Eliminate Excessive Paperwork

Problem:

Clients and counselors spend too much time on paperwork, which could otherwise be used to decrease the waiting time for intake, assessment, and treatment.

Solution:

Eliminate excessive paperwork so that the required information is captured once, in a timely fashion, in as few pages and with as few signatures as possible. Delay paperwork until it is actually needed to make a timely decision—just-in-time.

Featured Stories

The Drug Abuse Comprehensive Coordinating Office (DACCO) in Tampa, Florida reduced their intake paperwork from 40 to 20 pages and reduced the time required for the intake appointment from 1.5 hours to 1 hour, allowing counselors more time to connect with and engage clients in treatment. DACCO held a training session to talk about why specific forms were used and which ones were unnecessary, learning that even though a form was not required by the Department of Corrections, it was useful for counselors and kept information requirements consistent across patients with different payers. For more information, see the list of DACCO forms.

The Center for Drug Free Living in Orlando, Florida decreased the time required for documentation after the assessment from 60-90 minutes to 15 minutes and reduced the time between screening and assessment completion from 10 days to 3 days by modifying their intake and assessment paperwork. They also increased the average number of assessments completed, from 2 to 4 assessments each day. They no longer required clients to complete an 11-page psychosocial form before assessment and they identified admission paperwork that clients can complete without a clinician while waiting for their appointment. They also implemented the Addiction Severity Index-Multimedia Version®, a client self-administered interactive computerized assessment with a psychosocial summary. Questions and answer options are presented verbally as well as written on the screen, so that clients need not be literate to self-administer the ASI. Lastly, they developed Microsoft Word templates for clinicians to use to document staffing placement, individual placement, individual session, and group notes more efficiently. For examples, see the Aftercare Plan, Brief Mental Status Exam, and Discharge Summary documents.

Lessons Learned

• When you evaluate paperwork, consider the following questions:
  • Is it required? Ensure compliance with state regulations, contracts, grants, managed care, and credentialing agencies, such as JCAHO and CARF.
  • Is it redundant? Make it your goal to collect a given piece of information once. Is it timely? Collect information in a just-in-time fashion.
  • Who completes it? Does paperwork have to be completed with a clinician present? Separate out forms that clients can complete without a counselor present. Consider having a non-clinical staff person assist clients, if necessary.
• You can identify the paperwork used by collecting forms during the walk-through, by checking for paperwork in client charts, and/or by asking the staff for all of the forms they use.
• Break the change process into small, manageable pieces by focusing on eliminating excessive paperwork at one point in the treatment process at a time:
• Before assessment (e.g., first contact, screening, intake)
• During assessment
• After assessment and during treatment (e.g., treatment planning, transfer, discharge)
• Post-discharge (e.g., follow-up to track outcomes)
• Make sure you figure out how staff will use time gained by eliminating paperwork. Some agencies have added assessment appointments; others use the extra time for Motivational Interviewing to engage clients in treatment.
• Review forms regularly so that forms that were eliminated don’t creep back in and forms that may have been added for a special project or grant and are no longer needed can be eliminated.
• The amount of paperwork that clients have to fill out even before having an assessment appointment may cause clients to drop out before they even begin treatment.

Tracking Measures

Cycle Measure

• Number of pages used
• Time required for staff to complete paperwork
• Time required for clients to complete paperwork

Data Collection Form

None

ActionSteps

Plan

• 1. Appoint a single person to be responsible for paperwork changes (not a committee).
• 2. Collect samples of all existing paperwork.
• 3. Collect baseline data for two weeks:
  • Number of pages of paperwork

Do

• 4. Review every form to determine:
  • Is it required? Ensure compliance with state regulations, contracts, grants, managed care, and credentialing agencies such as JCAHO and CARF.
  • Is it redundant?
  • Is it collected in a just-in-time fashion?
  • Who completes it? Does it have to be completed with a clinician present? Separate out forms that clients can complete without a counselor present. Consider having a non-clinical staff person assist clients, if necessary.
• 5. Redesign the package of forms as required.
• 6. Pilot test the new paperwork package for the next two weeks.
• 7. Track these measures:
  • Number of pages of paperwork
  • Time required for staff to complete the paperwork
  • Time required for clients to complete the paperwork.

• 8. Check the fidelity of the change. Was the change implemented as planned?
• 9. Evaluate the change:
  • Did the time required for staff to complete paperwork decrease?
  • Did the time required for clients to complete paperwork decrease?
  • Was the information available when needed?

Act

• 10. If this change was an improvement:
  • Adopt this change or adapt it for more improvement and re-test it.
  • Document the new package of forms that resulted in an improvement.
  • Train all staff in new process.
  • Figure out how staff will use the freed up time.
  • Repeat forms revision for the next point in the treatment process.
  • Test other, related promising practices that apply to your setting.

If this change was not an improvement and you can’t make it work, abandon this practice and test other promising practices that might be more successful in your setting.

More Stories

Community and Family Resource in Fort Dodge, Iowa shortened the screening time for assessment from 2 hours to 1 hour by delaying paperwork that was not necessary until admission. They realized that they were completing a psychosocial history unnecessarily on clients who were not recommended for any treatment. This change helped reduce the waiting time for treatment from 39 days to 4 days. See the CFR Improvement Report for more information about these changes.

Gateway to Prevention in Shawnee, Oklahoma reduced the time required to collect information at first contact from 20 minutes to less than 5 minutes and decreased the time that counselors and clients spend together on intake paperwork from 1 hour to 20 minutes. They reviewed every piece of paperwork to determine whether it improved access to treatment; if not, they eliminated it.

Catalyst Behavioral Health in Oklahoma City, Oklahoma reduced intake paperwork from 25 pages to 10 pages and combined two intake appointments into a single appointment. They removed redundant questions, used a simple yes/no checkbox format, and created a preliminary information packet that clients can complete without a counselor present. They also told counselors that if they had other questions to ask, they could do so—but not during intake; delay those questions until later.

Island Grove Regional Treatment Center in Greeley, Colorado consolidated many forms and combined forms that required a signature, reducing client signatures required from 16 to 7.

STEP 2 in Reno, Nevada reduced the time counselors spend writing group notes from 2 hours to 45 minutes per week after finding that the state required group documentation only once a week, not for each session. At each group session, clients are asked to write 2-3 sentences identifying what they learned. At the end of the week, the counselor writes one group note per client for all of the groups attended, including notes about what the client learned as well as their own observations.

The Delaware Division of Substance Abuse and Mental Health (DSAMH) reduced paperwork by 2 hours per client by reviewing every form completed at each point in the continuum of care—intake, assessment, discharge, and transfer—at six different agencies, and identifying forms that were not required by the state, grant, contract, managed care, or credentialing agencies or did not need to be completed as frequently. This same approach could be used by provider agencies.

Mid-Eastern Council on Chemical Abuse (MECCA) in Des Moines and Iowa City, Iowa reduced the initial appointment time from 60 to 45 minutes by reviewing and updating the information sent by Employee and Family Resources (the centralized assessment center) instead of collecting the same information again.

The Patrician Movement in San Antonio, Texas reduced non-billable counseling hours spent screening clients for outpatient care by providing clients with a self-screening tool and videotape that explained the form. One staff member remained available to answer questions. Clients that choose self-screening also talk briefly with a staff member regarding the possible ramifications of their decision. This change allows staff to devote more time to client care.