Quality Assurance Guideline #1 OUTPATIENT PSYCHIATRIC PRACTICE

Transcription

1 THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF PSYCHIATRISTS Quality Assurance Guideline #1 OUTPATIENT PSYCHIATRIC PRACTICE 1. BACKGROUND The Royal Australian and New Zealand College of Psychiatrists' Quality Assurance Committee was formed on an interim basis in late 1989 and formally constituted in The main functions of the Committee as outlined in its terms of reference include: 1.1 To develop and recommend to General Council policy in relation to QA within the College 1.2 To develop and promulgate `standards' of psychiatric clinical practice 1.3 To consider and develop review mechanisms of quality assurance activities. One of the first objectives of the Quality Assurance Committee was to develop `practice guidelines'. Rather than proceeding by imposing a series of principles in a `top down' manner, the Committee elected to use a `bottom up' strategy. Thus, the Committee surveyed all Fellows of the College regarding structural and some basic process characteristics of their practices. Questionnaire data were analysed and provided a framework for the present guidelines. The QA Committee has chosen at this time to disseminate guidelines rather than standards, as standards often connote a necessity for rigid adherence, whereas guidelines imply broader parameters within which activities may occur. The Committee has also chosen not to describe the guidelines either as `minimal', `optimal' or `ideal', instead preferring to view them as reflecting `appropriate' practice. The guidelines are being promulgated for two main reasons. Firstly, so that practitioners can review and reflect upon their own practices. This has already occurred to some extent for those who participated in the survey but it is hoped that the derived guidelines may give further food for thought regarding current practices. Secondly, as a number of institutions and practices already have in place peer review mechanisms, these guidelines could well be utilised to assess the management of patients and organisation of practices, whether by peer review or other strategies. If recertification of College Fellows is instituted and, if practice accreditation were to be a component in recertification, then it might be expected that the guidelines would define some of the parameters to any such assessment. It is important to note again that these guidelines are not absolute and should not be interpreted as standards of practice. They are statements intended to give practitioners some broad parameters by which to assess and structure their own practices. 2. AREAS COVERED BY GUIDELINES Every practitioner should have clearly defined procedures which address the following areas:

2 Quality Assurance Guideline #1 Page Intake Clear definition of intake procedures, including the specific roles of the psychiatrist and the secretary Clear statement of the information to be collected at the time of referral A procedure allowing differentiation between routine and urgent referrals Assessment Discuss with patients the procedures of psychiatric assessment, treatment and confidentiality Psychiatric history recorded for every patient Relevant mental state examination findings recorded for every patient Relevant previous psychotropic treatment (its efficacy and important side-effects) documented Consideration of the patient's general medical condition as part of the psychiatric assessment, and which might include making arrangements for a physical examination and/or physical investigations Procedures for obtaining and recording collateral information in some patients Judgements regarding suicidality and dangerousness recorded, where potentially relevant Provision of a formulation or a summarising statement, as relevant or apposite Diagnosis recorded for each patient Management plan or interim management plan recorded for each patient at the time of assessment Procedures regarding investigations, including a recording system and a reminder system Management Reporting to the referral source after assessment completed Progress reports to the referral source following significant changes in the patient's condition or treatment Report to the referral source at the completion of treatment Regular documentation of progress in the patient's notes Procedures for patients who fail to respond to treatment Procedures for review of patients undergoing long-term treatment, including obtaining second opinions where relevant.

3 Quality Assurance Guideline #1 Page When lithium, carbamazepine or similar drugs are prescribed, there exist clear procedures for monitoring and recording serum levels and side-effects Procedures regarding treatment drop-outs (for example, whom to contact) Procedures for interviewing families of patients, including whether and how permission is obtained from patients Procedures maintaining patient confidentiality Procedures ensuring confidentiality and security of files Where relevant, procedures for obtaining and documenting informed consent regarding ECT for voluntary/informal patients Procedures for obtaining and documenting informed consent regarding the long-term use of phenothiazines Procedures for providing educational information/materials to the patient and/or the patient's family Clear policy and procedures regarding cover when the psychiatrist is absent from the practice Review of procedures All policies and procedures which are addressed by this document should be reviewed on a regular basis regarding their effectiveness or appropriateness. 3. STRATEGIES FOR IMPLEMENTING PROCEDURES AND POLICIES There are a number of different ways of approaching the organisation of psychiatric practice to address the guidelines. What follows is a selection of strategies (not intended to be exhaustive) derived from the outpatient psychiatric practice questionnaire circulated by the Quality Assurance Committee. These are reproduced to give an idea of the diverse range of strategies currently utilised by various practitioners. Some were developed because of particular geographical, professional or subspecialty needs, and some because they suited the practice style of the individual practitioner or institution. Ensuring clarity of procedures and policies may require that they be written, signed and up-dated as required, particularly where there are a number of individuals involved (for example, psychiatrist and secretarial staff) Intake procedures Clear definition of intake procedures, including the specific roles of the psychiatrist and the secretary There are a number of ways of organising an intake system, with varying degrees of responsibility accepted by the secretary and the psychiatrist. It is important to have clear procedures so that people, apart from the psychiatrist, who are involved in intake, have a complete understanding of their responsibilities and those of the others involved in intake. The only way to be certain of this is to have a written statement. Some psychiatrists speak to the referring doctor, some to the patients, whilst others delegate most responsibility to their secretaries.

