Before we can look at the future of quality improvement in behavioral healthcare, we have to look to the past to understand problems that have hindered quality improvement. For most of the history of medicine, behavioral healthcare as a discipline has been ignored, largely due to the public stigma around behavioral health and an even greater misunderstanding of the factors at work in mental illness.  (The origin of the term “lunatic” is a good example of this long-held misunderstanding; it was derived from the Latin word for moon because it was thought that the cycle of the moon had an effect on a person’s mental state. )   

Quality improvement in healthcare as we recognize it today began with the establishment of the federal Medicare and Medicaid programs in 1965. As participants in those programs, providers had to meet a number of requirements – the most significant being the creation of the utilization review processas a safeguard against unnecessary and inappropriate medical treatment. Unfortunately, this requirement had the unintended consequence of creating a hyper-focus on documentation.  Accurate and detailed documentation is both positive and necessary in making sure patients receive appropriate treatment; however, when quality improvement systems and regulatory systems are designed solely with content of documentation in mind, rather than the outcome of the individual patient, it is negative. The hyper-vigilance on documentation will be an issue that hinders quality improvement in behavioral healthcare for the next fifty years.  

A second major constraint in quality improvement is the understanding about what is actually meant by quality. During the 1960s and into the 1980s a number of federal and state healthcare-related laws were passed with quality components to them. At the same time, the three largest accrediting agenciesthe Joint Commission, Det Norske Veritas Healthcare, Inc., and the Healthcare Facilities Accreditation Program- also incorporated quality improvement components to their accreditation processes. But amid all the efforts to improve the services being provided, there was no single clear operational definition of what quality meant or how to improve it in the healthcare context, and this gap led to a number of false starts, incomplete projects and disillusionment among providers, who grew more resistant to try to improve or even to evaluate what currently was being done.   

With no clear definition of quality in a healthcare context, and with accrediting bodies, state regulators and managed care organizations focused primarily on documentation, providers responded by creating quality assurances (QA) departments – a fixture in manufacturing industries since the 1920s.  However,  quality assurance in a manufacturing operation is designed to remove defective parts from the assembly line by the use of audits and sampling before they were sold to a customer – not on preventing the creation of a defective part (or delivery of a substandard service) in the first place. 

During the 1980s and 1990s, QA departments in behavioral healthcare providers attempted to use Statistical Process Control (SPC) and Total Quality Management (TQM) tools. Both methods of continuous improvement failed to reach their true potential in those operations for two reasons – the lack of highly skilled individuals needed to administer QA efforts correctly, and the continuing hyper-vigilance on documentation rather than on patient care and outcomes. 

As a result, during the 2000s a number of quality assurance departments changed their name to Quality Improvement (QI) departments, as a way to note a commitment to actually improving quality. The Plan-Do-Check-Act (PDCA) circle and Plan-Do-Study-Act (PDSA) circle was added to the QI toolbox, along with Correction Action Plans, later called Quality Improvement Plans. But again the issues of hyper-focus on documentation and unclear meaning of quality in a behavioral health context resulted in these tools from the manufacturing sector, intended to improve services for the patient, being corrupted.

What was lost from the transition from the manufacturing sector to the behavioral healthcare field was the “how” and “why” of the Corrective Action Plan process. Instead of a thorough review dedicated to finding the true root cause of a defect in the process, and a clear unbiased evaluation of the impact on the patient’s treatment and quality of life, more often than not in behavioral health settings you get a quick ”looks good” plan focused on documentation. 

Here’s an example: during an audit of a patient’s record  the outside auditor finds that one note documenting a group session with the patient was missing a required field. The normal course of action of the outside auditor is to issue some type of infraction and request a correction action plan be done to prevent the error in the future. The provider’s normal response is a Correction Action Plan listing what steps they will or have done, most likely some type of training. On the surface everything looks good: the outside auditor found an error and requested it corrected, and the provider responded with a plan on how to correct it using training. But the larger question is, did reviewing the document notes of treatment, or training a mental health professional for the second time to write a better note, actually improve the providing of servicesto the patient?

2010’s federal Affordable Care Act required the development of a core set of health quality and performance measures to reduce cost and improve services. A number of groups began abandoning the old standards and applying the new health care metrics from the Centers for Medicare & Medicaid Services (CMS) to behavioral healthcare.  In a short amount of time they realized that behavioral healthcare metrics and goals are different than those in medical healthcare.  The underlining complexity and chronic nature of mental health conditions do not lend themselves to the same simple outcome measures as medical conditions. Metrics for behavioral healthcare need to be more segmented so that data can be compared among groups with similar factors which would impact the metric.  For example, instead of comparing a patient’s length of stay with a provider against the length of stay of the total population, the length of stay should be compared against the length of stay of other patients who were in the same factor segments for age, gender, education, location, and mental health diagnoses. 

Fortunately, quality improvement is now evolving in ways that actually improve the system for both the patient and the provider, while maintaining quality and cost standards. This is largely done by first questioning if each metric and standard is truly helping the patient, and then asking how we can improve to surpass the metric and standard. Behavioral health providers have started to use continuous improvement methods like Lean and Lean Six Sigma (LSS). These approaches each feature their own methods, tools, definitions and philosophies, but they share the ability not to be limited by incorrect or false assumptions.  Both look for unbiased data to analyze, as well as identifying known and unknown factors that influence the process (as measured in metrics like length of stay or readmission rates).

By combining real-time data with a number of different continuous improvement tools, a behavioral health provider is able to make real-time changes to treatment to improve the current service for an individual or a segment group.  Thus, the use of these new continuous improvement methods can improve the effectiveness and efficiency of treatment services for both the patient and provider.

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Jason J. Raines

Jason J. Raines

Jason James Raines is a Six Sigma Black Belt and university certified Lean Sensei. Jason is currently working on his Doctorate in Business Administration. His dissertation is on barriers and drives to the successful implementation of continues improvement methods in behavioral healthcare setting. Jason is the founder of Raines Consulting Group LLC.