Core Measures in Psychiatric Nursing
Jessica A. Ebsen, RN, BSN
College of Saint Mary
Explanation of Critical Issue
Core measures are a valuable and necessary tool for evaluating the quality and effectiveness of health care. The Joint Commission has developed the Specifications Manual for National Hospital Inpatient Quality Measures, which contains common data terms, measures and collection forms. The goal is to establish common measures, minimize data collection efforts, and use the data to improve the health care delivery process. The current core measure sets include the areas of substance use, tobacco treatment, venous thromboembolism, pneumonia, immunization, acute myocardial infarction, children’s asthma care, heart failure, surgical care, perinatal care, stroke, hospital outpatient department, and hospital-based inpatient psychiatric services (Joint Commission, 2012).
The hospital-based inpatient psychiatric services (HBIPS) consist of seven core measures. The measures include (1) admission screening for violence risk, substance use, psychological trauma history and patient strengths; (2) hours of physical restraint use; (3) hours of seclusion use; (4) patients discharged on multiple antipsychotic medications; (5) patients discharged on multiple antipsychotic medications with appropriate justification; (6) post discharge continuing care plan created; and (7) post discharge continuing care plan transmitted to next level of care provider upon discharge. The risk assessment must include a minimum of two strengths, complete history of psychological trauma, use of drugs and alcohol for the past twelve months, and risk of violence to self or others for the past six months. The minutes in restraints and seclusion must include the total time that all patients were held in personal or mechanical restraints or seclusion, the start and stop times for all restraint and seclusion events, and a ratio measure per 1,000 hours. Measures 4 and 5 must include the total of all patients discharged on two or more antipsychotic medications and the justification for use. Patients who are discharged on two or more antipsychotics must be justified by three or more trials of monotherapy with the failed trial medications listed, plans to taper to mono therapy in progress with medications listed, or a listed medication augmented with Clozapine. Measure 6 requires a completed continuing care packet which must include a discharge diagnosis, reason for hospitalization, recommendation for the next level of care, and a list of patient’s medications including dosage and rational for each medication. Measure 7 requires that the complete continuing care packet must contain all elements, and must be sent to the medication provider or therapist within five days of discharge. Patients sent to corrections or who have left against medical advice are not excluded from this requirement (The Joint Commission, 2012).
The population affected by the implementation of quality measures includes both patients and providers. The core measures can help to standardize care, and will ideally improve care and patient outcomes. These core measures have recently been developed and are in process of implementation. Implementation of new standards of care and data collection can be quite stressful on organizations and employees. There is a learning curve associated with new procedures, and the process of change is complex. This requires hours of education, policy development and revision, and reinforcement. The hope is to improve patient care and outcomes.
Health Care Policies
The requirement of reporting HBIPS core measures is driving the development of organizational health care policies and procedures. In order to achieve and maintain Joint Commission accreditation, organizations now must report and meet expectations of these core measures. These measures will help to provide standardized care throughout the United States and throughout the world. A study conducted in South Africa demonstrated the cross-cultural effectiveness of implementing core measures in the psychological clinical setting (Campbell & Young, 2011).
Main variables that affect the implementation of these core measures include funding, availability of resources, and the current organizational culture. Facilities must have funding available to implement new standards and policies. They will also need to have personnel available to learn requirements, educate other employees, and implement the data collection and reporting of data. According to Rao, Hendry & Watson (2008), routine outcome measurement is a significant undertaking that “requires the development of a culture of clinical curiosity, proactive and committed management approach, and adequate resources, positive engagement of practitioners and users, and robust strategy to overcome challenges.” Facilities with less financial and personnel resources will find difficulty with implementing the core measures.
Access to Care
One argument about implementing core measures is the possibility of decreased patient contact. Time is a limited resource. If nurses are required to spend more time documenting core measures, there may be less time available to spend with patients. An essential aspect of psychiatric nursing is spending time talking with patients and developing therapeutic relationships. If nurses have to spend some of that time focused on data collection and documentation, patients may not have as much access to the therapeutic relationship. Despite the worry of access to care, research has demonstrated that consumers are in favor of routine measures in psychiatric care. According to Guthrie, McIntosh, Callaly, Trauer, & Coombs (2008), sixty six percent of consumers consulted believed that routine measures improved their care.
A significant trend in nursing is to collect and analyze data. Purposes of this are to gain a better understanding of the environment and challenges, decrease costs, and improve patient outcomes.
