AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022
A quality management system in practice: meeting the
standards
Basil Hanna, Nat Hanna, Princess Margaret & King Edward Memorial Hospitals
Abstract
Introduction
Body
Conclusion
Acknowledgements and References
In 1998/99 the Mental Health Division of Western Australia funded a project at Warwick CAMHS headed up by Margaret Jones and Phillipa Drew, to establish standards specific to the field of child, adolescent and family mental health care. These standards were to be derived out of the National Standards for Mental Health Services.
Psychological Medicine at Princess Margaret Hospital then gained some funding to assist in the trialing of the ‘CAMHS Standards’. Thus, a new quality management system was implemented at Princess Margaret Hospital. Psychological Medicine used these standards as a benchmark when developing their new Work Practice Guidelines for their seven relative programs.
This process is still new and has not undergone rigorous testing but our early data
suggests that the CAMHS standards guide practice well and they result in consumer focused
care. When the standards are married with a Quality Management System they bring objective
evidence that work practice’s are of a high standard and are continually improving.
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In the service delivery of mental health care, standards of practice have frequently been profession dependant, implemented in an ad hoc fashion, and have rarely been seen as making a positive contribution to improving the quality of care provided in a dynamic manner.
In an attempt to address these issues, the National Standards for Mental Health Services were published. Despite input from the Child and Adolescent Mental Health sector during the development of these standards, they were not viewed as being relevant to guide practice in our specialty area.
In 1998/99 the Mental Health Division in Western Australia funded a project based at Warwick CAMHS Clinic to establish standards for Child and Adolescent Mental Health Services based on the blue print derived from the National Standards for Mental Health Service’s (1996). The standards developed incorporate a series of outcome based criteria by which Child and Adolescent Services should operate.
Princess Margaret Hospital for Children, Department of Psychological Medicine, then gained some funding to institute a project with in the Training, Research, Education and Evaluation (TREE) Program to measure these specialised standards against current work practices.
This Quality System promotes participation from all staff working with in our directorate, and is a dynamic process. It was designed to avoid hierarchical approaches to the delivery of care, and to provide ownership of the processes to the users, namely the staff and the consumers. As such, it makes an important contribution to the building of bridges between clinicians, administrators, consumers and carers.
So, we then aligned ourselves with Scally and Donaldson, believing that assessment and appraisal of our actions must become the foundation of our service. This structure taking us further away from the world of ‘opinion based’ work practice guidelines which is still common place in medicine, despite the push for evidenced based care modalities. [8]
With this in mind a Quality System was designed to enable review and amendment of processes to continuously improve work practices, using the agreed clinical and administrative standards as a base line.
We at psychological medicine have set ourselves a formidable challenge, to place
continious improvement at the heart of our directorate. [10]
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Quality Management Systems are not new. They have underpinned work practice in private industry for more than half a century. Unfortunately the industrial model cannot easily be aligned with the needs of a health service as the relation between process and outcomes are often untested. Product, price, promotion and place, the composition of the industrial model have to be replaced with, Perspective’s, paradigms, processes and principles. [6] With this change in focus, processes have been adapted to reflect the complex nature of health organisations in their pursuit to exhibit continious quality improvement. [9]
In light of the rapid expansion in the area of quality systems in health care it is important to be clear about the purpose and provenance of practice guidelines. The popularity of such tools have grown due to the beliefs that; guidelines will enable efficient use of resources, contribute to a reduction in the inappropriate use of clinical practice variance, be a means of support for staff, and to promote the delivery of researched based care to consumers. [3]
A random audit of some clinical work practices revealed that many commonly used processes were carried out inconsistently and in an ad hoc fashion. This, as a result of having no standards, nor agreed consensus on documentation, for which to guide practice. It was thought, that if clinicians and administrators could agree on a particular course of action, it would improve the standard of care for the consumer, create more efficacy as well as avoid confusion and errors. [3]
The outward face of the system is the Work Practice Manual. This consists of all the processes which apply to the work-site. Some are generic in nature, that is, having application to Psychological Medicine in entirety. Whereas others are program specific, being the focus of Delivery of Care. This Manual is a live document which is subject to ongoing change as a result of system reviews, system improvement reports, as well as the introduction of new processes.
With the knowledge that a manual must be dynamic to be effective, input from all members is required to ensure we function at an optimal level. Feedback is encouraged from all team members to foster the further development of the system.
A team of delegates from each program were bought together to develop the written
policies / processes. These were to be based on the CAMHS standards, but they were to
clearly demonstrate current practice with in the directorate. This being the first stage
– ‘Say what we do’. It was then a matter of finding the processes
relevance to the performance standards of CAMHS. With this manner of implementation it
became evident where practice needed to be refined / improved or where alliance with the
standards already existed.
