Innovative service redesign and resource reallocation: responding to political realities, mental health reform and community mental health needs

General hospital mental health programs in large inner city communities face challenges in developing responsive services for populations facing high rates of serious mental illness, substance abuse, homelessness, and poverty. In addition provincial political pressures such as Mental Health Reform and hospital restructuring have caused general hospital mental health programs to reevaluate how services are delivered and resources are allocated. This paper describes how one inner city mental health service in a university teaching setting developed successful strategies to respond to these pressures. Strategies included: (a) merging two general hospital mental health services to pool resources; (b) allocating resources to innovative care delivery models consistent with provincial reforms and community needs; (c) fostering staff role changes, job transitions, and the development of new professional competencies to complement the innovative care delivery models; and (d) developing processes to evaluate the effects of these changes on client.     

Simple-minded questions and twirling stools.

This reply to Ullman includes the following points: (a) The 2 variables he implicates as spuriously producing the relationships found between the social atmosphere and effectiveness of hospitals, namely, percentage of personnel responding and percentage of psychiatric beds, yield relationships with the criteria which are either O or opposite in sign from what he supposes. When these are allowed for, the relationships we posit increase. (b) Hospital size and staff/patient ratio undoubtedly bear on effectiveness, but do so through their effects on staff attitude. (c) Ullman is mistaken in his belief that psychiatrists' means on Opinions about Mental Illness Scale (OMI) authoritarianism and social restrictiveness are unrelated to hospital effectiveness. In fact, psychiatrists' means are more highly correlated (-.38 to -.66) than are those of representative staff samples (-.35 to -.44). These additional analyses strengthen the conclusion Ullman questions: "Authoritarian-restrictive hospital atmospheres are bad for patients." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What influences patients' reports of three aspects of hospital services?

OBJECTIVES: Market forces make it essential to know what policies and actions influence patients' reports of hospital services. No studies have examined the role of patient characteristics, labor quality and staff characteristics, nonlabor resources, managerial practices, and employee attitudes within a single investigation. METHODS: The authors collected, simultaneously, data about labor, management and service processes, nonlabor resources, and employee attitudes on 117 nonintensive medical-surgical inpatient units in 17 hospitals selected from a pool of 69 institutions within a metropolitan area by a stratified random sample. Of the 2,595 patients who agreed to participate, 2,051 (79%) completed telephone interviews regarding their experiences with physical care, education, and pain management services within 26 days of hospital discharge. RESULTS: A significant amount of variation in patients' service reports was explained (adjusted R2 = 0.41 physical care, 0.35 pain management, 0.44 education). Although the predictors varied for each service report, patient characteristics, especially those related to personal resources, had a large explanatory role. A labor assignment pattern that could explain why earlier studies found labor quality and staff characteristics to have only a weak role in the prediction of patients' service reports was noted. CONCLUSIONS: The results related to patient characteristics may indicate opportunities to improve care by confronting service design strategies that erroneously rely on a homogeneous patient population. Measurement challenges identified by this study must be addressed to determine the role of labor quantity and staff characteristics.     

Day hospital/crisis respite care versus inpatient care, Part II: Service utilization and costs

OBJECTIVE: The authors compared service utilization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program. METHOD: The patients (N = 197) were randomly assigned to one of the two programs and followed for 10 months after discharge. Both programs were provided by a community mental health center (CMHC) in a poor urban community. Data were collected for developing service utilization profiles and estimates of per-unit costs of the inpatient, day hospital, and outpatient services provided by the CMHC. RESULTS: On average, the day hospital/crisis respite program cost less than inpatient hospitalization. The average saving per patient was +7,100, or roughly 20% of the total direct costs. There were no significant differences between programs in service utilization or costs during the follow-up phase. Cost savings accrued in the index episode because per-unit costs were lower for day hospital/crisis respite and the average stay was shorter. Significant differences in cost were found among patient groups with psychosis, affective disorders, and dual diagnoses; psychotic patients had the highest costs in both programs. The two programs had roughly equal direct service staff and capital costs but significantly different operating costs (day hospital/crisis respite operating costs were 51% of inpatient hospital costs). CONCLUSIONS: The programs were equally effective, but day hospital/crisis respite treatment was less expensive for some patients. Potential cost savings are higher for nonpsychotic patients. Cost differences between the programs are driven by the hospital's relatively higher overhead costs. The roughly equal expenditures for direct service staff costs in the two programs may be an important clue for understanding why these programs provided equally effective acute care.     

Attaining medical staff membership and privileges for psychologists: A case study.

