IMPLEMENTATION GUIDELINES FOR THE

OQ-ANALYST (OQ-A)

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 Introduction

This document provides specific information for the use of the Outcome Questionnaire (OQ
45.2) for adults 18 and older and the Youth Outcome Questionnaire (Y-OQ 2.0) for children 4 to
17 years of age. Its purpose is to familiarize the user with material found in the technical
manuals for each test as well as the user guide developed for the OQ-A. The test manuals were
written by the authors and contain essential information on the background theory, development,
validity and reliability of the OQ & Y-OQ and are referenced throughout this document. The
user guide describes how to setup and use the OQ-A which is a software product that administers
scores and reports on the above outcome tools. A major advantage of the OQ-A is that it
contains empirically derived algorithms that predict cases that are likely to “fail” which is
defined as individuals leaving treatment with no change or with exacerbated symptoms.

The guidelines are organized with basic questions in mind that clinicians may ask as they
implement the OQ or Y-OQ in their practice. As evidenced in the following table of contents
these questions provide a high-level introduction to help clinicians “hit the ground running”. In
addition, the appendices are provided for support technical implementation and training of
support and clinical staff.

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 Table of Contents

1. What is the value of using standardized instruments to measure clinical

change?............................................................................. 4

2. What do the OQ- 45.2 and Y-OQ measure?..................................5

3. Why select these specific instruments?..........................................6

4. Guidelines for administering the instruments to patients………...8

5. Scoring the QO 45 and Y-QO……………………………………11

6. Interpreting the results: How to use the instruments to monitor patient

progress?.........................................................................................12

7. How can the instruments and the OQ-A benefit the process of
treatment?........................................................................................14

8. Monitoring the quality of care using the instruments……………..14

Appendix A Checklist for implementing the OQ-A……….…………17

Appendix B Installation instructions for the OQ-A…………………..20

Appendix C Instructions for setting up clinics, staff and clients……..44

Appendix D Sample training for support staff using the OQ-A

Appendix E Sample training for clinical staff using the OQ-A……

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What is the value of using standardized instruments to measure clinical change?
There are several reasons for using standardized instruments to measure clinical change during
mental health treatment.
1. The principal reason is to provide you (the treating clinician) with objective and quantitative
feedback about your patient’s progress. You can use this information as a check and balance
against more subjective impressions of the patient's progress or deterioration. Furthermore,
since the results are quantified, the OQ-Analyst software compares each patient's progress
against the progress of other patients who began treatment with similar levels of disturbance.
Of course, measurements of clinical change using standardized instruments should never be
used as a substitute for clinical judgment. They are most useful as adjuncts to clinical
assessment that support your judgment rather than dictate your decisions. The OQ-Analyst
offers information that has been shown to enhance patient’s treatment outcome

2. A second reason for using standardized measures of clinical change is to streamline

communication between you (the provider) and those tasked with utilization management.
When you and the utilization management contact are looking at the same standardized set of
results, you have a shared point of reference, so communication is simplified and more
concise.

3. A third reason for using standardized measures of clinical change is that purchasers of mental
health services (patients, families, employers, and governments) are requiring objective and
quantitative evidence of the effectiveness of treatment delivered. There are at least two major
trends that are converging to increase purchasers' demands for this kind of accountability
from mental health managed care companies and providers

a. The first trend is the tightening of financial resources available to spend for mental
health treatment.

b. The second is the increasing societal awareness of the potential effectiveness of

mental health treatment, when delivered appropriately

Thus, purchasers are demanding more for their dollar, both because dollars are tighter and
because expectations are higher for mental health treatments. Standardized instruments that
measure clinical change offer a potentially powerful response to such demands for evidence and
provide one way to report patient outcomes.

4. A fourth reason is that the feedback provided by the OQ-A has been shown in five randomized
clinical trials in North America to have beneficial results on patient outcomes. These trials show
that clinicians who are alerted to treatment failure cases can reduce overall treatment failure from
50-66% when compared to clinicians who are not alerted to symptom deterioration.

What do the OQ- 45.2 and Y-OQ measure?

The OQ-45.2 has 3 subscales that measure an individual's subjective distress, quality of
interpersonal relationships, and adequacy of social and occupational functioning. The following

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excerpts from the Administration and Scoring Manual for the OQ-45.2 describe the purpose of
each of the three subscales:

 The Symptom Distress Scale (SD) measures subjective discomfort related to intrapsychic
symptoms of depression, stress, and anxiety. Research shows that the majority of patients
in outpatient mental health treatment have diagnoses that are depression or anxiety based.
The OQ-45.2 is heavily loaded with items related to these symptoms.

