Total quality management and performance in substance abuse treatment centers.

During the past decade, issues of quality have been central in development of standards applied to the delivery of treatment for behavioral health disorders. High-quality mental health and substance abuse treatment includes both focus on the comprehensive physical and mental health status of patients and commitment to use of practice based on the best available evidence (Institute of Medicine 2005; Rosenberg 2007;). Comprehensive care in substance abuse treatment refers to rigorous assessment not only of addiction severity but also development of treatment plans that cover both core treatment for addiction, needed general health and support services, as well as follow-up/aftercare for patients (Price 1997; Ducharme et al. 2007; Drake, O'Neal, and Wallach 2008;). Evidence-based treatment includes use of treatment approaches including both medications and psychosocial interventions that have been proven effective in outcome-focused research supported by agencies such as the National Institute on Drug Abuse (NIDA) ( Johnson et al. 2005; Emmelkamp and Vedel 2006; Rosenberg 2007;). Although numerous evidence-based practices (EBPs) have been identified and promoted for use in substance abuse treatment, implementation of these practices within treatment settings has been slow and uneven (Weisner and McLellan 2004; D'Aunno 2006;). Previous studies have focused on organizational characteristics of treatment centers that may be related to comprehensive care and EBPs (Knudsen and Roman 2004; Ducharme et al. 2007; Garner 2009; Knight et al. 2008). Organizational characteristics studied include (a) nature of a center's market orientation such as inpatient/outpatient services offered; competition from other providers; and referral sources; (b) structural characteristics such as size, location, ownership, sources of funding; and (c) external influences such as accreditation or managed care. Little attention has been given to the systems used to operate treatment centers (Etheridge and Hubbard 2000). Areas for needed research identified by Weisner and McLellan (2004) included alternative organizational models of service integration, strategies to increase implementation of evidence-based treatment, and measurement of the effects of organizational management on quality, access, outcomes, and costs of service delivery. A treatment center's internal management practices may critically support capabilities to diagnose, deliver, and coordinate comprehensive care and evidence-based treatment approaches needed for successful treatment outcomes (Milne, Blum, and Roman 2000; Chong et al. 2003; Ford et al. 2007; Garner 2009;). Previous studies in hospitals and substance abuse treatment centers indicate that internal management practices, such as collection and use of data in decision making, may be major determinants of organizational performance (Shortell et al. 1995; Easton and Jarrell 2000; Milne, Blum, and Roman 2000; Douglas and Judge 2001; Lozeau, Langley, and Denis 2002;). This study examines the relationship of internal quality management practices with the provision of comprehensive care and the use of EBPs in a sample of over 700 substance abuse treatment centers. The focus is on two research questions: (1) Which organizational characteristics predict the use of total quality management (TQM) processes? (2) Do quality improvement focused management practices (TQM) explain incremental variance in provision of comprehensive care and the use of evidence-based treatment practices?