Jane S. Mahoney

Integrating outcomes assessment and research into clinical care in inpatient adult psychiatric treatment.

The authors describe an evolving outcomes project implemented across the adult inpatient programs at The Menninger Clinic. In the inpatient phase of the project, patients complete a computerized battery of standardized scales at admission, at biweekly intervals throughout treatment, and at discharge. In addition to providing aggregate data for outcomes research, these assessments are incorporated into routine clinical care, with results of each individual assessment provided to the treatment team and to the patient. The inpatient phase of the project employs Web-based software in preparation for a forthcoming follow-up phase in which patients will continue after discharge to complete assessments on the same computer platform. This article begins with a brief overview of related research at the Clinic to place the current project in local historical context. Then the authors describe the assessment instruments, the ways in which the assessments are integrated into clinical care, plans for follow-up assessments, the central role of information technology in the development and implementation of the project, the primary research questions, and some of the major challenges in implementing the project. The article concludes with a discussion of the ways in which the project can serve as a platform for a broad future research agenda.

Modeling Trajectory of Depressive Symptoms Among Psychiatric Inpatients: A Latent Growth Curve Approach

OBJECTIVE Changes in the parameters of inpatient psychiatric care have inspired a sizable literature exploring correlates of prolonged intervention as well as symptom change over varying lengths of hospitalization. However, existing data offer limited insight regarding the nature of symptom change over time. Objectives of this longitudinal research were to (1) model the trajectory of depressive symptoms within an inpatient psychiatric sample, (2) identify characteristics associated with unique patterns of change, and (3) evaluate the magnitude of expected gains using objective clinical benchmarks. METHOD Participants included 1,084 psychiatric inpatients treated between April 2008 and December 2010. Latent growth curve modeling was used to determine the trajectory of Beck Depression Inventory II depressive symptoms in response to treatment. Age, gender, trauma history, prior hospitalization, and DSM-IV diagnoses were examined as potential moderators of recovery. RESULTS Results indicate a nonlinear model of recovery, with symptom reductions greatest following admission and slowing gradually over time. Female gender, probable trauma exposure, prior psychiatric hospitalization, and primary depressive diagnosis were associated with more severe trajectories. Diagnosis of alcohol/substance use, by contrast, was associated with more moderate trajectories. Objective benchmarks occurred relatively consistently across patient groups, with clinically significant change occurring between 2-4 weeks after admission. CONCLUSIONS The nonlinear trajectory of recovery observed in these data provides insight regarding the dynamics of inpatient recovery. Across all patient groups, symptom reduction was most dramatic in the initial week of hospitalization. However, notable improvement continued for several weeks after admission. Results suggest that timelines for adequate inpatient care are largely contingent on program-specific goals.

Supporting a Psychiatric Hospital Culture of Safety

Background: Concerns for patient safety have risen to the forefront of health care, including mental health care. Safe patient care depends, to a large extent, on high functioning teams, yet team training is lacking in basic professional training programs. To address the need for team training, one psychiatric hospital adopted the Team Strategies and Tools to Enhance Performance and Patient Safety program (TeamSTEPPS). Objectives: To describe the implementation of TeamSTEPPS throughout the organization and to describe the differences in team attributes prior to and following implementation of TeamSTEPPS. Design: Quality improvement project using a pre–post survey design. Results: TeamSTEPPS was successfully implemented, and changes in all team attributes trended in a positive direction with 5 of 7 subscales reaching significance (p ≤ .01). Conclusions: TeamSTEPPS provided a practical approach for our hospital to systematically weave safety throughout the culture and improve team functioning and other attributes of highly effective teams.

Assessing and addressing patient satisfaction in a longer-term inpatient psychiatric hospital: preliminary findings on the Menninger Quality of Care measure and methodology.

Patient satisfaction is increasingly used as an indicator of health care quality. Few measures are available to assess characteristics unique to inpatient psychiatric hospitals, especially those that provide longer-term care. Furthermore, there is limited guidance on how to utilize patient satisfaction data to guide quality improvement initiatives. The authors developed the 20-item, Menninger Quality of Care measure at The Menninger Clinic in Houston, Texas. Psychometric analyses were based on responses from 337 adult inpatients. The measure has excellent internal reliability (Cronbach &agr; = 0.92) with adequate concurrent and construct validity. We present a methodology to identify targeted quality improvement efforts by (1) highlighting the perspective of patients who are generally satisfied but had at least some reservations regarding the care they received and (2) highlighting areas of concern that are most associated with overall quality of care. We discuss our findings in light of national health care quality trends.

Improvement in health-related quality of life among adults with serious mental illness receiving inpatient treatment: a prospective cohort study.

