A CASE STUDY OF ACCREDITATION STANDARDS ANSD PERFORMANCE INDICATORS IN A 30 BEDED PSYCHIATRIC NURSING HOME TO ENHANCE THE QUALITY OF CARE
There are grave problems with the quality of mental health care in India., including extensive gaps between evidence-based guidelines and current clinical practice, as well as difficulties with access, detection, continuity and efficiency of care. Faced with these renowned deficits and requirements from accreditors, hospitals should invest substantially in quality improvement programs.
The development of systematic, integrated Quality Improvement Program has advanced and various researches are being done throughout the world, but the issues has not resolved completed.
Today, if a mental health facility wishes to gain accreditation by the National board, there are no specific guidelines available.
Although, there is a dire need for a standard which identifies key functions of the quality improvement process which includes monitoring, evaluation and improvement in patient care. Taken together these activities become the backbone of an effective Quality Improvement Program.
The Quality Improvement Program in Mental Health care today is incomplete and inadequate attention is paid to monitoring, evaluation and improvement.
An explanation after offered in this situation is that “Complexities of Mental Health Care preclude use of standardized criteria for evaluating its appropriateness and outcomes” (Grant’ 1982). Although there is a degree of validity to this assertion, it should not become rationalization for failure to adopt rigorous Quality Improvement Program in Mental Health facilities.
There are substantial differences between General Hospitals and Mental Health facilities which make standardized accreditation measures difficult to implement and effective Quality Improvement Program more difficulties in the latter.
The following differences are noted:
- Diagnosis takes time as there is low consensus of team often.
- Difference between In Patient satisfaction and Out Patient satisfaction considering most inpatient admissions are involuntary in psychiatric illnesses and outpatient consultations are voluntary.
- Medicines takes time to act.
- Length of the stay is not specified in psychiatric illnesses.
Careful monitoring of quality of care has become a professional responsibility of practitioners which cannot be ignored. Quality improvement program is an important source of information for the administration to deal with divergent influences of malpractice litigation, technological advances and other budget constraints. An effective quality improvement program ensures administrators and caregivers that the quality of care is maintained in the rapidly changing environment of health care.
There are many definitions of ‘‘quality assurance”. ‘‘Quality assurance is generally defined as the process where the performance of a system or service is assessed and evaluated to ensure that a high-quality, safe service is offered and delivered to those using it, and that it complies with agreed standards, accreditation and any relevant legislation and safety requirements.’’ WHO (2003) formulated that quality assurance was defined as ‘‘Activities intended to ensure the quality of care in a defined setting or programme.’’ Quality assurance (QA) is an important part of quality management, which is a set of coordinated activities to direct and control healthcare organizations. The main goal of quality management in healthcare is to continuously assure and advance the quality of health care.
In the WHO quality assurance process model, planning, implementation and evaluation of quality assurance are interrelated. The first three steps of identifying goals, selecting interventions and defining standards fall in policy making. Steps 4 and 7 deals with the implementation of care services and steps 5 and 6 refer to the appraisal of care provided. The model depicts that quality assurance involves a comparison between predefined standards and observed care practices (WHO 2003).
Quality measures are used at multiple levels of the health care system—clinicians, practices, clinics, organizations, and health plans—and for multiple purposes, including clinical care, quality improvement, and accountability. At the patient level, quality measures address the patient experience of care and issues that are important to the patient’s plan of treatment. At the clinician level, quality measures can be used to assess the effectiveness and efficiency of care and inform quality improvement efforts. At the organization level, quality measures address how well the organization supports effective care delivery. At the policy level, quality measures are used to assess the effect of policies, regulations, or payment methodologies in supporting effective care. And at the level of the clinician or care team and organization, quality measures are used for accountability purposes—for example, through feedback.
The goal of our research is to improve mental health care by identifying problems with quality of care and address them effectively. The specific aims of this study are to identify performance indicators for enhancing quality of care in a psychiatric nursing home.
The objectives are:
1. To study how the accreditation standards, differ for hospitals and psychiatric nursing home.
2. To explore the performance indicators to enhance the quality of care in a psychiatric nursing home.
To accomplish these aims, we are conducting interviews with department heads and survey clinicians in a purposive sample of a psychiatric nursing home in a metro city.
To study the applicability of accreditation standards of a general hospital to a psychiatric nursing home and identify performance indicators for enhancing quality of care in a psychiatric nursing home.
1. What are the performance indicators which can enhance the quality of care in a psychiatric setup?
2. How the accreditation standards differ for hospitals and psychiatric units?
- To study how the accreditation standards, differ for hospitals and psychiatric nursing home.
- To explore the performance indicators to enhance the quality of care in a psychiatric nursing home.
Research design: A case study design is used in the study to translate knowledge and skills in psychiatry to decipher the key performance indicators essential for improvement of quality of care in the psychiatric nursing home.
Sampling: Purposeful sampling was done.
1. A psychiatric hospital.
2. Both IPD & OPD services
3. Comprehensive working team with psychiatrist, psychologist, psychiatric social worker, psychiatric nurses & attendants
- A multispecialty unit
- Single unit team
- Only IPD or OPD services
Data collection: Data was collected from a 30-bedded psychiatric nursing home, with inpatient and outpatient facility. It is a Care and Cure Center for Psychiatric, Psychological, Social and Occupational problems. Specializing in Psychological Testing, Wellness Management and Rehabilitation Services. Performance indicators were established using the literature available for mental health facilities and indicators were monitored over a period of 2 years to see the efficacy and improvement in the quality of care for patients.
An interest in accreditation of hospitals is growing rapidly among many countries to enhance the quality of health care services. The literature showed a positive association between accreditation and some processes of health care (Braithwaite J, Greenfield D, Westbrook J, et al 2010).
