Founder of ACLP’s Quality & Safety SIG, David Kroll, MD, director of quality and safety for the Psychiatry Department at Brigham and Women’s Hospital, leads new thinking on business issues in occasional articles for ACLP News

Why Measure Quality in C-L Psychiatry?

Getting it right: Your strategy for tracking outcomes

Some C-L Psychiatry services struggle to prove their worth to their own health systems. 

It may be easy to assume that your service is doing a good job when you’ve hired good psychiatrists and, generally, your patients and consultees seem happy with the consults they’re receiving. And that’s probably fair—your good psychiatrists probably are providing good care most of the time. 

It’s also easy to point to research showing the ways in which C-L Psychiatry services usually improve value for health systems by advancing health outcomes, lowering costs, or both. But the sound of academic research unfortunately doesn’t move all listeners, and there is only one way to know for sure what the direct impact of your service is. That is by tracking outcomes.

Tracking outcomes seems like an obvious step in any effort to assess quality or drive improvements in service delivery, but the field of C-L Psychiatry has not come to an agreement regarding what outcomes should be measured, or how. 

Several metrics have been proposed, and studied, including consult volume, consult type, consult response time, consultee satisfaction, patient satisfaction, patients’ relatives’ satisfaction, consultee concordance with recommendations, documentation elements, nurses’ difficulty in caring for patients, global assessment of functioning scores, symptoms at follow-up, adherence to recommendations at follow-up, length of stay, utilization, and costs. I’ve written about the obstacles to measuring quality on C-L Psychiatry services before in this column. Today, I want to try to map out a strategy for getting it right.

The first question we should ask ourselves is this: why do we want to measure quality in the first place? Is it to drive improvements in patient care? Quality measurement can be an effective tool for refining best practices and promoting adherence to those best practices at the local level. That is indisputably a good goal, but it is not the only one. 

Another reason to measure quality is to prove our worth to hospital systems. C-L Psychiatry services, no matter how good, can’t operate without money, and most of us cannot generate that money by billing for clinical services (not if the clinical services are psychiatry consults, anyway). In order to grow (and therefore to care for a higher volume and complexity of patients), we may need to demonstrate the ways our work adds value for the health systems we serve. There is some overlap between these two priorities, but they aren’t identical. 

A third reason to measure quality is to facilitate comparisons between services in different health systems—basically asking the question of whether service A is doing a better job than service B, as opposed to whether service A can do a better job this month compared to last month. This is not just about vanity. Comparisons can be used in a positive way to help set standards, and their usefulness in marketing and recruitment can be a powerful incentive for greater investment by health systems.

Once we answer that first question (and we haven’t, by the way), then we can ask the second question: where are the quality gaps? Or put another way: where is there variation in quality? If our goal is to drive improvements in patient care by promoting best practices, then we should find areas where best practices are not yet known, or where adherence to best practices is inconsistent.

If our goal is to prove our worth to hospital systems, we should look for the hospital system’s pain points. Is it in long lengths of stay? Or constant observation costs? It may be that the hospital system is struggling to meet its own quality measures that are not obviously related to C-L Psychiatry, such as 30-day readmissions, and this could present new opportunities. 

Finally, if our goal is to facilitate comparisons, we can decide amongst ourselves which metrics we think are already most representative of service quality and propose a standard tool.

We still have a long way to go before we can all agree on a universal framework for measuring quality in C-L Psychiatry. But if we can figure out why we want to do this in the first place, I think we’ll get there sooner.

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