Quality in Mental Health Services: Is Accreditation the Answer? Dr Adrian Worrall

Quality in Mental Health Services: Is Accreditation the Answer? Dr Adrian Worrall

Overview Background to mental disorder, mental health services and policy Elements of clinical service accreditation Does accreditation work? How does accreditation work? Critique Is accreditation the answer?

Mental disorders Mental disorders are prevalent and disabling Depression is the second highest cause of disability in Europe fatigue, decreased ability to work, and suicide Anxiety is one of the top 10 causes Schizophrenia, bipolar disorder, drug and alcohol use disorders, and dementia are all in the top 20 causes Others: personality disorder; learning disability; eating disorder

Mental Health Services Primary care (GP) Secondary care services Community Mental Health Services; acute psychiatrist ward; home treatment team; memory clinic; child and adolescent service; forensic ward...

Background International Classification of Diseases (WHO) Many measures of mental, physical, social health and functioning Large evidence base for what works drugs and psychological therapies

What is healthcare trying to achieve? Health: a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO, 1948) Ageing with long term conditions is now he norm. the ability to adapt and to self manage Diabetes, heart problems, liver disease, respiratory problems; most mental disorders New role for health services and clinicians coach versus a miracle healer

Quality in Healthcare Care Quality Commission safe effective caring responsive to patients needs well-led

Is the health service a special case? Very big The NHS costs about 100 billion p.a. and is the UK s biggest employer Unusually high levels of policy changes including major structural changes Large number of interconnected systems Large number of safety critical systems Complex ownership and management structures Professional autonomy and professional supervision run in parallel to managerial supervision

Landscape for Quality Healthcare Providers internal governance systems Commissioners Regulators Care Quality Commission (safety versus excellence) Professional regulation (General Medical Council) Other national organisations Professional Bodies (Royal College of Psychiatrists) NICE (Clinical standards) NHS Trust Development Authority National Quality Board

Policy Appointment of general managers Lead health services, to be set targets (Griffiths, 1983) Purchaser/ provider split, 1989 Competition would drive up standards New Labour (NICE, Regulator and clinical governance) Choice and Payment by Results

Top Down Targets and directives National campaigns Payment mechanisms National clinical guidelines Regulatory & legal Inspection, accreditation

Bottom Up Industrial approaches (PDSA, LEAN, process mapping, etc) Local clinical audit Local action plans addressing deficits identified in national initiatives Good governance and leadership Clinicians excellence versus system excellence

Blend of Top Down and Bottom Up National initiatives (top down) to create a stable and harmonious context for clinical excellence National One size fits all interventions fail because they do not anticipate context and do not make the most of local expertise Local managers and clinical teams should create excellence (bottom up) They know the issues and solutions

Elements of Accreditation of Clinical Services

A Definition of Accreditation Self-review and external peer review of clinical services against standards in order to (i) inform a decision about their level of performance and (ii)identify areas for improvement Adapted from ISQua, 1999

Standards 1. Environment and Facilities 2. Staff and training 3. Access, Admission and Discharge 4. Care and Treatment 5. Information, Consent and Confidentiality 6. Safety and Security Some minimum standards, but in general are aspirational To promote excellence rather than to assure safety

Example of a Standard 38.6 Essential: At least one staff member delivers one basic, low intensity psychological intervention 38.5 Expected: All patients are offered specific psychosocial interventions appropriate to their needs 38.8 Desirable: At least one staff member delivers two or more problem- specific, high intensity psychological interventions

Accreditation Cycle Agree Standards Accreditation Decision Self Review Local Report Peer Review Method: Clinical audit within a peer support network

What Level? Hospitals Services (adult mental health) Clinical teams * Individual practitioners Pathways

Involvement of Stakeholders Standards Workshops: HIGH Patients, carers, commissioners, service providers, clinical staff (all relevant professions) NHS and Independently-funded services Project Team: MEDIUM Designing methods and tools: LOW Writing reports: LOW Advisory Group: HIGH Self review and external peer review: : HIGH Accreditation decision: HIGH and LOW

The Accreditation Decision Accreditation Commitee reviews a report and makes a recommendation A separate senior committee checks and formally accredits Not Accredited, Deferred, Accredited, Accredited with Excellence Accreditation is prospective for 3 years

Accreditation is More Top Down and Bottom up Top down Centrally driven National standards Common process Bottom up External peer review involves local staff Support through the network Local staff find solutions and make action plans

College Centre for Quality Improvement Work with nearly all mental health trusts in UK Cover most specialised mental health services, n = 17, started in 2000 About 1000 peer reviews in 2013 Services pay about 2000 per annum Networking function with email groups and forums 2013: Cross College Accreditation Alliance Care Quality Commission will use accreditation info Frameworks: UKAS/ISO versus ISQua

Does Accreditation Work? Typically compliance increases Ask participants to attribute reasons for improvement Controlled trial David Greenfield UNSW: Accreditation improves organisations in some circumstances Accreditation uses clinical audit which has an evidence base

ECT Clinics Performance against 10 standards 3 Clinical audits: 1981; 1992; 1998 Accreditation: 2003-2009

Can Accreditation Prevent Large Scale Tragedies?