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As we undertook the first phase we learnt that we practiced in effective ways prior to the implementation of a quality system such as this. Thus we documented how we were actually practicing, not always directly attempting to fit to the CAMHS Standards. From this we found that many of our practices aligned with the standards. It too, was an efficient way to tackle the writing of processes. It made sense that we should only change what was indicated. The old adage was all too true, ‘don’t fix what ain’t broke’.
The documentation phase consumed by far the greatest period of time. The processes were written, reviewed and rewritten to ensure that they reflected the multi-disciplinary roles of our team. The redrafting of our processes ruled out the inclusion of ‘opinion based’ policy, and ensured the accurate recording of our activities.
The local ownership of the documentation facilitated an understanding that there lies, no constraint for the continual evolution of our practice. [3] The originators have recorded what already occurs and allows this to be measured in form of audit / review. The audit will then ask, ‘Did the quality of our actions meet the agreed standard, and if not, why not?’ These questions will be asked from colleagues from those of whom developed the processes. This ensures that the inter-disciplinary nature of health care provision remains. [1]
A facilitator was required to oversee the implementation and maintenance of the quality program. A decision was made that this person should have a clinical background so as to have a working understanding of the delivery of mental health care. This in addition to a keen interest in evidenced-based practice and consumer focused outcomes.
The systems coordinator quickly became active in the development of the quality program, providing training, education, support and a resource to the directorate. The Director played an important role in both supporting and driving this quality system.
Some 9 months in to the implementation of the quality system the Manuals were launched. An educative model was utilised, with the focus being on local ownership. Our task here was to show how the system could and would, aid the clinician in their practice. It emphasised a focus on changing the system not the individuals within it, thus removing any blame mentality. This would only be achieved if staff could be encouraged and motivated towards taking ownership of their processes.
This made for the simplest stage, where staff carry out their work according to the agreed documented process. This being the second stage - ‘Do what we say’. Ensuring compliance is essential. Thus regular reviews must be undertaken following a systematic review schedule, that demands each process within the directorate is reviewed at a minimum, once annually. This examines compliance and forms an educative tool to enhance employee’s knowledge of their practice requirements.
When evidence suggests non-compliance, the System Coordinator must facilitate action.
Within Generic processes this is to be done with a collaborative team, incorporating the
reviewed program leader, reviewer, system coordinator and system council members.
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On the occasion that the process is program specific (delivery of care) the issue should first be attempted to be resolved within the program, as this greatly enhances the ownership factor.
In either case there must be change. This can either be; change the process to reflect the new practice expressions or take action through education to encourage compliance of practice modalities.
Thus different categories have been developed. Internal – raised by a staff member. External – raised as a result of a complaint / suggestion from a consumer or external agency. Review – raised as the result of a scheduled internal review. This makes the third stage – ‘Check on the results’.
At this time, a committee was formed (Systems Council) to facilitate the governance of the quality efforts within Psychological Medicine. A Multi-disciplinary genre was employed, (nursing / psychiatry / psychology / social work / counselling / administrative / management) with it’s members being from varying hierarchal stance within the program that they represent. This being the fourth stage – ‘Act on the difference’. The focus of the Systems Council is to provide multidisciplinary input into the monitoring of the system. Such factors as system reviewers, amendments to generic processes and actioning improvement reports are debated.
The biggest obstacle facing the implementation of this quality system was modifying the cultural ethos of the service. Studies show that staff can feel intruded upon, and that their professional competence is in question when under review, and they can often be cynical about the unknown. This leads to depleted enthusiasm and a lack of commitment to the implementation of quality processes. [11]
Staff feeling overburdened by their workload inhibits the development of a ‘stop and take an overview’ of priorities attitude. [5] Cultural changes are less arduous when the staff feel in control of the process and the notion of ownership is pronounced.
Our directorate is no different to the ‘norm’ of health services in that
change is not only difficult to implement but also a challenge to maintain. Acceptance is
greatly affected by the perspective in which it is appraised and the context in which they
are put into practice. [3] Nether-the-less, work needs to be implemented to engage health
care staff and assuage their fears and misconceptions of the quality process. [10]
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The initial stage of engaging staff was in the education and awareness sessions. However, it was not until the face to face encounter with the review that the staff member develops an appreciation of what is being done. It is therefore fundamental that the systems coordinator and reviewers are mindful of an educative approach rather than that of a punitive methodology towards non-compliance’s that may be identified upon review.