OBJECTIVE This study examined changes in health-related quality of life in adult inpatients with serious mental illness engaged in a 6- to 8-week intensive treatment program. METHOD Admission and discharge assessment with the MOS 36-item Short-Form Health Survey was completed (June 2010-June 2012) for 410 adults aged 18-68 years. Paired t tests and effect size estimates were calculated for the overall sample, and reliable change index scores and clinical significance were calculated to estimate individual-level response and recovery rates. Hierarchical stepwise regression analyses were conducted to explore patient pretreatment characteristics, including total number of DSM-IV-TR diagnoses, that influence treatment response. RESULTS Large effect size improvements were demonstrated for the Mental Component Summary score (Cohen d = 1.5), including subjective ratings of vitality (Cohen d = 1.1), social functioning (Cohen d = 1.3), role-emotional functioning (Cohen d = 1.3), and mental health (Cohen d = 1.3). Equivocal findings for change in physical health were demonstrated, with the majority of patients demonstrating no significant change in function (t409 = 0.14, P = .89) but approximately equal numbers of patients demonstrating improvement and deterioration. The pretreatment characteristic of a tendency to be interpersonally distant, cold, and disengaged was predictive of a poorer outcome on Mental Component Summary treatment response (P < .001). CONCLUSIONS In light of a heavy burden of illness and high psychiatric comorbidity of this sample, treatment response was generally positive for improvement in mental health functioning. This study adds to a growing body of evidence indicating robust treatment response even for those with serious mental illness when treatment is intensive and multimodal.

Psychosocial characteristics of psychiatric inpatients at admissions and discharge: The Menninger Clinic Adult Outcomes Project.

The authors present a first look at the data from The Menninger Clinic Adult Outcomes Project. They provide descriptive data from 443 patients admitted to the Clinic between April 2008 and May 2009. Patients show significant improvement on a range of standardized measures from admission to discharge (effect sizes range from moderate to large, 0.31 to 1.44), and there are some differences among clinical programs within the hospital in the extent of change on some scales. A comparison of patients who did and did not complete discharge assessments showed minimal differences between groups on admissions variables. These results attest to the substantial impact of relatively long-term intensive inpatient treatment on improving clinical symptoms and functioning, but further studies are needed to determine the trajectory of change in the hospital and, most importantly, at follow-up.

Utility of an integrated electronic suicide alert system in a psychiatric hospital.

Management of suicide-related behaviors in a hospital is challenging. This article (1) describes integration of an electronic suicide risk notification system to improve assessment of psychiatric inpatients, (2) details the manner in which these alerts complement standard of care, and (3) provides support of using aggregate data to inform administrative decision-making. Complementing routine clinical care and under the supervision of an assessment coordinator, adult inpatients at a specialty psychiatric hospital complete a computerized battery of outcome assessments throughout the course of their hospitalization. A critical-item response notification system for suicide-related behaviors was implemented within the larger, assessment architecture, sending an alert e-mail to unit staff if patients endorsed suicidal ideation on any 1 of 6 critical items. Analysis of aggregate data over a 19-month period reveal a linear trend of increasing rate of suicide alerts from October 2012 to April 2013 (Phase A) with a stabilization at the heightened level from July 2013 to April 2014 (Phase B), R = 0.697, P = .007. Findings suggest that more nuanced training in the management of suicide-related behavior may be necessary and that traditional approaches to staffing may need to accommodate patient acuity. The communication innovation of this system is in line with the Joint Commissions emphasis on designing and implementing patient-centered systems that enhance quality of care, including improved safety.

Integrating caring into patient-centered care through interprofessional education and ethics: The Caring Project

In an era of health care that is driven by biological and technical advances, there is a need to safeguard the caring component of care, the humanistic part of care. With this in mind, the authors constructed a Patient-Centered Caring model consisting of three overlapping constructs: delivering customer service, understanding the illness experience, and providing trauma-informed care. These practices operate within an interprofessional competency context. The authors describe an interprofessional educational project focused on understanding the illness experience and providing trauma-informed care to faculty, staff, and administrators in an inpatient psychiatric setting. The authors discuss the project through a number of ethical lenses that may help explicate the ethics of patient-centered care and caring and can be useful in the development of interprofessional competence.

Using Liberating Structures to Increase Engagement in Identifying Priorities for the APNA Research Council

Background: In 2015, the Co-Chairs and Steering Committee of the Research Council members recognized the need to reevaluate the council’s priorities. Objective: To determine the top priorities for the Research Council. Design: Use of liberating structures: Impromptu Speed Networking, 1-2-4-all, and Crowd Sourcing. Results: Identified Research Council priorities included the following: efforts to increase psychiatric mental health (PMH) research funding; serve as a connector to bring researchers together; foster research through state chapters; increase collaboration between PhDs and DNPs; and develop models for organizational support for PMH staff nurse involvement in research. Conclusions: The liberating structures used are valuable strategies for engaging groups of people to identify what matters most to the group. Through the use of these novel techniques, the American Psychiatric Nurses Association Research Council has identified priorities for the work of the council. This has led to actions planned for the coming future with the intent to move PMH nursing research forward.