LITERATURE REVIEW REPORT
AUSTRALIAN NATIONAL STANDARDS PROJECT 2008/09
Australasian Therapeutic Communities Association
Jill Rundle
November 2008
CONTENTS
1.
The Project ............................................................................................................... 3
2. Purpose of the literature review ................................................................................ 4
3. Background ............................................................................................................. 5
3.1 The ATCA and ATCA developments towards TC standards .............................. 5
3.2 Standards ........................................................................................................... 7
Relevant AOD service standards in the Australian context .......................... 8
Relevant AOD service standards in the New Zealand context ..................... 9
International standards developed specifically for TCs .............................. 10
Progress towards a National Quality Framework in Australia ..................... 12
3.3 Training specific to TCs .................................................................................... 13
3.4 Expectations following this project ................................................................... 15
4. Standards development/setting .............................................................................. 15
4.1 Defining standards ........................................................................................... 16
4.2 Requirements for developing standards........................................................... 17
4.3 Common elements of standards ..................................................................... 19
5. Standards implementation ...................................................................................... 21
5.1 Defining continuous quality improvement and total quality management ........ 21
5.2 Key elements of CQI ........................................................................................ 22
5.3 Defining change management ......................................................................... 26
5.4 Change management principles ...................................................................... 26
6. Standards assessment/review/accreditation ........................................................... 28
6.1 Defining quality assurance and accreditation ................................................... 28
6.2 Issues of accreditation .................................................................................... 29
7. Training package development ............................................................................... 33
7.1 About training in general .................................................................................. 33
7.2 Training effectiveness ..................................................................................... 35
The training and learning context ............................................................... 35
Training transfer ......................................................................................... 36
What makes effective training design? ....................................................... 37
References ................................................................................................................... 41
Appendix A. ATCA Members ....................................................................................... 44
Appendix B. Matrix comparing standards ..................................................................... 48
Appendix C. Summary of project considerations .......................................................... 64
Appendix D. Draft consultation plan ............................................................................. 66
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1.
The Project
As per the project tender document, the Department of Health and Ageing provided
funding to the Australasian Therapeutic Communities Association (ATCA) on 30 June
2008 to develop National Standards for Therapeutic Communities (AOD) in Australia.
ATCA’s objective is to ensure the integrity of the “Therapeutic Community” principle is
maintained and will continue to stand as a model of best practice in the treatment of
substance misuse and co-occurring disorders.
To meet this objective this project is to develop a set of service standards which identify
and describe good practice and will facilitate service evaluation within a quality
framework. In concert with the development of service standards a training package for
the professional development of management and staff working within the Therapeutic
Community (TC) sector will also be produced. This package will primarily focus on an
induction kit for staff entering the TC field.
Project Objectives:
1. To develop a set of service standards which identify and describe good TC
practice and facilitate service evaluation within a quality framework; and
2. To produce a training package for the professional development of management
and staff working within the TC sector. This package will also include an
induction kit for staff entering the TC field.
Project Outcomes:
1. Provide specialist service standards that identify and describe good TC practice
which can be incorporated into a national quality framework;
2. Enable TCs to engage in service evaluation and quality improvement using
methods and values that reflect the TC philosophy;
3. Develop a common language which will facilitate effective relationships with all
jurisdictions (federal, state and territory);
4. Provide a strong network of supportive relationships;
5. Promote best practice through shared learning and developing external links;
6. Develop a strategy that would contribute to the workforce capacity within the
AOD and comorbidity sector; and
7. Create an environment for sustaining the career paths of trained AOD workers
within the NGO sector, including the valued practice of workers with “lived”
experience of the field. TCs particularly value the experience of staff who are
graduates of therapeutic programs, and seek to incorporate learned knowledge
and experience into their professional practice.
Project Stages:
1. A literature review report summarising identified requirements of developing
standards, issues to consider in developing standards, implementing and
reviewing standards, and issues to consider when developing an effective
training package to support workforce development;
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2. Consultation with Australian and New Zealand TCs to allow the sector to
contribute to the development of standards and the implementation and review
process. This will support a common language and ownership of the quality
improvement process, and ensure the training package developed is of maximum
benefit to the sector;
3. Development of draft standards, a draft implementation plan for the standards,
and a training package structure;
4. Trial implementation of the draft standards and the training package;
5. Develop a final draft of the standards, implementation plan and training package.
Purpose of the literature review
2.
The primary purpose of this literature review report is to support the development of the
standards and training package for the TC sector in Australia and New Zealand, that is,
to inform and support the next stages of this project. As such this literature review report
is not intended as a “stand alone” document, or for publication/general distribution.
Consultation, trialing and piloting will further enhance the development of standards and
the training package through ensuring ownership of the development, maximum
applicability and process for engagement. Reports on each of the development stages
will be produced to provide background to the resources.
There are a number of existing documents which provide literature reviews of TC theory
and models, as well as standards that are currently used by the alcohol and other drugs
(AOD) sector, and literature reviews and consultation documents summarising key
issues for setting, implementing and reviewing standards. This literature review does
not intend to duplicate these efforts, and instead builds on them where it is appropriate
for the sole purpose of this project.
The structure of this report is as follows:
•
•
A background which provides an overview of:
the progress to date undertaken by the ATCA which will inform this
project;
AOD service specific standards being used within Australia;
AOD service specific standards in New Zealand;
international TC specific service standards;
relevant training packages and manuals
A summary of identified requirements for standards setting. This includes:
a checklist of issues to consider when developing the standards;
a matrix of common standards areas;
a table linking Australian and New Zealand identified TC essential
elements to key standard areas; and
a list of considerations for consultation;
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•
•
•
A summary of identified requirements for implementing standards. This includes
a list of considerations for consultation, which together will inform the
implementation plan;
A summary of identified requirements for reviewing standards. This also includes
a list of considerations for consultation, which will ultimately inform the trial of the
implementation undertaken in this project; and
A summary of identified requirements for inclusion into effective training
packages. This again includes consultation considerations that will inform the
development of the training package.
3.
Background
3.1
The ATCA and ATCA developments towards TC standards
ATCA’s membership consists of TCs from throughout Australia and New Zealand (see
members list and location in Appendix A). While the Australian Commonwealth
Department of Health and Ageing have provided the funding for this project, and the
tender document specifies the Standards are for Australian TCs, the development of the
service standards are to ensure relevance for the Australian and New Zealand TC
sector.
Many TCs in Australia and New Zealand, like those internationally, have adapted to
ensure maximum benefit for different population groups. These include dedicated TCs,
or TCs providing appropriate services to people with co-occurring mental health
disorders, young people, women with children, those involved in corrective services,
and indigenous peoples. TCs in Australia and New Zealand are also located in both
metropolitan and regional settings, where access to relevant support services may vary.
The development of the ATCA service standards, therefore, needs to be flexible to
enable modification for TC service provision to different population groups and to be
considerate of location limitations. While ATCA members and currently recognised TCs
are primarily provided in residential settings, the developed service standards also need
to be considerate of the potential establishment of TCs in non-residential settings.
Since its inception in 1986 the ATCA has demonstrated considerable intent to support
the continuous quality improvement of the services offered by its members. This is
evident through research and tool development. In 1990 a peer review system was
developed which was reviewed and updated in 1996. Two Organisations, Mirikai TC in
Queensland and Killara House in Victoria, participated in a pilot review in 1992 and up
to two organisations were reviewed per year until the reviews were suspended in 2001.
The review focused on eight areas, with each area having an overriding statement of
standard and a number of indicators (Australasian Therapeutic Communities
Association 2000, p 20). The areas included:
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1.
2.
3.
4.
5.
6.
7.
8.
Organisation and management;
Physical Environment;
Records Management;
Assessment and Treatment;
Rights of Clients;
Research, Planning and Evaluation;
Staff Development and Education;
Community Liaison and Participation.
The peer review system provided guidance in order for reviewers to undertake the task
objectively and effectively. When assessing this system against current standards
literature for this Project, the areas and the overall system are in line with many
identified standards requirements. In general, however, the standards and indicators
used were generic and did not identify the standards and indicators specific to TC
principles and approaches. The standards development for this project is intended to
focus on TC specific service requirements.
In 2001 a project was initiated by the ATCA, with the primary objective ‘to ensure the
effectiveness of TCs as a residential treatment option through a process of ongoing
quality assurance’. The intention of the project was to produce ‘a better practice
manual’, and identify a number of aspects to be addressed in the manual, including:
1.
2.
3.
4.
5.
6.
7.
8.
a description of program elements;
a model/s for routine evaluation of similar services;
standards for staff competency and training;
standards for the physical environment of TCs;
standards for the operational costs of TCs;
some matching of program elements to specific client characteristics;
some form of industry centred accreditation process; and
a description of the unique nature of the TC intervention in the context of the
range of accepted alcohol and other drug interventions (Gowing et al 2002).
The project report ‘Towards Better Practice in Therapeutic Communities’ addresses
each of these aspects and presents a total of thirty five recommendations, many of
which directly inform the further development of standards and staff training
requirements. Appendices to the report identify what a TC is; define TCs in Australian
and New Zealand; and suggest modifications to the Survey of Essential Elements
Questionnaire (SEEQ) to better suit the Australian and New Zealand context. The
SEEQ was developed in the USA by Melnick and De Leon (1999) in order to define the
elements of TCs. While the suggested modified SEEQ survey questions presented by
Gowing et al (2002) are not validated, it is expected they will significantly inform the
development of standards and/or indicators within the standards, as they provide
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agreed Australian and New Zealand TC principles that allow for continuous quality
improvement.
The ATCA have been the primary drivers of quality processes for TCs in Australia and
New Zealand. In addition, a number of member organisations have participated or
initiated evaluation processes or research. This, together with the ATCA’s
developments, clearly demonstrates a potential willingness and readiness of the
Australian and New Zealand TC sector to participate in the development and
implementation of specific TC standards. This augers well, as a potential implication of
the development of ATCA endorsed standards is that they will provide a benchmark for
services wishing to be recognised as TCs in Australia and New Zealand.
3.2
Standards
This Project is seen as part of an overall development of national standards for AOD
agencies in Australia and, as such, the TC service standards needs to fit within any
national framework. To ensure that this requirement is met, this literature review
considers the range of Jurisdiction and nationally approved quality processes and
progress towards health service quality and safety accreditation expectations for the
future. To maximise the applicability of the literature review this report focuses on health
service delivery expectations in quality and implementation of standards, and accepted
review and accreditation requirements. The established elements (principles, methods,
values, etc) of TCs will then be assessed re their “fit” within these expectations.
In addition to the ATCA developments informing service quality, a number of TCs in
Australia and New Zealand are voluntarily or required to, as determined by each
jurisdiction, follow or meet a range of guidelines, expectations and standards. Only
some of these are specific, or have components that are specific, to AOD services.
Some of these are briefly discussed in the section below. Further general “core”
standards that may be applied at TCs include:
•
•
•
•
Quality Improvement Council (QIC) Health and Community Services Core
Standards;
International Organization for Standardisation (ISO) 9001 Standards;
Australian Council on Health Care Standards (AHCS) Evaluation and Quality
Improvement Program (EQuiP); and
National Standards for Mental Health Services.
These standards are reviewed by a variety of accreditation bodies, significantly in
Australia by the Quality Management Services Inc (QMS) and the Institute for Health
Communities Australia Ltd (IHCS). Any additional “core” standards that TCs in Australia
and New Zealand apply will be determined in the consultation process. In order to
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reduce duplication and minimise the burden on TCs with additional standards to those
that they currently apply, it is important that the standards developed for this project can
be easily linked to existing “core” standards.
Relevant AOD service standards within the Australian context
•
‘Drug and Alcohol Treatment Guidelines for Residential Settings’ were
established by the New South Wales Department of Health (2007). The
guidelines ‘provide recommendations for residential treatment of people with
drug or alcohol dependency’ and are intended to support increased effectiveness
of treatment and improved treatment outcomes. The guidelines provide a
distinction between residential AOD services and TCs, and have a dedicated
section on guidelines specifically for TCs. These specific guidelines are drawn
from the modified SEEQ as presented by Gowing et al. The guidelines also
present consideration for services to particular population groups, including
women, young people, Aboriginal and Torres Strait Islander peoples, and people
with co-occurring mental health and AOD issues. The specifics of the guidelines
are explored in more detail below.
• The Quality Improvement Council’s (QIC) ‘Alcohol, Tobacco and Other Drugs
Module’ was launched in November 2005 at the Australian Professional Society
on Alcohol and other Drugs (APSAD) conference in Melbourne. This module was
presented as one of a variety of modules for service specific standards, which
would be an addition to the core standards. Organisations were eligible for
accreditation against the standards only if they met the core standards. The
standards within this module are not specific to TCs, and are relevant to the
range of AOD service types. In 2008 the QIC announced that they would be
reducing this two tiered approach to standards, reverting to a single core set of
standards in order to simplify the accreditation process (Quality Improvement
Council, accessed 2008). None of the other key health and community service
standard bodies have specific AOD service specific standards. The specifics of
the QIC standards are explored in more detail in the matrix of standards in
Appendix B.
• ‘The Western Australian Alcohol and Other Drug Sector Quality Framework’ was
developed by the WA Drug and Alcohol Office in partnership with the WA
Network of Alcohol and other Drug Agencies in 2005. The Quality Framework
was developed to support ‘program and service development to better meet the
needs of consumers and improve outcomes’ for a diverse range of AOD services
throughout Western Australia. The Quality Framework ‘Performance
Expectations’ are not specific to TCs, as they are intended to be flexibly
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translated to meet the variety of treatment modalities within the sector. The
specifics of the Quality Framework Performance Expectations are explored in
more detail in Appendix B.
Relevant AOD service standards within the New Zealand context
• In 2003 the New Zealand Ministry of Health and Standards New Zealand
published the ‘Alcohol and Other Drug Treatment Sector Standards: Paerewa
Rángai mó te Maimoatonga Waipiro me te Taru Kino’. These standards
‘establish the minimum requirements that should be met by service providers
offering treatment and support to a wide range of people with alcohol and other
drug problems’. These standards are not specific to TCs, and are relevant to the
range of AOD residential and non-residential service types. The standards
supplement New Zealand Standards for the health and disability sector, and are
aligned to the mental health sector standards (Standards New Zealand 2003).
The specifics of the New Zealand standards are explored in more detail below.
International standards developed specifically for TCs
The establishment and evolution of TCs internationally clearly influence the TC
movement in Australia and New Zealand. Just as there are distinct differences between
the TC movements in the United Kingdom and the United States of America, the
political context of Australia and New Zealand, including language, culture, and
perspective of drug use, need to be considered in the development of service standards
that will apply to the ATCA members. The international standards, however, are
examples to consider as they have been informed by relevant literature and consultation
with relevant service representatives.
