvement
Specialist
Department
M.S. in Healthcare
methodologies, ensuring the
Administration; Lean
project aligns with industry
Six Sigma Green Belt
best practices and
contributes to data-driven
decision-making.
J. Rodriguez’s background
Licensed Clinical
J. Rodriguez
Substance Abuse
Behavioral Health
Counselor
Services
Social Worker
(LCSW); Substance
Abuse Counseling
Certification
in substance abuse
counseling brings a crucial
perspective to address the
project’s focus on alcoholrelated concerns, ensuring
patient-centered and
empathetic interventions.
15
M. Nguyen’s analytical
skills and experience in
B.S. in Health
M. Nguyen
Data Analyst
Health Information
Informatics; Certified
Management
Health Data Analyst
(CHDA)
health informatics
contribute to effective data
collection and analysis,
facilitating evidence-based
decision-making in the
quality improvement
process.
As a Psychiatrist, Dr.
Borrego provides a clinical
P. Borrego
Psychiatrist
Behavioral Health
Doctor of Medicine
(MD); Psychiatrist
perspective, ensuring the
project addresses the needs
of patients comprehensively
and aligns with medical best
practices.
16
S. Kim’s expertise in
cultural competency ensures
S. Kim
Cultural Competency
Diversity and
Trainer
Inclusion Department
M.A. in Cross-
that the project considers
Cultural
diverse perspectives,
Communication;
fostering an inclusive
Certified Diversity
approach in implementing
Professional (CDP)
Alcohol Screening, Brief
Intervention, and Referral to
Treatment (SBIRT) tools.
T. Jackson’s role in
community outreach
T. Jackson
Community Outreach
Coordinator
Community
Engagement
Department
B.A. in Community
ensures that the project is
Health; Experience in
attuned to the specific needs
community outreach
and concerns of the local
and engagement
community, facilitating
successful implementation
and acceptance.
Communication Plan
The communication plan aims to ensure effective and tailored communication with team members and stakeholders
throughout the project. It outlines the purpose, frequency, methods, responsible person, and potential challenges or assets for each
communication, addressing diverse needs and fostering engagement. This strategic approach recognizes individual roles, expertise,
and potential obstacles to enhance project success.
17
Team
What is the
Frequency and
Method of
Who is
Potential challenges/
Member/Stakeholder.
purpose of
timing of
communication
responsible
barriers or assets with
communication
communication.
(consider
for
communication
(Inform, share,
(How often,
audience,
communicati
(barriers, language,
engage, solicit
specific stages
method,
ng with this
culture, different
information)?
of a project?)
culture,
member?
disciplines, best
language,
(Why is it
practices
inclusion).
important
who delivers
the
message?)
A. Patel
Inform, Engage,
Bi-weekly
Team meetings,
Team Leader
Ensure that A. Patel stays
and Solicit
during project
email updates,
or Project
informed about quality
Information
implementation;
and periodic
Manager
improvement initiatives,
Monthly during
progress reports
planning
addresses potential
challenges with varied
communication
preferences, and fosters
engagement through open
communication channels.
18
J. Rodriguez
Inform, Engage,
Bi-weekly
Team meetings,
Team Leader
Effective communication
and Solicit
during project
email updates,
or Project
with J. Rodriguez involves
Information
implementation;
and periodic
Manager
addressing potential
Monthly during
progress reports
language barriers and
planning
ensuring that substance
abuse counseling
perspectives are integrated
into project developments.
Asset: Unique clinical
insights.
M. Nguyen
Inform, Engage,
Bi-weekly
Team meetings,
Team Leader
M. Nguyen’s
and Solicit
during project
email updates,
or Project
communication may
Information
implementation;
and periodic
Manager
benefit from tailored data-
Monthly during
progress reports
planning
focused updates and
ensuring that health
informatics perspectives
are considered. Asset:
Analytical skills for
effective data-driven
decision-making.
19
P. Borrego
Inform, Engage,
Bi-weekly
Team meetings,
Team Leader
Regular communication
and Solicit
during project
email updates,
or Project
with P. Borrego ensures
Information
implementation;
and periodic
Manager
that clinical perspectives
Monthly during
progress reports
align with project goals
planning
and that family medicine
insights contribute to
comprehensive care.