The profession of psychology has grown substantially over the last 20 years, yet throughout the United States, there are disparities in practice expansion. One notable disparity is in the domain of hospital practice. Why do psychologists lack parity in various hospital settings? The purpose of this article is to draw attention to the issue of professional inequities psychologists face in inpatient medical facilities, and to question why more has not been achieved. The article provides a theoretical foundation in support of full medical staff membership for psychologists, key principles or “how to” guide for obtaining medical staff membership, and a case example that describes an innovative, primary care solution that worked in a large hospital system. The article concludes with a frank look at obstacles that psychologists continue to face and discussion regarding how to navigate these barriers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Understanding NHS indemnity

The NHS indemnity scheme began in January 1990 and covers all NHS hospital and community health service staff (but not general practitioners). However, some doctors continue their membership with medical defence organizations for continuing advice and assistance regarding medicolegal issues.     

Staff attitudes toward patient care and treatment-disposition behavior.

Treatment milieus (staff attitudes) were related to treatment-disposition behavior in 4 autonomous units with comparable staff and patients. Only measures on which units showed significant differences or ratios of these measures were analyzed. Attitudes toward rules informing patients, impact of staff attitudes, and patients' characteristics, and measures of use of restraint and seclusion trial visits, and maximum hospital benefit discharges met this criterion. The main focus was on 3 related attitudes interpreted as indicating openness, frankness, and trust in interactions with others and their significant relationships to an index of trust in patients' capabilities. These attitudes appeared sufficiently important in the treatment climate to merit further exploration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Correspondence of supervisor and subordinate perspectives during major organizational change.

Staff members (N?=?2,605) and supervisors (N?=?55) of 39 administrative units in 2 healthcare organizations completed a survey measuring confidence in the organization, engagement with their work, and occupational hazards. A correlational analysis determined correspondence between the perspectives of supervisors with those of staff reporting to them as their facilities adjusted to major organizational changes. Supervisors' scores were significantly and positively correlated with the corresponding scores of staff members on cynicism, meaningfulness, acceptance of change, goals, hospital reputation, and health risks. Regression analysis found that relationships were relatively domain specific: Supervisor engagement with work was positively related to that of their staff members, and supervisor evaluations of the organization were positively related to those of their staff members. Supervisor assessment of occupational hazards was related to all 3 areas of staff perception. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The correspondence of patient satisfaction and nurse burnout

This study examined the relationships of nurse burnout, intention to quit, and meaningfulness of work as assessed on a staff survey with patient satisfaction with nursing care, physician care, information provided and coordination of care, and outcomes of the hospital stay assessed post-discharge. Sixteen inpatient units from two hospital sites formed the data base and included 605 patients and 711 nurses. Patients' perceptions of the quality of each of the four care dimensions corresponded to the relationships nurses had with their work. Patients on units where nurses found their work meaningful were more satisfied with all aspects of their hospital stay. Patients who stayed on units where nursing staff felt more exhausted or more frequently expressed the intention to quit were less satisfied with the various components of their care. Although nurse cynicism was reflected in lower patient satisfaction with interactions with nursing staff, the correlations between cynicism and other aspects of care fell below statistical significance. No significant correlations were found between nurse professional efficacy and any of the patient satisfaction components measured. The implications of the relationship between patient satisfaction and nurses' perception of their work is discussed.     

Social perceptions and borderline personality disorder: The relation to mood disorders.

Used the Structural Analysis of Social Behavior to compare the social perceptions of borderline, unipolar, and bipolar-depressed inpatients. As predicted, borderline Ss differed from bipolar-depressed and unipolar Ss in their social perceptions. Borderline Ss viewed their relationships to their mother, hospital staff, and other patients as more hostile and autonomous than did mood disordered Ss. The results are discussed in terms of an integrative theory of borderline personality that considers the psychobiology of interpersonal relationships and attachment disruptions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of nurse practitioners in the acute care setting

A collaborative practice model was initiated in a university hospital to assist resident physicians to coordinate patient care on specialty services. Nurse practitioner (NP) data were collected on daily work activities and categorized as direct care, indirect care, administration, education, and research. Satisfaction surveys were collected from patients, physicians and nursing staff. Data on clinic evaluation and management service provided by the NPs were reported. The study supported the appropriateness of NPs in the acute care setting.     

Physician-hospital integration strategies: impact on physician involvement in hospital governance

This study investigated the impact of three physician-hospital contractual arrangements (PHCAs)--joint ventures, management service organizations, and not-for-profit foundations--on physician involvement in hospital governance and physician-hospital relationships. Analysis of data collected from a national sample of 1,013 hospitals revealed that PHCAs generate greater physician involvement in hospital decision making and result in lower physician-hospital conflict.     