•
In the UK in 2002 the Community of Communities quality network was
established by the Royal College of Psychiatrists’ Research Unit and the
Association of Therapeutic Communities. The Community of Communities
developed the ‘Service Standards for Therapeutic Communities’ in 2001, and
have reviewed them regularly, with a review in 2006 resulting in the 5th edition
(Keenan et al). These service standards are primarily targeted at TCs working
with adults in the mental health, voluntary and corrections sectors. In 2006 the
Community of Addiction Therapeutic Communities grew out of the Community of
Communities. Together with practitioner representatives from the European
Federation of Therapeutic Communities and the ATCA, the Community of
Communities developed the first edition of Service Standards for Addiction
Therapeutic Communities. Consultation informing the development of these
standards has ensured they reflect contemporary addictions TC practice and
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represent central elements of TC practice in the UK and across Europe (Shah et
al, no date provided). The Service Standards for Addiction Therapeutic
Communities has six standard areas. These areas are:
Physical Environment;
Staff;
Joining and Leaving;
Therapeutic Environment;
Treatment Program (an additional area to the Service Standards for
Therapeutic Communities); and
External Relations.
With the diversity of approaches and philosophies behind treatment of substance
misuse the United Kingdom Drug Policy Commission (2008) undertook a process
to establish agreement and clarity about the goals of substance misuse treatment
and rehabilitation. This was formulated through a consensus “vision” for what is
meant by the term “recovery”. Eight key features of recovery were identified as
providing a focus for the development of services for individuals at various stages
of an on-going process. Briefly the key features include:
Recovery is about the accrual of positive benefits, not just reducing
or removing harms caused by substance use.
Recovery requires the building of aspirations and hope from the
individual drug user, their families and those providing services and
support.
Recovery may be associated with a number of different types of
support and interventions or may occur without any formal external
help: no ‘one size fits all’.
Recovery is a process, not a single event, and may take time to
achieve and effort to maintain. The process and the time required
will vary between individuals.
Recovery must be voluntarily sustained in order to be lasting,
although it may sometimes be initiated or assisted by ‘coerced’ or
‘mandated’ interventions within the criminal justice system.
Recovery requires control over substance use (although it is not
sufficient on its own). This means a comfortable and sustained
freedom from compulsion to use. This is not the same as controlled
use, which may still be harmful. Having control over one’s
substance use means being able to make the choice to use a
substance in a way that is not problematic for self, family or society.
For many people this will require abstinence from the problem
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substance or all substances, but for others it may mean abstinence
supported by prescribed medication or consistently moderate use
of some substances (for example, the occasional alcoholic drink).
Recovery maximises health and well-being, encompassing both
physical and mental good health as far as they may be attained for
a person, as well as a satisfactory social environment. The term
‘maximises’ is used to reflect the need for high aspirations to
ensure that users in treatment are enabled to move on and achieve
lives that are as fulfilling as possible.
Recovery is about building a satisfying and meaningful life, as
defined by the person themselves, and involves participation in the
rights, roles and responsibilities of society. The word ‘rights’ is
included here in recognition of the stigma that is often associated
with problematic substance use and the discrimination users may
experience and which may inhibit recovery. Recovery embraces
inclusion, or a re-entry into society and the improved self-identity
that comes with a productive and meaningful role. For many people
this is likely to include being able to participate fully in family life
and be able to undertake work in a paid or voluntary capacity.
These key features inform the goals/objects of service delivery, and as such
provide a sound basis for determining areas of evaluation of desired outcomes
that may be associated with service standards.
•
In 2000 within the USA, George De Leon (2000, p 7) made a call for the need to
develop standards for TC program. The rationale for this call was ‘to maintain
quality assurance and best practice, to guide staff training, and to evaluate the
effectiveness and cost benefit of TC treatment’. De Leon also listed a number of
caveats to the discussion on TCs which need to be considered in the
developments of standards, including rigidity; artificiality; variability; and lack of
consensus.
Therapeutic Communities of America undertook a project to develop ‘minimum
standards for operating modified TC programs in prison settings’. These
standards were developed utilising existing field review protocols, which were
derived from a criminal justice version of the Survey of Essential Elements
Questionnaire (SEEQ). Eleven Standards Domains were established, each with
a general rationale or intent, and each listing a number of standards. The Domain
areas include:
Theoretical Basis;
General Clinical Principles;
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Administration;
Staffing;
Facility/Environment;
TC Program Elements;
TC Process;
Stages of Treatment;
Community and Clinical Management;
Intake Screening and Assessment;
Community Based Aftercare (The Criminal Justice Committee of
Therapeutic Communities of America 1999).
While these standards are designed for prison based services, many of the
standards would translate to TCs generally.
Progress towards a National Quality Framework for Health Care in Australia
Two significant literature reviews on developing standards have been produced over the
last few years, the first undertaken by the Quality Improvement Council entitled
Standards and Quality Improvement Processes in Health and Community Services
(June 2000). This has since been updated by the review report produced by the
Australian Council for Safety and Quality in Health Care entitled Standards Setting and
Accreditation Literature Review and Report (July 2003a). The Australian Council for
Safety and Quality in Health Care review looked at international safety and quality
approaches to health care, accreditation systems applied in other countries, including
New Zealand, a comparison of quality management approaches in Australia, and the
impact of accreditation. Significantly the Australian Council for Safety and Quality in
Health Care report (July 2003a) looks at issues related to setting standards, identifying
a core set of standards, and desirable aspects with regards to setting standards and
accreditation. The report also identifies areas for the Australian Council for Safety and
Quality in Health Care to follow up with through consultation with stakeholders and
policy directions. The results of this consultation are reported in a paper entitled
Standards Setting and Accreditation Systems in Health: Consultation Paper (Australian
Council for Safety and Quality in Health Care, 2003b).
In 2004 the Review Team for the Review of Future Governance Arrangements for
Safety and Quality in Health Care was established. The Review Team undertook further
extensive consultations through submissions and consultation meetings throughout
Australia, and reviewed the work undertaken by the Australian Council for Safety and
Quality in Health Care. It was reported that the Council lacked ‘formal links and
partnerships’ with’ jurisdictions and other key bodies’, hampering the effectiveness of its
objective (Review Team for the Review of Future Governance Arrangements for Safety
and Quality in Health Care, 2005, p iv). This report made a series of recommendations
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to progress a national governance approach, significantly recommending a new national
safety and quality body and defining its scope and functions alongside the functions of
the jurisdictions. In 2006 the Australian Commission on Safety and Quality in Health
Care was recommended by this report. A discussion paper was produced by the
Commission to support further consultation to advance a National Strategic Framework
for Improving the Safety and Quality of Health Care (Australian Commission on Safety
and Quality in Health Care, 2006). This discussion paper again defined relevant terms,
reviewed accreditation and standards as they apply in the health sector, identified
issues, and made strategic proposals to guide submissions.
Both of the Australian Council for Safety and Quality in Health Care reports (2003a,
and 2003b) and those undertaken by the Review Team (2005) and the Australian
Commission on Safety and Quality in Healthcare (2006) were intended to provide the
basis for the development of a national quality framework for health care. As such they
are of primary significance to informing the development of standards for this project.
Literature exploring the variety of related areas, especially those raised in the
government reports but not explored in detail such as continuous quality improvement
and change management, are also drawn on to inform the discussions below.
3.3
Training specific to TCs
One of the aims of this project, as stated in the tender document, was the development
of a Training Package for the professional development of management and staff
working within the TC sector. The training package would support the TC approach to
good practice and professional service provision, and include an induction kit for staff
entering the TC field. The Training Package is to include manuals and other written
materials and DVD presentations. It is seen that this resource would assist all TCs who
are engaging and training staff as well as organisations looking to develop into TCs (this
will be of particular value to Provisional Members of the ATCA who are working towards
Full Membership). As the training package forms an essential part of the overall project,
which has as a significant component the development of standards for TCs, it is also
implied that there is a link between the two project components, i.e. that the training
package will support the appreciation of and implementation of the standards.
There is general recognition of the need to link AOD training and workforce
development to quality standards and processes. The New Zealand Te Awhiti National
Mental Health and Addictions Workforce Development Plan for, and in support of, NonGovernment Organisations (2006 – 2009) makes these connections throughout the
plan. There is a stated ‘emphasis on building a knowledgeable, skilled, competent and
recovery-focused mental health and addiction workforce and fostering a culture
amongst service providers that is “person centred, culturally capable and delivers an
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ongoing commitment to assure and improve the quality of services for people” [citing the
Minister of Health: 2005] (Health Research Council of New Zealand, 2006, p 8).
To enhance the development of the training package this review report will examine key
literature which focuses on the aspects that enhance the ‘user friendliness’ of training
packages or the application of training in practice. TCs have historically valued the
experience of staff who are themselves graduates of TC programs, and seek to
incorporate learned knowledge and experience into their professional practice.
Supporting the professional development of these workers contributes to the workforce
capacity of the TC and the broader AOD (including comorbidity) sector. TCs in Australia
and New Zealand engage a mix of qualified people with or without “lived” experience of
recovery from substance use. The training package to be developed for this project will
need to consider the needs of staff from this range of backgrounds.
Few analyses of training needs for TCs have been reported, particularly within Australia
and New Zealand. Stace (2007) undertook a study to ‘examine whether staff training
needs are adequately addressed in TCs in Australia in relation to working with residents
who have a diagnosis of Personality Disorder’. The TCs that participated in the study
included The Buttery (NSW), Karralika (Qld), and Mirikai (ACT). While the responses
from staff at these TCs overwhelmingly indicated they would benefit from further training
in this area and indicated, without exception, an interest in learning more about
Personality Disorders, the research ‘failed to ascertain the depth and breadth of
knowledge already held by staff’ (Stace, 2007, pp 26 – 27). While this was a brief
research and paper, the study does provide an indication of the need to clearly establish
existing skills and knowledge from which to build on in training.
The US Centre for Substance Abuse Treatment (2006) has developed a Therapeutic
Community Curriculum: Trainer’s Manual which does consider the range of staff needs.
This is demonstrated within the overall goals of the Manual, which are:
•
•
To provide a common knowledge base for all staff members working in TCs; and
To encourage [staff] to work on [their] professional growth and development
(Centre for Substance Abuse Treatment, 2006, p PM3).
The Manual drew from George De Leon’s book Therapeutic Community: Theory, Model,
and Method (2000), as a primary source for this curriculum. As such it significantly
incorporates training on the identified essential elements. The curriculum includes
eleven modules:
1.
2.
3.
4.
Introduction to the TC Curriculum
The History and Evolution of the TC
Treatment and Recovery—The TC View
The Community-as-Method Approach
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5. The TC Social Structure and Physical Environment
6. Peer Interpersonal Relationships
7. Staff Roles and Rational Authority
8. TC Treatment Methods
9. Work as Therapy and Education
10. Stages of the TC Program and the Phases of Treatment 1
11. How Residents Change in a TC
Each module includes:
•
•
•
•
•
•
•
a preparation checklist;
goals, objectives and timeline;
introduction;
presentations and exercises;
resources;
summary and review; and
tasks and/or pre-reading.
This manual provides a model for a training package which focuses on essential
elements and standards, and which is directed towards staff with varying backgrounds
and training.
3.4
Expectations following this project
Byproducts of the development of the standards and a supporting training package may
include:
•
•
•
•
•
4.
enhanced capacity of TCs to undertake quality improvement using methods and
values that reflect an agreed TC philosophy;
a framework for a common language of quality expectations, enabling the
facilitation of effective relationships with all jurisdictions. This common language
will also support network opportunities between TC services;
enhanced capacity of TCs to engage in consistent service evaluation, supporting
collective research and further development of best practice;
support improved shared learning throughout the TC sector; and
support TC specific workforce development and workforce planning for TCs.
Standards development/setting
The objective of the following section is to summarise what is in the literature in relation
to standards development. This will enable an identification of issues to consider when
consulting the Australian and New Zealand TC sector and developing the service
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standards. Drawing on the guidelines, standards and expectations of the quality
processes listed in the background the key “domains” for standards will be identified.
Also the essential elements previously identified by ATCA are matched to these
domains.
4.1
Defining standards
In the development of a National Framework for Standards Setting and Accreditation in
Health the Australian Commission on Safety and Quality in Healthcare (2006) identified
a need to clearly define terms, including standards and accreditation as they apply in
the health setting. Additional terms that the Australian government reports do not cover
extensively, and yet are identified as key considerations in quality processes, include
continuous quality improvement and change management. A definition of all relevant
terms is provided throughout this report where they arise in the broader discussion.
Standards Australia (2008 p 1) defines a standard as ‘a document, established by
consensus and approved by a recognised body, that provides, for common and
repeated use, rules, guidelines or characteristic for activities or their results, aimed at
the achievement of the optimum degree of order in a given context’. ‘Standards
therefore can provide standardisation of approach and achieve consistent outcomes
which can be applied widely and repeatedly’ (Australian Commission on Safety and
Quality in Healthcare, November 2006, p 5).
The Australian Council for Safety and Quality in Healthcare devised a definition of
standards to better encompass standards that may apply across the breadth of health
services and that impact on the continuum of care. The Council’s definition of standards
is ‘an agreed attribute or process designed to ensure that a product, service or method
will perform consistently at a designated level’ (Australian Commission on Safety and
Quality in Healthcare, November 2006, p 5).
While the definitions of standards above are broad, to encapsulate a general
understanding of standards across sectors or within the health care sector , the
identified role of standards provides a clearer guide to inform the development of a set
of standards.
Standards are used to define the conditions for quality and are an essential
component of an industry-wide quality improvement system. They reflect the
view of organisational or professional peer groups on the structure, process and
outcomes that are considered to represent acceptable practice (Australian
Council for Safety and Quality in Health Care, 2003b, p 6).
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Standards articulate levels of expected performance (Australian Council for Safety and
Quality in Health Care, 2003b, p 7) and are used to guide organisations in developing
their service activities, to influence the behavior of people or organisations, and to
provide the basis for accreditation or an assessment of an organisation’s quality
practices (Australian Council for Safety and Quality in Health Care, 2003b, p 6).
The primary objective of health care standards is to improve safety,
effectiveness, cost and efficiency for the benefit of the community (Australian
Commission on Safety and Quality in Healthcare, 2006, p 9).
4.2
Requirements for developing standards
There are a range of issues that inform the development of standards.
Who develops them?
1.
Commonly recognised providers of health care standards and/or accreditation
services include the Australian Council for Health Care Standards (ACHS), the
Quality Improvement Council (QIC) and the International Organization for
Standardization (ISO). There are standards setting and accreditation processes
operating in a range of specialist health sector areas, including general health
and mental health. Some established standards are set and then picked up by
accreditation bodies (ACHS and QIC in particular) (Australian Council for Safety
and Quality in Health Care, 2003b, p 7).
2.
