Quality: A Moral Imperative

Harry L. Mills, Ph.D.

In an era in which costs are paramount and price is driving the healthcare market, it is essential to restore balance by giving greater emphasis to value. In that context Total Quality Management (TQM) becomes an ethical imperative for behavioral health delivery systems. 

Under capitation arrangements which permit short term profits by restricting access to needed care, quality management systems are essential.  In a market in which a smaller and smaller percentage of the premium dollar is being devoted to specialized behavioral health care, a commitment to total quality management is required to reinvigorate and renew behavioral health delivery systems and to convince increasingly skeptical payers to invest in behavioral health.

A commitment to quality management cannot be expressed through badges of pretension, purchased through accreditation charades, that encourage form without substance. Quality management cannot be reduced to recursively trivial  PDCA cycles spiraling, one upon another, while patients continue to suffer. Vacillation from triviality, to academically inspired impracticality, will not enhance quality. The processes of service delivery must be designed so that the results are achieved the first time. Always the first time.

Where does NCQA fit?  Does it certify quality or is it a badge, available for purchase, behind which those companies with the cash can hide continued pursuit of profits, at the expense of adequate care? Do committee minutes reflect quality? Or will companies with the resources hire platoons of nurses to have meetings and craft minutes that are little more than works of fiction? Is an on site visit for a few days, during which wheelbarrows of paper are shuffled about, the way to "inspect" for quality? While debatable, I doubt it will produce anything other than a shield for those buying the badge from public scrutiny, for a little while. But not for long. JCAHO never worked. NCQA will never work. Inspection, as Deming was fond of saying, never produces quality. Never.

Behavioral health professionals and organizations must not depend on inspection. We should advocate for a shift from cost driven to value driven care.  The definition of value is:

VALUE = QUALITY/COST

The equation defines our challenge:  Deliver greater quality at less cost.  It is the same challenge facing all healthcare in the United States.  It means accepting that costs are a factor and at the same time facing the necessity to define quality in ways that payers will accept.

Total Quality Management

Total quality management (TQM) may be defined in terms of these three elements:

·         QUALITY PLANNING - planning and designing processes to avoid problems.

·         QUALITY CONTROL - management within the control limits for a process.

·         QUALITY IMPROVEMENT - changing processes to improve outcomes.

Quality planning may involve planning and designing service elements (e.g. hospitals and SIO) so that there is an adequate match between the patterns of presentation for services in the designated population (e.g. HMO plan membership) and the number and types of practitioners and service programs.  It may also involve insuring the availability of special therapy programs (e.g. for panic disorder or substance abuse) that are most likely to produce positive outcomes. 

Quality Control in behavioral health means management within control limits for key processes.  For example, the proportion of patients with outpatient appointments within three days of hospital discharge or proportion of patients with Major Depression referred for possible medication.  Control limits are defined and outliers are carefully monitored.

Quality Improvement is viewed as part of TQM.   Opportunities for improvement are identified and the scientific method is employed to produce changes in processes that are likely to improve outcomes.  For example, it may be necessary to add providers to insure appointments within three days of hospitalization.  Or it may be necessary to establish formal criteria for referral to a psychiatrist and train non medical providers on the application of those criteria.

The TQM  philosophy in behavioral health involves at least these basic elements:

·         Management decisions are based on measurement and data

·         Efforts are ultimately judged by their value to customers of the delivery system

·         Problems are defined with care and precision

·         Variation and variability are understood and monitored

·         Systematic analysis of causal influences are undertaken

·         Focus is on processes likely to produce outcomes that are favorable

·         Change methods are will defined and carried out systematically

·         Results of interventions are carefully evaluated

·         Every defect is seen as an opportunity for improvement and not for scapegoating

·         Systemic thinking and problem solving rule.

An outcomes management model includes these key elements:

·         Efficacy

·         Effectiveness

·         Quality Assessment

·         Quality Improvement

Efficacy in behavioral health is defined by research, consensus and/or experience.   Efficacy refers to therapeutic processes that work in general with a specific clinical presentation or type of problem (e.g. readmission).  On the other hand effectiveness refers to the application of knowledge to a specific population.   For example a group therapy model with panic patients may have demonstrated efficacy, but when applied to a specific delivery network that same group approach may or may not prove effective.