 The Interpersonal Relations Scale (IR) measures both satisfaction with and problems in
interpersonal relations. Research on life satisfaction and quality of life suggests that
people consider relationships essential to happiness. Research on people seeking therapy
has shown that the most frequent problems addressed in therapy are interpersonal in
nature. Therefore, items that attempt to measure friction, conflict, inadequacy, and
withdrawal in friendships, family, and partnerships are included.

 The Social Role Scale(SR) measures dissatisfaction, conflict, distress and inadequacy in
performance of tasks related to employment, school, family roles and leisure life. (Note:
employment is used here in the broadest sense encompassing activities such as
housework, yard work, volunteer work etc.).

Included in the above subscales are five "critical items" that alert the clinician to the presence of
suicidal thoughts, violent thoughts, and substance abuse. For more detail clinicians are
encouraged to read the Administration and Scoring Manual for the OQ-45.2.

The Y-OQ 2.0 has 6 subscales which assess and track the behavioral functioning and subjective
experience of a child or adolescent. The following excerpts from the Administration and Scoring
Manual for the Y-OQ 2.0 describe the purpose of each of the six subscales:

 The Intrapersonal Distress Scale (ID) assesses the child/adolescent's emotional distress,
including anxiety, depression, fearfulness, hopelessness, and thoughts of self-harm.

 The Somatic Scale (S) assesses the somatic distress a child/adolescent may be
experiencing, addressing symptoms that are typical presentations, including headaches,
dizziness, stomach aches, nausea, bowel difficulties, and pain or weakness in joints.

 The Interpersonal Relations Scale (IR) assesses issues relevant to the child/adolescent's
relationships with parents/guardians, other adults and caregivers, and peers. Items cover
attitude toward others, communication and interaction with friends, cooperativeness,
aggressiveness, arguing, and defiance.

 The Critical Items Scale (CI) assesses the presence and change in observed features of
paranoia, obsessive-compulsive behaviors, hallucinations, delusions, suicidal ideation,
mania, and eating disorder issues. (Note: a high score on any single item should receive
immediate and serious attention from the treating clinician.)

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  The Social Problem Scale (SP) assesses problematic behaviors that are socially related.
Although aggressiveness is also assessed in the IR scale, the aggressive content found in
this scale is of a more severe nature, typically involving the breaking of social mores.
Items in this scale include truancy, sexual problems, running away, destruction of
property, and substance abuse.

 The Behavior Dysfunction Scale (BD) assesses the child/adolescent's ability to organize
tasks, complete assignments, and concentrate, including times of inattention,
hyperactivity, and impulsivity.

Why select these specific instruments?

Various properties of the OQ-45.2 make it an excellent instrument for measuring treatment
effectiveness:

 The OQ-45.2 is user friendly to both the patient and to the clinician. For the patient, it is
brief (generally completed in 5-10 minutes) and easy to understand (questions are written
at a fifth grade reading level). For the clinician, it is easy to administer (i.e., support staff
typically hand it to the patient before a session in the waiting room). Because of these
practicalities, the OQ-45.2 doesn't take valuable time away from therapy sessions yet still
provides clinicians with a “snap shot” of patient functioning as they begin a therapy
session.

 The use of the OQ and Y-OQ allows for all patient outcomes to be assessed on a common
metric enabling comparability across cases. This can assist the clinician in developing
their “base rate” of effectiveness over time.

 Research documents the strong validity of the OQ as a scientifically grounded measure of

psychological distress, satisfaction with interpersonal relationships, and adequacy of
social and occupational functioning. For instance, one way its validity has been tested is
by correlating scores on the OQ-45.2 with other, well-established measures of
psychological distress (such as the Beck Depression Inventory, the Symptom Checklist
90R, the Zung Self-Rating Depression and Anxiety Scales, and the Taylor Manifest
Anxiety Scale), measures of interpersonal functioning (such as the Inventory of
Interpersonal Problems and the Rand SF-36), and measures of social role functioning
(such as the Social Adjustment Scale). OQ-45.2 scores correlated highly with scores on
all of these instruments.

 The OQ has strong reliability. Its test/retest reliability is high in the range of .79-.84.
This means that scores of persons with stable psychological and functional status tend not
to change from one administration to another. Because of this high reliability, the
instrument can be viewed as capturing meaningful change in patient populations. For
more detailed discussion of the psychometric integrity of both instruments, the clinician
is advised to consult the technical manual which detail ample references supporting
extensive testing in North American and abroad.