Financial implications of these requirements can be astronomical for an organization. The cost of personnel to plan, develop, implement and educate others of this change can be huge. But with improved outcomes, streamlined processes and efficient and effective care, long term costs can hopefully be contained or reduced.
There is an ethical responsibility to provide effective, quality care. These core measures are an indication of the quality and effectiveness of inpatient psychiatric care provided. With the development and use of core measures for inpatient psychiatric services, there is opportunity to evaluate and improve patient care and outcomes.
Theory in Mental Health Nursing
A standard theory in mental health nursing is Barker’s Tidal Model of Mental Health Nursing. Barker defined it as “a philosophical approach to the discovery of mental health. It emphasizes helping people reclaim the personal story of mental distress, by recovering their voice. By using their own language, metaphors and personal stories people begin to express something of the meaning of their lives. This is the first step towards helping recover control over their lives" (Current Nursing, 2012). Barker also stated that it provides a practice framework to explore the patient’s needs and provide individualized care (Current Nursing, 2012).
The Tidal Model is applied through six assumptions. The model assumes a belief in the virtue of curiosity to learn a person’s individual story, recognition of the power of resourcefulness rather than a focus on weakness, respect for the patient’s wishes, acceptance of the paradox of crisis as opportunity, acknowledgement of patient’s goals, and pursuance of the simplest means toward achieving goals. Individuals are represented by three personal domains: self, world and others, and a person’s sense of well-being depend on their individual life experiences. The model is distilled into ten commitments, which are to value the voice, respect the language, develop genuine curiosity, become the apprentice, reveal personal wisdom, be transparent, use the available toolkit, craft the step beyond, give the gift of time, and know that change is constant. The model then elaborates twenty competencies for a practitioner to develop in order to facilitate those commitments. Competencies include such things as active listening, showing interest and willingness to help, develop a care plan, and helping the person to develop awareness and identify strengths and weaknesses, ability to help themselves, problems and possible changes to be made (Current Nursing, 2012).
This theory is very clear in definitions and the role of the mental health provider. It clearly identifies the goal of the nurse, and provides guidelines for providing optimum therapeutic care. Concepts are clearly defined and explained. The theory is simple, logical, and easy to understand. It provides a clear and easy to follow guideline for mental health nursing, with a focus on patient-centered individualized care. The theory can also be generalized within areas of psychiatric nursing, and nursing in general. All nursing should be patient centered and individualized. Nurses in all areas should facilitate patients’ healing and independence. The Tidal Model lacks empirical precision. It is difficult to assign quantitative measures to this theory. The derivable consequence of this theory is great. It is widely accepted and used in the practice of mental health nursing, and is accepted to encourage positive outcomes.
Often in nursing, there seems to be a bit of a gap between theory and practice in regards to the implementation of core measures for psychiatric services. Lakeman (2004) asserts that “routine standardized outcome measurement in its current form can only provide a crude and narrow lens through which to witness recovery.” Much of psychiatric nursing is qualitative, rather than quantitative. Quantitative measures such as time spent in restraints or number of antipsychotic medications prescribed do not capture the qualitative art of psychiatric nursing. Core measures are essential in providing standardized care, and analysis and improvement of services.
Campbell, M. M., & Young, C. (2011). Introducing the CORE-OM in a South African context: validation of the CORE-OM using a South African student population sample. South African Journal Of Psychology, 41(4), 488-502.
Current Nursing (2012). http://currentnursing.com/nursing_theory/Tidal_Model.html
Guthrie, D., McIntosh, M., Callaly, T., Trauer, T., & Coombs, T. (2008). Consumer attitudes towards the use of routine outcome measures in a public mental health service: a consumer-driven study. International Journal Of Mental Health Nursing, 17(2), 92-97.
The Joint Commission (2012). http://www.jointcommission.org/core_measure_sets.aspx
Lakeman, R. (2004). Standardized routine outcome measurement: Pot holes in the road to recovery. International Journal Of Mental Health Nursing, 13(4), 210-215. doi:10.1111/j.1445-8330.2004.00336.x.
Rao, A. S., Hendry, G., & Watson, R. (2010). The implementation of routine outcome measures in a Tier 3 Psychological Therapies Service: The process of enhancing data quality and reflections of implementation challenges. Counselling & Psychotherapy Research, 10(1), 32-38. doi:10.1080/14733140902886893.