Winterbourne View and Mid Staffordshire External peer review brings light Standards and norm group offer a benchmark Reports amplify voices and empower staff Record patient views Good processes cannot guarantee no bad outcomes, but should reduce the likelihood

Critique Gains are not sustained Too much focus on process and not outcome Tyranny of the trivial versus a focus on the quality critical Standards do not get to the heart of the issues (construct validity) Shallow intervention Tell people what they already know vs. help them improve

Performance Time

Accreditation

Process or Outcomes?

Is accreditation just part of the endless growth of quality in healthcare? Torrent of quality initiatives and policies result in redisorganisation (Walshe) Services need resilience to survive What is driving this growth? Desire to improve? Desire to be seen to making changes? The big business of quality? Our anxiety?

Sheldon: Juggernaut of Quality (2005) Computers are driving an obsession with measurement to find deviant behaviour Quality is used in a normative, coercive way Can annihilate the worst and best of services Need more trust promoting approaches rather than trust eroding ones combination of oversight and active professional selfregulation is probably the best way forward

Measurement without meaning We need a deep understanding of problems Shared understanding with the service concerned Long term relationships versus short term policy Critical friend A blend of large scale scanning initiatives (scanning) Small scale more intense initiatives (trouble shooting)

Don t try and understand em, just round em up and brand em We need to a deep understanding of problems through measuring the right things well and forming long term relationships with services

Isabel Menzies Lyth: Social Structures as a Defence Against Anxiety (1960) Are we using accreditation as a defence against anxiety? Psychoanalysis of nursing in a London hospital Healthcare is inherently difficult, risky, demanding, distressing, disgusting We need defence mechanisms, but should choose them carefully. Some can diminish performance Accreditation can help contain and reduce anxiety Could lead to complacency and lack of engagement with patients complaints

How Does Accreditation Work?

Themes 1. Local ownership and leadership It was our project. We signed up; decided who attends reviews of other services; planned review; saw it through; acted on feedback 2. Other people s suggestions and recommendations were very, very useful, we came away with a lot of ideas that we have adopted. SU feedback was very helpful. We gained ideas, about increasing SU involvement and timely recording of assessments. (sharing good practice)

Themes 3. Exposure of bad practice Either by external reviewers or by staff voicing their own concerns Really want accreditation (feel proud) Definitely don t want failure (feel embarrassed) 4. Don t want to be different benchmarking shows differences, raises questions and difference reduces confidence in service

Themes 5. Feeling connected The networking aspect has been of real value in helping to implement change we have felt quite disconnected in the past but now we feel more enthusiastic (confidence in support available). 6. Willingness of others in the network to help

Themes 7. Time for reflection as a team Staff found time to discuss and reflect in detail on their prescribing practice 8. Insight through discussion with reviewers liaison team realised local acute trust passes patients too often to them (they are very responsive).

Themes 9. Courage and realising one s limits It has helped us to feel more comfortable and honest about what we can and cannot do, and through this we have made some improvements. Need courage to say you are struggling and then trust in others to help 10. Willingness to deal with organisational constraints Staff members want to do a good job, but the systems they work within prevent them. Successful staff think about systems and how they might be changed (POMH)

Themes 11. Improved morale The team were quite buoyed up by it. Being accredited with excellence raised the spirits of the whole service and increased interest in Liaison Psychiatry (confidence) 12. Long term helped stop longer term goals from being buried under the shorter term ones... Some change takes years

Themes 13. Focus and vehicle for change...gave us the focus to initiate, accelerate and finalise improvements 14. Enabled broad engagement across the trust Reductions in prescribing of high dose antipsychotics after wide dissemination of reports.

Themes 15. Data used in governance Some used prescribing data as part of Trust performance management targets

Themes 16. Leverage after being accredited Accreditation helped the team argue to retain the clinical lead in context of cuts. Excellent accreditation raised our profile in the trust and within PCT. 17. Used tactically Team used ECTAS to show what they already knew could not provide consistent anaesthetist cover. Imminent failure gave team support to close down clinic (Later reopened in a new location)

Summary of Themes Staff feelings and attitude ownership, morale, pride, embarrassment, willingness to take on the system How the work is actively used in the organisation leverage, use of data, others ideas, focus, time to reflect

Summary Accreditation gives patients and professionals a rare opportunity to lead quality improvement Agree standards together and apply them together Gives a voice and leverage to effect improvement Colleges are well placed to maintain long term relationships with clinical teams and to be a critical friend But Need to be aware of the growing industry of quality (Sheldon) and measurement without meaning Need to build trust in professions and not build coercive normative quality systems (Sheldon) Valid need to contain anxiety, but this can bring problems (Menzies Lyth)

Summary Accreditation is not the sole answer to improving quality in health services, but it has a role to play in the blend of initiatives Accreditation can provide the context for quality. Real improvements should come from the bottom up Blend of top down and bottom up initiatives Bottom up: Clinicians excellence versus system excellence? Blend of large scale scanning and small scale intensive initiatives National bodies should co-ordinate their work to provide the context and the scanning Who should provide the small scale? Different initiatives to assure minimum standards (Regulation) to those that drive excellence (Accreditation + small scale work)