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  The OQ-45.2 is sensitive to change over short periods of time. Data from the field tests
described in the technical manual show significant differences in the pretreatment and
post-treatment scores after brief therapy. This demonstrates that the OQ-45.2 can
highlight quick changes due to psychotherapy. Such sensitivity to change is exactly what
the clinician needs to validly identify change during treatment.

 The OQ-45.2 is easy to interpret. There are three subscales. The Symptom Distress Scale
(SD) measures the severity of psychological distress. The Interpersonal Relations Scale
(IR) measures the patient's satisfaction with current interpersonal relationships. The
Social Role Scale (SR) measures how well the patient is functioning at work or school, in
the family, and in leisure activities. As an added feature, the OQ-45.2 has certain "critical
items" that alert the clinician to the presence of particularly concerning symptoms that
require detailed inquiry, such as suicidal thoughts or excessive use of substances. While
the subscale scores and responses to individual items provide the clinician with a
qualitative picture of the patient's current symptoms and functioning, the total score is
tracked as a quantitative measure of clinical change.

Y-OQ

 The Y-OQ 2.0 is the child and adolescent equivalent of the OQ-45.2. Like the OQ-45.2,
the Y-OQ 2.0 is user friendly to both the parent/guardian and to the clinician. Written at
the fifth grade reading level, it is easy to understand. It requires no instructions beyond
those printed on the questionnaire itself. It can be scored instantaneously by the OQ-
Analyst providing the clinician with real time feedback on patient status.

 Designed to cover the wide range of symptoms and behaviors found in child and
adolescent mental disorders, the Y -OQ 2.0 allows all children and adolescents seen in
psychotherapy to be measured with a single instrument. It reflects total distress in a
child/adolescent's life, incorporating the six most salient content areas of a child or
adolescent's behavioral and subjective experiences, as well as his ability to function in
society.

 The Y-OQ 2.0 was constructed to be sensitive to change over short periods of time while
maintaining high psychometric standards of reliability and validity. For a more detailed
discussion of the measure's development and psychometric properties, please refer to the
Administration and Scoring Manual for the Y-OQ 2.

 Like the OQ-45.2, the Y-OQ 2.0 is easy to interpret. There are six subscales. The
Intrapersonal Distress Scale (ill) measures psychological distress. The Somatic Scale (S)
assesses the extent to which the child/adolescent is reporting somatic symptoms common
to anxiety and depressive disorders in youth. The Interpersonal Relations Scale (IR)
measures the quality of the patient's functioning in relationships with others. The Critical
Items Scale (CI) measures a set of symptoms and behaviors that require immediate
clinical attention. The Social Problems Scale (SP) measures the presence of problematic
behaviors that are socially related. The Behavioral Dysfunction Scale (BD) measures the

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 patient's ability to function appropriately in the completion of tasks. While the subscale
scores and scores on individual items provide a qualitative view of the child/adolescent's
condition, as with the OQ-45.2, the most reliable and valid quantitative measure of the
child/adolescent's condition is the total score.

Guidelines for administering the instruments to patients

Scope of use
Both measures were initially developed to be used in outpatient care. However, over the past 15
years their use has been extended to a variety of populations. For instance, the OQ has been
applied in inpatient, employee assistance and primary care medical settings. The Y-OQ has been
applied in inpatient, residential, educational, wilderness and juvenile justice settings.
Description of relevant norms and findings from these extensions can be found in the technical
manual.

Frequency of administration
The OQ-45.2 and the Y-OQ 2.0 should be administered at intake or first session to capture the
beginning level of distress. The developers of the instrument recommend that it be administered
at each outpatient visit. Experience has shown that approximately 50% of psychotherapy cases
conclude in 3 or fewer visits and that many of these cases show positive gains. Continuous
assessment is necessary in order capture change that takes place in relatively short psychotherapy
episodes.

It is recommended that assessment take place at the beginning of treatment providing clinicians
with real time information on patient status as well as critical items (e.g., suicide, drug use, etc.).
In outpatient settings having longer average length of stay and in other settings (inpatient,
residential) frequency of administration can be guided by other parameters. For instance, in
long-term residential care settings, the OQ/Y-OQ has been administered on a 30-day cycle.
Conversely in acute short-stay inpatient settings administration can be separated a week.

Recommendation for how to present the instruments to patient

The intake worker, therapist or support staff should explain to the patient, parent, or guardian
that the Y/OQ can be viewed a routine questionnaire that monitors the patient's sense of well
being, just like a lab test on blood or blood pressure measurement answers questions about a
patient physical health. The patient, parent, or guardian should be informed that completing the
Y/OQ is strongly encouraged, but voluntary. Patients should be told that completing the tools are
a routine part of treatment for all patients and that they are not being singled out. Experience
shows that the attitude of patients toward completing the measures is highly dependent on staff
member’s positive or negative attitudes. Few patients reject the measures if clinicians suggest
they will be valuable and helpful to the patient.