Patel explains that health care professionals often feel that quality systems are yet another ‘stick to beat them with’. Hence the need to relinquish the watchdog come inspectorate stance. As, "The name, blame and shame culture just doesn’t work." [5]
With the thought in mind that it may well take years to counter, we have adopted the attitude that the implementation of a quality management system and subsequent cultural difficulties is one of an ongoing growth process, not a short lived, one time event. [4]
The cultural change required obligated total commitment from senior management. Active participation from management has been highly visible within the directorate. They not only drove the implementation of the continious improvement, but they too played their part in the ‘hard slog’ both as educators and reviewers. Isouard’s study recommended that managers must take up position’s in the implementation of such change and continue to be an active participant in the education, training and other general implementation activities in order for a change in the cultural milieu to come about. [4]
It has been clearly evident that in developing a system which incorporates agreed standards and processes, our staff have adopted a cultural change which will take some time to realise. And since education underpins quality a life long learning cycle needs to be adopted for health care services to take full advantage of this genre of quality improvement. [10]
The realisation came early that no matter how qualified, intelligent or experienced reviewers are, auditing systems can be scary. Hence, an application of a ‘buddy’ system, where reviewers undertake the audits/reviews with the aid of the Systems Coordinator or the Director. However, having one’s program reviewed can also be scary. This we felt could only be overcome with positive exposure to the system.
The review schedule allows program delegates to re-familiarise themselves with processes which inturn stimulates thought and discussion on what can be done to improve the service delivered.
Review’s have had their obstacles, such as delaying the audit by either program or
reviewer (this overcome with added support), but for the most part little protest has been
expressed. Feedback following the reviews has been positive in that reviewers and
program’s report a decrease in their levels of anxiety about the unknown.
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In a geographically fragmented directorate such as ours, the ability for reviewers to audit processes in alternative programs, assists internal clinical collaboration, and information sharing. The knowledge of what other programs have to offer has been largely unknown until this time. Now, with the frequent review schedule, team members are seeing what there is to complement their specific area. This has also facilitated the familiarity between the professionals within the directorate, especially so for those on the grass roots who rarely have the opportunity to liase in person with members from another program / site.
A simple motto of change was taken to heart; if the process isn’t working, amend the process or update the work practice. The foundation of ‘practice generates improvement’ is the cornerstone to the initial phases. There has been no assumption that all standards will always be met to the ‘t’. But regular review can help ensure all round continual improvement within Psychological Medicine services.
Those who have gone through the process a few times neglect to think of quality systems as a beuracratic chore. More so, it is seen as a disciplined and effective systematic way of reviewing organisational and clinical practice. [7]
Slowly but surely staff have taken the initiative to introduce their own system improvement reports to amend both practice and process. Currently, five months since the introduction of system improvement reports, approximately half of those raised have been proactive. That is, raised by staff members in pursuit of improvement rather than via the internal review process. This, in itself supports the notion that staff feel in control of their processes and work practices, thus representing the general consensus of ‘ownership’. It can be said that the Psychological Medicine Department has come along way, but indeed the journey has only just begun.
Paula Johnston and Karen Gullick who dedicated extensive time during the tedious stages
of drafting processes and developing the implementation plan of the CAMHS Standards based
Work Practice Manual.
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References
Burnett, AC. And Winyard, G. (1998) Clinical audit at the heart of clinical effectiveness. Journal of Quality Clinical Practice. Vol. 18 : pp. 3-19
Christie, B. (2000) Scotland’s way to guarantee quality [Interview with Lord Patel] British Medical Journal. Vol. 320 : p. 78
Hutchinson, A. (1998) The philosophy of clinical practice guidelines: purposes, problems, practicality and implementation. Journal of Quality Clinical Practice. Vol. 18 : pp. 63-73
Isouard, G. (1999) The key elements in the development of a quality management environment for pathology services. Journal of Quality Clinical Practice. Vol. 19 : pp. 202-207.
Marshall, M. (1999) Improving quality in general practice: quality case study of barriers faced by health authorities. British Medical Journal. Vol. 319 : pp. 164-167
Petrick, J. (1998) Chapter 7 -Building organisational integrity and quality with the four P’s: Perspectives, paradigms, processes, and principles. Managerial Ethics: Moral Management of people and processes. Lawrence Erlbaum Associates Inc publishers, New Jersey, USA.
Pownall, M. (1999) Quality Street. British Medical Journal. Vol. 318 : p 758
Scally, G. and Donaldson, L. (1998) Clinical governance and the drive for Quality Improvement in the new NHS in England. British Medical Journal. Vol. 317 : pp. 61-65
Scrivens, E. (1997) Putting continuous quality improvement into accreditation: Improving approaches to quality assessment. Quality in Health Care. Vol 6 : pp. 212-218
Thompson, R. (1998) Quality to the fore in health policy – at last. British Medical Journal. Vol. 317 : pp. 95-96
Tobin, M and Chen, L. (1999) Initiation of Quality Improvement Activities in Mental Health Services. Journal of Quality Clinical Practice. Vol. 19 : pp.111-116
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