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Assessing the Performance of Inpatient Mental Health Care

Assessing the Performance of Inpatient Mental Health Care. Elizabeth Lin, Ph.D. January 21, 2002. Colleagues. Funding -- MOHLTC and OHA Project administration -- Adalsteinn Brown, Paula Blackstien-Hirsch (Dept. of HPME, U of T) Research Team Janet Durbin Niki Degendorfer

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Assessing the Performance of Inpatient Mental Health Care

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  1. Assessingthe Performance of Inpatient Mental Health Care Elizabeth Lin, Ph.D. January 21, 2002

  2. Colleagues • Funding -- MOHLTC and OHA • Project administration -- Adalsteinn Brown, Paula Blackstien-Hirsch (Dept. of HPME, U of T) • Research Team • Janet Durbin • Niki Degendorfer • Peter Prendergast • Paula Goering

  3. Objectives • Evaluate the feasibility of using the balanced scorecard for inpatient mental health care • Identify/recommend performance indicators for inpatient mental health care • (Provide provincial level estimates where possible from existing data)

  4. Balanced Scorecard (I) • Kaplan & Norton, HBR, 1992 • Comprehensive view of a business • Based on strategic objectives

  5. Balanced Scorecard (II) • Assess business from 4 perspectives • customer • internal • innovation & learning • financial (shareholders)

  6. Balanced Scorecard (III) • Indicator characteristics -- • small number • considered simultaneously • can be disaggregated to determine where change is needed Shift from control to strategy

  7. Study Rationale (I) • Why inpatient mental health care? • Non-trivial prevalence of mental/addictions disorders in population • hospital $ over 1/2 provincial MH dollar • psychiatric hospitalizations = 15% of all hospital days

  8. Study Rationale (II) • Why a feasibility study? • Role of inpatient MH care is to stabilize individuals in crisis and discharge rapidly to appropriate community-based service • Type of procedure and diagnosis not as predictive of MH hospital LOS • Mortality and post-treatment complications not as informative for MH as for other kinds of care

  9. Methods • Literature review -- published and ‘grey’ • Site review • Consultations • (Data review)

  10. Literature review: FRAMEWORKS • Canadian Council on Health Services Accreditation (CCHSA) • Canadian Institute for Health Information (CIHI Roadmap) • B.C. Resource Kit for Performance Monitoring • MHSIP Consumer Oriented MH Report Card • Basis-32 Plus Performance Measurement System

  11. Site review • U.S. Veteran’s Administration • B.C. Mental Health Framework • Georgia’s PERMES system • Pittsburgh’s Western Psychiatric Institute and Clinic

  12. Preliminary Lessons • No shortage of ‘indicators’ or frameworks • Serious shortage of indicators used in planning or resource allocation Seeming disconnect between scorecard and commonly used MH frameworks

  13. Balanced Scorecard (Hospital Report) Four quadrants • System integration and change • Clinical utilization and outcomes • Client satisfaction • Financial performance and condition Assessed from individual hospital’s perspective

  14. B.C. Toolkit(McEwan & Goldner, 2001) Eight domains • Acceptability (client satisfaction) • Accessibility (outreach to homeless and SMI) • Appropriateness (readmission rate) • Competence (knowledge of legislation)

  15. B.C. Toolkit(McEwan & Goldner, 2001) Eight domains -- continued • Continuity (cases lost to follow-up) • Effectiveness (community tenure) • Efficiency (community/institution balance) • Safety (critical inpatient incidents) Assessed from wider system’s perspective

  16. Proposed Modifications 1. Add wider system perspective 2. Use critical strategic objectives to narrow down or suggest indicators

  17. Province Region Individual hospital MH/addictions program or unit #1: Adding wider system perspective

  18. #2: Using strategic objectives (I) Mental Health Reform • Improving quality of life and well-being of priority population • Providing comprehensive and integrated continuum of services based on best practices • Providing timely care matched to the individual’s needs • Delivering care in a responsible and accountable manner

  19. Integr & change Utiliz & outcome Satis-faction Financial Accessibility    Appropriateness    Outcomes   Participation   System management    #2: Using strategic objectives (II)

  20. Synthesis COMMON Province-specific COMMON Region-specific COMMON Hospital-specific COMMON Program/unit-specific

  21. Indicator selection: criteria • Reflects strategic goal of MH Reform • Addresses priority issue • Has a desirable direction • Is ‘actionable’ • Based on valid available data (or soon to be available) • Final set fits on one page

  22. Indicator selection: definitions • Indicator – measures strategic objective • Adjustment variable – increases comparability (NOT under hospital/unit’s control) • Contextual variable – helps explain or interpret indicator value

  23. Indicator examples (I) System integration & change • % receiving OHIP post-discharge care within 30 days (appropriateness) – INTERIM INDICATOR • Average LOS (system management) Clinical utilization & outcomes • % Ontarians hospitalized by age, sex, region (accessibility) • % discharges readmitted within 30 days (outcomes)

  24. Indicator examples (II) Client satisfaction • User perceptions of appropriateness (appropriateness) • User perceptions of consumer/family inclusion in treatment decisions (participation) Financial performance & condition • Total cost/weighted day (system management) • Cost/outpatient weighted visit (system management)

  25. Adjustment variable examples Patient demographics – Age, sex Special populations -- % elderly, children/adolescents, forensic Severity/complexity – % comorbid illnesses (physical, other mental/addictions), % involuntary admissions

  26. Contextual variable examples System capacity – # acute MH beds, psychiatrists/capita, % of health funding which is MH, % of MH funding which is inpatient Revenue source – % MOHLTC revenue Geographic distribution of services – regional per capita spending for MH, distance to nearest Schedule 1 hospital

  27. Results 40 indicators recommended • 9 are currently feasible • 23 expected within 1-5 years • 8 need clearer definition and data-gathering infrastructure

  28. Next Steps (I) • Investigate problematic variables • Calculate indicators for regions (and possibly peer groups) • Collect data for interim indicators (resource inventory or hospital survey) • Work with CIHI to incorporate new data elements

  29. Next Steps (II) • Incorporate user perspective throughout scorecard quadrants (via self-ratings, user perceptions, user satisfaction) • Develop small set of mandated outcome measures plus complementary toolkit of approved indicators • Develop summary indicators

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