The provider, or whomever is instructing the patient, parent, or guardian to fill out the instrument
should encourage him or her to do so in an honest and conscientious manner, and to be careful to
complete all items. It is critical that anyone who administers the OQ-to patients understand and
accept the use of these questionnaires because any negative feelings or beliefs they may have
about the instruments may impair the validity of the results.

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Developing a standard administration process
Clinicians have found that the administration of the OQ-integrates most smoothly into the flow
of their practice if they develop a standard administration process. Toward this end, we suggest
that each provider develop a standard process whereby patients, parents, and guardians can
complete the questionnaire shortly before their visits, so that valuable clinical time is not lost.
Use of the OQ-A enables the questionnaires to be taken on either a hand held PDA or in standard
paper format that is later scanned into the OQ-A system by the support staff. Time motion
studies have shown that after support staff become accustomed to the OQ-A, administration time
per patient is typically 30 seconds per patient inclusive of handing the instrument/PDA to the
patient and uploading the data into the OQ-A.

Anticipating situations where administering the instruments become a challenge

 Missing items on the tests. The OQ-A automatically estimates missing items that
do not exceed 10% of the total number of questions. It also flags missing items for
the clinician so that they can follow up on them in the early minutes of a session.
Experience has shown that missing information—particularly critical items (e.g.,
suicide, weight loss, drug use)—are indicators that should be followed up by
clinicians.
 Forgetting or losing the questionnaire. If you are aware and there is time, give the
patient another questionnaire and ask them to fill it out before beginning the session.
If there is inadequate time, you may want to have the patient use the first few minutes
of the session to fill it out so that you can make use of the information during the
session.

 Partially completed questionnaire. If the patient or parent/guardian has begun the

questionnaire, but has not completed it, it is recommended that the first few minutes
of the session be used to complete the form.

 Refuses to complete questionnaire. If at any time the patient or parent/guardian

refuses to fill out the questionnaire, or is highly resistant to it, it may be clinically
useful to identify the reasons and discuss them therapeutically. If misconceptions
exist, the provider can clear these up and can reiterate to the patient or
parent/guardian that the results can be useful to the treatment process.

 Illiteracy. The reading level required for the OQ-45.2 and Y-OQ 2.0 is that of the
fifth grade. They are written in simple jargon-free language so that most patients,
parents, and guardians can easily understand the themes that are addressed. In some
settings, patient advocates or peers have been used to assist patients completing the
instrument. In other settings, clinicians have assisted patients in completing the
instruments. The effect of assistance on the veracity of the scores at this time is
unknown.

 Lack of fluency in English. Both instruments are available in a variety of languages.

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 Identify the most common native languages (e.g., Spanish) and contact the OQM
office for alternative forms. In some instances, the results may need to be “keyed”
into the OQ-A manually. The effect of cultural differences on test scores is handled
in the technical manuals.

 Symptoms of dementia or psychosis. Neither the OQ-45.2 nor the Y-OQ 2.0 should
be administered to patients or parents/guardians who are unable to comprehend the
meaning of questions due to psychosis or dementia. If the symptoms are sufficiently
mild that the clinician feels that the patient or parent/guardian is able to understand
what is being asked, the questionnaire should be administered. If the patient's
symptoms of psychosis or dementia fluctuate from one session to another, have the
patient fill out the questionnaire only when he/she is able to understand the meaning
of the questions.

 Patient arrives late for a session. If the patient is late and has not filled out the
questionnaire, the clinician is advised to consider whether the 5-7 minutes for
completing the instrument would provide useful clinical information. In some cases,
patients arrive late to avoid completing the questionnaire and revealing information
covered in critical items that may prove useful to discuss in treatment. In the case of
a child/adolescent, the parent/guardian can be completing the test while therapy takes
place with the clinician.

 Arrives in state of extreme upset or crisis. If the patient or parent/guardian has not
already filled out the questionnaire and arrives, for whatever reason, in a state of
upset or crisis, the provider must judge whether the patient's or parent's/guardian's
frame of mind allows him to fill out the answers accurately, and whether
administration of the OQ-45.2-OQ 2.0 is clinically appropriate at this particular time.
In some instances, completing the tools provides a stimulus for communicating
specific symptoms that are causing the crisis or upset.

 Physically handicapped. If a patient or parent/guardian is physically handicapped in

such a way so as to make filling out the questionnaire very difficult or impossible, it
can be administered verbally.

