Treatment Outcome

============================================================ PHASE 2: MEASUREMENT TOOL VALIDITY ANALYSIS

INSTRUMENT INVENTORY:

• Enumerate all standardized instruments implemented in the system.
• For each instrument, document: name, construct measured, number of items, scoring range, clinical cutoff thresholds, psychometric properties (reliability, validity).
• Standard instruments to check for:
  • PHQ-9: Depression severity (0-27, cutoffs at 5/10/15/20).
  • GAD-7: Anxiety severity (0-21, cutoffs at 5/10/15).
  • PCL-5: PTSD severity (0-80, provisional diagnosis cutoff at 31-33).
  • AUDIT: Alcohol use risk (0-40, hazardous use at 8+).
  • PHQ-A, SCARED, SDQ for adolescent populations.
  • WHO-5, WHODAS 2.0 for general wellbeing and functioning.

SCORING ACCURACY:

• Read the scoring logic for each instrument.
• Verify that scoring matches published scoring guides exactly.
• Check for subscale score calculations where applicable.
• Verify that missing item handling follows instrument guidelines (prorated scoring, minimum items required).
• Look for critical item flagging (suicidal ideation items, safety items).

CLINICAL INTERPRETATION:

• Examine how scores are translated to clinical severity categories.
• Verify that cutoff thresholds match published validation studies.
• Check for clinically meaningful change calculations (Reliable Change Index, Minimal Clinically Important Difference).
• Look for normative comparison capabilities (where does this score fall relative to clinical and non-clinical populations).

INSTRUMENT SELECTION LOGIC:

• Check for diagnosis-driven instrument recommendations.
• Verify that the system supports multiple instruments per client.
• Look for adaptive measurement (shorter instruments for routine monitoring, full batteries at intake and discharge).
• Examine whether custom or non-validated instruments can be added and whether they are clearly distinguished from validated tools.

============================================================ PHASE 3: LONGITUDINAL TREND ANALYSIS

TREND COMPUTATION:

• Examine how individual client trends are calculated and visualized.
• Check for: score-over-time plots, severity band tracking, trajectory classification (improving, stable, deteriorating, variable).
• Verify that trend analysis handles irregular assessment intervals.
• Look for statistical trend fitting (linear regression, segmented regression, growth curve modeling).

CLINICALLY MEANINGFUL CHANGE:

• Check for Reliable Change Index (RCI) calculation per instrument.
• Verify that the system distinguishes statistically reliable change from noise.
• Look for response and remission tracking against published criteria:
  • PHQ-9 response: 50% reduction from baseline.
  • PHQ-9 remission: score below 5.
  • GAD-7 response: 50% reduction from baseline.
  • PCL-5 response: 10+ point reduction.
• Check for early warning detection when trends indicate deterioration.

TREATMENT PHASE ANALYSIS:

• Examine whether trends are segmented by treatment phase (acute, continuation, maintenance).
• Check for expected trajectory modeling (when should improvement be expected based on treatment type and baseline severity).
• Verify that treatment changes (modality switch, medication change, dose adjustment) are annotated on trend visualizations.
• Look for plateau detection (client has stopped improving but has not reached recovery).

DROPOUT AND MISSING DATA:

• Check for last-observation-carried-forward or other missing data handling.
• Examine how treatment dropouts are represented in outcome data.
• Verify that outcome reports distinguish completers from dropouts.
• Look for re-engagement tracking when clients return after a gap.

============================================================ PHASE 4: TREATMENT PLAN EFFECTIVENESS

PLAN-OUTCOME LINKAGE:

• Examine how treatment plans are linked to outcome measures.
• Check for goal-measure mapping (each treatment goal has an associated outcome measure).
• Verify that treatment plan reviews incorporate outcome data.
• Look for automated recommendations when outcomes indicate plan adjustment is needed.

EFFECTIVENESS METRICS:

• Check for aggregate effectiveness metrics:
  • Overall response rate (percentage of clients showing clinically meaningful improvement).
  • Overall remission rate.
  • Average time to response.
  • Average time to remission.
  • Deterioration rate (percentage getting reliably worse).
  • Dropout rate and average length of stay.
• Verify that metrics can be filtered by diagnosis, treatment type, severity, and setting.

TREATMENT MODALITY COMPARISON:

• Examine whether the system supports comparison across treatment modalities (CBT vs. DBT vs. psychodynamic, individual vs. group).
• Check for baseline severity matching in comparisons (severity-adjusted outcomes).
• Verify that comparison handles selection bias (clients are not randomly assigned).
• Look for dose-response analysis (relationship between session count and outcome).

QUALITY IMPROVEMENT FEEDBACK:

• Check for outcome feedback to clinicians during active treatment.
• Examine whether off-track alerts notify clinicians when a client is not progressing as expected (based on expected treatment response curves).
• Verify that feedback includes actionable suggestions (consider treatment plan review, consider adjunctive treatment, consider increasing session frequency).
• Look for client feedback tools (therapeutic alliance measures, session rating scales).

============================================================ PHASE 5: PROVIDER COMPARISON WITH RISK ADJUSTMENT

PROVIDER OUTCOME METRICS:

• Examine how outcomes are aggregated at the provider level.
• Check for: average improvement per client, response rate, remission rate, deterioration rate, dropout rate, caseload size, average length of treatment.
• Verify that provider metrics are computed over a meaningful time period with sufficient sample sizes.
• Look for confidence intervals or statistical significance testing on provider metrics.

RISK ADJUSTMENT:

• Check for case-mix adjustment in provider comparisons.
• Examine adjustment factors: baseline severity, diagnosis complexity, comorbidity count, prior treatment history, socioeconomic factors, treatment setting.
• Verify that risk adjustment uses validated methodology (not ad hoc).
• Look for transparency in risk adjustment methodology (clinicians can understand how their adjusted scores are calculated).

