Leaving Hospital: A Step too Far for Risk-Based Regulation?

Discharges from hospital are internationally recognised as a dangerous time in the care pathway of a patient, posing a risk to both their physical wellbeing and dignity. This article examines the effectiveness of risk-based regulation as a tool to address patient safety incidents linked to the hospital discharge process within the English National Health Service. It examines how the risk of this process is identified, conceptualised, and prioritised amongst the relevant statutory regulators, and argues that the risk is neither uniformly recognised by the statutory regulators within the English NHS, nor sufficiently addressed. Professional regulators in particular appear to have a poor awareness of the risk and their role in addressing it. Until these issues are resolved, patients leaving hospitals will continue to be exposed to patient safety incidents which should be avoidable.

The importance of the patients deemed not guilty by reason of insanity for the psychiatric reform.

According to the Greek Penal Law if someone "because of a morbid disturbance of his mental functioning" (article 34) is acquitted of a crime or misdemeanour that the law punishes with more than 6 months imprisonment, then the court orders that this individual should be kept in a public psychiatric institution if the court reaches the conclusion that this person poses a threat to public safety.1 Individuals who have broken the law and deemed "not guilty by reason of insanity" are treated in psychiatric units of Psychiatric Hospitals according to the article 69 of the Penal Code. In Athens, in the Psychiatric Hospital of Athens and the Dromokaiteion Psychiatric Hospital, and in Thessaloniki in the Unit for "Not guilty by reason of insanity (NGRI)". The person who is deemed not guilty by reason of insanity following a crime is facing double stigmatisation and marginalisation from both the legal and the health system. He/she is usually treated initially with fear and later since there is no therapeutic aim but only the court instruction for "guardianship", with indifference. The patient who is committed by the courts in a psychiatric unit for being "NGRI" is facing a unique legal and psychiatric status.2 In this respect he/she is disadvantaged when compared to either convicted criminals or psychiatric inpatients. If the patient was not found "NGRI" (ie innocent as far as sentencing is concerned) he would have been punished with loss of liberty for a certain (specific) amount of time, and like all individuals convicted in court he/she would have the right to appeal and reduce his/her sentence in a higher court and maybe released from prison earlier for good behaviour etc. In this respect the individual found to be "NGRI" is disadvantaged when compared to a convicted felon since he/she is kept for an undefined period of time. Additionally, he/she will be allowed to leave the psychiatric unit following a subjective assessment of a judge with no psychiatric knowledge who will decide that this certain individual has "ceased to be dangerous". These problems are accentuated by the difficulties that the Greek justice system is facing. On the other side, from the psychiatric point of view, the "NGRI" patient who is an inpatient is not receiving the holistic, (bio psycho social) treatment and assessment of needs he/she requires. The psychiatric team looking after him, once the acute symptomatology is controlled is just getting used to a patient who will not be discharged in the immediate future. These patients form the "new chronic asylum psychiatric inpatients" for whom the treating psychiatrists are not allowed to discharge back into the community whilst it is unclear whether they can be transferred to supported rehabilitation units. It is a medical but also legal paradox to assign to contemporary psychiatric units aiming mainly to treat patients in the community to "keep and guard" inpatients whilst these psychiatric units should focus on care and rehabilitation of the patients (including the "NGRIs").3 Keeping patients like these in psychiatric units creates problems in the functioning of the units. These patients are "kept" in acute beds for long periods of time (5 to 6 years minimum) with patients treated voluntarily or against their will and cannot be discharged without a court's decision. The problems are obvious if one realises that the average time of hospitalisation is not exceeding 2 months for the vast majority of psychiatric patients. With the prolonged stay patients of the "article 69" (NGRIs) they not only burden the already limited resources (there is an established lack of psychiatric beds nationwide) but also this prolonged hospitalisation increases their stigmatisation and marginalisation. Thus the prolonged hospitalisation for "safety" reasons according to the court decision leads to the absence of a therapeutic aim other than maintaining the patient on the ward. Greece has agreed that there is an urgent need in developing community psychiatry services and closure/transformation of the big psychiatric hospitals (asylums). It is impossible to close hospitals where "NGRIs" are kept. The decision to move them into the community is not a medical-psychiatric but a legal one. In this respect it is imperative to establish a Forensic Psychiatric Unit for these patients. In our country as the "Psychargos" external evaluation highlighted, there are great gaps in the provision of Forensic psychiatric services.3 It must be emphasised that these gaps affect negatively psychiatric reform and social reintegration not only for the forensic psychiatric patients but for the whole of mentally ill individuals. Given that forensic Psychiatric services are developed in Athens and Thessaloniki and that training in Forensic Psychiatry has moved forward, it is imperative that the state should build upon the existing knowledge and experience and create specialist forensic units aiming to treat and rehabilitate this special and important group of patients.4 Only when the patients found "not guilty by reasons of insanity" have their own (safe for the society and them) therapeutic and rehabilitative services the aim of de-institutionalisation will be visible and realistic to implement.