Challenges may include
time constraints. Asset:
Clinical expertise.
S. Kim
Inform, Engage,
Bi-weekly
Team meetings,
Team Leader
Communication with S.
and Solicit
during project
email updates,
or Project
Kim should include
Information
implementation;
and periodic
Manager
cultural competency and
Monthly during
progress reports
planning
diversity considerations,
ensuring an inclusive
approach to project
implementation (Mayo,
2020). Asset: Expertise in
fostering cultural
inclusivity.
20
T. Jackson
Inform, Engage,
Bi-weekly
Team meetings,
Team Leader
Tailoring communication
and Solicit
during project
email updates,
or Project
to T. Jackson involves
Information
implementation;
and periodic
Manager
recognizing the
Monthly during
progress reports
importance of community
planning
outreach insights in
shaping the project’s
success. Asset: Direct
connection to community
perspectives.
Dr. M. Trujillo
Inform and
Quarterly project
Virtual meetings
Team Leader
Communication with Dr.
Engage
reviews and
and written
or Project
M. Trujillo should focus
Manager
on aligning project goals
monthly progress updates
reports
with organizational
strategies and addressing
potential time constraints.
Asset: Strategic direction
and support from
leadership.
21
T. Aguila, RN
Inform and
Bi-monthly
Virtual meetings
Team Leader
Effective communication
Engage
updates on
and tailored
or Project
with T. Aguila involves
project
emails
Manager
ensuring that nursing
developments
perspectives align with
project goals and
addressing potential
challenges related to
varied communication
preferences. Asset:
Clinical and patientcentered insights.
Sarah Adams
Inform, Engage,
Weekly updates
Team meetings,
Project
Communication with
and Solicit
during project
email updates,
Manager or
Sarah Adams should
Information
implementation;
and periodic
Executive
ensure alignment with
Bi-weekly
progress reports
Sponsor
quality improvement goals
during planning
and address potential
challenges in executivelevel understanding.
Asset: Leadership support
and guidance.
22
J. Reid
Inform and
Monthly updates
Virtual meetings
Project
Communication with J.
Engage
on training and
and tailored
Manager or
Reid should focus on
development
emails
Executive
training initiatives and
Sponsor
address potential
initiatives
challenges in ensuring
consistent and effective
training for healthcare
staff. Asset: Expertise in
training and development.
Y. Mendez
Inform and
Monthly updates
Virtual meetings
Project
Communication with Y.
Engage
on MAT
and tailored
Manager or
Mendez ensures alignment
program
emails
Executive
with MAT program goals
Sponsor
and addresses potential
developments
challenges related to
program dynamics. Asset:
Insights into challenges
and opportunities within
MAT programs.
23
Executive Sponsor
Inform and
Quarterly project
Virtual meetings
Team Leader
Communication with the
Engage
reviews and
and written
or Project
Executive Sponsor should
Manager
focus on aligning the
monthly progress updates
reports
project with
organizational strategies
and addressing potential
challenges in ensuring
executive-level
understanding. Asset:
Leadership support and
strategic direction.
24
Intervention and Measurement
25
Planned Intervention
Interventions:
1.
Provider Training and Education Program
2.
Integration of SBIRT into Clinical Workflows
3.
Feedback and Continuous Quality Improvement (CQI) Process
Incorporating evidence-based practices is paramount to the success of the proposed
interventions. The Provider Training and Education Program, aimed at enhancing the skills of
healthcare professionals in addressing mental health and substance abuse concerns, finds support in
the study conducted by Moser et al. (2020). The research highlights the effectiveness of a best practice
quality improvement process in identifying and eliminating barriers to integrating Screening, Brief
Intervention, and Referral to Treatment (SBIRT) in a Federally Qualified Health Center. The results
demonstrate improvements in workflow related to SBIRT, emphasizing the positive impact of targeted
training programs (Moser et al., 2020).
The Integration of SBIRT into Clinical Workflows aligns with the findings from Evans,
Kamon, and Turner’s (2023) study, which explores a 5-year SBIRT effort using a mixed-methods
approach. The research delves into the challenges and successes of integrating SBIRT into routine
clinical practice, emphasizing the importance of a supportive outer context, key facilitators, and the
impact of site and patient characteristics. This evidence supports the rationale behind integrating
SBIRT into clinical workflows, ensuring a comprehensive and adaptable approach to address
variations in service delivery (Evans et al., 2023).
