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Table 3 Example of quality improvement report for one indicator

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

Criterion number 34
Domain Organization and management
Theme Coordination with other levels of care
Indicator Establish stable relationships and coordination with affiliated social services and agencies competent in legal matters pertaining to the Department of Justice.
Rationale The range of legal and social problems associated with drug use requires a suitable level co-operation and coordination with the network of social services and agencies in legal matters in the Department of Justice.
Measurable elements This will be assessed in terms of:
     - stable mechanisms for interaction and coordination
     - an established work plan containing a schedule of meetings
     - communication channels
     - a registry system
     - specific protocols.
Standard 100,0% (all measurable elements should be in full compliance with)
Sector performance (2001) 68.2% (the average compliance with the criterion in the overall center)
Your performance (2001) 47.3% (the compliance with the criterion in your center)
Results The average performance of this indicator in the sector (68.2%) is below the established standard. Of all centers in the sector, none was completely non-compliant and 15 of the 22 centers were fully compliant.
Targets for quality improvement action Compliance with measurable elements was as follows:
     - Evidence of some coordination with other levels of care: 93,5%
     - Calendar of Meetings: 29,5%
     - Stable communication channels: 15,9%
     - Registration system: 13,6%
     - Consensus protocols of action: 40,9%
     - Referral protocols and tracking: 43,2%
  The main reason for non-performance of this indicator has been the lack of systematic work with the department of justice followed by lack of collaboration with other social services. Moreover, compliance with protocols for intervention and monitoring of cases is low. The areas indicated above should be the target of further improvement work.