Quality Assessment means evaluating the results of an application. Quality Improvement should be based on the results of an assessment.  To continue the example, specialized training in the application of the group model may provide for improvement in effectiveness when applies to a specific population.  Or perhaps a change in selection and referral patterns can lead to improved group composition.

Avedis Donabedian, a physician, has made an exceptional contribution to thinking about the issue of quality in healthcare.  In a career that spanned four decades, he has virtually defined the boundaries of the field.  One of his most important contributions was to suggest that quality in healthcare is defined in three distinct dimensions:

·         Structural Factors

·         Process Factors

·         Outcome Factors

Meaningful discussions of quality must include all three components, even though specific projects tend to focus within a given dimension.  The politics of quality management often lead to restricted focus at the expense of quality.  Managed care finance managers prefer to ignore structural factors because they cost money.  Telephone systems, facilities and staff reduce short term profits.  Accreditation bodies like NCQA and the Joint Commission over-emphasize process factors at the expense of outcomes.  They place absurd confidence in structural factors like policies and procedures.  The guilds give lip service to outcomes but devote little in the way of activity and resources to overcoming the barriers to outcome evaluation.  One of the many reasons the current healthcare environment is so destructive of quality is that narrow business interests encourage pretensions that quality can be adequately managed by addressing one set of factors at the expense of the other two.  Total Quality Management requires addressing all three dimensions and accepting that the interactions between the factors are the very heart of the matter.

Structural Factors

Structural factors refer to resources and the capacity of a behavioral health delivery system to deliver care.  The qualifications of practitioners and/or staff, types of programs and services, facilities, computers and other equipment are all structural factors.   Availability of different type of practitioners (e.g. psychiatrists, psychologists, and social workers) with key areas of expertise (e.g. substance abuse or eating disorders) that can meet the needs of a given population is often an issue in behavioral health systems.  It is even more of an issue in service systems designed for Medicare or Medicaid populations.  In the public sector coordinated services in a continuum of care that includes "wraparound" services such as transportation, employment and legal assistance must be part of the quality equation.  The child and adolescent population presents its own challenges and requires the development of a system that addresses their unique dependent status.

Poor quality behavioral health delivery systems have the following structural deficiencies:

·         ACCESS - Poor intake and triage with delays in entry into the system and inadequate initial planning.  Access designed to meet needs of providers and not consumers.

·         CARE - Methods of service provision are based more on the biases of the professionals than the needs of the patients and there is wide variation in practice patterns.

·         SERVICES - Delivery is fragmented, uncoordinated and communication among practitioners is minimal.   Excessive focus on acute care.  Services are designed more for current payment schemes than to produce positive outcomes.

·         SYSTEMS - No continuum off care is provided and linkages are minimal between the elements of care.

·         OPERATIONS - Lack of adequate measurement, monitoring and evaluation of the performance of the system.

·         TECHNOLOGY -- Technology serves the narrow interests of isolated profit centers rather than advances being systematically integrated in the interest of patient outcomes.

·         COST - Measurement of actual costs is not addressed in favor of monitoring of immediate cash outlay.  Leads to penny wise pound foolishness.

·         KNOWLEDGE - The delivery system learns little and thus changes little in response to market changes.   Becomes a learning disabled organization.  A rigid organizational fossil.

A high-performance behavioral system which applies TQM on a day-by-day basis will have these structural characteristics:

·         ACCESS - Access to care is actively managed, triage systems insure access at the appropriate point and needs of special patient populations are anticipated and thus  crisis and need for access averted.

·         CARE - Outcome focused protocols are developed and employed.  Methods of intervention are selected based on probability of producing positive outcomes.  Practitioners are trained in what is likely to work.  Therapeutic processes are subjected to continuous improvement.  Practice variation is reduced.

·         SERVICES - Services are planned, organized and coordinated.  Vertical, horizontal and backward integration is emphasized.  Preventive care and health promotion is provided.