The Feedback and Continuous Quality Improvement (CQI) Process draws support from the
work of Nordberg, McAleavey, and Moltu (2021), which emphasizes the importance of continuous
quality improvement in measure development. The study discusses the iterative cycles of measure
26
development, focusing on stakeholder feedback and systematic improvements. This evidence
reinforces the significance of implementing a structured CQI process to enhance the effectiveness of
the proposed Feedback and CQI Process in the project (Nordberg et al., 2021).
Gardner-Buckshaw et al. (2023) provide valuable insights into increasing primary care
utilization of Medication-Assisted Treatment (MAT) for Opioid Use Disorder. Their research
highlights the effectiveness of a MAT training program designed for primary care providers, resulting
in increased confidence and willingness to implement MAT. This evidence supports the planned
intervention, affirming the importance of targeted training programs to enhance the utilization of
MAT in primary care settings (Gardner-Buckshaw et al., 2023).
The collaborative implementation of an evidence-based package for integrated primary
mental healthcare in South Africa, as detailed by Gigaba et al. (2023), serves as a model for utilizing a
continuous quality improvement (CQI) approach to embed mental health interventions into routine
care. This study emphasizes the effectiveness of a CQI strategy to facilitate the embedding of
evidence-based interventions, supporting the planned Feedback and CQI Process in the project
(Gigaba et al., 2023).
Provider Training and Education Program is shown in Appendix 2.
27
Improvement Model / Framework
The selected improvement model for this project is the Plan-Do-Study-Act (PDSA) cycle, a vital element of the Model for
Improvement. This well-established framework is widely recognized in healthcare settings for its effectiveness in facilitating
iterative and continuous quality improvement. The rationale behind choosing this model is multi-faceted.
Firstly, the iterative nature of the PDSA cycle is well-aligned with the adaptive approach required for the planned
interventions. The cycle’s distinct phases – Plan, Do, Study, Act – provide a systematic method for testing changes on a small
scale, evaluating the outcomes, and then refining the approach based on these findings. This process ensures that interventions
constantly evolve and improve in response to real-world feedback and results.
Secondly, the PDSA cycle inherently supports continuous improvement. The Feedback and Continuous Quality
Improvement (CQI) Process intervention integrates smoothly within the Model for Improvement framework. During the Study
phase, feedback is gathered and analyzed, informing the Act phase. Here, necessary adjustments and refinements are made,
perpetuating a cycle of ongoing enhancement to increase the effectiveness of the interventions.
The applicability of the PDSA cycle to multiple interventions is another crucial reason for its selection. For instance, in the
Provider Training and Education Program, the cycle allows for systematic planning, execution, and evaluation. Feedback from
training sessions is directly used to inform and improve subsequent cycles. Similarly, when integrating SBIRT into clinical
workflows, the PDSA cycle’s iterative nature is particularly beneficial, enabling step-wise adjustments to ensure effective and
seamless integration. The embedded CQI Process within the PDSA cycle ensures active utilization of feedback loops to refine and
enhance the overall project. This promotes a culture of continuous learning and improvement.
Lastly, the Model for Improvement, including the PDSA cycle, aligns with evidence-based practice. It is grounded in
principles that have succeeded in various healthcare improvement initiatives. This structured approach aids in integrating evidencebased practices, ensuring that interventions are implemented and refined systematically and evidence-backed.
