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Table 2 Evaluation of individual center's performance: domains, themes, indicator and measurable element

From: Results of a sector-wide quality improvement initiative for substance-abuse care: an uncontrolled before-after study in Catalonia, Spain

Domain Theme Indicator N (cases revised)* Standard Compliance
      At baseline At follow up Change
Care pathway Process of admittance 1. Ensure follow up visits after user contacts and hospitalizations. 2476 75% 100.0% 100.0% 0.0%
  Process of care 2. Offer an individualized treatment plan in appropriate timeframe. 1312 90% 100.0% 95.5% -4.5%
   3. Offer vaccination against hepatitis B to all users at risk. 757 90% 40.9% 63.6% 55.5%
   4. Provide access to counseling services to HIV positive users. 703 85% 4.5% 57.1% 1168.9%
   5. Provide a list of treatments and services, including a description of the nature of the intervention. 184 100% 45.5% 86.4% 89.9%
  Pharmacological treatment 6. Register patients drug prescriptions properly. 1223 100% 72.7% 90.9% 25.0%
  Follow up care 7. Follow up users in the methadone maintenance programme at least every 6 months. 1119 90% 90.9% 77.3% -15.0%
   8. Support the user in adhering to the care pathway. 14256 85% 65.0% 86.4% 32.9%
   9. Actively follow up patients that do not attend the dispensing of methadone. 542 90% 50.0% 50.0% 0.0%
  Prevention 10. Promote and participate in prevention activities (on own initiative, in coordination with community agencies or by indication of agencies). 64 100% 95.5% 95.5% 0.0%
  Harm reduction program 11. Have standardized guidelines for the prevention of risk behaviors associated with substance use and sexual behavior. 152 100% 63.6% 90.9% 42.9%
   12. Provide injection equipment (syringes) to intravenous drug users. 52 100% 59.1% 100.0% 69.2%
   13. Have programs aimed at (potential) users not yet in contact with the center. 53 100% 86.4% 90.9% 5.2%
Relations and user rights Confidentiality 14. Ensure confidentiality of all user-related data. 83 100% 40.9% 72.7% 77.7%
  Information 15. Ensure that users have all the necessary information to take an informed decision regarding all health-related actions. 1150 100% 4.5% 22.7% 404.4%
  User satisfaction 16. Demonstrate a system of dealing with complaints (ensuring feedback within two weeks).. 59 80% 80.0% 76.9% -3.9%
   17. Assess the satisfaction of users with the services received. 100 100% 36.4% 36.4% 0.0%
  Family involvement 18. Have an action plan with families, encompassing monitoring and periodic contacts, every six months. 683 80% 90.9% 86.4% -4.9%
  Community involvement 19. Promote the reintegration of the user in the community. 528 80% 100.0% 95.5% -4.5%
   20. Engage in efforts to improve community acceptance. 57 100% 100.0% 95.5% -4.5%
   21. Conduct activities to improve social acceptance of care in collaboration with associations, councils, regional councils, etc. 56 90% 86.4% 95.5% 10.5%
Environment and infrastructure Appropriateness of the facilities 22. Designate a space reserved for the intake and dispensing of methadone. 53 100% 81.8% 95.5% 16.7%
  Organization and waiting times 23. Provide written information to the population at risk about the services, including information on treatment, hours, place of care. 124 100% 40.9% 95.5% 133.5%
   24. Anticipate the provision of services to patients outside opening hours. 61 100% 63.6% 81.8% 28.6%
   25. Initiate diagnosis and therapy in a period no longer than 2 weeks of initial visit. 1325 80% 88.2% 76.2% -13.6%
  Documentation systems and registries 26. Document the clinical history for all users actively attended in center. 1266 100% 59.1% 86.4% 46.2%
   27. Make accessible the clinical documentation generated during the visits to all members of the multi-professional team. 1321 95% 95.5% 100.0% 4.7%
Organization and management Multi-professionalcare 28. Assess all patients in the care at least once by the professionals who comprise the multi-professional team. 1197 75% 31.8% 63.6% 100.0%
  Protocols 29. Demonstrate protocols for the triage of users with organic pathologies. 159 100% 36.4% 90.9% 149.7%
   30. Demonstrate protocols for the triage of users with psychopathologies. 81 100% 45.5% 72.7% 59.8%
   31. Demonstrate protocols for the triage of pregnant woman users. 101 100% 40.9% 90.9% 122.2%
  Continuing education 32. Professional should participate in continuing education activities. 375 80% 45.5% 63.6% 39.8%
  Professionals' opinion 33. Carry out regular surveys on the opinion of professionals. 57 100% 18.2% 40.9% 124.7%
  Coordination with other levels of care 34. Establish stable relationships and coordination with affiliated social services and legal agencies. 170 100% 45.5% 68.2% 49.9%
   35. Coordinate work plan with the health care area administration, mental health centers and referral hospitals. 219 100% 54.5% 72.7% 33.4%
  1. * the differences in the denominators between indicators is due to the level at which the indicators is selected: records (depending on type of user) at user level or organizational policies at center level.