Quality Assurance

Quality assurance is monitored in a number of ways. First, the Client Satisfaction Questionnaire is completed immediately post-treatment to assess the extent to which clients are satisfied with the services they received during treatment sessions. This permits consumers the ability to influence the quality of service to future clients. Second, an extensive protocol adherence method has been developed to assure therapists are implementing Family Behavior Therapy (FBT) as intended. Third, clinic procedures, program charts and data management, are routinely evaluated following standardized protocols. A summary of these methods follows:

The Client Satisfaction Questionnaire 

(CSQ-8; Larsen, Attkisson, Hargreaves, & Nguyon, 1979) is an 8-item measure designed to measures services received, and has been used effectively in controlled outcome studies involving substance abusers (see Fals-Stewart, O’Farrell, Birchler, & Kelley, 2004) to assess satisfaction of clients with the services they receive. Scores range from 8 to 32, with higher scores indicating greater satisfaction. This questionnaire is administered to all clients at the conclusion of intervention. The CSQ-8 is commercially available for a small fee from its developers.

Integrity of FBT and Therapist Adherence/Competence 
Several strategies are employed to ensure the integrity of FBT (Yeaton & Sechrest, 1981), including 1) intervention manuals and therapist step-by-step protocol checklists to be utilized during session, 2) written documentation by the therapist of techniques used during the session, ratings of the extent of client participation, and client progress towards treatment goals, 3) audio taping of all sessions, 4) on-going clinical supervision of treatment sessions, review of selected audible audiotapes, and corrective feedback to therapists, and 5) detailed protocol checklists by therapists that indicate the materials needed for each session, specific tasks to be completed, and the order in which treatment tasks will be completed. These checklists assist in determining therapist adherence and competence. Therapists indicate on each protocol checklist whether each therapy task was performed. Independent raters then listen to the audio- tapes, and indicate on a separate protocol checklist the extent the therapy tasks have been completed. The therapists, and raters' lists are compared, and a reliability estimate is computed. Reliability is calculated by dividing the total number of agreements by the total number of agreements plus disagreements, and multiplying the resulting dividend by l00. The validity estimate is based only upon the lists completed by therapists, and is calculated by dividing the number of tasks completed by the total number of possible tasks, and multiplying the dividend by 100. This method of protocol adherence has been utilized in controlled treatment studies funded by NIH (most recently Azrin, Donohue et al., 2001). Ninety percent therapist adherence is customarily required for therapists to be judged satisfactorily competent in the administration of FBT protocol.

Quality Assurance

Quality assurance is also maintained by monitoring approximately 5 to 10% of client charts of therapists, as well as various clinic procedures, on a random basis. To assist in this process, a chart has been developed to record all necessary quality assurance data that closely corresponds with the detailed step-by-step protocol checklists. All forms are standardized, so the process is relatively quick (less than a couple of minutes per chart). Therapists who evidence errors are required to fix all problems, and the issues are brought to the attention of supervisors. The charts of these therapists are also examined more frequently in future reviews. When a database is established, it is necessary to assure the data is accurately managed as protocol dictates. Therefore, data for approximately 15 to 20% of clients is monitored on a random basis. When errors are detected, the database is checked more frequently, and feedback is provided to data management specialists so future errors are less likely to occur. As might be expected, these assurance procedures and forms are freely available to participants of the FBT workshops.