BENCHMARKING:

• Check for internal benchmarking (provider vs. organizational average).
• Look for external benchmarking (organization vs. published norms or registry data).
• Examine whether benchmarks are updated periodically.
• Verify that benchmarking accounts for population differences.

PROVIDER FEEDBACK:

• Check for individual provider dashboards showing their outcomes.
• Examine how provider feedback is delivered (confidential report, supervisor meeting, peer comparison).
• Verify that feedback is constructive (highlights strengths as well as areas for growth).
• Look for peer learning facilitation (connecting high-performing providers with those seeking improvement).

============================================================ PHASE 6: EVIDENCE-BASED PRACTICE ALIGNMENT

EBP REGISTRY:

• Check for a registry of evidence-based practices used in the system.
• Examine whether treatment protocols are linked to specific evidence bases (clinical practice guidelines, systematic reviews, RCT evidence).
• Verify that the evidence base is cited and accessible to clinicians.
• Look for fidelity monitoring tools for structured treatment protocols.

PRACTICE PATTERN ANALYSIS:

• Examine whether the system tracks adherence to evidence-based protocols.
• Check for deviations from recommended practices (treatment duration, session frequency, instrument use, intervention selection).
• Verify that deviation tracking is informational, not punitive.
• Look for practice variation analysis across providers.

OUTCOME-PRACTICE CORRELATION:

• Check for analysis linking practice patterns to outcomes (do clients treated with protocol-adherent approaches have better outcomes).
• Examine whether the system can identify effective local adaptations.
• Verify that correlation analysis includes appropriate caveats about causation.
• Look for continuous learning capabilities (outcomes data informing practice guidelines).

REPORTING AND COMPLIANCE:

• Check for payer-required quality measure reporting (HEDIS, MIPS, state mandates).
• Examine accreditation reporting capabilities (CARF, Joint Commission, NCQA).
• Verify that reports can be generated on demand and on schedule.
• Look for data export capabilities for research and quality improvement.

============================================================ SELF-HEALING VALIDATION (max 2 iterations)

After producing output, validate data quality and completeness:

1. Verify all output sections have substantive content (not just headers).
2. Verify every finding references a specific file, code location, or data point.
3. Verify recommendations are actionable and evidence-based.
4. If the analysis consumed insufficient data (empty directories, missing configs), note data gaps and attempt alternative discovery methods.

IF VALIDATION FAILS:

• Identify which sections are incomplete or lack evidence
• Re-analyze the deficient areas with expanded search patterns
• Repeat up to 2 iterations

IF STILL INCOMPLETE after 2 iterations:

• Flag specific gaps in the output
• Note what data would be needed to complete the analysis

============================================================ OUTPUT

Treatment Outcome Tracking Analysis

Platform: {detected stack and integrations}

Scope: {subsystems analyzed}

Instruments Implemented: {N} standardized measures

Outcome Metrics: {N} aggregate metrics tracked

Provider Comparison: {risk-adjusted/unadjusted/absent}

System Health Summary

Critical Findings

1. {OUT-001}: {title}
   • Domain: {Measurement/Trends/Effectiveness/Provider/EBP}
   • Location: {file:line}
   • Impact: {what could go wrong for outcome validity or treatment quality}
   • Recommendation: {specific improvement}

Instrument Implementation

Trend Analysis Capabilities

• Individual trends: {present/absent}
• Reliable change calculation: {present/absent}
• Deterioration alerts: {present/absent}
• Treatment phase segmentation: {present/absent}

Effectiveness Metrics

• Response rate tracking: {present/absent}
• Remission rate tracking: {present/absent}
• Dropout analysis: {present/absent}
• Modality comparison: {present/absent}

Provider Comparison Architecture

• Risk adjustment: {method or absent}
• Sample size requirements: {enforced/not}
• Confidence intervals: {present/absent}
• Feedback delivery: {dashboard/report/meeting/absent}

EBP Compliance

• Practice registry: {present/absent}
• Fidelity monitoring: {present/absent}
• Regulatory reporting: {list of standards}

DO NOT:

• Make clinical recommendations about treatment approaches or medication changes.
• Evaluate the psychometric properties of instruments (focus on implementation accuracy).
• Draw causal conclusions from observational outcome data.
• Identify or compare individual providers by name (use anonymized identifiers).
• Ignore risk adjustment limitations when interpreting provider comparisons.
• Assess client care quality from outcome data alone (outcomes are one dimension).

NEXT STEPS:

• "Run /crisis-risk-monitor to analyze how crisis events correlate with outcome trajectories."
• "Run /care-plan-optimizer to evaluate treatment planning integration with outcomes."
• "Run /therapist-documentation to review clinical documentation supporting outcome data."
• "Run /security-review to audit access controls on outcome data and provider reports."

============================================================ SELF-EVOLUTION TELEMETRY

After producing output, record execution metadata for the /evolve pipeline.

Check if a project memory directory exists:

• Look for the project path in ~/.claude/projects/
• If found, append to skill-telemetry.md in that memory directory

Entry format:

### /treatment-outcome — {{YYYY-MM-DD}}
- Outcome: {{SUCCESS | PARTIAL | FAILED}}
- Self-healed: {{yes — what was healed | no}}
- Iterations used: {{N}} / {{N max}}
- Bottleneck: {{phase that struggled or "none"}}
- Suggestion: {{one-line improvement idea for /evolve, or "none"}}

Only log if the memory directory exists. Skip silently if not found. Keep entries concise — /evolve will parse these for skill improvement signals.