Impact of a peer-review network on the quality of inpatient low secure mental health services: cluster randomised control trial.

BACKGROUND: Peer-review networks aim to help services to improve the quality of care they provide, however, there is very little evidence about their impact. We conducted a cluster randomized controlled trial of a peer-review quality network for low-secure mental health services to examine the impact of network membership on the process and outcomes of care over a 12 month period. METHODS: Thirty-eight low secure units were randomly allocated to either the active intervention (participation in the network n = 18) or the control arm (delayed participation in the network n = 20). A total of 75 wards were assessed at baseline and 8 wards dropped out the study before the data collection at 12 month follow up. The primary outcome measure was the quality of the physical environment and facilities of the services. The secondary outcomes included: safety of the ward, patient mental wellbeing and satisfaction with care, staff burnout, training and supervision. We hypothesised that, relative to control wards, the quality of the physical environment and facilities would be higher on wards in the active arm of the trial 12 months after randomization. RESULTS: The difference in the primary outcome between the groups was not statistically significant (4.1; 95% CI [- 0.2, 8.3] p = 0.06). The median number of untoward incidents rose in control services and remained the same at the member of the network (Difference between members and non-members = 0.55; 95% IC [0.29, 1.07] p = 0.08). At follow up, a higher proportion of staff in the active arm of the trial indicated that they felt safe on the ward relative to those in the control services (p = 0.04), despite reporting more physical assaults (p = 0.04). Staff working in services in the active arm of the trial reported higher levels of burnout relative to those in the control group. No difference was seen in patient outcomes. CONCLUSIONS: We did not find evidence that participation in a peer-review network led to marked changes in the quality of the physical environment of low secure mental health services at 12 months. Future research should explore the impact of accreditation schemes and examine longer term outcomes of participation in such networks. TRIAL REGISTRATION: ISRCTN79614916 . Retrospectively registered 28 March 2014.

Impact of peer-led quality improvement networks on quality of inpatient mental health care: study protocol for a cluster randomized controlled trial.

BACKGROUND: Quality improvement networks are peer-led programmes in which members of the network assess the quality of care colleagues provide according to agreed standards of practice. These networks aim to help members identify areas of service provision that could be improved and share good practice. Despite the widespread use of peer-led quality improvement networks, there is very little information about their impact. We are conducting a cluster randomized controlled trial of a quality improvement network for low-secure mental health wards to examine the impact of membership on the process and outcomes of care over a 12 month period. METHODS: Standalone low secure units in England and Wales that expressed an interest in joining the quality improvement network were recruited for the study from 2012 to 2014. Thirty-eight units were randomly allocated to either the active intervention (participation in the network n = 18) or a control arm (delayed participation in the network n = 20). Using a 5 % significance level and 90 % power, it was calculated that a sample size of 60 wards was required taking into account a 10 % drop out. A total of 75 wards were assessed at baseline and 8 wards dropped out the study before the data collection at follow up. Researchers masked to the allocation status of the units assessed all study outcomes at baseline and follow-up 12 months later. The primary outcome is the quality of the physical environment and facilities on the wards. The secondary outcomes are: safety of the ward, patient-rated satisfaction with care and mental well-being, staff burnout, training and supervision. Relative to control wards, it is hypothesized that the quality of the physical environment and facilities will be higher on wards in the active arm of the trial 12 months after randomization. DISCUSSION: To our knowledge, this is the first randomized evaluation of a peer-led quality improvement network that has examined the impact of participation on both patient-level and service-level outcomes. The study has the potential to help shape future efforts to improve the quality of inpatient care. TRIAL REGISTRATION: Current Controlled Trials ISRCTN79614916 . Retrospectively registered 28 March 2014].

Does sustained involvement in a quality network lead to improved performance?

PURPOSE: The purpose of this paper is to explore the effects of prolonged investment in one quality improvement method, which are uncertain. The authors aim to examine the extent to which sustained involvement in a quality network over five years led to improved performance against standards, and whether improvement was achieved in areas where service staff could exercise direct control. DESIGN/METHODOLOGY/APPROACH: A prospective cohort design was used to examine data from 48 UK inpatient child and adolescent mental health units between 2005/2006 and 2009/2010, which had been Quality Network for In-patient CAMHS members for two years. These were selected to remove the initial marked increase in compliance identified in an earlier study. The main outcome measure was compliance with organisation process standards. FINDINGS: Units meeting "excellent" quality status across all standards rose from seven (14.6 per cent) to 18 (37.5 per cent). Standards for Environment and Facilities and Access, Admission and Discharge improved the most. Units meeting the "excellent" quality status for criteria over which staff had direct control criteria rose from 17 (35.4 per cent) to 29 (60.4 per cent) over the five-year period. The unit modal quality status categorisation for criteria where staff had no direct control in 2005/2006 was "poor" (n=25; 52.1 per cent) but had progressed to "good" in 2009/2010 (n=24; 50.0 per cent). ORIGINALITY/VALUE: The authors provide evidence that sustained investment in one QI method raises service compliance against standards. Trends showed improvement for direct control standards from "good" to "excellent" levels and improvement for no direct control from "poor" to "good".

Three decades of quality improvement in electroconvulsive therapy: exploring the role of accreditation.