 Change of parent/guardian bringing child into treatment. ? The same parent or

guardian should fill out the questionnaire at each visit because use of multiple
responders may adversely affect the validity of the results. The initial reporting parent
or guardian becomes the "designated parent/guardian" for purposes of questionnaire
completion. If the same parent/guardian will not be able to bring the patient in each
time for appointments, it is suggested that questionnaires be sent home to be filled out
by the designated parent/guardian within 24 hours before each appointment. The OQ-
Analyst tracks the respondent to indicate their relationship to the patient (e.g., father,
mother, guardian, etc.). If the provider notes that the questionnaire has been
completed by multiple respondents, they will need to study ratings made by the same
respondent in order to understand the respondent’s perception of the patient.

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  Child dropped off by non-custodial adult. If the designated parent/guardian will
not be able to bring the patient in each time for the appointment, have the designated
parent/guardian fill out the questionnaires within 24 hours before the appointments
and give the forms to who ever will be transporting the child/adolescent.

 Determining episodes of care. The OQ-A has empirically derived algorithms that
base prediction upon the number of sessions of therapy received by the client since
intake or first session. At times there can be extended delays between sessions. If the
delay between session is extensive (e.g., 180 days) the provider may reinitiate the
OQ-A by administering the instrument and recoding the OQ-A to accept it as the first
session and begin a new episode of care. There is no empirical research to guide
clinicians on this practice although it occurs frequently in outpatient care.

Scoring of the OQ and Y-OQ

The OQ-45.2 and the Y-OQ 2.0 can be administered in two different forms. One option provided
by the OQ-A is a paper administration format. Here, a test is completed by the client and then
scored by a scanner that is connected to the host OQ-A system. Patients complete the paper
forms and then give them to a support staff member in the office for data entry via scanner. The
OQ-A software computes the total score, subscale scores (3 for the OQ-45.2 and 6 for the Y -OQ
2.0), and identifies any critical items with elevated scores (i.e., these items turn “red” on your
computer screen or report). All of this information is provided on the “clinician report” that can
be either viewed on a computer linked to the host system or printed for insertion into the client
file.

The second type of administration is through the use of a PDA or handheld personal digital
assistant. The OQ-A is built to accept data from a Dell PDA—Note PDAs manufactured by
other companies are sometimes compatible. In this administrative format, a support or clinical
staff member “signs into” the PDA OQ-A software and locates the client’s files. If the client is
in the system, the OQ-A “knows” which test to administer and automatically moves to the first
question. For instance, if the last Y-OQ in system was a self-report, the OQ-A will “queue up”
this test. If however, you would like to administer an “other-completed” YOQ (e.g., parent-
completed) you can override the system default and administer an alternate test.

After a client completes the OQ or Y-OQ, they typically hand the PDA back to a designated staff
member. In wireless environments, the client or staff member can transmit the information by
simply “syncing” the PDA with the OQ-A. In facilities that are not wireless, docking the PDA
automatically triggers a data download into OQ-A. Transmission by both methods take
approximately 3 seconds and then the information is available for the clerical staff to print out or
for the clinician to review on their own computer if it is “linked” to the OQ-A"host system". A
third optional scoring method built into the OQ-A enables a staff member to enter the data into
OQ-A manually if there is a scanner or PDA hardware failure. In this instance, the OQ-A acts
like a “10-key” data entry system accepting manually entered OQ or YOQ test scores.

Providers who do not have direct access to the OQ-A software on their computer may want to

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examine their clients scores so that they can be discussed during the session (rather than waiting
for return of results from OQ-A). In this instance, a clinician report can be printed from the
clerical staff’s computer and provided to the clinician within 3 seconds of data entry (i.e.,
scanning or PDA syncing).

Interpreting the results: Using the instruments to monitor patient progress

Clinicians will want to consult the Administration and Scoring Manual for the OQ-45.2 and the
Administration and Scoring Manual for the Y-OQ 2.0 for detailed background on these
instruments and the interpretation of results. However, we would like to offer providers some
specific suggestions for interpreting results. In general, there are two ways that the results from
these questionnaires can be used by providers.

1. Quantitative tracking of overall change using the OQ-45.2 or the Y-OQ 2.0 total score.
2. Qualitative tracking of specific symptoms or behaviors using subscale scores or ratings
on individual questionnaire items.