4 Quality Assurance Guideline #1 Page Clear statement of the information to be collected at the time of referral Many psychiatrists, psychiatric practices, and psychiatric institutions have developed standard intake forms to be filled out at the time of referral. A majority of Australasian psychiatrists have a standard procedure but the information collected varies considerably. A small number collect only basic demographic and patient identifying data, whereas up to one-third include the name and address of the referring doctor, reasons for referral, and other medical practitioners involved in the patient's care. An additional few also collect information on the presenting problem, current treatment, and degree of urgency of the referral A procedure allowing differentiation between routine and urgent referrals Most psychiatrists rely on the judgement of the referring doctor to determine the urgency of referrals, while some contact the patient to clarify urgency. Some psychiatrists give their secretary a triage role, with those whom the secretary judges as urgent referrals being discussed further with the psychiatrist. A considerable number of psychiatrists clearly differentiate between routine and urgent referrals when outlining the waiting period, and have strategies for urgent referrals. Written procedures help avoid mistakes, particularly when patients make contact during a crisis Assessment procedures Discuss with patients the procedures of psychiatric assessment, treatment and confidentiality When a patient presents to a psychiatrist for the first time, it is often necessary to explain to the patient what is involved in the psychiatric assessment and treatment process and to discuss any particular concerns they may have regarding that process. This often also involves reassurances about issues relating to confidentiality Psychiatric history recorded for every patient A number of psychiatrists consider that it may take several sessions to obtain a complete psychiatric history. Those who do not record a complete history (at the initial session or over an assessment period) have varying emphases. Some focus on the medical history, family history, personal history, substance abuse or details of previous treatment, whilst others emphasise the presenting problems and recent history. Clearly, the prioritised areas vary to some degree on the clinical circumstances, but decisions not to record a complete psychiatric history require justification Mental state examination findings recorded in the history for every patient Most psychiatrists document a complete mental state assessment for most patients, but a significant minority record only the positive or unusual findings or relevant negative findings.

5 Quality Assurance Guideline #1 Page Relevant previous psychotropic treatment and its efficacy documented If a patient has previously been treated with psychotropic medication, it is important to record relevant details (for example, response, dosage, side-effects and compliance) Consideration of the patient's general medical condition as part of the psychiatric assessment, which may include making arrangements for a physical examination and/or physical investigations There are a variety of approaches to considering a patient's general medical condition. Some psychiatrists regularly perform physical examinations, some occasionally perform limited ones and some never perform physical examinations. A common thread is that all psychiatrists are expected and required to consider a patient's medical condition and to clarify responsibility for ensuring that relevant physical examinations are performed. The psychiatrist has similar responsibilities when it comes to organising physical investigations. If the psychiatrist does not feel comfortable about undertaking a physical examination or arranging investigations, either for reasons related to transference issues or because of medical complexities, the psychiatrist should refer the patient back to the general practitioner or specialist physician, or refer to another doctor for further assessment. It is not sufficient for a psychiatrist to presume that relevant physical assessments have occurred. Accepted, unaccepted or delegated responsibility for such issues should be noted in correspondence with the referral source Procedures for obtaining and recording collateral information The majority of psychiatrists judge that it is often helpful (and important) to record collateral information. Many will not proceed with obtaining collateral information unless they have the patient's explicit permission Judgements regarding suicidality and dangerousness are documented where potentially relevant It is essential to record one's judgement on both suicidality and dangerousness when there is any possibility about either issue being of relevance Provision of a formulation or summarising statement, as relevant or apposite There is a variety of approaches to the formulation, but in essence such a statement should make reference to the presenting problems, current symptoms and mental state findings, past history and relevant psychosocial factors. The emphasis of the statement will vary considerably across differing psychiatric practices. In some cases it may take several sessions to obtain enough information before documenting an accurate and useful formulation/summary, but such a statement should be provided at some stage in the assessment process.