28
Proposed Outcomes
Metric
Outcome Measure
Process Measure
Balancing Measure
Improved referral rate to
Medication-Assisted
MAT services within the
Provider Adherence to
Provider Perception of
Treatment (MAT) Referral
specified project duration
SBIRT Protocol (Ordinal:
Implementation Challenges
Rate
(Ratio: Count of referrals per
Likert scale)
(Ordinal: Likert scale)
Timeliness of Referrals to
Patient Satisfaction with Alcohol-
MAT Programs (Interval:
Related Interventions (Ordinal:
Time in hours/days)
Likert scale)
unit time)
Provider Knowledge and
Competence in Alcohol
Screening
Increased provider
knowledge and competence
in alcohol screening
(Ordinal: Likert scale)
Enhanced patient compliance
Patient compliance and
Understanding of SBIRT
and understanding of SBIRT
Provider Perception of
(Nominal: Frequency
Implementation Challenges
distribution, percentage
(Ordinal: Likert scale)
N/A (Balancing measures may not
directly apply to this outcome)
analysis)
Reduced time intervals in the
Timeliness of Referrals to
referral process (Process:
MAT Programs
Interval – Time in
hours/days)
Patient compliance and
Understanding of SBIRT
(Nominal: Frequency
distribution, percentage
Provider Adherence to SBIRT
Protocol (Ordinal: Likert scale)
analysis)
29
Provider Satisfaction with
SBIRT Tool and Impact on
Referral Rate
Positive provider satisfaction
with SBIRT tool and its
impact on referral rate
(Ordinal: Likert scale)
N/A (Balancing measures
may not directly apply to this
outcome)
N/A (Balancing measures may not
directly apply to this outcome)
Part III
Data Collection & Management
Develop a plan for collecting, managing, and stewardship of the data you will collect for your Project Charter.
30
Data to be
Who will collect
When will it be
How will the data How will the data Consider aspects
collected:
it?
collected?
be stored?
be protected?
related to diversity,
Medication-
Trained research
Baseline data pre-
Secure electronic
Who will have
equity, and inclusion.
Assisted
assistants and
implementation.
databases with
access?
Is the data stratified by
Treatment (MAT)
project
Ongoing data
restricted access.
Data will be de-
gender, race, ethnicity,
Referral Rate:
coordinators.
collection during
identified and
age, disability, and
Number of
the 12-week
stored securely.
socioeconomic status?
referrals per unit
intervention
Access is limited
How might this
time.
period.
to authorized
information be utilized
Provider
Post-intervention
personnel.
to address population
Knowledge and
assessments.
Principal
health, equity, and
Investigator and
health disparities?
designated
Data will be stratified by
research team
gender, race, ethnicity,
Competence in
Alcohol
Timeline:
Screening: Pre and
post-intervention
Weeks 1-2:
members will
age, disability, and
Likert scale
Baseline data
have access.
socioeconomic status.
assessments.
collection.
The analysis will assess
Patient
Weeks 3-10:
disparities in referral
Compliance and
Continuous data
rates and satisfaction
Understanding of
collection during
across demographic
SBIRT: Frequency
intervention.
groups.
distribution and
31
percentage
Weeks 11-12:
Utilize information to
analysis.
Post-intervention
implement targeted
Timeliness of
assessments.
interventions for
Referrals to MAT
underrepresented groups,
Programs: Time
promoting equity in
intervals in the
healthcare access
referral process.
(Baumann et al., 2023).
Provider
Identify and address
Satisfaction with
disparities in MAT
SBIRT Tool: Post-
referral rates among
implementation
diverse demographic
Likert scale
groups.
assessments.
Tailor interventions
based on demographicspecific findings to
improve equity.
Publish findings and
recommendations to
contribute to the broader
discourse on health
disparities and strategies
for improvement.
32
Data Analysis
33
1. Project Design:
•
Quality Improvement Project with a Quantitative Approach.
•
Model for Improvement: Utilizing Plan-Do-Study-Act (PDSA) cycles.
2. Outcome Measures and Analysis:
•
•
•
•
•
•
Medication-Assisted Treatment (MAT) Referral Rate:
•
Method of Analysis: Comparative analysis (pre-post implementation).
•
Data Type: Quantitative (Ratio: Count of referrals per unit time).
Provider Adherence to SBIRT Protocol:
•
Method of Analysis: Descriptive statistics, trend analysis.
•
Data Type: Quantitative (Ordinal: Likert scale).
Provider Knowledge and Competence in Alcohol Screening:
•
Method of Analysis: Descriptive statistics, pre-post comparisons.
•
Data Type: Quantitative (Ordinal: Likert scale).
Patient Awareness and Understanding of SBIRT:
•
Method of Analysis: Frequency distribution, percentage analysis.
•
Data Type: Quantitative (Nominal).
Timeliness of Referrals to MAT Programs:
•
Method of Analysis: Time-to-event analysis, comparison of referral timelines.