Quantitative tracking of overall change using the total 00-45.2 or Y -00 2.0 score
Using the initial total OQ-45.2 or Y-OQ 2.0 score as a baseline, clinicians can compute a change
in total score for subsequent visits. The change in score should be compared to the Reliable
Change Index, which is 14 points for the OQ-45.2 or 13 points for the Y -OQ 2.0. The basis for
these Reliable Change Indices is explained in the Administration and Scoring Manual for the
OQ-45.2 and the Administration and Scoring Manual for the Y-OQ 2. O. A small amount of
change from visit-to-visit in the total OQ45.2 or Y-OQ 2.0 score can be explained on the basis of
chance, however, changes in OQ score that equal or exceed the Reliable Change Index can be
assumed, with a high degree of certainty, to represent true change in the patient's clinical
condition.

Using the Reliable Change Index, at any point in treatment, a clinician is presented with one of
the five (5) following situations:
1. Reliable Improvement: The total OQ-45.2 or Y-OQ 2.0 score has declined since the
first visit by equal to or more than the Reliable Change Index.
2. Possible Improvement: The total OQ-45.2 or Y-OQ 2.0 score has declined since the
first visit, however by less than the Reliable Change Index.
3. No Change: The total OQ-45.2 or Y-OQ 2.0 score is identical to the first visit.
4. Possible Worsening: The total OQ-45.2 or Y-OQ 2.0 score has increased since the first
visit, however by less than the Reliable Change Index.
5. Reliable Worsening: The total OQ-45.2 or Y-OQ 2.0 score has increased since the first
visit by equal to or more than the Reliable Change Index.

Thus, a change in the OQ-45.2 or Y-OQ 2.0 score is used to quantitatively inform the clinician of
the patient's progress and determine which patients need the most careful reevaluation of their
treatment plans. Patients in group #5, Reliable Worsening, should probably receive the most
intensive treatment plan review. Patients in groups #3 and #4 No Change and Possible
Worsening, should also have detailed reevaluation of their treatment plans. This should not be
interpreted as a suggestion that clinicians replace their clinical assessments with OQ-45.2/Y-OQ

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2.0 results. Instead, we are suggesting that the questionnaire results be used to provide an
additional objective and quantitative perspective on the patient's progress.

Ways in which the total score should not be used clinically include:
 The total OQ-45.2 or Y -OQ 2.0 score should never be used as the sole determinant of
whether a patient needs treatment. As is shown in Administration and Scoring Manual for
the OQ-45.2 and the Administration and Scoring Manual for the Y-OQ 2.0, patient and
non-patient samples both show wide and overlapping ranges of total scores. Thus, the
absolute score, at any point in time, cannot be taken alone as an indicator of treatment
necessity. The determination of need for treatment is based on the entire clinical
assessment, of which the OQ-45.2/Y-OQ 2.0 score is just one part.

 We do not recommend use of the sub scale scores by themselves as indicators of

reliable change. As is described in Administration and Scoring Manual for the OQ-
45.2 and the Administration and Scoring Manual for the Y-OQ 2.0, the subscales (3
for the OQ-45.2 and 6 for the Y-OQ 2.0) are highly correlated, such that when a
patient changes on one subscale he/she tends to change in the same direction on the
other subscales as well.

Qualitative tracking of specific symptoms or behaviors.

As was noted above, for each visit for which a completed OQ-45.2 or Y-OQ 2.0 is entered into
OQ-A, clinicians will receive a report of results that includes the total score, the subscale scores,
and any critical items with elevated scores. The subscale scores and ratings on critical items will
alert the clinician to clinical areas that should receive particular attention.

How can the instruments and the OQ-A benefit the treatment process?
There are a number of ways that the OQ-45.2 and Y-OQ 2.0 can be helpful clinically to the
provider and patient.

 As was discussed in the previous section, the change in OQ-45.2/Y-OQ 2.0 total score
can be used quantitatively as an indication of whether therapy is having the desired effect
of reducing the patient's psychological distress and improving his/her functioning.

 The subscale scores and individual item responses can be used qualitatively to identify
particularly problematic areas to be targeted by the treatment plan. This applies both to
the initial treatment plan and its subsequent revisions.

 Patient responses to particular items can draw the provider's attention to areas that need
investigation during the current therapy session. The patient's responses to the critical
items probably should be given the highest priority in this regard.

 The OQ-45.2 and Y-OQ 2.0 results allow the provider and patient to jointly monitor the
patient's progress from a shared point of reference. This helps facilitate discussions
between the provider and patient regarding whether treatment is producing the desired
results.

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  The OQ-45.2 and the Y-OQ 2.0 can be included as part of patients' medical records.
Since the questionnaire results contain a great deal of specific clinical information,
providers' progress notes can reference the questionnaire results, thereby reducing the
necessary length of providers' progress notes.