Standards are generally ‘developed directly by, or with assistance of, experts
in relevant fields’, including through a consultative process (Australian Council
for Safety and Quality in Health Care, 2003a, p 5). It is recognised that many
not-for-profit membership based groups, such as the ATCA, which are formed
because of a strong commitment by their members to improving safety and
quality, are in a sound position to develop standards (Australian Council for
Safety and Quality in Health Care, 2003b, p 7). As such the process undertaken
by this project is in keeping with expectations.
What stakeholders should be involved?
3.
‘Organisations want a system that reassures the board, management,
consumers and clinicians that their facility is providing care of an acceptable
standard of safety and quality’ (Australian Council for Safety and Quality in
Health Care, 2003b, p 11).
4.
It is desirable to have stakeholder involvement in the development of
standards. This will ensure increased support by stakeholders of the standards
and the credibility of the standards (Australian Council for Safety and Quality in
Health Care, 2003a, p 7).
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5.
Standards should be developed with expert and consumer involvement
(Australian Council for Safety and Quality in Health Care, 2003a, p 6, and
Australian Council for Safety and Quality in Health Care, 2003b, p 9). In practice
this consumer involvement has proven to be limited (Australian Council for
Safety and Quality in Health Care, 2003a, pp 7 - 8).
6.
Government involvement in standards setting varies internationally and within
the Australian health care sector. Standards are an instrument that can be used
within a voluntary or regulatory framework to achieve a desired influence on the
behaviour of people or organisations’ (Australian Council for Safety and Quality
in Health Care, 2003b, p 6).
Project Considerations:
1. Consumers need to be involved in the consultation process.
2. Key government stakeholders need to be informed of the process of the
standards development.
What focus needs to be kept in mind?
7.
Standards should be consistently applied to all relevant service providers for
best effects to the sector (Australian Council for Safety and Quality in Health
Care, 2003a, p 6).
8.
Regular review of standards to ensure continued relevance is an important
part of standards development processes (Australian Council for Safety and
Quality in Health Care, 2003a, p 5). As such a review mechanism should be
incorporated into the standards package.
9.
‘The underpinning philosophy of standards varies widely. For example, some
define minimum acceptable structure, processes or outcomes, while others are
goal oriented/ideal statements’ (Australian Council for Safety and Quality in
Health Care, 2003b, p 10). Standards for health care have traditionally focussed
on organisational structures and processes. They are moving towards an
outcome orientation and need to address consumer safety (Australian Council
for Safety and Quality in Health Care, 2003b, p 11).
10.
It is common that standards are developed and reviewed to enhance their
useability. As such they:
should be outcome oriented, have clear objectives;
focus on measurable outcomes rather than detailed process
requirements;
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are generally underpinned by indicators, guidelines for criteria on
how the standards might be interpreted or assessed, or with
examples of quality practice or service provision against which an
organisation’s performance can be quantitatively measured;
should be ’relatively few in number’
should encourage continuous quality improvement, if not actually
incorporating a system of continuous improvement (Australian
Council for Safety and Quality in Health Care, 2003a, pp 5 - 6);
should be flexible. If standards are made too stringent it may impact
on compliance. Organisations will weigh up the costs of
compliance versus the costs of non-compliance. This will in turn
impact on overall performance and consumer outcomes.
(Australian Council for Safety and Quality in Health Care, 2003b, p
6);
11.
There are a growing number of standards and standards setting bodies in
health care. There is little coordination to prevent duplication of standards across
organisations and service delivery areas, yet there exists a high degree of
similarity and consistency in many of the standards used’ (Australian Council for
Safety and Quality in Health Care, 2003b, p 10).
Project Considerations:
3. The standards are to be developed to enable maximum participation of the
Australia and New Zealand TC sector.
4. A review mechanism is to be incorporated into the development of the
standards.
5. The standards are to incorporate consumer safety considerations.
6. The standards developed are to be outcomes oriented, with clear objectives,
measurable outcomes, indicators, guidelines for criteria, and examples of
appropriate practice.
7. The number of standards developed are to be kept to a minimum.
8. The standards developed will focus specifically on TC service requirements,
and be able to be linked wherever possible with “core” standards
requirements that services may be engaged in.
4.3
Common elements in standards
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There is significant commonality, internationally and in Australia and New Zealand, with
regards to standards setting and accreditation. Generally ‘standards combine a mix of
standards relating to health care or service provided and standards relating to
organisation management and continuous quality improvement’ (Australian Council for
Safety and Quality in Health Care, 2003a, p 5).
Standards in the health care sector, and with other related sectors, in general have
consistent components, and there has been increased convergence over time as these
standards are reviewed (Australian Council for Safety and Quality in Health Care,
2003a, pp 5 - 13). The differences more often reflect the different focus of the sectors or
sub-sectors. The Australian Council for Safety and Quality in Health Care (2003a, pp 38
– 41) provided a matrix of core components comparing those offered by the Australian
Council on Healthcare Standards (ACHS) with a range of other standards, including:
The Quality Improvement Council (QIC) standards; The Royal Australian College of
General Practitioners (RACGP) standards; Aged Care Standards; National Standards
for Mental Health; The National Pathology Accreditation Advisory Council standards;
Business Excellence Australia (BEA) standards; and the International Organisation for
Standardization (ISO) standards. They established that the standards had significant
commonalities, particularly those standards that were health related. The generalised
group of ACHS standards was provided as encapsulating these common components,
which include:
1
2
3
4
5
6
7
8
Appropriate and timely service provision;
Leadership and management principles;
Consumer participation;
Strategic human resource management;
Information management and appropriate use/evaluation of data;
Occupational health and safety;
Health and safety risk management; and
Continuous improvement.
In order to determine whether these commonalities are also recognised in AOD/TC
specific standards/guidelines/performance expectations and the ATCA Towards Better
Practice in Therapeutic Communities (Gowing et al 2002) recommendations and
modified essential elements, a matrix was developed and is provided in Appendix B.
While the TC specific standards focus significantly on service provision and staff
requirements, the matrix demonstrates potential for grouping relevant standards under
these component areas. Developing standards within these generalised groups would
essentially support “fit” with the range of standards/quality processes that TCs in
Australia and New Zealand additionally apply. To reduce duplication the standards
developed will focus solely on TC specific elements within these generalised groups.
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Project Considerations:
9. The standards developed are to fit within the ACHS generalised group areas
to enable TCs to link TC specific standards with existing standards and
quality requirements.
10. The standards developed will focus solely on TC specific elements.
5.
Standards implementation
The objective of the following section is to summarise the key elements of implementing
and supporting the implementation of standards. These elements significantly include
continuous quality improvement (CQI) and change management. They are important
concepts to consider if ongoing and meaningful development is the desired outcome of
any standards process.
It is also important to acknowledge that TCs are, by their very nature, involved in the
“CQI and change management” of the consumers accessing the services. There are
obvious parallels with the “stages of change” that are recognised and supported in the
AOD sector. It is also a significant focus within literature on TCs, including in DeLeon’s
(2000) Therapeutic Community: Theory, Model and Method, which devotes a section of
seven chapters to the process of change. While there are these parallels, the literature
on CQI and change management in this review is offered to enable a consideration of
the key elements for organisational change. Following consultation and in application of
these processes the “language” of the key elements presented in this report may
change as they are applied to any resources developed to better mirror and
demonstrate consistent community process for ongoing improvement.
5.1
Defining Continuous Quality Improvement (CQI) and Total Quality
Management
As the term suggests, continuous quality improvement is the process of continually
improving the quality of service provided. It utilises standards and accreditation
processes, but more significantly ‘involves procedures for the ongoing review and
evaluation of the service delivered by an organisation’ (Australian Council for Safety and
Quality in Health Crae, July 2003a, p 4). It is a ‘structured organisational process for
involving personnel in planning and executing a continuous flow of improvements to
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provide quality health care that meets or exceeds expectations’ (McLaughlin et al, 2004,
p 3). As such continuous quality improvement is the means by which standards are
implemented.
Total quality management and continuous quality improvement are terms that are often
used synonymously. Teasing out the differences between the two, total quality
management implies an overall systemic intent that supports continuous quality
improvement within an organisation (Cruickshank et al, 2002, p 364). For the purposes
of this report continuous quality improvement is used as an overriding term.
It has already been identified in the section above that standards should encourage
continuous quality improvement, if not actually incorporate a system of continuous
improvement (Australian Council for Safety and Quality in Health Care, 2003a, pp 5 - 6).
This section therefore examines the elements of CQI to determine how any
incorporation into the standards can be achieved – in order to support CQI in practice.
5.2
Key elements of CQI
The traditional focus on quality has been one of searching for negative factors,
such as mistakes, incompetence or harmful outcomes, followed by the
introduction of corrective action. The emphasis has been largely on inspection
and finding faults, and the meeting of specifications or standards. However,
quality in health care management is now seen as having a much broader focus
and includes such dimensions as organisational vision, values, attitudes, policy
planning, leadership, and the pursuit of excellence through continuous
improvement (Cruickshank et al, 2002, p 368).
There is no certainty that a continuous improvement program at a given
institution will enhance quality for the patient and the providers and reduce costs
for all concerned. If CQI is managed properly, however, it can and will provide
such benefits. The challenge is to design, implement and lead a CQI effort that is
successful for a given institute (McLaughlin et al, 2004, pp 55 – 56).
Depending on the improvement being made the CQI approach taken may vary.
McLaughlin et al (2004), however, identify seven common characteristics, ten
philosophical, and eight structural elements of continuous quality improvement. Some
of these characteristics and elements may not apply literally considering the structure of
some TCs (i.e. they are not large institutions like hospitals). They are presented in full,
however, in order to provide an initial broad overview. The seven common
characteristics identified (McLaughlin et al, 2004, p 3) include:
1. A link to key elements of the organisation’s strategic plan;
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2.
3.
4.
5.
6.
7.
A quality council made up of the institution’s top leadership;
Training programs for personnel;
Mechanisms for selecting improvement opportunities;
Formation of process improvement teams;
Staff support for process analysis and redesign; and
Personnel policies that motivate and support staff participation in process
improvement.
These characteristics, while all focusing on continuous quality improvement, also fit
within the generalised standards grouping areas provided in the previous section. As
such it is not difficult to imagine standards (or indicators within them) that incorporate
the characteristics of continuous quality improvement. For example there may be an
indicator that supports the incorporation into a strategic plan that would demonstrate
management and leadership support for continually reviewing the integrity of the TC
service, or supporting increased recruitment and support of staff with a personal
background as TC residents.
The ten philosophical elements of CQI identified (McLaughlin et al, 2004, p 8) include:
Strategic focus – emphasis on having a mission, values, and objectives that
performance improvement are designed, prioritised, and implemented to
support;
Customer focus – emphasis on both customer satisfaction and health outcomes as
performance measures;
Systems view – emphasis on analysis of the whole system, providing a service, or
influencing an outcome;
Data-driven analysis – emphasis on gathering and using objective data on system
operation and system performance;
Implementer involvement – emphasis on involving the owners of all components of
the system in seeking a common understanding of its delivery process;
Multiple causation – emphasis on identifying the multiple root causes of a set of
system phenomena;
Solution identification – emphasis on seeking a set of solutions that enhance overall
system performance through simultaneous improvements in a number of
normally independent functions
Process optimisation – emphasis on optimising a delivery process to meet customer
needs regardless of existing precedents and on implementing the system
changes regardless of [attachment to existing processes];
Continuing improvement – emphasis on continuing the systems analysis even when
a satisfactory solution to the presenting problem is obtained; and
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Organisational learning - emphasis on enhancing the capacity of the organisation to
generate process improvement and foster personal growth.
The eight structural elements identified (McLaughlin et al, 2004, p 9) include:
Process improvement teams – emphasis on forming and empowering teams of
employees to deal with existing problems and opportunities
Use of tools – including flow charts, cause-and-effect diagrams, check sheets,
histograms, Pareto charts, control charts, and correlation analysis;
Parallel organisation – development of a separate management structure to set
priorities for and monitor continuous quality improvement strategy and
implementation;
Top management commitment – top management leadership to make the process
effective and foster its integration;
Statistical analysis – use of statistics to identify and reduce unnecessary variation in
process and practice;
Customer satisfaction measures – introduction of market research instruments to
monitor customer satisfaction at various levels;
Benchmarking – identification of best practice in related and unrelated settings to
emulate as processes or use as performance indicators; and
Redesign of process from scratch – ensuring that the end product conforms to the
customer requirements by using techniques of quality function deployment
and/or process reengineering.
In many ways these CQI elements are obvious and many TCs may already have such
elements in place, formally or informally. The introduction of a strategic CQI approach
into the workplace is, however, generally seen as ‘a relatively lengthy process and
requires committed and patient leadership. For health service managers it represents a
major shift in organisational culture and management philosophy’ (Cruickshank et al,
2002, p 371 - 374). Cruickshank et al (2002, p 371) identifies four main stages of CQI
implementation:
•
•
•
building awareness – with managers/senior staff exploring the CQI approach to
gain understanding, determine strengths to build on, and identify areas for
possible improvement;
developing a CQI plan – defining the goals, the critical measures of success and
strategies to achieve the organisation’s quality endeavour, including staff/team
involvement and training (CQI models to support this are presented below);
deployment – rolling out the plan across the organisation, including celebrating
and communicating achievements and improvement results, benchmarking,
documenting, and incorporating consumer feedback into improvement systems;
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•
full integration – evaluating progress, maintaining momentum, ensuring the
sustainability of changes made, and continuing the improvements.
Potential barriers to CQI implementation need to be addressed. Some key barriers
include: time, territory, tradition; and trust (Cruickshank et al, 2002, p 374).
A key consideration is that learning by staff members is always taking place, and that
the autonomy of staff may result in localised changes and variation in approaches
across an organisation. While this may be appropriate in some instances, such as when
the learning influences only those staff required to undertake a specific task, it is
important to ensure an organisational learning approach also occurs. This will ensure
consistency as needed, increased sustainability, and that localised learning is
complemented across an organisation. It also supports the identification of when it is
best to engage an external body to re-engineer or re-design a process if the
components become incompatible (McLaughlin et al, 2004, p 3 – 30).
To provide an organisation’s workers with a ‘common language and an orderly
sequence for implementing the cycle of continuous improvement’ (McLaughlin et al,
2004, p 27) a number of tools and/or series of questions have been developed. A well
known tool is Shewhart’s Plan, Do, Check, Act (PDCA) cycle as presented below
(McLaughlin et al, 2004, p 21).
PLAN
What could be the most important accomplishments of this team?
What changes might be desirable? What data are available? Are
new observations needed? If yes, plan a change or test. Decide
how you will use the observation.
DO
Search for data on hand that could answer the question
propounded in planning. Or, carry out the change or test decided
upon, preferably on a small scale.
CHECK
Observe the effect of the change or test.
ACT
Study the results.
What did we learn?
PLAN
Repeat process, with knowledge accumulated.
