Quality assurance of psychiatric day hospital treatment: I. Individual level

The article describes a quality assurance system for psychotherapeutic day units. The system was developed through a collaboration between different day units at different hospitals in Norway and the University Institute at the Department of Psychiatry, Ullevål Hospital, Oslo. The system consists of a series of tests, schemes, and procedures, which are processed by a software program. The system is described through a presentation of routine data from the treatment of a single patient: application procedures, patient preparation, waiting list, procedures for evaluation at intake, discharge, and 1-year follow up, postdischarge treatment, and so forth. The system provides good documentation of crucial elements in psychiatric treatment and assures the patient and referral agencies that these elements are carried through in accordance with high quality demands. The staff perceives the system as highly useful for clinical purposes. The system presupposes secretary assistance and user support.     

Quality assurance in a children's psychiatric hospital

The use of short-term isolation (STI) in a children's psychiatric hospital was examined using the Joint Commission on Accreditation of Hospitals (JCAH) quality assurance mode. A Clinical Care Evaluation addressed two questions: Are we providing quality use of STI? And are we adequately documenting its use? A medical record audit of 78 discharged patients and a review of unit records provided hospital staff with utilization and demographic statistics; structured interviews with staff and inpatients were conducted that provided information about their opinions of STI. The data gathered served as the basis for recommendations that led to planned, informed program changes.     

Quality assurance and quality of care: II. Monitoring treatment

The absence of meaningful linkages between quality assurance programs and quality of care has alienated them from each other, especially in psychiatry, where standards of care and process and outcome of treatment are vaguely defined and vigorously debated. This paper describes several factors contributing to the gap between quality assurance and quality of care as well as a treatment-monitoring process that attempts to bridge the gap. The form and review process described are criteria-based and concurrent, and they use methodology that both assesses documentation and promotes an interactive clinical review. Preliminary data that demonstrate the clinical usefulness of the process and its impact on a treatment service are presented.     

A psychiatric key: the day hospital

After being the first structure of this type in Belgium, the day hospital "La Clé" from the University of Liège exhibit the modalities of its functioning with some comments. It is considered as a dynamic structure in the view of a intergrated psychiatry. The specificity of the day hospital is discussed.     

Case-based reimbursement for psychiatric hospital care.

A fixed-prepayment system (case-based reimbursement) for patients initially requiring hospital-level care was evaluated for one year through an arrangement between a private nonprofit psychiatric hospital and a self-insured company desiring to provide psychiatric services to its employees. This clinical and financial experiment offered a means of containing costs while monitoring quality of care. A two-group, case-control study was undertaken of treatment outcomes at discharge, patient satisfaction with hospital care, and service use and costs during the program's first year. Compared with costs for patients in the control group, costs for those in the program were lower per patient and per admission; cumulative costs for patients requiring rehospitalization were also lower. However, costs for outpatient services for patients in the program were not calculated. Treatment outcomes and patients' satisfaction with hospital care were comparable for the two groups.     

Community families: an alternative to psychiatric hospital intensive care.

For the past four years Southwest Denver Community Mental Health Services, Inc., has had a system of alternative families who take one or two psychiatric patients who need intensive treatment into their homes; the clients' average stay is ten days. Thus far approximately 220 client placements have been effectively carried out in a network of five homes. Clients who receive psychotropic medication have its effects monitored by a staff psychiatrist, medical nurse coordinator, and nurse clinician. A study conducted by independent researchers over the initial two-year period indicates that the homes are more effective in certain respects than a psychiatric hospital in providing intensive care.     

Quality assurance and quality of care: I. Finding the linkages

Efforts to adapt the problem-oriented record to the complex biopsychosocial determinants of illness and therapeutics are especially difficult with the seriously and persistently ill patient who requires more than a minimal hospital stay and for whom standards of care have not been developed. By focusing on a treatment system's capacity to achieve its goals, this report demonstrates one method for linking quality assurance behaviors with quality of care and integrating the work of the hospital psychiatrist and multidisciplinary team into the medical record. The vehicle for implementing this method is a multidisciplinary treatment-planning form currently used in the charts of an extended-length-of-stay treatment service. Its evolution and rationale are described, and an example form follows this report.     

Psychiatric day hospital treatment of terminally ill patients.

The psychiatric Day Hospital offers a forum for working out bereavement issues of terminally ill patients. Through individual and group psychotherapy, patients and their families are assisted in coping with the issues of death and dying. Coordination of medical, surgical, and psychiatric treatment of dying patients is enhanced by Day Hospital educational and treatment programs which afford continuity of care at the interface area between treatment specialties.     

Severity of psychiatric disorder in day hospital and in-patient admissions

This study assessed whether severity of psychiatric disorder varies across day hospital and in-patient units according to local need, and whether severity of disorder predicts length of stay and therefore costs. Data were collected for a consecutive series of 2230 in-patients and 712 day patients using the Social Behaviour Scale (data completed by nurses) and diagnosis and Clinical Global Impression (CGI) (completed by doctors). Severity of illness of subjects admitted to in-patient units, but not to day hospitals, was associated with under-privileged area score (UPA). Length of in-patient stay is most accurately predicted by Clinical Global Impression and six other variables relating to diagnosis, demographic status and individual hospital. Improved resource allocation for mental health services could be achieved if severity of disorder was routinely collected.     

Predictors of outcome in a short-term psychiatric day hospital program

This study assessed selected chronicity, social support, and personality variables as predictors of outcome in a 3-week psychiatric day hospital program. Measured outcome included pre- and post-treatment scores on the BDI, STAI, and SCL-90-R from 224 patients. A single outcome variable based on the average standardized residual changes scores for these measures was derived to assess whether symptom severity at discharge was greater or less than predicted. Predictor variables were analysed using multiple regression. Chronicity variables predicted outcome, with patients hospitalized more than once and those with personality disorders more symptomatic than expected after treatment. Social support and personality variables failed to predict outcome; however, patients who scored higher on the MMPI Si scale were more symptomatic than expected at discharge. Although these results possess marginal clinical utility in terms of accounting for symptom change variation, this study overcame some methodological difficulties seen in prior day hospital literature. Future research should consider a prospective approach, including random treatment assignment, comprehensive and diverse outcome measures, and exploration of specific diagnostic groups.