Monitoring quality of care using the instruments

The OQ and Y-OQ can be used for quality monitoring in two general ways:
 Monitoring individual patient progress in real time
 Evaluating health system performance at a unit or program level.

1. Monitoring individual patient progress in real-time

Utilization management supervisors can use the OQ-45.2 and the Y-OQ 2.0 to track patient
progress. Comparisons of the total score at entry into treatment and the most recent scores
using the Reliable Change Index can enable a real-time profiling of aggregate change
patterns across a unit or program. This profile can be used to support clinical review and
determine which patients may need a more detailed treatment plan review. Patients in group
#5, Reliable Worsening, may require more intensive treatment plan review. If the provider
feels that the impression of clinical worsening is not an accurate representation of the
patient's progress, this can be discussed, since the Y/OQ is only one data point in an array of
clinical indicators.

Patients in groups #3 and #4, No Change and Possible Worsening, may also be monitored by
utilization management clinicians. Herein lies an advantage of the OQ-A for providers and
utilization management clinicians: Since less time needs to be devoted to treatment plan
review for patients in groups #1 and #2, more time is available for review of patients who are
worsening or not progressing and who, therefore, need more detailed treatment plan review.

Two ways in which the OQ score should not be used by utilization management:
 The total OQ score will never be used as the sole determinant of whether services are
authorized. Determination of whether or not to authorize services is based on the
utilization management criteria. The OQ score, by itself, cannot indicate, with certainty,
whether clinical necessity exists.

 The subscale scores will not be used by utilization management supervisors as indicators
of reliable change. As is described in Administration and Scoring Manual for the OQ-
45.2 and the Administration and Scoring Manual for the Y-OQ 2.0, the subscales (3 for
the OQ-45.2 and 6 for the Y-OQ 2.0) are highly correlated, such that when a patient
changes on one subscale he/she tends to change in the same direction on the other
subscales as well. Thus, it does not appear that the subscales are measuring clinically
distinct phenomena, so there is no statistical basis for using the individual subscale

scores, distinct from the total score, as indicators of reliable change.

2. Evaluating health system performance

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Increasingly, continuous performance evaluation of mental health care delivery systems are
being requested. The OQ-45.2 and Y-OQ 2.0 results can be used for this purpose. For
example:

a. Evaluating treatment outcomes for patient sub-populations: Overall OQ-45.2 and YOQ
2.0 results can be aggregated by diagnoses, demographic groups, and settings of care in
order to identify patient sub-populations whose needs may be underserved.
b. Average (mean) change in OQ-45.2 and Y-OQ 2.0 scores can be used to compare
between diagnoses, age groups, and settings to identify patient subpopulations where
improvements can be made. Because differences in mean change in OQ-45.2 or Y-OQ
2.0 score can simply be due to differences in the treatment-responsiveness of particular
subpopulations, it cannot be concluded that smaller rates of improvement represent
inadequate programming. Additional data should be reviewed including measures of
utilization and access, assessments of quality of care, and results from patient and family
member satisfaction surveys. Such analyses can be conducted as part of quality
improvement studies. If deficiencies in the delivery system are identified, they can
become the subject of future quality improvement initiatives.

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 Appendix A
CHECKLIST FOR IMPLEMENTING THE OQ-A

This checklist provides step by step recommendations for implementing the OQ-A within a small
clinic. It identifies major decisions and the support manuals that will assist you in implementing
the OQ-A. It is NOT intended to replace technical or user guides.

Step 1—Selecting and orienting the three champions

The most critical step in the entire implementation plan is staff three roles
associated with outcome management in your clinic. Since the OQ-A is a software
application that was developed for small clinic use, it will be run on the existing
computer system. Hence, the first champion is the person charged with information
technology (IT). As described in step 2 & 4 below, this person can be the manager of
computer operations in your clinic or may be a staff member with skills and knowledge
in IT. Nonetheless, success depends upon having someone familiar with computer
applications and hardware. The second champion comes from the support staff ranks.
This can be an administrative assistant, head receptionist or intake coordinator but a key
component of successful outcome management systems is collecting data before the
client is treated. Pre-treatment contact is most often managed at the “front desk” when a
client checks in to see their clinician and involves receptionists or support staff who must
not only understand why the clinic is engaged in outcome assessment but also their role.
The third champion comes from the ranks of the clinicians and is someone who has a
vision for outcomes-informed treatment; treatment guided by regularly assessing how the
patient is functioning and tracking change so that it can inform the clinician. Each
champion can operate independently and a single person may play more than one role.