Demming’s FOCUS – PDCA approach is also well known and used within the health
care system. McLaughlin and Kaluzny suggest it ‘is especially useful in health care
because professionals [workers] already have knowledge of the subject matter and
have a set of values and disciplines that fit the Demming philosophy’ (McLaughlin et al,
2004, p 27).
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F
O
C
U
S
PDCA
Find a process to improve
Organise team that knows the process
Clarify current knowledge of the process (undertake a PDCA cycle for this stage)
Understand causes of process variation (undertake a PDCA cycle for this stage)
Select a process improvement
Plan the improvement and collect the data
Do the improvement, collecting and analysing the data
Check the data for process improvements, customer outcomes, identify lessons learnt
Act to hold the gain, reconsider owner, to continue improvement
The FOCUS – PDCA approach allows a focus on the following questions that support
continuous quality improvement:
-
5.3
What are we trying to accomplish?
How will we know when that change is an improvement?
What changes can we predict will make an improvement?
How shall we pilot test the predicted improvements?
What do we expect to learn from the test run?
If we get positive results, how do we hold on to the gains?
If we get negative results, what needs to be done next?
When we review the experience, what can we learn about doing a better job in
future?
Defining Change Management
Implementing a quality process implies implementing a process of change. It is
generally appreciated that without effective change management and leadership there
will be resistance to change, there may be reduced productivity, possible increased
turnover of staff, and a reduced probability that the desired results will be achieved
(Hiatt et al, 2003).
Change management is about helping people through change. It is the process, tools
and techniques for proactively managing the people side of change in order to achieve
the desired business results (Hiatt et al, 2003, pp 10 – 11).
5.4
Change Management Principles
There are two perspectives of change: the “top-down” view of managers/executives and
the “bottom-up” view of staff. Top-down change is generally broad with an emphasis on
‘communication, training and the overall culture or value system of the organisation’
(Hiatt et al, 2003, p 10). In reality it is ultimately the staff that will implement any practice
change. As such principles behind supporting effective bottom-up change need to be
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considered. Change management may include a focus on the ‘tools and techniques’
that will support staff change processes, including coaching and establishing clear
roles/job descriptions (Hiatt et al, 2003, p 10).
Hiatt et al (2003 p 15 - 42) identified the primary principles for change management,
these include:
•
•
•
•
•
•
•
Every change can be viewed from the perspective of a sender and receiver,
where the sender is the one providing information about the change, and the
receiver is the one given the information. While the sender is aware of the issues
and need for change, the receiver will consider the personal implications and
risks. A significant management consideration is to identifying the preferred
“sender” who is in a position to inform the “receiver“ of the rationale and potential
personal impacts;
Change management practitioners and business leaders often underestimate the
level of comfort with the current state. The natural and normal reaction to change
is resistance, however each individual reacts differently depending on past
change experiences. Hiatt et al (2003 p 21) suggests change managers should
not react to resistance with surprise, and need to demonstrate patience, consider
any individual’s change history, and assess the risk of the resistance
compromising success;
The number one success factor for implementing change is visible and active
executive sponsorship;
The value system of the organisation needs to be considered. For example the
success of top down motivated change within traditional hierarchical structures
will be different to a structure that supports the empowerment of staff. Decision
making processes for identifying change need to be consistent with the value of
the organisation;
Change management activities should be scaled based on the size of the change
and the immediacy requirements. Incremental change is behind the CQI
principles, however, there may be times when radical change is needed. Radical
change is often in response to a crisis or a business opportunity and is not ‘an
improvement on today’s processes, but rather a replacement of processes’ (Hiatt
et al 2003 p 28);
A good solution design does not mean that implementation will always be
successful or that you will actually realise the expected results. “Knowing what is
needed” may blind us all to the fact that change is in reality being forced before
the environment is adequately ready;
Change is a process. Change is not implemented in a single moment, and
change should not be reduced to a single event. Matching the speed of change
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as desired by the change initiator to what is possible for all those involved in the
change is important.
A well known gauge for determining the efficiency of organisation function is the 7S
Checklist, as presented by Peters and Waterman (cited in Lloyd et al, 2002, p 155). The
seven S’s are: Strategy, Structure, Systems, Staff, Skills, Style, and Shared values. It is
proposed that when all seven elements are in harmony, an organisation is working at
peak efficiency. The checklist can be used to support change by assessing each S
element relative to how consistent or otherwise it is with the desired new direction. This
allows a better appreciation of any obstacles to change.
Project Considerations:
11. Standards need to incorporate a system of continuous improvement.
12. Consultation needs to determine the extent of CQI elements and Change
Management principles currently incorporated into TC processes.
13. To support a common language and shared understanding of CQI and
Change Management consultation needs to determine existing language of
change.
14. Consultation needs to determine a willingness of managers and senior staff to
see CQI and Change Management awareness and implementation as a
dedicated module or something that is woven into the training package.
6.
Standards assessment/review/accreditation
The objective of this section is to examine the issues associated with the assessment of
a set of standards at an organisation. Many of these issues cannot be overcome,
however it puts the processes of assessment and accreditation into perspective.
Movement toward ensuring the accreditation of health services in Australia is implied in
the reports informing the development of a National Framework for Standards Setting
and Accreditation in Health. This is realised in the recent announcement that
organisations within the Aboriginal and Torres Strait Islander community controlled
health sector are required to demonstrate a willingness to undertake an accreditation
process, and be accredited by June 2011 (Australian Government Department of Health
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and Ageing, 2008). This prospect is expected to apply to all health services within a
similar timeframe.
6.1
Defining Quality Assurance and Accreditation
Quality Assurance is the traditional approach to monitoring standards, which focuses on
individual performance, deviation from standards, and problem solving. As standards
have became increasingly mandatory, the monitoring system has consequently become
more refined. The focus of “repairing” problems changed to an increased focus on
‘proactive prevention, innovation, and personnel development’ – i.e. continuous quality
improvement (Cruickshank et al, 2003, pp 362 – 363).
Quality assurance is essentially a point in time assessment of compliance
against a set of standards – survey processes undertaken as a part of
accreditation provide assurance of quality at the time the survey is undertaken
(Australian Council for Safety and Quality in Health Care, 2003a, pp 3 – 4).
Accreditation generally encompasses quality assurance and quality
improvement processes, and also provides some form of credential (or awarding
of accreditation) to indicate the organisation has met the necessary
requirements of the accrediting agency (Australian Council for Safety and
Quality in Health Care, 2003a, p 4).
The Australian Council for Safety and Quality in Healthcare defines accreditation as the
‘granting of recognition for meeting designated standards for structure, process and
outcomes, where outcome is the status of an individual, group of people or population
which is wholly attributed to an action, agent or circumstance’ (Australian Commission
on Safety and Quality in Healthcare, November 2006, p 5). ‘The two conditions for
accreditation are an explicit definition of quality (i.e. standards) and an independent
review process aimed at identifying the level of congruence between practices and
quality standards’ (Australian Council for Safety and Quality in Health Care, July 2003b,
p 5).
6.2
Issues of accreditation
What is the purpose of accreditation?
•
The core purpose of accreditation in health settings is to promote quality and to
protect the public. As health services are complex, there are risks involved in the
provision of service. Accreditation is only one of a variety of strategies that can
be adopted to promote and validate the quality of an organisation’s service
(Australian Council for Safety and Quality in Health Care, 2003b, p 6).
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•
A number of factors impact on this aim, including whether it is a voluntary or
mandatory process, and whether there are incentives and funding options made
available to organisations that may achieve accreditation (Australian Commission
on Safety and Quality in Healthcare, 2006, p 6). Accreditation cannot provide an
assurance that an adverse event will not happen however, and due to the
‘snapshot’ nature of accreditation it ‘does not “endorse” or “guarantee” an
organisation’s quality of care’ (Australian Commission on Safety and Quality in
Healthcare, 2006, p 8). Accreditation may be a strong motivating factor for an
organisation to review and improve its practices. While stakeholders, including
consumers, funding and insurance bodies, often place a lot of weight on
accreditation, participation in accreditation processes at best demonstrates the
commitment of an organisation to continually improve their services, and is only
one factor in this process.
What is involved in accreditation?
•
•
•
•
Accreditation systems generally ‘encourage self-assessment against standards,
involve a formal on-site visit by an external peer review team, a formal report of
the outcomes of the review, an assessment by the agency of the review [eg an
accreditation body] and some form of recognition of compliance with the
standards and assessment system [eg the granting of accreditation]’ (Australian
Council for Safety and Quality in Health Care, 2003a, p 5)
‘Most accreditation services have been designed and are delivered to maximally
capture the benefits of peer review, knowledge sharing and professional support’
(Australian Council for Safety and Quality in Health Care, 2003b, p 7).
Most accreditation systems ‘operate on a continuous quality improvement model,
rather than on an inspectorial and strict enforcement of compliance basis, and
they remain highly committed to supportive, peer-based approaches to
accreditation that foster the development of continuous quality improvement
cultures within health care organisations’ (Australian Council for Safety and
Quality in Health Care, 2003b, p 7). This also ensures the ‘organisation is
monitoring its performance over time and making ongoing improvements to its
service delivery, instead of relying on a snap-shot of quality assessment as
provided by the survey [review] process’ (Australian Council for Safety and
Quality in Health Care, 2003a, pp 5- 6);
Any accreditation process needs to incorporate elements of continuous quality
improvement to be effective. While accreditation generally encompasses the two
elements of quality assurance (snap-shot survey/assessment) and quality
improvement processes, these two elements cannot be considered in isolation,
and need to operate together in a complimentary way. By doing so there will be
enhanced transparency and accountability. There will also be increased integrity
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of the system as these elements will inform any review of the standards in
relation to their relevance and useability (Australian Council for Safety and
Quality in Health Care, 2003a, pp 3 – 11);
Who should be involved in an accreditation system?
•
•
•
The accreditation process should be consistently applied to all service providers
within a sector i.e. ‘there should be a high level of consistency between
assessments’ (Australian Council for Safety and Quality in Health Care, 2003a, p
6).
‘The accreditation system should be managed by an accreditation body that is
industry based’, and which has ‘a degree of autonomy from direct government
control’ (Australian Council for Safety and Quality in Health Care, 2003a, p 6).
Accreditation status is seen to be achieved through a process of successful
assessment against a set of standards by a recognised and authorised
accreditation body. Most accreditation bodies operate on a continuous quality
improvement basis, rather than assessing basic compliance (Australian
Commission on Safety and Quality in Healthcare, 2006, p 7).
The Australian Council for Safety and Quality in Health Care – Standards and
Accreditation Framework Working Group ‘strongly believe that consumers should
be involved at all levels ‘ of any accreditation system including participating in
service assessments (Australian Council for Safety and Quality in Health Care,
2003b, p 9)
What are the issues of mandating accreditation or imposing sanctions?
•
•
Government involvement in mandating accreditation varies internationally and
within the Australian health care sector. It is generally understood that there is a
risk of government involvement, particularly where there are sanctions imposed
for non-compliance including funding sanctions. Such sanctions may result in
outcomes or review results being “massaged”. It is recognised that this in turn
impacts negatively on consumer outcomes (Australian Council for Safety and
Quality in Health Care, 2003a, pp 1 – 9). Such massaging is referred to as
“reactive compliance”, which, if it becomes a part of an organisation’s culture,
can result in restricted peer-based support and limits continuous quality
improvement, replaced instead with a culture of blame. ‘A blame-free culture has
been identified as a key element of a safe culture’ (Australian Council for Safety
and Quality in Health Care, 2003b, p 9).
It is desirable that accreditation or assessment systems are transparent and
accountable, allowing scrutiny from the service, funders and consumers. This
needs to be balanced with a requirement for confidentiality as total openness can
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•
also lead to a “massaging” of results (Australian Council for Safety and Quality in
Health Care, 2003a, pp 7 – 8);
If participation in applying a set of standards and accreditation is voluntary the
only sanction is to remove or not award the status of accreditation. As
accreditation systems now typically include continuous quality improvement
elements the process is supportive in terms of assisting any problems to be
rectified. Any additional formal sanction needs to ‘balance the need to protect the
safety of consumers’ verses the impact of the sanction (eg the involvement of the
service in ongoing support to improve, or at an extreme end the closure of the
service) (Australian Council for Safety and Quality in Health Care, 2003a, pp 7 –
10).
What are the issues to consider re accreditation?
•
•
•
•
•
Evidence supporting accreditation is limited. This has lead to an increased use of
performance indicators being linked to standards, although the jury is still out re
the extent to which these indicators truly reflect performance. While the
“evidence” is limited there remain a number of positives for engaging a set of
standards and assessment process, including motivation to continually improve
(Australian Council for Safety and Quality in Health Care, 2003a, pp 7 – 12,
(Australian Council for Safety and Quality in Health Care, 2003b, pp 1 - 7);
The award of accreditation is intended to be ‘an assurance that at a particular
point in time’ an organisation has ‘instituted structures and was adhering to’
quality requirements. ‘Neither accreditation, nor any other quality system, can
provide an assurance that an adverse event will not occur in a health care
organisation’ (Australian Council for Safety and Quality in Health Care, 2003b, p
8);
Many stakeholders, including consumers, funding bodies and insurance bodies,
‘place considerable reliance on the accreditation status’ of an organisation.
Increased reliance has led to increased scrutiny – including scrutiny of the
validity of the standards, rigour of the assessment/accreditation process, and the
extent to which assessment findings are acted on (Australian Council for Safety
and Quality in Health Care, 2003b, p 8);
Accreditation bodies fund that activity through fees charged to participating
organisations. There is concern that the competitive imperative may impact on
the rigour of the accreditation system and costs of compliance by organisations
(Australian Council for Safety and Quality in Health Care, 2003b, p 10);
‘Informed consumers are concerned that accreditation based on an
organisation’s commitment to continuous quality improvement may overlook the
possible inadequacy of the starting point from which improvement is being
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•
•
•
encouraged’ (Australian Council for Safety and Quality in Health Care, 2003b, p
11);
‘There is little being learned by the health care system from the wealth of data
collected through the accreditation processes’ (Australian Council for Safety and
Quality in Health Care, 2003b, p 11);
‘There is a strong imperative to reduce the administrative burden of
accreditation.’ Particular concerns are:
That accreditation costs are diverting resources from strategies
aimed at improving services;
That organisations are increasingly needing to be accredited by
multiple providers or against multiple standards;
That the burden of accreditation for smaller organisations is
disproportionate to their funding ;
That any administrative burden for meeting accreditation
requirements is on top of administrative requirements to meet
contractual obligations with funding bodies. It has been suggested
that a ‘robust accreditation system could more completely meet the
requirements of these stakeholders’, thereby alleviating the
burdens of the additional compliance (Australian Council for Safety
and Quality in Health Care, 2003b, p 11);
There is a need to find an acceptable balance between assuring consumers and
other stakeholders of minimum standards compliance versus fostering a
desirable culture of self-regulation and continuous quality improvement
(Australian Council for Safety and Quality in Health Care, 2003b, pp 12 – 14);
7.
