Making things better?

Do we want better outcomes for our patients? Of course. The harder question is how to improve standards, at both the individual level (the psychiatrist) and the system level (mental health services). Atul Gawande (2007), an American surgeon, comments, that ‘Betterment is a perpetual labour. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only humans ourselves’.

This paper looks at some of the strategies and activities that have been developed to make things better. There are many, each developed separately, and having different impacts on psychiatrists and their patients. Despite good intentions, not all of the consequences are positive.

Carrots, sticks and Medibank Private

In the parable of the recalcitrant donkey, sticks then carrots are employed to achieve the desired outcome, with carrots proving superior. This lesson is often forgotten. Medibank Private went for the big stick, announcing that hospitals and doctors would not be reimbursed for the costs of treating disorders which Medibank Private deemed preventable. So, either the patient paid the full cost or, more likely, the hospital and doctors would not be paid for their services. Medibank Private took the view that they were encouraging hospitals to maintain a focus on quality health outcomes, reducing readmissions and avoiding highly preventable adverse events. This approach was also intended to reduce costs, minimising rises in member premiums.

While the full list of the precluded events was not released, examples include falls and maternal death during childbirth. As yet, there are no ‘preventable’ mental health events. However, projecting forward, an obvious example would be inpatient suicide.

What would be the consequences of non-reimbursement for inpatients who suicide? It is unlikely that the hospital or doctor would pursue the patient’s family for payment in such a tragic circumstance. One possible consequence is that private psychiatrists and private hospitals would no longer admit suicidal patients. Current inpatients who became suicidal would be transferred to the public sector. Restricting private inpatient care in this way is clearly not in the interests of patients who have suicidal ideation or intent.

Does calling something quality assurance mean that quality is assured?

Reflect on these phrases – ‘safety and quality’; ‘quality assurance’; do you feel drowsy and disengaged? Walking along the corridor of a general hospital, the notice boards are cluttered with posters and notices from EQuIP National Standards, the National Safety and Quality Health Service Standards, the Australian Commission on Safety and Quality in Health Care and Work Health and Safety Services. The sheer volume of information is overwhelming. Some quality and safety measures, such as falls prevention in elderly services and training staff to manage aggression, are clearly applicable to psychiatry. However, psychiatrists working in general hospitals can be required to complete numerous online training modules, many of which are irrelevant to their work.

Within mental health, reducing rates of seclusion and restraint has been identified as a target. This is a worthy aim and, in an ideal world, would be achieved by changes to ward culture and environment. Such changes take time, expertise and resources. In reality, high doses of antipsychotic and sedating medications may be given, exposing the patient to the risk of adverse reactions including respiratory depression and dystonic reactions.

Standardised risk assessments

Risk assessment sounds like a good idea and has been widely adopted. Considerable staff time is spent completing and documenting these assessments, and compliance with this documentation is taken as an indication of good clinical practice. However, Large and Ryan (2014) have shown that risk categorisation of individual patients does not play any role in preventing inpatient suicides, and does not provide information that might usefully guide clinical decision-making. Similarly, Large et al. (2014) have demonstrated that violence risk assessment fails to predict violence after discharge from a psychiatric inpatient service. Furthermore, they raise the possibility of negative consequences of routinely undertaking violence risk assessments. They argue that patients who are found to be low risk on the standardised assessment might not receive treatment that they need. They also suggest that the emphasis on risk at the expense of care has made psychiatry more coercive and psychiatrists more risk-averse.

Guidelines, flowcharts and procedures

There are many evidence-based clinical practice guidelines (CPG), such as the recently published CPG for the treatment of eating disorders (Hay et al., 2014), and algorithms for physical health monitoring of patients with chronic mental illness (Stanley and Laugharne, 2014). There is much less emphasis on ensuring guidelines are disseminated and implemented. Barriers include lack of access to the guidelines at the point of care, that is, having the guideline or algorithm readily to hand and easy to use, either online or in hard copy. There is also a lack of systems to enable individual doctors to monitor their practice (e.g. medication choices, monitoring of physical health) and compare these data with colleagues and with published guidelines.

Continuing Professional Development

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Continuing Professional Development (CPD) programme aims to enable participants to maintain and enhance their knowledge, skills and performance. There are some sticks involved here; continuing membership of the RANZCP depends on completing sufficient CPD, and Australian Health Practitioner Regulation Agency (AHPRA) requires evidence of continuing professional education. In addition, some Medical Indemnity organisations provide continuing education, with a carrot of reduced annual fees if sufficient activities are completed. There are numerous avenues for professional education and each has advantages and disadvantages. While online tools provide the benefits of self-paced learning, conferences allow discussion with experts and colleagues. Of course, there is no guarantee that a person attending a learning activity is actually paying attention, unless there is a post-activity test.

Benchmarking

Atul Gawande (2007) has written eloquently about his attempts to understand why some clinical services achieve better outcomes than others. He explores ways to identify differences between clinical services and to encourage services with poorer outcomes to adopt more successful practices. He also talks about the obstacles to making these changes.

While benchmarking, as described by Gawande, is important, it is essential to ensure that criterion being benchmarked is the best one. For example, minimising length of stay can be seen as a priority, which is reasonable in terms of reducing health costs overall. Sometimes there is a push to discharge patients before they are well enough to leave, to make room for patients waiting in emergency departments. Psychiatrists can find themselves trying to balance the needs of current inpatients against the needs of patients not yet admitted. Length of stay becomes a major benchmarking measure, implying that clinicians achieving the shortest length of stay are performing better.

Conclusion

Quality assurance, professional development, benchmarking, risk assessments and guidelines consume an increasing amount of professional time. It would be reassuring to know that the investment of time and resources on the part of psychiatrists, as well as those preparing and delivering these activities, is well spent. It is taken as self-evident that these activities are a good thing, resulting in improved outcomes and not causing any harm, but the reality may not be so simple. To quote a very old proverb, the road to Hell is paved with good intentions.