Managed mental health: From cost containment to quality assurance

Administration and Policy in Mental Health and Mental Health Services Research -     

Systems for quality assurance in mental health services: A strategy for improvement

In this paper, we discuss the growing need for a systems-based approach to quality assurance in mental health services. This approach can provide useful information to administrators and practitioners as they endeavor to maintain or improve the quality of care provided to patients in a difficult and fluid environment. A generic model for monitoring and evaluating the quality of care is introduced, and potential barriers to its implementation are discussed. This suggested approach to quality assurance can assist mental health professionals to better meet the challenges of maintaining quality in today's rapidly changing healthcare environment.William F. Jessee, M.D., is Vice President for Education, and Gale Morgan-Williams, M.S.P.H., is Assistant to the Vice President, for the Joint Commission on Accreditation of Hospitals, 875 North Michigan Avenue, Chicago, IL 60611.     

From data to wisdom: quality improvement strategies supporting large-scale implementation of evidence-based services

The Hawaii Department of Health Child and Adolescent Mental Health Division has explored various strategies to promote widespread use of empirical evidence to improve the quality of services and outcomes for youth. This article describes a core set of clinical decisions and how several general and local evidence bases may inform those decisions. Multiple quality improvement strategies are illustrated in the context of a model that outlines four phases of evidence: data, information, knowledge, and wisdom.     

Linking quality assurance and quality of care

Since the introduction of the problem-oriented record into hospital work nearly 30 years ago, psychiatry has struggled to adapt it to the complex bio-psycho-social determinants of illness and therapeutics. This struggle has been especially difficult with the seriously and persistently ill patient who requires more than a minimal hospital stay. Justification of the work with the longer-stay patient has now come under extreme pressure from utilization review, third-party payors and quality assurance, but hospital psychiatrists continue to have the same difficulties with documentation. Based on two years of chart review with clinical teams, principles of psychosocial rehabilitation and a dynamically oriented philosophy of inpatient treatment for the long-term patient, this presentation demonstrates one method for linking problems and goals with length of stay, quality assurance behaviors with quality of care, and integration of the multidisciplinary team into the entire process.     

Introducing quality assurance to a state hospital medical staff

Establishing a quality assurance program in a developing state hospital requires considering the unique problems of being a physician in such a setting. The hospital and medical staff must be developed to the point where consideration of quality of care is a feasible goal. Managers can take advantage of the interests of individual medical staff as well as serendipitous factors promoting a program.     

A statewide quality assurance program

The Colorado Division of Mental Health implemented a quality assurance program in all of its mental health facilities. The system was designed to help managers know how they were doing on operational issues. The program was simple, low cost, and easy to implement. All levels of management found it a useful tool in getting control of important processes.     

Promoting quality assurance through performance contracting

Performance contracting is an essential component of quality assurance in human service settings. Performance contracting involves developing performance standards for administrative, support service, and direct service personnel; communicating and contracting with personnel to ensure that they agree to comply with the performance standards for their positions; and using standards to monitor and evaluate the quantity and quality of staff performance. Performance contracting also serves to reinforce organizational structure and facilitate program evaluation and is useful in helping to ensure that psychiatrists and other professionals are sufficiently committed to meeting organizational goals as well as those of their professional disciplines.     

Automated quality assurance routines for fMRI data applied to a multicenter study

Standard procedures to achieve quality assessment (QA) of functional magnetic resonance imaging (fMRI) data are of great importance. A standardized and fully automated procedure for QA is presented that allows for classification of data quality and the detection of artifacts by inspecting temporal variations. The application of the procedure on phantom measurements was used to check scanner and stimulation hardware performance. In vivo imaging data were checked efficiently for artifacts within the standard fMRI post-processing procedure by realignment. Standardized and routinely carried out QA is essential for extensive data amounts as collected in fMRI, especially in multicenter studies. Furthermore, for the comparison of two different groups, it is important to ensure that data quality is approximately equal to avoid possible misinterpretations. This is shown by example, and criteria to quantify differences of data quality between two groups are defined.     

Med-psych units. Financial viability and quality assurance

Although medical-psychiatric units may have unique advantages for treating patients with combined medical and psychiatric illness, they may be costly to run, and their success requires a sound financial basis. This begins with filling beds and instituting a waiting list, and then setting admission priorities to regulate case mix deliberately to address financial as well as ethical and clinical considerations. Development of short-stay geropsychiatric evaluation services may offset financial problems associated with long stays of elderly patients requiring definitive treatment for complex conditions. Data are presented to show the effectiveness of deliberate regulation of case mix. Regarding quality assurance, key issues include maintaining documentation to meet HCFA standards for DRG exemption, and effectively integrating physical and psychiatric care, with a special focus on drug interactions and psychiatric toxicities of medical drugs. Effective multidisciplinary treatment planning meeting help in this effort, as do periodic walking rounds focusing specifically on pharmacologic issues. Denials of payment by third parties are most likely to be a problem when both the medical and the psychiatric illness are subacute but their interaction requires conjoint inpatient treatment. Prospective work with PROs can minimize retrospective denials.     

Medical audit: an effective arm of quality assurance

The author discusses the use of the psychiatric audit system developed by the Joint Commission on Accreditation of Hospitals in conducting retrospective reviews of various aspects of patient care. Treatment or procedures reflected in the medical record are measured against standards or criteria set by an audit committee. Analysis of exceptions to or variations from the criteria points up deficiencies and areas for corrective action. The author describes an audit of patients placed on the self-injury precaution program at his hospital, the deficiences that were identified, and the results of a repeat audit made several months later to see if the deficiencies had been corrected.     

The quality assurance dilemma in psychiatry: A sociological perspective

Tensions between mental health practitioners and their colleagues in quality assurance can be reduced. A sociological view of the evolution of psychiatric practice from the doctor-patient dyad to the therapist-patient-third party triad and of the discontinuity between the new structure and the culture of professional practice frames the discussion. Drawing on approaches to quality developed in business settings, it is argued that third parties as well as patients are customers and that a different approach to quality is appropriate to each. Crosby's methodology is recommended as relevant to the management of relationships with third parties.     

Quality assurance in psychiatry: quality indicators and guideline implementation

In many occasions, routine mental health care does not correspond to the standards that the medical profession itself puts forward. Hope exists to improve the outcome of severe mental illness by improving the quality of mental health care and by implementing evidence-based consensus guidelines. Adherence to guideline recommendations should reduce costly complications and unnecessary procedures. To measure the quality of mental health care and disease outcome reliably and validly, quality indicators have to be available. These indicators of process and outcome quality should be easily measurable with routine data, should have a strong evidence base, and should be able to describe quality aspects across all sectors over the whole disease course. Measurement-based quality improvement will not be successful when it results in overwhelming documentation reducing the time for clinicians for active treatment interventions. To overcome difficulties in the implementation guidelines and to reduce guideline non-adherence, guideline implementation and quality assurance should be embedded in a complex programme consisting of multifaceted interventions using specific psychological methods for implementation, consultation by experts, and reimbursement of documentation efforts. There are a number of challenges to select appropriate quality indicators in order to allow a fair comparison across different approaches of care. Carefully used, the use of quality indicators and improved guideline adherence can address suboptimal clinical outcomes, reduce practice variations, and narrow the gap between optimal and routine care.