·         SYSTEMS - Full continuum of care is available and elements are linked through case management.

·         OPERATIONS - Organizational pulse points are continually monitored and there is continuous data driven process improvement.  Processes selected for improvement are presumed to influence outcomes.

·         TECHNOLOGY - Methods exist for identification of new behavioral health technology or positive results of efficacy studies and management encourages integration of such finding s in the delivery system.

·         COST - Monitoring of costs extends beyond current cash to include delayed or deferred costs, costs of opportunities and benefits lost and cost of failing to reap preferred results   in a cash outlay selected based on the lowest bidder.

·         KNOWLEDGE - Feedback loops and patterns of information of flow create a dynamic learning organization that adapts to changing environments and thus maintains a competitive level of quality.

Access is considered a structural component of quality measurement.  However, given the unique features of access in behavioral health additional discussion seems appropriate.   The continuing stigma associated with seeking care for behavioral health, creates a barrier to care even before the addition of copays and other measures common to the cost containment effort.  It remains all too common that patients with behavioral health problems remain undiagnosed and are never referred for specialized care even when such a referral is mostly appropriate.  First generation managed behavioral health companies found virtual gold mines for their stockholders by restricting access to care even further.  Access to practitioners was restricted by establishing staff model centers to which the vast majority of consumers were referred.  Outpatient copayment in behavioral health are much higher than in other healthcare areas.  Patients ambivalent about seeking care were thus induced to avoid care or to drop out of care early and too often.  Profits soared and quality plummeted in behavioral health delivery system , while the costs of the behavioral component of healthcare  continued to increase within the medical care delivery systems as a byproduct of that restricted access.  Gradually managers of healthcare have become aware that such restrictions are foolish when the total costs of care are considered.  Thus access is the most critical of the structural factors.

Thus is should not be surprising that access measures are a major component of the measures proposed by the National Committee on Quality Assurance (NCQA) and the American Managed Behavioral Healthcare Association (AMBHA).  Days and number of visits per 1000 population, average length of stay and number of sessions per episode are common.   Waiting time for appointments and telephone response are now part of HEDIS 3.0   Also healthplans are required to report on availability of chemical dependency providers.  The data set developed by AMBHA includes these access measures:

·         Penetration rates broken out by such factors as age, diagnosis, setting type of clinician.

·         Utilization of elements of the continuum like inpatient and outpatient and alternatives to inpatient care.

Behavioral health delivery systems must be funded at levels that encourage appropriate access to needed care and eventually it must be recognized, that as long as patients needing behavioral healthcare are cycling, underdiagnosed and undertreated, within the medical delivery system, the major access problem, and among the most foolish of cost problems, remains unaddressed. 

Process Factors

In business process is defined as a sequence of events an organization conducts that generates an output that is of value to the customer. I behavioral healthcare the processes of greatest importance are those events that take place in the encounter between a behavioral health caregiver and the recipient of that care. Such processes are considerably more complex than in other business spheres and the outputs of those processes are more difficult to define and measure. And yet the threats to behavioral health are so great that such measurement challenges must be overcome.

In the effort to influence processes, in ways likely to improve outcomes of care, internal self-regulatory and/or external regulatory methods are employed. The most common internal method is development of continuous quality improvement (CQI) programs. The most common external method is accreditation by such organizations as NCQA or the Joint Commission. The development of practice guidelines may be a part of internal or external approaches.

In an effort to demonstrate a capacity for self-regulation within the industry the American Managed Behavioral Healthcare Association (AMBHA) drafted a set of quality performance indicators known as Performance Based Measures Managed Behavioral Healthcare Programs (PERMS).  While it could not be considered a success because of poor reporting patterns and rivalries within the industry, PERMS had influence on other efforts.

