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).
Population
Affected
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.
Analysis
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).
Variables
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.
Current Trends
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
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.
Ethical Issues
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).
Theory
Analysis
Clarity
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.
Evaluation
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.
References
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.