6 Quality Assurance Guideline #1 Page Diagnosis recorded for each patient Although there are a number of different classificatory systems for psychiatric disorders, it is important to record a diagnosis, or the absence of a formal psychiatric diagnosis (for example, DSM-III-R V code) for every patient at the completion of the assessment process. Whereas most psychiatrists use a multiaxial diagnostic framework or a syndrome diagnosis, some record a symptom state plus relevant information regarding personality, while a small number document a problem list or a psychodynamic formulation. Again, the preference of the individual practitioner and the nature of their practice will influence the format and style of the recorded diagnosis, but there would be very few situations in which it was not appropriate to record some form of diagnosis Management plan or interim management plan recorded for every patient at the time of assessment Again, the preferred conceptual framework and treatment style of a practitioner will influence the form and perhaps content of a management plan. Nevertheless, a management plan (or interim management plan) should be recorded for most patients as part of the assessment process Procedures regarding investigations, including a recording system and a reminder system The number and complexity of investigations which a practitioner performs or requests varies enormously according to the different practice styles and referral patterns. Where investigations are to be performed, it is important to have a clear system for recording their ordering and a system for processing and retaining results. To avoid the misfiling of results, or the filing of results before they have been checked by the practitioner, this system should be known to all people who handle results, including clerical and secretarial staff. A written policy for the handling of investigation results may be necessary to avoid errors. For instance, some organisations and individuals keep a file into which all test results are placed until they have been seen, checked and signed by the relevant clinician, while some patient files contain a section where all test results are kept. Other practitioners keep an investigation sheet or a computer record of investigations ordered and results of those investigations Management procedures Reporting to the referral source after assessment completed All psychiatrists should provide some form of feedback to the referring doctor. A number of psychiatrists delay their report until the assessment process is complete. The form of the report is usually by letter but a significant number of psychiatrists also telephone the referring doctor. In the rare instances where this is not appropriate, there should be an explanation in the notes.

7 Quality Assurance Guideline #1 Page Progress reports to referral source following significant changes in patient's condition or treatment Significant changes in the patient's condition or treatment should be communicated to the referring doctor. Some psychiatrists report regularly to the referral source, but most do so on the basis of relevance or appropriateness Report to referral source at completion of treatment The treating psychiatrist should inform the referring doctor at the completion of treatment. Some will report back to the referring source, mainly to inform that treatment has ended. Others will provide a brief summary of the course of treatment, any changes that have occurred, and any recommendations regarding future treatment Regular documentation of progress in the patient's notes It is important to record some information regarding each contact with the patient. If not undertaken after every visit, it is necessary to summarise what has occurred in the intervening sessions between entries Procedures for patients who fail to respond to treatment Because of the diverse specialties, subspecialties and practice settings in which psychiatrists work, there can be no fixed procedure for dealing with patients who fail to respond to treatment. However, all psychiatrists will have treatment failures, so it is necessary for psychiatrists to have a clear procedure for helping such patients. Written procedures are preferable. For psychiatrists working in a hospital or group practice setting, it is relatively easy to obtain advice or a second opinion from colleagues or to utilise supervision sessions, peer review meetings or case presentation meetings to discuss difficult cases. For those in isolated practice, whether it be geographical or professional isolation, it is more difficult but still necessary to develop a workable procedure Procedures for review of patients in long-term treatment, including obtaining second opinions Review of patients in long-term treatment can be reassuring and enlightening to psychiatrist and patient alike. A `fresh look' at patients by outsiders may provide new insights or directions to treatment even for patients who are judged as proceeding `as expected'. Again, a number of psychiatrists report utilising peer review, supervision and case presentation meetings to review such cases, whilst others discuss the cases with their colleagues. Some psychiatrists (perhaps those with less access to the above avenues) will formally refer patients in long-term treatment periodically for a second opinion. The procedures to be followed should be written When lithium, carbamazepine or similar drugs are prescribed, there exist clear procedures for monitoring and recording serum levels and potential side-effects All psychiatrists prescribing drugs such as lithium and carbamazepine would be aware of the need to monitor serum levels for both and to monitor creatinine levels and thyroid functions for lithium and undertake a full blood count and assess liver function for carbamazepine. A number of practitioners have developed systems to remind or prompt them when such investigations are due. For some psychiatrists the procedure is merely acknowledgement that monitoring should occur. All psychiatrists