PERMS 1.0 measures included the following:

Access Measures

·         Percentage of enrollment served

·         Specific sub-populations served

·         Utilization of outpatient, inpatient and intensive alternatives

·         Cost data for severely mentally ill

·         Telecommunications access (e.g. call abandonment, average hold time)

Satisfaction Measures

·         Time interval for first appointment

·         Satisfaction with intake workers

·         Satisfaction with the therapist

·         Patient's assessment of outcomes

·         Patients' overall satisfaction rating

Quality of Care Measures

·         Effectiveness as measured by hospital follow up and repeat detox within 90 days

·         Efficiency as measured by continuity

·         Appropriateness as measured by:

o        Available medication for schizophrenia

o        Family visits for children

o        Minimal utilization for adjustment disorders.

The next generation of the AMBHA performance measures PERMS 2.0 is scheduled for release in 1998.

After the  initial failure AMBHA and NCQA officials met to discuss measurement options.   The newest version of the Health Plan Employer Data and Information Set (HEDIS 3.0) included elements of PERMS and emphasized behavioral health much more than previous versions.  Relevant measures in HEDIS 3.0 include the following:

·         Follow-up after hospitalization

·         Availability of specialty providers

·         Discharges and LOS

·         Percentages receiving levels of care

·         Readmission

·         Chemical dependency inpatient and LOS

·         Percentage in levels of care for Chem Dep

·         Readmission for Chem Dep

·         Access to pediatric mental health care

·         Availability of substance abuse counseling for teens

·         Continuity of care for substance abuse

·         Continuity in depressed patients

·         Available medical management for schizophrenics

·         Appropriate use of medications

·         Family visits for children

·         Patient satisfaction

·         Failure in substance abuse treatment

The Institute for Behavioral Health's National Leadership Council has proposed these quality indicators:

·         Acute inpatient days per 1000 and ALOS

·         Outpatient visits per 1000

·         Intensive outpatient LOS

·         Percent of patients readmitted

·         Percent reporting overall satisfaction

·         Telephone response time & call abandonment

·         Waiting time for appointment

·         Average number of outpatient sessions

·         Waiting time for emergent visits

The Institute for Behavioral Health's Council of Behavioral Group Practices has proposed the following benchmarks:

·         Routine appointment within 5 days

·         Urgent office appointment in 24 hours

·         Emergent appointment within 8 hours

·         Intensive outpatient with no waiting

·         Phone response within 4 rings or 16 seconds

·         Calls on hold for less than 10 seconds

·         Patients given authorization on first call

·         Immediate response to emergency calls

The Mental Health Statistics Improvement Program (MHSIP) have suggested the following items in their Consumer Report Card on Access:

·         Time from request to first face-to face visit

·         % for whom appointments convenient

·         Average resources expended on mental health

·         % services delivered in natural setting

·         % reporting sensitivity to ethnicity, age etc.

·         % reporting cost is an obstacle to needed care

·         % of patients dropping out of needed care

·         % of consumers who report caregivers can be reached easily

The MHSIP Report Card on Appropriateness includes:

·         % of consumers who report active participation in treatment planning

·         % of consumers who feel coerced into options

·         % of admissions that are involuntary

·         % of discharged patients seen in 7 days

·         % discharged from ER who receive visit in 3 days

·         % of patients who had multiple primary providers

·         % whose treatment is within guidelines

The MHSIP Report Card on Outcomes includes:

·         % of patients connected to primary care

·         % of patients with significant medication side effects

·         % of patients with significantly less distress

·         % with increased level of functioning

·         % who are using self help options

·         % reporting help with the problems they identified

·         % of children removed from home

Certainly the most powerful approach to external quality control is coming from employers who pay the bills and who can pull the purse strings.  Many employers are establish quality standards themselves rather than await the effects of self-regulation or the snail's pace that has been exhibited by accreditation organizations.  Digital Equipment Corporation (DEC) has developed exhaustive standards for the behavioral health components of HMOs.  DEC is clearly concerned about value and not simply benefit costs.  Those standards are summarized below:

DEC Standards for Access:

·         Non urgent appointment within 5 days

·         Urgent appointment within 24 hours

·         Emergency appointment within 4 hours

·         85% satisfaction with wait time

·         EAP may direct refer

·         Hospital drive 45 minutes or 45 miles

·         PH/IO drive 30 minutes or 30 miles