Training Package Development
7.1
About training in general
There is very little literature about training issues such as effective training design,
evaluation and learning transfer, specifically relevant to the AOD sector (Shoobridge,
2002, p153). Therefore, as well as the AOD specific literature, this section draws on
literature about training trends in general and looks at some of the implications of this
for the development of a training package for TCs.
Goldstein and Ford (cited in Shoobridge, 2002, p155) suggest training needs to be
understood as:
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a systematic approach to learning and development to improve individual, team
or organisational effectiveness. A systematic approach refers to the idea that the
training is intentional. It is being conducted to meet a perceived need. Learning
and development concerns the building of expertise as a function of these
systematic training efforts. Learning outcomes can include changes in
knowledge, skills and attitudes (KSAs). Improvement is measured by the extent
to which the learning that results from training leads to meaningful changes in
the work environment. Therefore, a critical issue is the extent to which the KSAs
are transferred to the job and improve individual effectiveness. Finally, employee
training can also be viewed from a broader, more macro perspective, as a
mechanism for enhancing work team and organisational effectiveness. In this
way, training is seen as integral to facilitating larger scale organisational change
and development issues.
With the elements within this quote in mind, the training package developed for this
project is intended to support organisational change and development that may result
from the implementation of standards. It is intended that the perceived training needs of
the TC sector, specifically in relation to implementing standards, will significantly be
determined during the consultation phase. Learning outcomes impacting on knowledge,
skills and attitudes of individuals need to be incorporated into any ongoing evaluation of
the training package. Further follow-up evaluation needs to assess the impact of the
training in terms of resulting in any meaningful change.
The literature on training suggests that there has been a change in the nature and
methods of training in organisations concomitant with recent workplace changes. There
has been a focus on individualised training and development with the aim to increase
workforce capability and performance (and ultimately better outcomes for consumers). It
is also widely acknowledged that good quality training assists with staff retention (Smith
et al cited in National Centre for Vocational Education Research, 2003, p 7).
An increased decentralisation of training has also been the trend, with an increase in
the number of workplace trainers, coaches and mentors assisting managers in staff
training. Although the importance of these trainers is acknowledged, concern has also
been raised about the quality of the training and about workplace trainers delivering
training that lies outside the national developed competency standards within training
packages (Harris et al cited in National Centre for Vocational Education Research,
2003, p7). However, in their study of workplace training, Harris et al (cited in National
Centre for Vocational Education Research, 2003, p 7) found that informal workplace
learning was of central importance and noted that this type of learning was ‘not an ad
hoc process but part of a deliberate strategy which takes into account the work which
needs to be done and the skills needed to do the work’. Figgis et al (cited in National
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Centre for Vocational Education Research, 2003, p 7) argue that ‘formal and informal
training should be used together, with informal learning amplifying the value of formal
learning’. It is recognised that training generally needs to have strategic focus to meet
specific organisational goals through customised design. Trainers also have a
responsibility for making explicit the links between training provided and organisational
outcomes (Shoobridge, 2002, p 153).
The increasing professionalisation of the AOD workforce has been the catalyst for
increased formal education and training in the sector (Skinner et al and Kennedy et al
cited in Roche et al, 2005, Section 9 p 12). Education and training options indicated as
promoted for the AOD sector include short non-accredited training courses, on-site
structured learning, and tertiary education (TAFE and University). Registered Training
Organisations (RTOs), including TAFE, currently provide a variety of AOD courses, and
the delivery mode has expanded to include flexible delivery, online (e-learning) and
workplace learning (Roche et al, 2005, Section 9 p4). While there has been much
promotion of education and training in the AOD field, recently there has been wider
recognition of the value of a range of complementary learning and development
opportunities. These include self-directed learning tools, mentoring and supervision
programs (Roche et al, 2005, Section 9 p 4). Shoobridge (2002, p 153) suggests a shift
from the focus and responsibility of training being the domain of the individual, to
organisations supporting sustainable training outcomes in return for their investment.
All of this has implications for the development of a training package for TCs.
7.2
Training effectiveness
Workplace learning is defined by The Australian National Training Authority as ‘learning
or training undertaken in the workplace, usually on the job, including on-the-job training
under normal operational conditions, and on-site training, which is conducted away from
the work process (e.g. in a training room)’ (National Centre for Vocational Education
Research, 2003, p2). As the proposed training package for TCs falls within the realm of
support for workplace learning, it is useful to ask “What makes good workplace
learning?” There are a number of factors that contribute to the effectiveness of
workplace training and learning.
The training and learning context
While training design and content is important, Shoobridge (2002, p 155) also suggests
that trainers [and training package developers], supervisors and managers ‘consider
issues beyond instructional design and training delivery, specifically to place training in
the broader picture of organisational and workforce development’. Learning (and
training) does not exist within a vacuum. It exists within the culture of an organisation.
Organisational cultures encompass diverse learning cultures that either support and
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value training and learning or hinder it (National Centre for Vocational Education
Research, 2003, p4). A workplace culture and organisation that supports and values
learning, training and professional development is of utmost importance in terms of
continuous quality improvement and successful work practice change (Roche et al,
2005, Section9 p15). The developed TC training package will need to support and
encourage positive organisational learning culture.
Johnston and Hawke (cited in National Centre for Vocational Education Research,
2003, pp 4 - 5) identified training supports offered by organisations that can enhance a
positive learning culture. In general these involve incorporating training and learning as
part of the core strategic business of the organisation, with training and learning
meeting both the needs of the organisation and the staff. Important features of positive
learning cultures include:
•
•
•
•
•
•
•
Open communication – where staff are encouraged to share their learning and
the organisation allows staff to use this learning to contribute to decision making;
Innovative systems and structures – including systems for learning and training
assessment (needs and outcomes), performance review, organisational
restructure;
Workplace trainers – who can initiate and support informal learning, one-on-one
learning, and/or facilitate the delivery of formal training packages;
Informal learning – deliberately built into organisational systems as a way to
enhance performance (for example assigning diversity of tasks and role sharing.
This supports improved psycho-social well-being, job satisfaction and an
appreciation of the combined workforce responsibilities);
Fostering generic skills – linked to recognised “core competencies” for any
workforce, such as communication, problem solving and team work.
Application of learning – to ensure training relevance and maximum learning
transfer. The workplace provides the opportunity for skills to be learnt on the job
or applied immediately after staff receive training;
Fostering an awareness of stakeholders and strategic partners - for example
where staff are encouraged to network and attend relevant external events.
These features could inform a module within the training package, specifically targeting
managers and change leaders.
Training Transfer
[Training transfer may be viewed as] the effective application, generalisability
and maintenance of new knowledge, skills and abilities to the workplace, as a
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result of undertaking an educational strategy (Holton 2000, cited in Shoobridge,
2002, p 156).
Factors within organisational structures and the workplace environments that may
impact on the effectiveness of training transfer include: supervisor support; peer/coworker support; organisational goals, strategic direction, systems and policies; and
endorsement or reward for training and workplace practice change (Roche et al, 2005,
Section 9 p 3). The organisation needs structures to support and enhance sustained
work practice change informed by the training, that is to enable the staff member to
apply skills and knowledge acquired. This can be seen as part of a broader change
management strategy, particularly in a TC setting where individual work practice
impacts on the whole staff team, any collective intervention, and the community.
Resistance to change from any of these parties needs to be both acknowledged as a
reality and considered in development of the training package.
As well as the environmental or situational factors, trainees are not empty vessels.
There are factors within the individual trainees that may influence training transfer and
therefore effectiveness. These include individual learning capacities, attitudes,
motivations, expectations, existing skills and knowledge, and different learning styles
(Roche et al, 2005, Section 1 p7) and also personality, coping patterns, beliefs and
emotional wellbeing (Ask et al, 2005, pp 60-62). This is particularly relevant to the broad
AOD sector as workers in this area have varied occupational, educational and
experiential backgrounds (Ask et al, 2005, p 59).
Goldstein and Ford (cited in Shoobridge 2002, p 154) identify four barriers to the
effectiveness of training transfer into the workplace:
•
•
•
•
Failure to consider trainees’ personal characteristics when designing training;
Conducting training in isolation from the job trainees perform;
Failure to consider strategies that may potentially enhance or detract from the
trainees’ ability to translate new skills into practice;
Failure to consider the role or aims of the organisation.
The consultation phase of this project will need to identify all of these factors to ensure
the effectiveness of the training package.
What makes effective training design?
To have knowledge is to make it, to construct it, not to record, absorb, or
memorise it. Teaching [training] is not simply telling (Bickman cited in National
Centre for Education and Training on Addiction Consortium, 2004 p 14).
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Literature on effective training focuses on adult learning principles. Adult learning
principles support an experiential model of training and learning where adults expect to
take responsibility for decisions (National Centre for Education and Training on
Addiction Consortium, 2004, p 11). One review of AOD trainers in the UK reported that
experiential training was more effective where attitudinal change and behavior change
was the goal (National Centre for Education and Training on Addiction Consortium,
2004, p 15).
Below is a matrix, outlining adult learning principles and conditions for effectiveness (as
drawn from NCETA, 2005, DVD Demonstration Training Booklet, p 24; National Centre
for Education and Training on Addiction Consortium, 2004 pp 11 - 13, Lee et al 2007
Section 3 p 4, Roberts, 2008 p 1; ), with complementary design implications.
ADULT LEARNING PRINCIPLE/CONDITION
TRAINING PACKAGE DESIGN CONSIDERATIONS
What’s in it for me – adults need to know why
they need to learn something
- Introduction to the training package that provides
rationale and background to the package
- Clear goals and objectives identifying what the
participant will gain, and what the organisation
may achieve through their participation – i.e. a
sound appreciation of the TC model
Self-directed learning - adults learn best
when they control the pace and content of the
learning within a problem solving framework
- Clear indication of how long each learning section
is likely to take
- A non-linear format encouraging flexible
exploration into interest areas or as problems
arise
Practical and applicable - the most effective
and efficient means of learning new skills is
through immediate application of new
knowledge, and is greatly aided by
observational learning/modeling and rehearsal
of skills. Adults learn best by putting new
knowledge into practice
- Use “realistic” examples and case scenarios from
the typical TC workplace, and encouraging
participants to use their own scenario examples to
apply learning to
Contextualised learning - the acquisition of
skills should be imbedded within a salient
context that is imbued with meaning for the
- Encourage trainees to reflect on the relevance of
the training for their work role at the TC, and role
National Standards Project
- Providing opportunities for immediate application
of learning at the TC they are engaged at. Follow
up on success, encourage discussion with
peers/colleagues
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trainee; ‘semantic based learning’ [i.e. the
relevance of training for the individual] is known
to be a powerful aid to integrating new learning
and aiding recall because it is of immediate
value. Adults learn best by connecting
information to past, present and future
experiences.
Responds to identified needs – deficits and
barriers of the trainees are identified and inform
a framework for learning with clear goals and
objective; adults learn best if they want to
and/or need to
within the team and community
- Encouraging trainees to acknowledge their
changing skills and knowledge – i.e. recall prior
learning and encourage reflection on where they
want to be, and identify TC mentors/colleagues
they can learn from
- Consultation for this project will identify some
generic strengths and barriers re training.
Consideration for these will be incorporated into
the package
- Within the package encourage self-analysis of
training strengths, deficits and barriers/resistance
to change
Time for reflection – to promote critical
thinking and learner ownership
- Assign and incorporate reflection tasks
Variety of teacher-learner styles –
negotiated, collaborative and participatory
- Trial and use different learning styles, eg
experiential, case based, project based learning
etc.
Model personal development
- Encourage for example an appreciation of
boundary setting, role clarity and assertiveness,
and explore appropriate approaches to
challenging behaviour of others
Flexibility and adaptability – to meet the
need of a non-homogenous group of
participants
- Offer a range of delivery modes, eg written based
material, interactive DVD, individual and collective
tasks
- Ensure language is appropriate
- Offer a range of task options
Quality feedback – a strong motivator for
participants encouraging change
- Potentially incorporating a self/peer assessment,
resulting in an indicator of achievement
Logical and creative – adults learn best if both
left and right brain processes are activated
- Ensure a balance of information, exercises,
reflective learning, activities, visual and written
material
Experiential – adults need to learn
experientially
- Request trainees use/integrate/trial/test/share/
discuss knowledge within their workplace
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Project Considerations:
15. Consultation needs to determine TC staff training needs in relation to
implementing standards/quality processes
16. Evaluation of the training package will be incorporated.
17. Consultation needs to determine staff opinion of what makes training effective
18. The training package will incorporate aspects that support positive
organisational learning culture.
19. The training package will incorporate aspects that support training transfer.
20. Consultation needs to determine what training supports are currently in place.
21. Consultation needs to examine the opinions re the considerations presented
in the matrix of adult learning principles.
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Ask A, and Roche AM, (2005). Clinical Supervision: A practical guide for the alcohol and
other drugs field. National Centre for Education and Training on Addiction
(NCETA). Flinders University: Adelaide.
Australasian Therapeutic Communities Association, (October 2000). Policies and
Procedures Manual.
Australian Commission on Safety and Quality in Healthcare, (November 2006).
Discussion Paper: National Safety and Quality Accreditation Standards.
Australian Council for Safety and Quality in Health Care, (July 2003a). Prepared by
Matthew Pegg Consulting Pty Ltd for the Department of Health and Ageing to
inform the development of a National Framework for Standards Setting and
Accreditation in Health. Standards Setting and Accreditation Literature Review
and Report.
Australian Council for Safety and Quality in Health Care, (July 2003b). Standards
Setting and Accreditation Systems in Health: Consultation Paper.
Australian Government Department of Health and Ageing, (August 2008). Establishing
Quality Health Standards, announcement.
Centre for Substance Abuse Treatment, (2006). Therapeutic Community Curriculum:
Trainer’s Manual. US Department of Health and Human Services. Publication
No. (SMA) 06-4121. Rockville, MD: Substance Abuse and Mental Health
Administration.
Cruickshank M, Isouard G, Blandford J, Irwin L, and Madison J, (2002). Managing
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De Leon G, (2000). The Therapeutic Community: Theory, Model, and Method. New
York: Springer Publishing Company Inc.
Gowing L, Cooke R, Biven A, and Watts D, on behalf of the Australasian Therapeutic
Communities Association, (2002). Towards Better Practice in Therapeutic
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Health Research Council of New Zealand, (2006). Te Awhiti National Mental Health and
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Organisations (2006 – 2009). Mental Health Programmes: Auckland New
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Hiatt JM, and Creasey TJ, (2003). Change Management: the People Side of Change.
Prosci Research: Colorado, USA.