8 Quality Assurance Guideline #1 Page 8 who prescribe these medications should have written procedures regarding monitoring. This may be as simple as a coloured sticker in the patient's file which signifies that they are receiving such a treatment, a flow chart which reminds the psychiatrist when tests are due, or a database system on a computer which can be programmed to prompt the psychiatrist when tests are due Procedures regarding treatment dropouts Psychiatrists use a range of different procedures when a patient `drops out' of treatment and may have a variety of responses depending on the clinical situation. In the first place, it has to be considered whether the procedure is necessary. If it is necessary, there should then be a written statement outlining the approach or approaches. Some psychiatrists make contact (either by letter or telephone) with the referring doctor, while some communicate directly with the patient (letter or telephone), with the patient's family or contact a community health centre to follow the patient further Procedures for interviewing families of patients, including whether and how permission is obtained from the patient If a decision is made to interview the patient's family, it is desirable to obtain the patient's consent. Some psychiatrists also prefer the patient to be present when the interview is being conducted. In some clinical settings, for instance child psychiatry, developmental disability or when assessing organic mental disorders, it is essential to gather as much information as possible from other sources. In some situations, psychotic or mute patients may be so disturbed as to be unable to provide important information. Assessment of potentially suicidal or dangerous patients is sometimes enhanced by obtaining information from their families and/or partners. There may be some clinical settings where it is inappropriate to interview the patient's relatives but clearly stated policies or procedures will clarify the appropriate and inappropriate cases Procedures maintaining patient confidentiality There are a number of different scenarios to be aware of when considering confidentiality. Some psychiatrists require the patient's permission before disclosing any information to anybody but this requirement may be overridden when information is required by the courts under subpoena. A number of psychiatrists will provide information to the referring doctor but some do so only if the patient gives permission. Some psychiatrists acknowledge that they may not maintain confidentiality if there is sufficient risk of potential harm to the patient or others. Perhaps being aware that protocols regarding confidentiality may be breached, some psychiatrists disguise the recording of sensitive information Procedures ensuring confidentiality and security of files Most psychiatrists keep patient files under lock and key (either a locked cabinet, a locked room or a locked building) and also limit access to files. Those who keep patient information on computers employ security measures such as passwords or hidden files.

9 Quality Assurance Guideline #1 Page Where relevant, there are procedures for obtaining and documenting informed consent regarding ECT for voluntary/informal patients It is always necessary to discuss ECT with a voluntary/informal patient and to obtain informed consent. A number of psychiatrists also document the discussion in the case notes while some also involve relatives in the consent process or routinely obtain a second opinion before commencing ECT Procedures for obtaining and documenting informed consent regarding the use of long-term phenothiazines This is a difficult clinical situation for a number of reasons. At times it is not possible to obtain informed consent regarding the use of phenothiazines because the patient is psychotic but the risk of sideeffects, particularly tardive dyskinesia, makes it important to discuss the issue at some stage and to document in the patient's notes that the discussion has taken place. A number of psychiatrists reinforce the discussion by providing their patients and/or the patient's relatives with written pamphlets giving them information about particular drugs Procedures for providing educational information/materials to the patients and their families There are a number of support groups for patients with mental illness and their relatives and these can be a useful resource in certain situations. Psychiatrists should be aware of the groups available and of the appropriate patients/clients to refer to these groups. There are also many sources of information/education leaflets for patients which help the patient and/or their relatives to retain important information about a particular illness and treatment Clear procedures regarding cover when the psychiatrist is absent from the practice It is the responsibility of the individual psychiatrist to arrange cover when not available. This is easier to do in settings where there are colleagues readily available. In some isolated settings it may be necessary to inform the referring general practitioner of one's impending absence and to offer contingency plans should problems arise with particular patients. It is important that the arrangements be clearly documented for the information of secretarial staff and colleagues. In situations where it is likely that certain patients will need to be reviewed, many psychiatrists make appointments for the patient to see a covering psychiatrist and also brief that psychiatrist Review of procedures All policies and procedures which are addressed by this document should be reviewed on a regular basis regarding their effectiveness or appropriateness. Just as it is important not to view these guidelines as absolute, it is also important that practice procedures be reviewed on a regular basis. In group practices, this could involve a committee. Solo practitioners may choose to set up informal groups of psychiatrists to achieve the same end or to compare their procedures periodically against the guidelines and modify as appropriate.

10 Quality Assurance Guideline #1 Page 10 NOTICE This document is not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns evolve. These borad parameters of practice should be considered guidelines only. They are not absolute and should not be interpreted as standards of practice. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. These practice guidelines were first published in August 1993 and reprinted as Guidelines for Outpatient Psychiatric Practice (QA Guideline#1) in April 1994.