•
Data Type: Quantitative (Interval: Time in hours/days).
Provider Perception of Implementation Challenges:
•
Method of Analysis: Thematic analysis, identifying common themes.
•
Data Type: Qualitative (Ordinal: Likert scale).
34
•
Patient Satisfaction with Alcohol-Related Interventions:
•
Method of Analysis: Descriptive statistics, identifying satisfaction trends.
•
Data Type: Quantitative (Ordinal: Likert scale).
3. Psychometric Properties of Instruments:
•
•
•
Instruments Used:
•
Validated screening tools (e.g., AUDIT).
•
Likert scale assessments for provider adherence, knowledge, and satisfaction.
Psychometric Properties:
•
Reliability and validity established in previous research.
•
Permission to use instruments obtained.
•
Attachments: Permission letters for non-public instruments (Appendix 3).
Describe the psychometric properties (reliability and validity) of any instruments, tools, surveys, or questionnaires used; the
status of permission to use instruments. If the instrument is not public, permission to use the instrument is attached as
Appendix 3.
SWOT Analysis and Business for Project
Strengths
1. Organizational Support: Strong support from leadership and key stakeholders.
2. Expertise: Experienced healthcare providers and a dedicated project team.
3. Resources: Access to financial and human resources for project implementation.
4. Technology Infrastructure: Well-established electronic health record system for seamless integration.
Weaknesses
35
1. Resistance to Change: Potential resistance among healthcare providers to adopt new practices.
2. Training and Education Needs: Identified gaps in provider knowledge and competence.
3. Workflow Integration Challenges: Possible disruptions during the integration of SBIRT into clinical workflows.
4. Limited Staffing: Adequate staffing is required for training and ongoing monitoring.
Opportunities
1. Improved Patient Outcomes: Enhancing MAT referral rates can improve patient outcomes.
2. Enhanced Provider Practices: SBIRT implementation can enhance provider skills and practices.
3. Cost Savings: Efficient referral processes may lead to cost savings in the long run.
4. Community Engagement: Strengthening community engagement through targeted interventions.
Threats
1. Competing Priorities: Other organizational priorities may divert attention and resources.
2. External Regulatory Changes: Changes in external regulations impacting project implementation.
3. Patient and Provider Resistance: Resistance from patients or providers to engage in SBIRT activities.
4. Technological Challenges: Unforeseen technical issues during the integration process.
36
Business Case:
•
•
•
Target Population Benefits:
•
Improved access to MAT services for individuals with substance use disorders.
•
Enhanced awareness and understanding of SBIRT among patients.
•
Timely and effective interventions lead to better treatment engagement and recovery.
Organization Benefits:
•
Increased efficiency in the referral process, potentially leading to cost savings.
•
Strengthened reputation as a provider of comprehensive and integrated care.
•
Improved patient and provider satisfaction contributes to organizational success.
Community Benefits:
•
Addressing substance use disorders as a public health concern.
•
Building a healthier and more engaged community through proactive interventions.
Conclusion: The project leverages organizational strengths to address weaknesses and capitalize on opportunities while actively
mitigating potential threats. The business case aligns with the triple aim of improving patient experience, enhancing population
health, and reducing per capita costs.
37
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40
Appendices
Appendix 1: Fishbone Diagram
Main Categories:
1. Process:
•
Lack of standardized alcohol screening protocols
•
Inefficient referral process to MAT programs
41
•
Limited communication channels between departments
2. People:
•
Insufficient provider knowledge on the importance of MAT for alcohol misuse
•
Lack of awareness among patients about available MAT services
•
Staff resistance to change in implementing SBIRT tools
3. Equipment/Resources:
•
Inadequate training resources for implementing SBIRT
•
Lack of technology support for streamlined data collection
•
Insufficient MAT program resources and capacity
4. Policy:
•
Absence of clear policies for routine alcohol screening in mental health services
•
Lack of incentives or recognition for providers engaging in SBIRT
•
Limited integration of SBIRT into existing healthcare policies
Procedure for Development:
1. Identify the Gap:
•
Low referral rates to MAT programs
•
Lack of timely screening for alcohol misuse in mental health services
2. Identify Major Causes:
42
•
•
•
•
Process:
•
Suboptimal workflow for SBIRT implementation
•
Inconsistent referral procedures
People:
•
Insufficient training on SBIRT for providers
•
Patient resistance due to lack of awareness
Equipment/Resources:
•
Outdated technology for data collection
•
Limited funding and resources for MAT programs
Policy:
•
Lack of specific policies mandating routine alcohol screening
•
Inadequate recognition for providers implementing SBIRT
3. Develop Interventions:
•
Implement a standardized SBIRT protocol
•
Provide comprehensive training for providers
•
Upgrade technology for efficient data collection
•
Advocate for policies supporting routine alcohol screening
4. Monitor and Evaluate:
43
•
Regularly assess referral rates
•
Collect feedback from providers and patients
•
Adjust interventions based on ongoing evaluations
Appendix 2: Provider Training and Education Program:
o Week 1-2: Planning and Preparation
▪
Activities:
▪
Conduct a needs assessment to identify specific training requirements.