Keenan S, and Paget S (eds), Community of Communities: A Quality Network of
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Hides L, and Ritter A (2007). PsyCheck: Responding to Mental Health Issues
within Alcohol and Drug Treatment. Canberra, ACT: Commonwealth of Australia.
Lloyd PJ, Johnstone PL, and Dwyer J, (2002). Managing and Leading Change. In MG
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McLaughlin CP, and Kaluzny AD, (2004). Continuous Quality Improvement in Health
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Prochaska JO, DiClemente CC, Norcross JC. In search of how people change.
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Roche AM, and Skinner N, (2005). Professional Development. In N Skinner, AM Roche,
J O’Connor, Y Pollard, and C Todd (eds), Workforce Development TIPS (Theory
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APPENDIX A.
ATCA Members
www.atca.org.au (accessed November 2008)
New South Wales
The Buttery
Phone: (02) 6687-1111
Fax: (02) 6687-1039
PO Box 42 Bangalow NSW 2479
info@buttery.org.au
Kamira Farm
Phone:(02) 4392-1341
PO Box 284 NORTH WYONG NSW 2259
chewett@kamira.com.au
The Salvation Army Rehabilitation
Service Centre
Phone:(02) 9212-4000
Fax: (02) 9281-9771
85 Campbell Street SURRY HILLS NSW
2010
Central Coast Recovery Service
(SELAH)
Phone: (02) 43884588
Fax: (02) 43891490
60 Berkeley Rd
BERKELEY VALE NSW 2261
ccrs@aue.salvationarmy.org
www.salvos.org.au
The Lyndon Community
Phone: (02) 6362-5444
Fax: (02) 6344-2041
PO Box 51 CANOWINDRA NSW 2804
cmills@lyndoncommunity.org.au
www.lyndoncommunity.org.au
Ted Noffs Foundation
Phone:(02) 9310-0133
Fax: (02) 9310-0020
PO Box 120 RANDWICK NSW 2031
www.noffs.org.au
Ngara Nura Therapeutic Program
Long Bay Correctional Centre
Phone: (02) 9289-2644
Fax: (02) 9289-2577
Locked Bag 23 Matraville NSW 2036
Peter.Townsend@dcs.nsw.gov.au
Wesley Rehabilitation Services
Phone:(02) 9608-0531
PO Box 161 MILLER NSW 2168
Nerida.Dunkerley@wesleymission.org.au
Odyssey House McGrath Foundation
Phone: (02) 9820-9999
Fax: (02) 9820-1796
PO Box 459 CAMPBELLTOWN NSW
2560
jap@odysseyhouse.com.au
WHOS
Phone:(02) 9318-2980
Fax: (02) 9318-1987
PO Box 1237
Strawberry Hills NSW 2012
info@whos.com.au
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www.odysseyhouse.org.au
www.whos.com.au
The Peppers
Phone: (02) 6926-6813
PO Box 618 WAGGA WAGGA NSW 2650
thepepp@bigpond.net.au
Wollongong Crisis Centre
Phone:(02) 4272-3000
Fax: (02) 4271-6173
PO Box 25 BERKELEY NSW 2506
manager@wccaod.com
Queensland
Gold Coast Drug Council - Mirikai
Phone: (07) 5535-4302
Fax: (07) 5576-2512
PO Box 2655 BURLEIGH MDC QLD 4220
www.gcdrugcouncil.org.au
Logan House – ADFQ
Tel: (07) 5546-3900
Fax: (07) 5546 8223
75 Kirk Road
CHAMBERS FLATS QLD 4133
www.loganhouse.org.au
Goldbridge
Phone:(07) 5591-6871
PO Box 3519 Australia Fair Southport
QLD 4215
info@goldbridge.com.au
www.goldbridge.com.au
Townsville Recovery Services
Tel: (07) 4772 3607
Fax: (07) 4772 3174
312 - 340 Walker Street
TOWNSVILLE QLD 4810
trs@aue.salvationarmy.org
www.salvos.org.au
Victoria
Odyssey House Victoria
Phone: (03) 9430-1800
Fax: (03) 9431-0816
28 Bonds Road LOWER PLENTY VC
3093
www.odyssey.org.au
The Windana Society
Phone:(03) 9529-7955
88 Alma Road EAST ST KILDA VIC 3182
The Salvation Army Basin Centre
Phone: (03) 8762 1166
Fax: (03) 9762 5767
PO Box 34
The Basin Vic 3154
the.basin@aus.salvationarmy.org
www.salvationarmy.org.au/thebasin
YSAS Birribi
Phone: (03) 9415-8881
Fax: (03) 9430-2301
PO Box 2950 FITZROY VIC 3065
www.ysas.org.au
ACT
Canberra Recovery Services (Salvation
Army)
National Standards Project
Karralika - ADFACT
Phone: (02) 6292-2733
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45
Phone: (02) 6295-1256
Fax: (02) 6295-3766
PO Box 4181 KINGSTON ACT 2604
robert.sneller@aue.salvationarmy.org
Fax: (02) 6292-7072
PO Box 2230 TUGGERANONG ACT 2230
clinicaldir@adfact.org
www.adfact.org
Northern Territory
Banyan House - Foster Foundation
Phone: (08) 8947-0832
Fax: (08) 8947-1093
PO Box 312 BERRIMAH NT 0828
Drug and Alcohol Services Association,
Alice Springs (DASA)
Phone: (08) 8952-8412
Fax: (08) 8953-4686
PO Box 3009 ALICE SPRINGS NT 0871
admin@dasa.org.au
South Australia
The Woolshed
Phone:(08) 8536-6002
Fax: (08) 8536-6282
PO Box 84 ASHBOURNE SA 5157
Uniting Care Wesley Adelaide Inc.
Phone:(08) 8556-7320
Fax: (08) 8556-7371
GPO Box 2534 ADELAIDE SA 5001
www.ucwesleyadelaide.org.au
Western Australia
Cyrenian House - WA (Council on
Addiction)
Phone:(08) 9328-9200
PO Box 49 NORTHBRIDGE WA 6865
www.cyrinianhouse.com
Palmerston Asssociation
Phone: (08) 9328-7355
Fax: (08) 9227-9158
PO Box 80 NORTHBRIDGE WA 6003
Serenity Lodge
Phone: (08) 9527 9999
Fax: (08) 9592 4711
106 Lewington St
Rockingham WA 6168
seren@iinet.net.au
New Zealand
Care NZ
Phone: + 64 (0) 4384 2958
PO Box 9183
Wellington NZ
www.carenz.co.nz
National Standards Project
Higher Ground Drug Rehabilitation
Trust
Phone: 0011 64 9 834 0017
Fax: 0011 64 9 834 0018
118 Beach Road, Te Atatu Peninsula,
Waitakere City 0610, New Zealand
PO Box 45 192, Te Atatu Peninsula,
Waitakere City 0610, New Zealand
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www.higherground.org.nz
hgdrt@xtra.co.nz
stuart@higherground.org.nz
Odyssey House Trust
Phone: 0011 64 3 358 2690
Fax: 0011 64 3 358 2907
PO Box 34009 FENDALTON
CHRISTCHURCH NZ 8030
odyssey.trust.chch@clear.net.nz
www.odysseyhouse.org.au
National Standards Project
Odyssey House Trust Inc.
Phone: 0011 64 9 828 7802
Fax: 0015 64 9 6239 151
Private Bag MBE M230 AUKLAND NZ
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APPENDIX B.
Matrix 1. Comparison of generalised groups of ACHS standards with AOD/TC
specific standards, guidelines, performance expectations, recommendations,
essential elements
Note: the comparison of these standards is subjective, and is informed by support
material that assists interpretation of the standards where possible. Additional indicators
within the standards are drawn on to support the comparisons. There are some
overlaps with standards within these generalised groups and these have not necessarily
been indicated.
1.
Appropriate and timely service provision
ATCA Peer Review Standards
Standard 4. A TC shall provide for the objective and comprehensive
assessment and treatment of clients with physical, psychological or social
problems arising from the abuse or misuse of alcohol or other drugs.
Standard 8. A TC shall strive to involve the community in the identification
and treatment of drug and alcohol related problems. TCs shall maintain
close liaison with relevant government and non-government bodies
ATCA Towards Better Practice in
TCs Recommendations
Recommendations
25 – TC Programs to suit individual needs …
26 - Cultural needs of minority populations determined …
29 – An effective treatment service is one that …
30 – TCs are most appropriate for …
31 – Determine effectiveness of approaches …
33 – Document admission processes … waiting periods …
34 – Effect of prior treatment experience …
SEEQ and ATCA Modified
Essential Elements
TC Perspective
The agency: treatment approach and structure
Community as Therapeutic Agent
Education and work activities
Formal therapeutic elements
National Standards Project
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Process
QIC ATOD Standards
Within Section 2. Providing quality services and programs
Within Section 3. Sustaining external quality relationship
NSW Health - Drug and Alcohol
Treatment Guidelines for
Residential Settings
Within Section 3. Effectiveness of residential treatment (evidence, principles
and minimum standards re assessment, treatment matching, clear aims and
objectives, clearly articulated approach, evaluation and relapse prevention
strategies)
Within Section 4. Who should receive residential treatment?
Within Section 6. Treatment (best practice, duration and retention, harm
reduction)
Within Section 7. Assessment during and after treatment
Within Section 8. Completion of treatment and continuity of care
Within Section 10. Guidelines specific to TCs (theoretic base, ethos,
program delivery, quality assurance)
Within Section 11. Groups with particular needs
WA AOD Sector Quality Framework
Performance Expectation 3. The service ensures consumers are well
informed of the service options available to them, receive a coordinated and
appropriately planned service in accordance with evidence based practice
and clinical/practice governance principles that is negotiated with the
individual and provided by appropriately experience staff to best meet the
consumer’s needs.
NZ AOD Treatment Sector
Standards
Within Standard 3. Client/tangata whai ora engagement
Within Standard 4. Service delivery
Community of Communities Service
Standards for Addiction Therapeutic
Communities
Core Standards
Standard 1. Physical Environment
Standard 3. Joining and Leaving
Standard 4. Therapeutic Environment
Standard 5. Treatment Programme
Standard 6. External Relations
US Prison based TC Standards (as
per the development project)
Standard Domain A. Theoretical Basis
Standard Domain B. General Clinical principles
Standards Domain E. Facility/Environment
National Standards Project
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Standards Domain F. Program Elements
Standards Domain G. TC Process
Standards Domain H. Stages of Treatment
Standards Domain J. Intake Screening and Assessment
Standards Domain K. Community-Based Aftercare
2. Leadership and management principles
ATCA Peer Review Standards
Standard 1. A TC should have an efficient and effective organisational
structure and appropriate management practices in order to facilitate the
achievement of its objects and aims
ATCA Towards Better Practice in
TCs Recommendations
Recommendations
20 – maintain appropriate financial systems …
21 – clear rationale for fees …
22 – fees set … not result in financial hardship …
23 – cost benefit of analysis
SEEQ and ATCA Modified
Essential Elements
QIC ATOD Standards
Within Section 1. Building quality organisations (leadership and
management etc)
NSW Health - Drug and Alcohol
Treatment Guidelines for
Residential Settings
Within Section 9. Management issues for treatment programs (organisation,
policy and procedures, philosophy and approach)
WA AOD Sector Quality Framework
Performance Expectation 5. Governance and management practices
maximise organisational efficiency, transparency, effectiveness and ensure
accountability.
NZ AOD Treatment Sector
Standards
Within Standard 2. Organizational Management
Community of Communities Service
Standards for Addiction Therapeutic
Communities
US Prison based TC Standards (as
per the development project)
Standards Domain I. Community TC and Clinical Management
3. Consumer participation
ATCA Peer Review Standards
National Standards Project
Standard 5. A TC shall ensure that clients are afforded their rights of
independent expression, decision and action, and shall ensure that
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consumers are treated with respect, dignity and consideration by staff and
other clients.
ATCA Towards Better Practice in
TCs Recommendations
SEEQ and ATCA Modified
Essential Elements
Within The agency (client roles and functions)
Within Community as Therapeutic Agent (mutual help, enhancement of
community belonging,
QIC ATOD Standards
Within Section 2. Providing quality services and programs (empowering
consumers etc).
NSW Health - Drug and Alcohol
Treatment Guidelines for
Residential Settings
WA AOD Sector Quality Framework
Performance Expectation 1. The service recognises clients as “health
consumers” with concomitant rights and responsibilities.
Performance Expectation 2. The service encourages consumer participation
and considers feedback from consumers on an ongoing basis to inform
planning and development of non-discriminatory practice.
NZ AOD Treatment Sector
Standards
Within Standard 1. Client/tangata whai ora rights
Within Standard 2. Organizational management (client/tangata whai ora
participation, family whanau participation)
Community of Communities Service
Standards for Addiction Therapeutic
Communities
Within Core Standards
US Prison based TC Standards (as
per the development project)
Standards Domain F. TC Program Elements
Within Standard 4. Therapeutic Environment
4. Strategic human resource management
ATCA Peer Review Standards
Standard 7. A TC should have and implement personal management
policies that promote the development of the knowledge and skills of staff.
ATCA Towards Better Practice in
TCs Recommendations
Recommendations
12 – range of skills, experience and qualifications …
13 – understanding of group dynamics …
14 – people with personal history …
15 – identify an appropriate balance … extent of training needs
16 – staff competencies …
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17 – staff training and development …
18 – supportive supervision and opportunities …
SEEQ and ATCA Modified
Essential Elements
QIC ATOD Standards
Within Section 1. Building quality organisations (human resources)
NSW Health - Drug and Alcohol
Treatment Guidelines for
Residential Settings
WA AOD Sector Quality Framework
Performance Expectation 4. The service provides adequate and appropriate
staffing, development and support for maximum effectiveness of service
delivery.
NZ AOD Treatment Sector
Standards
Within Standard 2. Organizational management (human resource
management, workforce development and support)
Community of Communities Service
Standards for Addiction Therapeutic
Communities
Standard 2. Staff
US Prison based TC Standards (as
per the development project)
Standards Domain D. Staffing
5. Information management and appropriate use/evaluation of data;
ATCA Peer Review Standards
Standard 3. A TC shall document its program and client work systematically
to ensure the availability of necessary information. A system of records
management should be established to ensure efficient controlled storage of
and access to records.
ATCA Towards Better Practice in
TCs Recommendations
Recommendations
4 – systematic evaluation …
5 – evaluations … identifying most effective elements of TC
6 – data collection on TC process ...
8 – appropriate and convenient instruments for recording …
9 – broad range of indicators …
31 & 32 – research effectiveness of approaches …
SEEQ and ATCA Modified
Essential Elements
QIC ATOD Standards
National Standards Project
Within Section 3. Sustaining external quality relationship (incorporating and
contributing to good practice)
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NSW Health - Drug and Alcohol
Treatment Guidelines for
Residential Settings
WA AOD Sector Quality Framework
Within Performance Expectation 5. Governance and management practices
maximise organisational efficiency, transparency, effectiveness and ensure
accountability.