Quality is a theoretical construct. Psychiatric interventions take place in complex bio-psycho-social interactions and settings. Various efforts have been done to find valid parameters of the quality of care including the structural characteristics of the settings in which care occurs, the processes of care, and the outcomes of care. Before assessing quality, there should be a definition of how quality of care should be defined and this depends on whether one assesses only organization performance or also the contributions of patients and of the health care system
Specifications of quality indicators often require the use of estimates, and some measures are a substitution for a broader concept. For example, using hospital re-admission rates as a substitution for the quality of discharge planning assumes that hospital admissions are an unintentional outcome. This builds on the ethics of a mental health care system that offers the least restrictive care which is effective. However, there may be research studies showing significant relations between re-admission rates and other measures of quality (Wray NP, Petersen NJ et.al. 1999).
An analysis of accreditation standards in India for small healthcare organization reveals that there are certain accreditation standards which should differ for psychiatric hospitals like there is minimal requirement for imaging services; use of blood and blood products; intensive care unit and surgical procedures, instead focus should be more on length of stay of patient as in psychiatry the length of stay of patient is more as compared to general hospitals, the diagnosis, treatment and management requires time, care providers should not be given access to current and past medical records without patient consent or legal requirement.
Efforts to improve the quality of care must be measured with simple and reliable criteria known as performance indicators.
The key performance indicators were figured out during the process using the organization, its processes and ultimately patient outcomes by general observations of the environment, patients- doctor setting, patient and family interviews, doctor - staff setting. Various studies were reviewed and the following performance indicators were chosen : Time for Initial assessment of IPD; Initial assessment of Emergency patients; Percentage of medication errors; Percentage of medication chart with error prone abbreviation; Percentage of adverse anesthesia events; Percentage of missing records; Percentage of employees provided pre-exposure prophylaxis; Number of needle stick injury; Percentage of adverse drug reaction; Waiting time for diagnostic lab procedures; Percentage of medical records without discharge summary; Client satisfaction OPD; Client satisfaction IPD; Percentage of leave against medical advice; Percentage of discharge against medical advice; Patient readmission; Average length of stay; Waiting time in OPD.
It was also seen that admissions at fully accredited hospitals were associated with a shorter LOS compared with admissions at partially accredited hospitals (Falstie-Jensen et.al., 2015). Since accreditation is a process to enhance the quality of patients’ care, the identification of performance indicators could lead to improvements in the quality of patients’ care.
It was seen in our study that there were 52 patients, during the post-accreditation period, compared to 37 patients during the pre-accreditation period. The performance indicators were calculated for 6 months pre and post accreditation period to see the difference accreditation made to the quality of care of patients.
The Graph below shows the change in the performance indicators before and after accreditation.
Results revealed that accreditation process reassures validating the good clinical practices. To ensure that accreditation presents a high quality of care, evaluation should be based on the outcome indicators of patients’ care. In agreement with previous research findings (Alkhenizan & Shaw; 2011), the results of this study support a positive effect of accreditation programs on performance indicators identified to ensure quality of care. Thus, performance indicators targeted for psychiatric hospitals could play a vital role in improving the quality of care for patients. An addition to the accreditation standards for general hospitals need to be made keeping in mind the following points for psychiatric hospitals.
- The team approach to mental health care often makes agreement on diagnosis and treatment plans more difficult to achieve.
- The same lack of agreement makes definition of achievable outcomes and outcome evaluation difficult.
- The chronicity of mental illness requires treatment goals that often are ameliorative, rather than curative, aggravating the difficulty of measuring outcomes.
- Tracking patients getting multiple types of services, from multiple practitioners, often in multiple settings, is difficult.
There is reliable evidence that shows that general accreditation programs improve the process of care provided by healthcare services. It also shows that general accreditation programs improve clinical outcomes of a wide spectrum of clinical conditions. There is also considerable evidence to showing accreditation programs of subspecialties improve clinical outcomes. Accreditation programs should be supported as a tool to improve the quality of healthcare services (Alkenhizan & Shaw 2011). The results of our study revealed that quality measures are important for ensuring the uptake and delivery of evidence-based care. Quality of care cannot be enhanced without monitoring how such care is delivered. Data analysis in case studies generally involves an iterative and spiraling process that proceeds from more general to more specific observations (Creswell, 1998; Palys, 1997; Silverman, 2000).
A similar trend was noticed in the analysis of data, wherein the key performance indicators were figured out from the organization, its processes and ultimately patient outcomes by general observations of the environment, patients- doctor setting, patient and family interviews, doctor - staff setting.
The key performance indicators which were figured out during the process included:
- Time for Initial assessment of IPD;
- Initial assessment of Emergency patients;
- Percentage of medication errors;
- Percentage of medication chart with error prone abbreviation;
- Percentage of adverse anesthesia events;
- Percentage of missing records;
- Percentage of employees provided pre-exposure prophylaxis;
- Number of needle stick injury;
- Percentage of adverse drug reaction;
- Waiting time for diagnostic lab procedures;
- Percentage of medical records without discharge summary;
- Client satisfaction OPD;
- Client satisfaction IPD;
- Percentage of leave against medical advice;
- Percentage of discharge against medical advice;
- Patient readmission;
- Average length of stay;
- Waiting time in OPD.
Measuring quality using quality indicators resulting from evidence-based practice guidelines is a vital step towards implementation of evidence-based care and monitoring quality improvement efforts. A few key performance indicators essential for continuous quality improvement could be inferred. It was also noted that the present accreditation standards do not specify and have adequate quality standards for a psychiatric setting which is different from a multi-specialty hospital setting in various ways. and hence a need for change and further research is evident.