BPA HEALTH

Clinician Interview

Provider Name: Audit Date:

Site ID: Audited by:

Chosen Evidence Based

Program/Practices (EBPP):

Score/Possible (1 possible
Clinician Interview Objectives (each clinician should be interviewed about 1 EBPP
for each clinican
and list that EBPP in Green box) Interview Comments
interviewed)

EBPP Scored Possible

What are the outcome goals for the chosen EBPP? Look for consistencies with EBPP.
1 NOTE: IF NO NEW CLINICIANS OR EBPP ENTER 0 FOR 0 AND NOTE IN
COMMENT BOX AND SKIP TO OBSERVATION TAB

What are some skills or methods you use to help clients achieve outcome goals?
2
Look for consistencies with EBPP

3 Describe your training process on the EBPP?

How do you determine when a client has met their individual goals for the EBPP
4
group and is ready for discharge from the group?

Sub-total: 0 0

Score/Possible (1 possible
Clinician Interview Objectives for each clinican
interviewed) Interview Comments

EBPP Scored Possible

1 What are the outcome goals for the chosen EBPP? Look for consistencies with EBPP

What are some skills or methods you use to help clients achieve outcome goals?
2
Look for consistencies with EBPP

3 Describe your training process on the EBPP?

PR-32-10/06/2015 Evidence-based Programs and Practices Audit 1

 BPA HEALTH
Clinician Interview

How do you determine when a client has met their individual goals for the EBPP
4
group and is ready for discharge from the group?

Sub-total: 0 0

Score/Possible (1 possible
Clinician Interview Objectives for each clinican
interviewed) Interview Comments

EBPP Scored Possible

1 What are the outcome goals for the chosen EBPP? Look for consistencies with EBPP

What are some skills or methods you use to help clients achieve outcome goals?
2
Look for consistencies with EBPP

3 Describe your training process on the EBPP?

How do you determine when a client has met their individual goals for the EBPP
4
group and is ready for discharge from the group?

Sub-total: 0 0

COMMENTS

PR-32-10/06/2015 Evidence-based Programs and Practices Audit 2

 BPA HEALTH
Client Interview

Provider Name: 0 Audit Date: 12/30/1899

Site ID: 0 Audited by: 0

Client Interview Objectives (Clients will be invited by provider to participate. Participation is voluntary. Score/Possible
Auditor will ask the following questions.)

Comments
Score =
total from
Scoring Enter # of Surveys: Possible
all
surveys

I have found that the treatment program I am currently in is helpful towards my recovery. [scoring:
1 0
Definitely =5, Somewhat=4, Not Sure= 3, Very little=2, Not at All=0]

I am aware of my specific treatment goals. [scoring: Definitely =5, Somewhat=4, Not Sure= 3, Very
2 0
little=2, Not at All=0]

3 I was a part of creating my treatment plan. [scoring: True = 1, False =0] 0

I have learned new behaviors and/or have a better understanding of recovery. [scoring: True = 1,
4 0
False =0]

Sub-Total: 0 0

COMMENTS

PR-32-10/06/2015 Evidence-based Programs and Practices Audit 3

 BPA HEALTH
Group Observation

Provider Name: 0 Observation Date:

Site ID: 0 Observer:

Name of Group: # of Group Members:

Chosen EBPP:

Score
(Yes=1, No & not
Live Group Observation (observation should be no shorter than 20 minutes or until observed=0) Observation Comments
all items have been observed)
Score Possible

Is feedback given and received among the members?

1

Are coping styles and interpersonal skills discussed (by group members or
2
facilitators)?

3 Is group participation encouraged?

Therapeutic Factors Sub-total: 0 0

Score
(Yes=1, No NA and
Psychoeducation (if group is not psychoeducation score NA on items 4 & 5 and Not observed=0) Observation Comments
write type of group in comments)
Score Possible

Group members demonstrated understanding of the EBPP (e.g., terminology used,

4
concepts discussed).

5 Facilitator used a balance of instruction and discussion.

Psychoeducation Sub-total: 0 0

Score
(Yes=1, No & not
Group Structure observed=0) Observation Comments

Score Possible

6 Facilitator demonstrated awareness/conceptualization of group dynamics.

Facilitator used interventions to maintain control of group time in a manner beneficial

7
to the group.

Group Structure Sub-total: 0 0

Score
(Yes=1, No =0)
Facility Observation Comments

PR-32-10/06/2015 Evidence-based Programs and Practices Audit 4

 BPA HEALTH
Group Observation
Facility Observation Comments
Score Possible

8 Group space was appropriate size.

9 Group space was clean and organized ahead of group time.

10 Group space was confidential and reasonably quiet.

Facility Sub-total: 0 0

Score
Complete only if no groups to observe, but clients have received treatment services (Yes=1, No =0)
Comments
Score Possible
Date of Chart Audit:
Review of service plans, encounter notes, and discharge summaries show evidence of
11 EBPP integration in client care.

Record review sub-total

COMMENTS

PR-32-10/06/2015 Evidence-based Programs and Practices Audit 5

 BPA HEALTH
EBPP Audit Totals
Provider Name: 0
Site ID: 0
Audit Date: 12/30/1899
RC Conducting Audit: 0

Key: S= Score, P= Possible

INDICATOR EBPP S P % Total

Clinician Interview 0 0 0 --
Clinician Interview 0 0 0 --
Clinician Interview 0 0 0 --
Client Survey 0 0 --
Observation: Therapeutic Factors 0 0 0 --
Observation: Psychoeducation 0 0 0 --
Observation: Group Structure 0 0 0 --
Observation: Facility 0 0 0 --
Record Review 0 0 --
TOTAL 0 0 --

Comments:

PR-32-10/06/2015 Evidence-based Programs and Practices Audit 6