NZ AOD Treatment Sector
Standards
Within Standard 5. Managing service delivery (client/tangata whao ora
records
Community of Communities Service
Standards for Addiction Therapeutic
Communities
Within Standard 6. External Relations (re research)
US Prison based TC Standards (as
per the development project)
Within Standard Domain C. Administration (re data, clinical records etc)
6. Occupational health and safety
ATCA Peer Review Standards
Standard 2. A TC shall have a functional, safe, healthy and satisfying
environment for clients and staff
ATCA Towards Better Practice in
TCs Recommendations
SEEQ and ATCA Modified
Essential Elements
QIC ATOD Standards
Within Section 1. Building quality organisations (legal and regulatory
compliance)
NSW Health - Drug and Alcohol
Treatment Guidelines for
Residential Settings
Within Section 9. Management issues for treatment (organisation, policies
and procedures)
WA AOD Sector Quality Framework
Within Performance expectation 4. The service provides adequate and
appropriate staffing, development and support for maximum effectiveness of
service delivery.
NZ AOD Treatment Sector
Standards
Community of Communities Service
Standards for Addiction Therapeutic
Communities
Partially within Standard 2. Staff
Partially within the Accreditation process (environment and facilities)
US Prison based TC Standards (as
per the development project)
7. Health and safety risk management
ATCA Peer Review Standards
National Standards Project
Standard 2. A TC shall have a functional, safe, healthy and satisfying
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environment for clients and staff
ATCA Towards Better Practice in
TCs Recommendations
Recommendation
19 – government requirements …
SEEQ and ATCA Modified
Essential Elements
QIC ATOD Standards
Within Section 1. Building quality organisations (risk assessment and
management)
NSW Health - Drug and Alcohol
Treatment Guidelines for
Residential Settings
Within Section 9. Management issues for treatment (organisation, policies
and procedures, risk management)
WA AOD Sector Quality Framework
Within Performance Expectation 5. Governance and management practices
maximise organisational efficiency, transparency, effectiveness and ensure
accountability.
NZ AOD Treatment Sector
Standards
Within Standard 2. Organizational management (quality improvement and
risk management)
Within Standard 6. Safe and appropriate environment
Community of Communities Service
Standards for Addiction Therapeutic
Communities
Within the Accreditation process (Clinical risk management)
US Prison based TC Standards (as
per the development project)
Within Standards Domain C. Administration
8. Continuous improvement
ATCA Peer Review Standards
Standard 6. A TC should continuously engage in research and evaluation
activities, the results of which should be used in forward planning. This will
ensure that the agency is meeting the needs of the community and the
service is of the highest quality.
ATCA Towards Better Practice in
TCs Recommendations
Recommendations
7 – routinely assess client satisfaction …
10 – set of indicator data …
11 – development of instruments that measure changes …
28 – peer review … promoting continuous quality improvement
SEEQ and ATCA Modified
Essential Elements
QIC ATOD Standards
National Standards Project
Incorporated throughout
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NSW Health - Drug and Alcohol
Treatment Guidelines for
Residential Settings
WA AOD Sector Quality Framework
Incorporated into the support material and within Performance Expectation 2.
The service encourages consumer participation and considers feedback
from consumers on an ongoing basis to inform planning and development of
non-discriminatory practice.
NZ AOD Treatment Sector
Standards
Within Standard 2. Organizational management (quality improvement and
risk management)
Community of Communities Service
Standards for Addiction Therapeutic
Communities
Within the Accreditation process (evaluating care and treatment)
US Prison based TC Standards (as
per the development project)
Within Standard Domain C. Administration (re quality assurance plan)
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Matrix 2: Comparison of generalised groups of ACHS standards with modified
essential elements from the ATCA Towards Better Practice in Therapeutic
Communities document
Note: the intention of the following additional two matrixes is to highlight in detail the fit with the previous
ATCA research on TC practice elements. Again the “fit” is subjective, however is informed by the
background material within the document. The matrix provides for improved scrutiny re the areas that
have been substantially established and those where there are some gaps to ensure a systemic
appreciation of the development of standards.
STANDARD CATEGORY/AREA GROUPING
1.
2.
3.
4.
5.
6.
7.
8.
1
2
3
4
5
Appropriate and timely service provision;
Leadership and management principles;
Consumer participation;
Strategic human resource management;
Information management and appropriate use/evaluation of data;
Occupational health and safety;
Health and safety risk management; and
Continuous improvement.
MODIFIED ESSENTIAL ELEMENTS
POTENTIAL
STANDARD
CATEGORY/AREA
Substance abuse is a complex condition combining social, psychological, behavioural and physiological
dimensions.
TCs focus on the social, psychological and behavioural dimensions that precede and arise from
substance abuse
Substance abuse is a symptom of underlying social, psychological or behavioural issues which need to
be addressed if recovery is to occur.
Patterns of drug use can be used to indicate underlying issues but are not the primary focus of
treatment.
Recovery involves personal development and lifestyle change consistent with shared community values.
2 - underlying
perspective
1
2 - underlying
perspective
1
1, 2 - underlying
perspective
1, 2 - values
7
Recovery involves learning or re-establishing the behavioural skills, attitudes and values associated with
community living.
The recovery process of the TC encourages a life-long commitment to personal development.
8
Living skills to support recovery develop from commitment to the values shared by the TC community.
1, 2 - values
9
1
10
Recovery requires establishment or renewal of personal values, such as honesty, self-reliance, and
responsibility to self and others.
Program involves abstinence from alcohol and other psychoactive drugs (unless authorised).
1
11
Residential TC treatment is of medium to long term duration, with actual length varied according to
1
6
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12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
individual requirements.
Residents are given a document clearly identifying their rights, and have these rights explained to them
on entry to the TC.
There are cardinal rules which if violated, can lead to termination from program (ie. no drug use, no
violence, no stealing, no sexual relations with other residents).
There is a written, agreed upon and periodically updated treatment plan for each resident.
[i] There are documented policies on aspects relevant to quality assurance, such as occupational health
and safety, equal employment opportunity, sexual harassment, confidentiality of residents' records,
staff training and qualifications etc. [ii] There are written, agreed upon and well known procedures for
management of residents’ affairs, such as admission and discharge, management of residents' finances,
arrangements for outings and visitors, complaints and appeals procedures.
Encouraging a sense of participation in and belonging to the community is critical to the effectiveness of
the TC approach.
Treatment involves learning and becoming committed to shared community values, including respect
for self and others, honesty, willingness to attempt personal growth, and responsibility to self and
others.
Treatment is multidimensional involving therapy, education, values and skills development.
TCs provide a safe, supportive environment for residents to experience and respond to emotions and
gain understanding of issues relating to their drug use.
The TC approach supports the development of individual responsibility for actions and their
consequences.
The TC approach involves supporting and acting responsibly towards other individuals and the
community.
Treatment encompasses developing a variety of approaches that help avoid the use of drugs, including
recreational activities and relapse prevention methods.
The presence in the TC of staff and volunteers with a history of addiction and recovery is encouraged to
provide residents with role models.
In general decision-making processes are consultative, with staff as objective facilitators and the final
decision-maker only where necessary.
Staff serve as role models for shared community values.
Through active participation in all aspects of the community, staff ensure the safe environment and
positive functioning of the TC is developed and maintained, encourage resident participation and
interaction, and provide appropriate therapeutic interventions.
Decisions on progression to the next stage of treatment or discharge from the TC involve community
consultation but staff retain ultimate responsibility.
Residents are informed of the consequences of breaches of rules and guidelines, and reasons for
decisions.
Specific processes are available and clearly explained for appeals of decisions and resolution of
conflicts.
Residents perform different tasks and acquire increasing responsibility and privileges as they progress
through the program, with consideration to individual circumstance.
Residents take responsibility for orienting, guiding and supporting new residents.
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2 – management
1
2 – leadership, 6, 4
2 – management
1, 3
1
1
1, 7
1, 3
1, 3
1
4
3
4
7, 3
1, 3
1, 2 – rules
1, 3
3
3
57
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
Residents conduct important peer management functions such as preparing work rosters, organising
and running house meetings.
Residents facilitate some group therapy or educational sessions with the support of staff.
3
3
Residents are expected to develop capacity to be a positive role model as they progress through the
program.
Access to health care is a routine part of the program.
3
Program provides information and the opportunity for residents to discuss the prevention and control
of health issues of particular relevance to drug users.
Program uses groups to provide encouragement to change behaviour and attitudes.
1
There are clear procedures for responding to breaches of community values, with differing levels of
response to reflect the specific circumstances.
Peer support and constructive feedback are integral to addressing negative behaviour and attitudes and
affirming positive achievements of residents.
Program fosters the development of supportive relationships between residents to facilitate individual
change.
Discussions and interactions between residents outside of structured program activities are an
important component of therapy.
Staff may involve themselves in activities such as recreation, meal preparation, dining and chores, on an
equal footing with residents, as a means of emphasising their membership of the community, and their
participation as role models.
Meetings are scheduled to occur frequently to provide information on arrangements, matters of
functional routine, and special events.
Meetings are convened within the community as needed to address significant issues affecting the
community, particularly those with a potentially negative impact.
Residents participate in program rituals and traditions, such as major festivals, birthdays and recovery
milestones, particularly graduation.
Leisure activities, such as organised sport, are encouraged for physical fitness, developing the sense of
community and team work, and to reinforce the message to residents that it is possible to have fun
without drugs.
Contact outside the TC is monitored or supervised, and restricted, particularly in the early stages of
treatment.
Sanctions issued in response to breaches of community standards, guidelines and values aim to provide
a learning experience, give the opportunity for behaviour to be adjusted, and give clear warning of
further consequences for behaviour that continues to be unacceptable.
Program includes regular drug screening, including where there are grounds for suspecting possible
drug use.
Residences are inspected at least weekly for cleanliness and completion of tasks, with occasional
additional inspections if needed to respond to issues such as theft or suspected drug use.
Support is given to residents who wish to seek education or training as part of their treatment program,
and all residents are encouraged to develop a vocational plan, particularly in the latter stages of
treatment.
Listening, speaking and communication skills are emphasised.
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1
2 – values
3
1, 3
1
1, 3
2 – management
3
3
1
1
2 – management, 7
1
1, 7
1
1
58
53
Program elements support the development of personal decision making skills.
1
54
Program includes opportunities for residents to discuss progress, emotions and experiences in a safe,
supportive environment.
Residents are encouraged to experience and appropriately express their emotions.
1, 3
55
1
66
Residents learn conflict resolution skills through discussion of principles in group sessions and the
practical experience of grievance and mediation procedures within the TC.
Selection of job functions takes into account residents’ capacity, developmental and vocational needs
and the demands of their individual treatment plan.
Work is used to enhance the sense of community, to build self-esteem and social responsibility, and to
develop communication, organisational and interpersonal skills.
The self-contained nature of TCs, with residents performing routine chores such as cooking and
cleaning, is important in encouraging residents to become self-sufficient and responsible for themselves
and others.
Residents are encouraged to attempt behaviours and activities, even if they doubt their abilities or the
reason for the behaviours and activities, as a means of developing a more positive attitude through
learning by doing.
The preparation for re-entry involves greater flexibility in the resident's personal program and increased
attention to relapse prevention, drawing together the skills, insight and behavioural change gained
through treatment, to support maintenance of lifestyle change outside the TC in a self-reliant manner.
The TC provides a combination of therapeutic involvements between residents and staff and among
residents (especially senior and junior residents) and living in a caring and challenging community as the
principal mediums to encourage change and personal development.
The right of residents to control the extent of disclosure in group settings of sensitive personal
information that is relevant to treatment is respected.
Program includes some use of formal instruction methods to present interpersonal skills and recovery
oriented concepts.
Interactions between residents and staff in an informal context during daily activities help establish a
relationship that facilitates therapeutic interactions.
Program provides a mix of group and one to one counselling based on individual need.
1
67
StafF offer personal experience as part of the therapeutic interaction.
1
68
Program identifies and subsequently addresses family issues, with family members and significant
others being engaged in a positive way, where possible.
Program has distinct stages generally reflecting a focus on assessment/orientation, treatment,
extended treatment or transition, and re-entry, respectively.
Treatment plans identify goals for each stage and achievement of these goals is assessed when
considering applications to move between stages.
In general, by the end of assessment/orientation, residents are aware of the rules and procedures of
the TC, are feeling comfortable as a member of the TC, and have committed themselves to the
treatment program.
Individual assessments are undertaken, including background issues, drug use history, physical and
mental health, either prior to or on entry to the TC.
1
56
57
58
59
60
61
62
63
64
65
69
70
71
72
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3
1
1
1
1
1
3
1
1
1
1
1, 3
1
59
73
74
75
76
77
There is an initial period in which new clients are assigned to senior residents or staff for introduction to
the program and initial support.
In general, by the end of the main treatment stage, residents have gained some understanding of the
issues underlying their drug use, are able to emotionally support other residents, and are not behaving
in an anti-social manner.
Program includes a process of setting individual goals that provides positive affirmation of strengths
and capabilities but also acknowledges boundaries to what is achievable.
In general the re-entry stage provides increased contact with the wider community, gives residents
increased independence, and focuses on preparing residents to cope with the outside world, including
developing supportive friendship networks and, where appropriate, re-establishing communication
with their immediate families.
[i] Planning during the re-entry stage includes establishing links with appropriate aftercare services and
support networks. [ii] Residents who leave without completion of the program are assisted with
alternative treatment arrangements.
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1 – outcome
1
1 – outcome
1
60
Matrix 3: Comparison of generalised groups of ACHS standards with
recommendations from the ATCA Towards Better Practice in Therapeutic
Communities document
POTENTIAL
STANDARD
CATEGORY/AREA
RECOMMENDATION
1
2
3
4
5
6
7
8
9
10
11
12
13
That further research be undertaken to validate the modified essential elements questionnaire (MEEQ)
as a description and definition of the components of the therapeutic community approach. Such
research should apply the MEEQ in other settings, such as substitution treatment and outpatient drugfree treatment, to determine the capacity of the MEEQ to distinguish TCs from other approaches.
Identification of items where differences are strongest would provide an indication of the unique
aspects of the TC approach.
Consideration needs to be given to which components of the MEEQ are most relevant to routine
monitoring and quality assurance aspects. Extraction of these components into much shorter
instruments is desirable for efficient application.
Using the MEEQ as a research tool, consideration should be given to the capacity of the essential
aspects of the TC approach to be delivered in a non-residential setting, and whether a non-residential
approach is most suited to particular groups of clients.
The day to day effectiveness of TCs should be determined by systematic evaluation activities that
consider inputs, processes, outputs, and outcomes.