▪
Develop training materials and resources.
▪
Estimated Hours: 20 hours
o Week 3-4: Training Implementation
▪
Activities:
▪
Deliver training sessions to healthcare professionals.
▪
Facilitate interactive sessions and practical exercises.
▪
Estimated Hours: 30 hours
o Week 5-6: Evaluation and Feedback
▪
Activities:
▪
Collect feedback from participants.
44
▪
Evaluate the effectiveness of the training program.
▪
Estimated Hours: 15 hours
▪
Integration of SBIRT into Clinical Workflows:
o Week 1-2: Workflow Analysis and Planning
▪
Activities:
▪
Analyze current clinical workflows.
▪
Identify integration points for SBIRT.
▪
Estimated Hours: 20 hours
o Week 3-4: Integration Implementation
▪
Activities:
▪
Implement SBIRT into identified workflows.
▪
Train staff on the new workflow.
▪
Estimated Hours: 25 hours
o Week 5-6: Monitoring and Optimization
▪
Activities:
▪
Monitor the integration’s impact on workflows.
▪
Optimize processes based on feedback.
▪
Estimated Hours: 15 hours
45
▪
Feedback and Continuous Quality Improvement (CQI) Process:
o Week 1-2: CQI Process Development
▪
Activities:
▪
Develop a structured CQI process.
▪
Establish feedback mechanisms.
▪
Estimated Hours: 20 hours
o Week 3-4: Pilot Testing
▪
Activities:
▪
Implement the CQI process on a small scale.
▪
Gather initial feedback.
▪
Estimated Hours: 25 hours
o Week 5-6: Full-scale Implementation
▪
Activities:
▪
Roll out the CQI process across the organization.
▪
Collect and analyze continuous feedback.
▪
Estimated Hours: 30 hours
46
Appendix 3: Request for Permission to Use [Instrument Name]
To [Owner/Creator’s Name],
I hope this letter finds you well. I am seeking permission to use the [Instrument Name] in our upcoming project titled
[Project Title]. The project aims to [briefly describe the project objectives and context].
We have identified [Instrument Name] as a valuable tool for our data collection and analysis. This instrument has
proven reliability and validity in previous research, and we believe it will significantly contribute to the success of our
project.
To ensure compliance with ethical and legal standards, we are seeking your formal permission to use the [Instrument
Name] in our project. Our use of the instrument will strictly adhere to the terms and conditions specified by your
organization.
As part of our commitment to transparency, a copy of our project proposal and a detailed description of how we intend
to use the instrument are included in this letter [or attached separately]. We are also committed to providing you with a
summary of our findings upon project completion.
We understand the importance of respecting intellectual property rights and will duly acknowledge the source of the
instrument in all project-related publications.
We kindly request your prompt consideration of this request. If you require any additional information or have specific
conditions for use, please feel free to contact us at [Your Contact Information].
Thank you for considering our request, and we look forward to your positive response.
Sincerely,
47
Appendix 4: Data collection sheet:
Participant Date Age Gender Referral
PrePostCompliance Understanding Timeliness
Provider
ID
of
Rate
Knowledge Knowledge
(Patient)
(Patient)
of
Satisfaction
Entry
(Number (Provider) (Provider)
Referrals
of MAT
Referrals
per Unit
Time)
48