OBJECTIVES: This study aims to track electroconvulsive therapy (ECT) clinics' compliance with standards for the administration of ECT before and after the introduction of the Electroconvulsive Therapy Accreditation Service (ECTAS) in 2003. METHODS: Three audits on the practice of ECT were retrospectively analyzed, and ECTAS data from 2004 to 2011 were prospectively analyzed. Overall compliance with 10 ECT audit standards was presented in 2 ways: annually and for each of the 3 waves of accreditation. RESULTS: There have been continuing improvements since the introduction of the accreditation service in compliance with all 10 ECT audit standards whether measured annually or by accreditation cycle, although these improvements have not been linked to changes in clinical outcomes. CONCLUSIONS: Although improvements in ECT delivery have coincided with the accreditation service, other factors may have also contributed.

The service context for clinical guidelines: supporting guideline implementation by assuring and improving the quality of service in which clinicians work.

This paper argues that accreditation schemes and quality networks promote good contexts for the implementation of clinical guidelines. It raises questions about how organizational standards should be developed, structured and focused, how clinical guidelines and organizational standards should connect, how to practically increase the number of such schemes and their scope, and the role of professional bodies in this. There is a considerable amount of administration involved in running an accreditation scheme or quality network and there are risks involved in starting in new areas. One way forward is for professional bodies to partner to share risks and to build a common operating platform for the administration of the work across the professional bodies. This platform could be guided by topic experts within the bodies.

Cost and impact of a quality improvement programme in mental health services.

OBJECTIVE: To estimate the cost and impact of a centrally-driven quality improvement initiative in four UK mental health communities. METHODS: Total costs in year 1 were identified using documentation, a staff survey, semi-structured interviews and discussion groups. Few outcome data were collected within the programme so thematic analysis was used to identify the programme's impact within its five broad underlying principles. RESULTS: The survey had a 40% response. Total costs ranged between pound164,000 and pound458,000 per site, plus staff time spent on workstreams. There was a very hazy view of the resources absorbed and poor recording of expenditure and activity. The initiative generated little demonstrable improvements in service quality but some participants reported changes in attitudes. CONCLUSIONS: Given the difficult contexts, short time-scales and capacity constraints, the programme's lack of impact is not surprising. It may, however, represent a worthwhile investment in cultural change which might facilitate improvements in how services are delivered.

Electroconvulsive therapy: the practice and training needs of referring psychiatrists in the United Kingdom and Republic of Ireland.

This study aims to gain a greater understanding of the clinical practice and training needs of psychiatrists who prescribe electroconvulsive therapy (ECT), including knowledge about ECT, obtaining informed consent, and the monitoring of patients after ECT. Four hundred ninety psychiatrists who refer patients for ECT were sent questionnaires as part of reviews conducted by the ECT Accreditation Service, and 56% responded. Data were analyzed using descriptive statistics and thematic analysis. Nearly all felt that they had adequate knowledge about ECT with 35% recognizing further training needs. Psychiatrists were likely to find difficulty explaining to patients more about how ECT works and the possibility of long-term cognitive side effects than the benefits of ECT. The main areas of training need are the obtaining of informed consent, including the choice between unilateral and bilateral ECT, and the assessment of cognitive function during and after the course. The study also reveals the need for further research into long-term cognitive side effects of ECT and the need for a reliable cognitive assessment tool for measuring persistent or autobiographical memory deficits.

The Staffing of Inpatient Child and Adolescent Mental Health Services.

BACKGROUND: There is a need for more accurate information regarding the staffing of Child and Adolescent Psychiatric inpatient units. This is both to facilitate clinical governance and to allow planning and focused further development of these services. METHOD: Postal surveys were sent to all units in England and Wales. RESULTS: Seventy-three percent (n = 1060) of the 1460 staff employed by the units were nurses; 43% of nurses were unqualified. On average there was one consultant psychiatrist for every 25 patients. Only 12% of nurses working on a 'census' day held a specialist qualification in nursing children. The use of agency and bank staff was higher in independent sector units than in NHS units (37% vs 10% of all nurses who worked a shift on the census day). CONCLUSIONS: Some child and adolescent inpatient units are not staffed by a multi-disciplinary team. There is evidence of problems of recruitment and retention of nurses.

Distribution and characteristics of in-patient child and adolescent mental health services in England and Wales.

BACKGROUND: Little is known about the current state of provision of child and adolescent mental health service in-patient units in the UK. AIMS: To describe the full number, distribution and key characteristics of child and adolescent psychiatric in-patient units in England and Wales. METHOD: Following identification of units, data were collected by a postal general survey with telephone follow-up. RESULTS: Eighty units were identified; these provided 900 beds, of which 244 (27%) were managed by the independent sector. Units are unevenly distributed, with a concentration of beds in London and the south-east of England. The independent sector, which manages a high proportion of specialist services and eating disorder units in particular, accentuates this uneven distribution. Nearly two-thirds of units reported that they would not accept emergency admissions. CONCLUSIONS: A national approach is needed to the planning and commissioning of this specialist service.

Characteristics of the Detained and Informal Child and Adolescent Psychiatric In-Patient Populations.

BACKGROUND: This project surveyed the use of the Children Act and the Mental Health Act in in-patient child and adolescent mental health services in England and Wales. METHODS: Data were collected as a day census from child and adolescent psychiatric inpatient units, questionnaire forms completed by consultant psychiatrists or key-workers. Returns were received from 71 of the 80 units. RESULTS: One hundred and twenty-seven of the 663 patients had been admitted formally, the great majority under a section of the Mental Health Act. Compared with those admitted informally, those admitted formally were older, contained a higher proportion of males and had 'adult-type diagnoses', mainly schizophrenia, mood disorders and personality disorder. The clinical and psychosocial characteristics of formal and informal patients were consistent with these differences. CONCLUSIONS: This study provides a timely and useful snapshot of the use of the Acts in this population.