Evaluation activities should be designed with a view to identifying the most effective elements of the TC
approach, taking into account client characteristics and other variables, so as to support a process of
continuous improvement.
Data collected on TC processes should incorporate measures of resident engagement and participation,
not just time in treatment.
Methods should be developed to enable TCs to routinely assess client satisfaction with the services
provided.
Further work should be undertaken to develop appropriate and convenient instruments for recording
TC processes.
Outcomes should be determined on a broad range of indicators of substance use, risk behaviour,
physical health, social functioning, emotional and psychological well-being. The set of outcome
indicators developed by Success Works Pty Ltd (2000) are supported as a useful basis for outcome
assessment.
Evaluation activities should involve the collection of a consistent set of indicator data at appropriate
points before, during and after treatment.
It is recommended that further research be undertaken to develop instruments that can be used to
measure changes in residents’ psychosocial dimensions associated with TC treatment.
TCs should include amongst their staff a range of skills, experience and qualifications encompassing
psychology, counselling, health and particular practice skills relevant to the activities undertaken in the
TC.
It is particularly important that TC staff possess the skills, attributes and understanding of group
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5, 8
5
8
5
5
8
8
4
4
61
21
dynamics that will enable them to establish and maintain the safe, supportive environment that is
essential to the therapeutic nature of TCs.
The presence on staff of people with a personal history of substance abuse is supported. Such
individuals should obtain appropriate training before becoming a member of staff.
Further work should be undertaken to identify an appropriate balance between experiential and
professionally qualified staff, and the nature and extent of training that would enable staff with a
personal history of addiction to most effectively apply that experience within the TC approach.
Research should be undertaken in a TC context to identify staff competencies important to the delivery
of effective interventions.
TCs should implement a program of staff training and development, drawing on nationally agreed
competencies for alcohol and other drug workers, to foster a culture of workforce development.
TCs should ensure supportive supervision and opportunities for staff to discuss potentially stressful
issues.
It is recommended that further work is undertaken to develop guidelines on standards for the physical
environment of TCs, with reference to relevant State, Territory and Federal regulations, and drawing on
requirements for general health and accommodation services and the existing ATCA peer review
manual.
TCs should maintain appropriate financial systems that clearly identify all costs and income relating to
operation of the facility.
TCs should be able to provide a clear rationale for fees charged to clients.
22
Fees should be set at a level that does not result in financial hardship for clients.
2
23
A full cost benefit analysis of TC treatment should be undertaken, with alternatives such as substitution
treatment, and outpatient drug-free treatment as comparisons. Cost savings from avoided judicial
system, health services and accommodation support utilisation should be taken into account.
Consideration should be given to using existing outcome data for TCs and methadone maintenance
treatment in a modelling approach to estimate relative long-term cost effectiveness of these
approaches for people who are opioid dependent.
Different ways of modifying TC programs to suit individual needs should be explored, with assessment
of the impact on treatment retention and outcomes as well as community dynamics. Possible
modifications include varying program intensity, incorporating additional elements to address specific
needs, developing introductory programs to help prepare clients for entry to the TC, varying the timing
of different elements of the TC program, and providing more coordinated aftercare programs.
The cultural needs of Aboriginal, Vietnamese and other minority population groups should be
determined, and ways of addressing these needs in the TC context considered.
It would be premature to establish a system of accreditation specific to TCs. Further work to establish
the purposes of such accreditation, conditions of accreditation, assessment and decision processes
would be required before such a move could be considered.
The existing process of peer review undertaken by the Australasian Therapeutic Communities
Association should be continued as a means of sharing information and promoting continuing quality
improvement of TCs, pending a decision on the desirability of a system of accreditation specific to TCs.
An effective treatment system is one that provides a diversity of options to suit the differing needs of
substance users, and the changing needs of individual users as they progress through treatment. TCs
should continue to be a component of a diverse treatment system.
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TCs are most appropriate for those more severely affected by substance use, criminal activity and social
disadvantage.
Research should be undertaken to explore the effectiveness of approaches such as preparatory
interventions, family involvement and program adaptations, in promoting increased retention and
increased levels of engagement and participation in TC treatment.
Research should be undertaken to further explore the effectiveness of methadone withdrawal within
the context of a TC program, and issues relating to this approach.
Further research should be undertaken to document admission processes and any interventions
provided to support prospective residents during waiting periods, and to investigate effects of
admission processes and waiting time on treatment outcomes.
Further research should be undertaken to explore the effect of prior treatment experience on
engagement and participation in TC treatment, and the outcome of treatment.
Research should be undertaken to compare treatment outcomes for residential rehabilitation facilities
that do, and do not, accord with the definition of TC developed by this project.
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APPENDIX C.
Summary of Project Considerations
1.
Consumers need to be involved in the consultation process.
2.
Key government stakeholders need to be informed of the process of the
standards development.
3.
The standards need to be developed to enable maximum participation of the
Australia and New Zealand TC sector.
4.
A review mechanism is to be incorporated into the development of the standards.
5.
The standards are to incorporate consumer safety considerations.
6.
The standards developed are to be outcomes oriented, with clear objectives,
measurable outcomes, indicators, guidelines for criteria, and examples of
appropriate practice.
7.
The number of standards developed is to be kept to a minimum.
8.
The standards developed will focus specifically on TC service requirements, and
able to be linked wherever possible with “core” standards requirements that
services may be engaged in.
9.
The standards developed are to fit within the ACHS generalised group areas to
enable TCs to link TC specific standards with existing standards/quality
requirements.
10.
The standards developed will focus solely on TC specific elements.
11.
Standards need to incorporate a system of continuous improvement.
12.
Consultation needs to determine the extent of CQI elements and Change
Management principles currently incorporated into TC processes.
13.
To support a common language and shared understanding of CQI and Change
Management consultation needs to determine existing language of change.
14.
Consultation needs to determine a willingness of managers and senior staff to
see CQI and Change Management awareness and implementation as a
dedicated module or something that is woven into the training package.
15.
Consultation needs to determine TC staff training needs in relation to
implementing standards/quality processes.
16.
Evaluation of the training package will be incorporated.
17.
Consultation needs to determine staff opinion of what makes training effective.
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18.
The training package will incorporate aspects that support positive organisational
learning culture.
19.
The training package will incorporate aspects that support training transfer.
20.
Consultation needs to determine what training supports are currently in place.
21.
Consultation needs to examine the opinions re the considerations presented in
the matrix of adult learning principles.
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APPENDIX D.
Draft Consultation Plan
Which TCs?
It is hoped that face to face consultation can be coordinated with as many of the ATCA TC members as possible.
The meetings will need to be coordinated to maximise travel arrangements and to meet the timeframe of the
project.
Who will be consulted?
1 – 1.5 hour meetings, involving guided open ended discussions, will be requested with the manager/CEO or
whoever they recommend is the most appropriate person.
Where face to face meetings cannot be coordinated telephone conversations will be requested with the
manager/CEO or whoever they recommend is the most appropriate person
A request will be made re meeting for 1 – 1.5 hour with staff/staff representatives of each TC
A request will be made of 2 large adult TCs to meet with senior consumers/consumer representatives (in order to
meet the requirement of consumer input)
A request will be made of 2 large/more “sophisticated” TCs to meet with a board member(s) (to determine the
potential leadership connections re potential standards)
The information provided
A summary of the project, intention of the consultation, what is hoped to be achieved will be prepared and sent to
participating TC managers/CEOs prior to
Information shared will be treated confidentially, with comments presented in a consultation report as a collective
comment, or only as a quote when permission has been obtained
Intention
Open Ended Discussion - Consultation Direction
Introduction
-
Confidentiality
-
About the project, what it hopes to achieve
-
Desire for honest responses to best inform process
Get to know the
TC
Determine
whether the TC
has
previously/is
currently
participating in a
Who
All
Determine
CEO/ Managers
-
how long the service has been operating
-
if they see the service as a TC – or developing towards a TC
-
what changes were needed to support this evolution/or are seen as a priority for the
ongoing development
-
what, in their eyes, makes a service a TC
-
what, in their eyes, makes a “quality” TC
-
what support do they draw on to develop the TC (eg literature, ATCA, peer services)
-
if they have been involved in the ATCA peer review process
-
the extent to which they implement/review the modified essential elements
-
if they have a focus on the provision of service to any particular population group
-
if they feel the TC approach to service provision is necessarily different for this/these
population groups
-
if the approaches used in their TC is informed by any literature or research in particular
The following questions will apply to each quality process they have been involved in (if any)
– including the ATCA peer review. If they have not applied any the discussion will be held as
a hypothetical. Determine
-
what quality process/ standards they are applying/have applied
-
whether they know anything about the development of the standards – who was involved
(is there any sense of ownership)
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CEO/ Managers
quality process
-
whether they have been involved in any review of the standards (is there a sense of
empowerment over the standards direction)
-
whether their engagement with the process is/was voluntary or imposed – determine any
real or perceived conditions and sanctions
-
if mandatory – whether they feel this has contributed in any way their own/staff noncompliance/resistance to the process
-
if involved voluntarily – whether the TC funders know about their involvement in the quality
process (accountability and transparency)
-
whether the service consumers know about the involvement (accountability and
transparency)
-
what impression they have of the standards (determining historic attitude towards quality
process re how it may influence attitude to the TC standards)
-
whether they feel the standards support the development of the service (attitudes – if
negative need to consider ways of overcoming that)
-
whether they feel the standards support the TC process (establish potential ownership)
-
whether they feel the process is in line with the general principles of a TC (eg supports
change, growth, collective planning and involvement, has rewards, announces
achievements, etc)
-
whether they feel the standards they are/have been engaged in cover the range of areas
that they expect of a set of standards. If not determine the gaps
-
whether the service has implemented any measuring of outcomes since applying the
standards (active participation in CQI)
-
whether they use any form of benchmarking in their quality process
-
whether the TC has a person on the team dedicated to addressing/driving quality
-
the extent to which the team are involved in the process (is it worker driven)
-
the extent to which the community/residents are involved in the process (parallel
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processes)
Determine
what would be
expected in
Australian and
New Zealand
TC specific
standards
-
whether they find any area/ particular standard more difficult to address
-
whether they find any area/ standard more easy to address
-
whether they have received any support to implement the standards, if so whether the
support has been used and useful
-
who has benefited most from the implementation support
-
what their understanding of CQI is
-
whether they feel the standards and any support (including resources) encourage CQI
-
whether they have been reviewed against a set of standards
-
whether they felt that process was useful
-
whether any changes resulted from the overall quality process
-
what the staff impression of the process is
-
what the board impression of the process is
-
if they have received a report – who has had access to the report (i.e. funders,
consumers, board, all staff, broader community)
-
Determine the sense of support for the TC specific standards and what their perception of
what would be required to implement them would be (eg requiring a lot of time where
there is none to spare, little gain for a lot of effort, fantastic, progress the whole TC sector
– good to know what we are dealing with in terms of change management requirements
and even management/leadership willingness)
Considering a “quality/ideal” TC service, determine specifically for TCs (using the AHCS
standards grouping as a guide):
-
Determine views on how it would ensure appropriate and timely service provision (much of
this information can be gleaned/supported by previous ATCA supported processes or
literature. Drawing on the language of the sector will be important and will support
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Managers, staff
(at some
services
consumers
and/or board
members)
ownership). Potential prompt questions may include:
-
how would a “consumer” get into the service
what would be the criteria for their acceptance into the community
what would the service look like
what do they see as the TC service specific qualities that most enhance the
outcomes for consumers
what are the specific things to consider in a TC re safety for the consumers
what are the environmental considerations that are needed to support the ideal
TC
determine if they feel the TC is already working towards these “ideals” and
discuss any barriers to achieving them
-
Determine views on what (if anything) is seen as different in the ideal TC service
compared to other general AOD services in relation to management and leadership
-
Determine the current extent of consumer participation and any perceived barriers to high
level participation. Question for prompting may include:
-
-
-
how is consumer feedback used to inform the TC generally
are consumers currently on the board, included in processes of staff
recruitment, involved in community decisions, can they determine their own
level of engagement,
ideally what do you think the extent of consumer participation is good for a TC
(beyond the direct participation in their own “recovery” and supporting it in
others in the community)
what support would there need to be in place to support a high level of
consumer participation
Determine the range of TC specific requirements re strategic human resource
management. Possible prompt include:
-
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what would be the ideal mix of staff working at the TC (qualifications, gender,
recovery experience, population groups, etc)
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-
-
what are the different support needs for staff in a TC compared with other
services(eg supervision, training, networking, communication, participation in
planning/decision making, peer support, etc)
are there different supports needs again for people who have a personal
history of AOD treatment/TC graduation
should there be different recruitment processes for staff working in a TC
compared with employees of other AOD services
what is satisfying about working in a TC that you may not get in other services
Determine how information management and appropriate use/evaluation of data is seen
as different in the TC setting. Possible prompts include:
-
-
where is it most important to exchange information in a TC (eg shift handovers,
debriefing, supervision, case discussions) and is this in a written form or just
verbal
are their particular issues for a TC re client records or are they much the same
consideration for any AOD service
is ongoing research, gathering of data, and/or evaluation against performance
indicators currently in place
what level of data collection would be of most use re informing ongoing
improvement practice at a TC
What are the barriers to maximising the use of information and data
-
Determine any perceived specific staff safety considerations for a TC
-
Determine the extent of consciousness re health and safety risk management of staff and
consumers. Potential questions
-
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what level of critical incidents occur in the TC
how should risks be assessed in a TC (reactive/proactive, who should be
involved in the identification, prioritization, etc)
what is the best way, in a TC, to ensure everyone (staff and consumers) is
aware of why some rules are in place – i.e. to prevent risk and ensure the
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safety of the community
-
Determine the extent of awareness of continuous quality improvement processes
-
-
Do you think it is of particular importance that staff and consumers are aware
of policies and processes in a TC
what is the current process for p&p development and implementation, and is
this effective in terms of everyone who needs to knows the process
what should the idea planning or decision making process look like in a TC
can they provide and example of a changed approach at the TC that improved
the service (for staff or for consumer outcomes) – what were some of the
issues, what made it work/or not, how do they know if it was an improvement
or not
do you think the process of putting a new/changed approach in place needs to
be particularly supported in a TC (is it easier, what are the things you see
would make it easier)
Determine the willingness of services to discuss the development of specific TC standards
with their jurisdiction government stakeholders
Stakeholder
consultation
-
Determining
the views on
what makes a
good training
package and
what needs to
be in it
Determine
-
if staff or managers can identify some recent training/learning tool accessed that was
“good” (what made it good)
-
if staff and managers have attended any TC specific training – if they feel they were able
to apply what they learnt in practice and what supported or blocked this happening
-
the top 3 training area needs of staff when they first start working in a TC
-
the current top 3 training area needs generally for staff working at the TC
-
any specific training needs for managers of a TC
-
any specific training needs of board members
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Managers/CEOs
Management
and staff