Installing the OQ-A in your clinic

Step 2—Identify who will be responsible for the installation of the OQ-A. In large
clinics this is typically the manager of information technology (IT) while small clinics
typically assign this task to a staff member with IT skills or knowledge. Provide this
person with:
 Information on system requirement provided on page 5 of the OQ-A User’s
Guide. Note—the entire user guide can be found on-line under the “HELP” tab.
 Installation guide for the OQ-A. This is on the installation CD but for ease of use
it’s included as Appendix B
 OQ Measures (OQ-M) toll free IT support line—888-MH-SCORE (888-647-
2673)
 Note—the hosted solution (OQ-AHS) requirements are different and coordinated
directly with the OQ Measures IT manager.

Step 3—Using the guide found in Appendix B, install the OQ-A first so that subsequent
training of support and clinical staff can be guided by using the system (training
protocols covered in steps &). We’ve found that using the system during training is
superior to simply reading technical or user manual. Note—Appendix B also includes

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 setup guidelines for scanning paper instruments which is recommended for high-volume
clinics.

Step 4—Identify a system administrator. This is often the same person installing the
OQ-A but they can also be a senior support or IT staff member. This person will be
given executive privileges in the OQ-A to add, modify and deleting staff and client
information.

Step 5—Train support staff on how one inputs staff member and client information into
the OQ-A. An illustrative power point training protocol is included in Appendix D to
supplement the User’s Guide. We strongly recommend that more than one person in the
clinic be trained in the clinic to perform this function for coverage during illness or
vacation. We recommend that you consider training support and clinical staff at the same
time and that this training be initiated by joint meeting where the OQ-A training and
orientation DVD is viewed—Note clinical staff are trained in step 11 below on how to
use clinician and client reports as well as administrative reports. If support staff,
clinicians and administrators are trained together they’ll have a common beginning point
for their role-specific training. A recommended training agenda is included in Appendix
D

Adding clinic, staff and client information into OQ-A

Step 6—(OPTIONAL) If your setting has multiple clinics or programs AND you want to
track and profile client outcome information by these programs/clinics, each unit (clinic,
program, etc.) will need to be added using the “clinic” tab (see Appendix C)

Step 7—Identify which staff members will be using the OQ-A. In small clinics this can
be created quite easily while in larger clinics the clinic administrator may need to tap
personnel records to capture all clinicians operating in the clinic. Limited information
will be needed to add each staff member (clinicians, support staff & administrators)
including:
 First & last name
 Role in the clinic (clerical, clinician, corporate or supervisor).
 Access level (standard, administrative, executive & system administrator). Note
this is a critical assignment since it controls what information is accessible.
Privileges for each role are described in the OQ-A User’s Guide on page 6.
 Email address—recommended user name
 Supervisor
 Clinic assignment—if there are more than one

Step 8—Input all staff members who will be using the OQ-A into the system (see
Appendix C).
 Note—for clinics with a large number of staff members, a separate software
module (WSI) can be purchased to transfer staff member information directly into
the OQ-A from existing electronic systems (e.g., electronic medical record
software programs).

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 Step 9—Decide whether you’ll use the OQ-A with new or existing clients. If you begin
with new clients, there is no need to enter existing clients into the OQ-A. Rather, each
new client will be entered into the system as the support staff processes initial intake
paperwork using the procedure outlined in Appendix C. If the decision is made to track
all clients (new & existing), limited client information (name, medical record number,
birth date, gender, diagnosis, clinic, & primary/secondary clinician; required field
italicized) will need to be retrieved and tabulated from paper or electronic medical
records.
 Note—for clinics with a large number of clients, a separate software module
(WSI) can be purchased to transfer client information directly into the OQ-A from
existing electronic systems (e.g., electronic medical record software programs).

Step 10—Decide on how frequently clients will be assessed using the instruments. We
strongly recommend that outpatient facilities assess outcome each time the client comes
into treatment. Inpatient, residential, medication management, school-based programs
will undoubtedly develop assessment protocols based on their goals as well as average
length of treatment and expected change trajectories

Train clinicians and begin to use OQ-A

Step 11—Training clinicians and administrators in how the OQ-A can improve the
efficiency and effectiveness of therapy is an essential component. OQM provides onsite
training but a sample training using power point slides is included in Appendix E. Again,
it may be advantageous to have a joint training for support and clinical staff where the
OQ-A orientation DVD is viewed.

Step 12—It is useful to build in discussion time during staff meetings one a periodic
basis to discuss the ongoing use of the OQ-A in treatment. The introduction of an
outcomes-informed treatment approach is a significant change in practice and most
clinics will need to measure their accommodation to this change in 6-, 12- and 18-month
increments.

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