Evaluation of Geese Theatre's Re-Connect program: addressing resettlement issues in prison.

This study examined the impact of Geese Theatre's Re-Connect program on a sample of offenders who attended it. This program used theatre performance, experiential exercises, skills practice role-plays, and metaphors such as the masks to invite a group of offenders to consider and explore issues connected with their release and reconnecting with a life outside prison. Pre- and postprogram psychometric tests, behavior ratings, and interviews were completed to assess the effectiveness of the program. Significant changes were observed from pre- to posttreatment in terms of self-efficacy, motivation to change, and improved confidence in skills (i.e., social and friendship, occupational, family and intimacy, dealing with authority, alternatives to aggression or offending, and self-management and self-control skills). Improved behavior and engagement within the program was observed over the 3 days of the program. Interviews also revealed the positive impact the program had on the participants. This provides evidence supporting the short-term effectiveness of the Re-Connect program.

Liability in triage: management of EMTALA regulations and common obstetric risks.

The Emergency Medical Treatment and Active Labor Act (EMTALA) affects all clinicians who provide triage care for pregnant women. EMTALA has specific regulations for hospitals relative to women in active labor. Violations can carry stiff penalties. It is critical for clinicians performing obstetric triage to understand the duties and obligations of this law. This article discusses EMTALA and reviews common liability risks in obstetric triage as well as strategies to modify those risks.

[Work profile of social work in inpatient psychotherapy. Clinical fields and social rights implications]. / Das Tätigkeitsprofil der Sozialarbeit in der stationären Psychotherapie. Klinische Arbeitsfelder und sozialrechtliche Implikationen.

OBJECTIVES: The task profile of social work in (acute) inpatient psychotherapy--unlike psychiatric inpatient treatment--is only fragmentarily described by the so-called Psychiatrie-Personalverordnung (Psych-PV). The aim of the present investigation was, therefore, to provide valid and representative data to define its respective scope of duties. METHODS: During a prospective one-year assessment at the Department of Psychotherapy and Behavioral Medicine at the Philipps-University of Marburg/Germany, we recorded corresponding data of social work referring to three areas of interest, i.e., "education and occupation", "housing and family", and "psychotherapy support". RESULTS: Our data suggest a broad overlap with the corresponding task profile of social work at psychiatric hospitals, which clearly differs, however, from the more therapeutical approach in social work as practiced in Anglo-American countries. CONCLUSIONS: Our findings stress the need for a re-evaluation of social work in inpatient psychotherapy concerning its specific task profile and the respective time values.

QI as resolution to a major lawsuit.

BACKGROUND: In 1991, in response to a lawsuit filed in 1974, the Texas Department of Mental Health and Mental Retardation (TXMHMR) became the first major state agency in Texas to implement a systemwide effort to implement quality improvement (QI) in its Quality System Oversight (QSO) program. QSO: The QSO approach includes a uniform internal hospital management structure focusing on teams and data-based decision making; the development of uniform work processes for each of the issues cited in the lawsuit; and a uniform set of procedures for determining compliance, including the establishment of numeric targets for which each hospital is accountable. CASE STUDY: At one TXMHMR hospital, patient records in a monthly random sample were below the performance target. Data showed that approximately 40% of the patients leave the hospital (many for a community mental health center) before a treatment plan (at 14 days) is developed. Based on a team's recommendations, a uniform assessment package is being developed for use by all TXMHMR hospitals and community mental health centers. THE NEXT STEP: In 1994, again in response to external pressures to improve quality, TXMHMR used a simplified version of the Malcolm Baldrige National Quality Award criteria for organizational self-assessment. Two pilot sites have developed action plans for improving performance as indicated on the self-assessments. SUMMARY AND CONCLUSIONS: The QSO program, put into place as a result of a lawsuit, provides a structure and database for TXMHMR to efficiently and effectively manage the performance of all hospitals in the system. All but one of the eight hospitals have exited, or are close to exiting, the lawsuit.