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Quality Indicators in Consultation–Liaison Psychiatry

TO THE EDITOR: As the leadership of two academic general-hospital programs in Consultation–Liaison (C–L) Psychiatry, we are increasingly involved in a quality-improvement environment. In addition to external accreditation organizations such as The Joint Commission (TJC), payers are increasingly requiring their own quality indicators (QIs), often linked to payment requirements.¹ Quality report cards, including those for government-prescribed indicators,² are now published online for outcomes of a variety of medical conditions and surgical procedures.

C–L Psychiatry has struggled to find its rightful place at the table in general hospitals, facing a variety of exclusionary issues, including stigma and financial disincentives. The expectation for routine reporting of QIs challenges us to participate as peers among other medical/surgical services. The selection and reporting of QIs often begins within departments, but eventually becomes highly visible in executive committees and boards of trustees. Behavioral health, as compared with other medical disciplines, suffers from a relative lack of quality-control infrastructure,³ and psychiatry is the only medical discipline in which quantified measurements of outcome are not the standard of care.⁴ Many medical/surgical QIs are selected from national lists required for public reporting. Our lack of standard and relevant QIs contrasts with other departments and conveys a message that either we are not doing anything important or that we do not have objective interventions.

Our own QI process started with indicators such as: "time between consultation request and performance;" "documentation of complete diagnostic assessment;" and documentation of "timely communication of findings with the requesting physician." Other medical specialties no longer use such basic indicators, and it is difficult to support their continued use long after demonstrating a high level of performance. We have not had an easy time coming up with QIs analogous to starting an antibiotic within 6 hours of admission for pneumonia, or documenting the use of an ACE inhibitor on discharge for patients with congestive heart failure. We were surprised to learn that our specialty organization, The Academy of Psychosomatic Medicine (APM), does not have published QI guidelines for us to adopt.

One of our ideas involves the use of our service to measure the quality of other programs. For example, we are in a position to monitor how often the referring service documents the presence of clinically-important problems, such as substance abuse or delirium, which substantially affect patient outcomes. Although this approach could have important quality implications, some would argue that this indicator says more about other services than about our own. However, one of C–L psychiatry’s core roles includes the identification of systems issues pertaining to clinical care. Other, more recent, ideas include documentation of a recommendation for a cholinesterase inhibitor for appropriate dementia patients, implementation rate of a Clinical Institute for Withdrawal Assessment (CIWA) protocol when clinically indicated, and use of standard screening instruments for identification and monitoring of depression or delirium.

The APM could consider posting a website blog devoted to the identification of promising QIs, as a prelude to organizational recommendations. Since future program quality-evaluations might depend on these indicators, we must exercise due diligence in our choices. We are not alone among the mental health specialties in searching for meaningful quality indicators, given that the measurement of quality in mental health care is a relatively nascent area.

REFERENCES

1. Baker G, Carter B: Pay-for-Performance Incentive Programs:2004 National Study Results. San Francisco, CA, Med-Vantage,2005
2. www.hospitalcompare.hhs.gov
3. Bremer R, Scholle S, Keyser D, et al: Pay for performance in behavioral health. Psychiatr Serv 2008; 59:1419–1429[Abstract/Free Full Text]
4. Zimmerman M, McGlinchey J, Chelminski I, et al: A clinically useful depression outcome scale. Compr Psychiatry 2008; 49:131–140[CrossRef][Medline]

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