Instruction in organizational psychology: A "survival kit" for new workers in a state hospital.

Presents a training program for mental health workers at a state hospital to emphasize the ways in which patient behavior is influenced by social and environmental factors. The training program was also designed to increase appreciation of how patient and staff behavior is influenced by the characteristics of the hospital as a complex social system. The course gave attention to psychological research on management and administration in order to enable trainees to work more effectively with others. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Implementation of neuropsychiatric research programs.

"This paper presents a philosophy of the research service unit's approach toward implementing neuropsychiatric research." The philosophy was developed at the Palo Alto VA Hospital and is being applied at the Chicago VA Research Hospital. A research service unit is an administrative staff developed to serve, train, and encourage the research efforts of the entire professional hospital staff or of a division. A basic rationale is indicated. 8 pressing problems encountered in carrying out psychiatric research are listed. Major topics are "Attitude of Personnel and Time Allotted for Research," "Presentation and Discussion of New Developments," "Methods of Training," "Assistance of Library for Up-To-Date Information," "Expenditures for Personnel and Equipment," "Effective and Efficient Research Design," "Aid of Volunteer Help," and "Preparation and Publication of Research Reports." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Violence and aggression in psychiatric units

OBJECTIVE: To help predict aggressive and violent behaviors, the frequency and types of these behaviors in acute psychiatric inpatient settings were examined, and potential interactions between staffing and patient mix and rates of the behaviors were explored. METHODS: Data on violent incidents were gathered prospectively in three adult acute psychiatric units in a general hospital and two units in a primary psychiatric hospital in Sydney, Australia. Staff recorded violent and aggressive incidents, which were ranked on an 8-level scale. They also completed weekly reports of staffing levels and patient mix. Poisson regression analysis was used to calculate relative rates, 95 percent confidence intervals, and p values. RESULTS: A total of 1,289 violent incidents were recorded over a seven-month period. Based on the scale, 58 percent of the incidents were serious. Seventy-eight percent were directed toward nursing staff. Complex relationships between staffing, patient mix, and violence were found. Relative risk increased with more nursing staff (of either sex), more nonnursing staff on planned leave, more patients known to instigate violence, a greater number of disoriented patients, more patients detained compulsorily, and more use of seclusion. The relative risk decreased with more young staff (under 30 years old), more nursing staff with unplanned absenteeism, more admissions, and more patients with substance abuse or physical illness. In total these factors accounted for 62 percent of the variance in violence. CONCLUSIONS: Violent incidents in psychiatric settings are a frequent and serious problem. Incidents appear to be underreported, and the seriousness of an incident does not guarantee it will be reported.     

A systems approach to developing staff training

This chapter shows how concepts from organizational psychology can be used to design a comprehensive staff training model for a statewide mental health service system, and emphasizes the importance of competency identification in this model.     

Is it ever acceptable to deceive a patient?

This article describes a dilemma in clinical practice. The critical incident illustrates how a patient was deceived in hospital and how this was simply accepted by the majority of the ward staff. The situation is analysed by the student nurse involved, who found it difficult to accept, and a call is made for nurses to challenge decision-making processes based on inequalities of power.     

Evaluation of an intensive case management program for short-term nursing home residents

This study examines the impact of intensive case management services on nursing home length of stay and use of community-based resources for short-term nursing home residents. The findings did not reveal statistically significant effects, indicating that the outcomes of the services provided by the nursing home social workers and the intensive case managers were essentially the same. Discussion focuses on additional variables, such as rural/urban location and social service/nursing home staff relationships that may impact on the effects of case management on the discharge process.     

Resources and responsibility for professional education in blood transfusion therapy

Two current problems in blood transfusion services are the widespread lack of information on this subject among practicing physicians, house staff, and medical students, and the dearth of broadly trained, full-time professionals in the field. Our most important and urgent responsibility is to train physicians who seek full-time careers in any aspect of blood transfusion services, blood center management, hospital transfusion services, research, or combination thereof. Successful training programs require sufficient space, personnel, and funds. In addition, blood centers have a responsibility to educate practicing physicians and house staff by formal teaching sessions, or informally when problems arise. Medical school curricula usually contain little on blood banking; exposure to some basic immunohematology or a visit to a blood center will help sensitize students to the availability of blood. Hospital administrators, regional medical society officers, and corporate medical directors, informed of the blood centers' activities, can help improve relationships between center, hospital, and community.