Quality of Inpatient Services in National Institute of Mental Health
1.1 Introduction
To determine what psychiatric services are required for a community, it is necessary to know the frequency of mental disorder in the population and the needs for the treatment of the people with the disorders identified in this way. Policy decisions have to be made about the division of care between primary and specialist medical services, between medical and social services and people with different kind of mental disorders. In the National Health Service priority is given to people with serious mental illness. It is difficult to determine the exact frequency of mental disorders in a community, but approximate estimate are usually sufficient for service planning.(1)
Assessment of the quality of psychiatric care is currently a challenge in the whole world.
Definitions of quality in each country may be based on cultural values and national traditions. An international discussion should consider national peculiarities and priorities. Different papers and study in different countries, which presents a international approach to quality assessment of psychiatric care, is intended to contribute to such an international discussion.(1)
Quality assurance project as proposed by the government of Bangladesh focuses on the following issues-
- Adequacy of the care provided – is the care provided appropriate for the patients and their health problem?
- Effectiveness of care provided – has the health care provided obtained his/her goal i.e has the health problem being solved?
- Safety of care provided – was the care provided safety and have preventable side effects been prevented or if not prevented have they been documented and taken care of?
- Efficiency of care provided – has care been provided with minimum of unnecessary use of resources?
- Satisfaction among patients and health care workers with the care provided.
- Resources utilization – includes manpower and technology.
Approach to evaluation of a psychiatric service:
There are two approaches to the evaluation of psychiatric services for a community;
- Studies of whole services, and
- Studies of particular element of service, such as the inpatient’s care.
The two approaches are complementary. Either evaluation requires a clear statement of aims in which inputs, processes, and outcomes are distinguished. Inputs are the resources made available such as the number of beds or the number of community psychiatric nurses. Processes are the ways that resources are used ,for example the number of in-patient admissions and length of stay. Outcomes are the measures of the effects of the services such as symptom reduction, burden on cares and suicide rates.(ref.1,p-787).
Wing and Haily (1972) suggested six questions that should be asked about the psychiatric services for a population:
· How many patients are in contact with the service?
· What are their needs and those of the relatives?
· Are services meeting these needs at present?
· How many others, not in contact with the service, also have needs?
· What new services, or modifications to existing services, are required to cater for unmet needs?
· Having introduced the new or modified services, are the needs met?
The question can be asked as a check on an established service, or to examine the effect of a change such as the closure of a hospital. Question of cost can be added to the above list. (1)
An increasing concern with improving the quality of care in various components of health care system has led to the adoption of quality improvement approaches originally developed for industry. These include total quality management(TQM) (Deming 1986), an approach which employs process control measures to ensure attainment of defined quality standards and continuous quality improvement (CCQ) (Juran 1988), a strategy to engage all personnel in an organization in continuously improving quality of service. (4)
The quality assurance project for National Hospital inpatient quality measures was set by DGHS. There is also an international standard for Inpatient psychiatric services finalized. A three dimensional model was developed was developed in which 23 quality standards may be applied to 28 areas of practice. (2)
The group defined 23 quality standards in four categories: treatment goals, primary intentions, means and organization, and optimal use of resource. The group outlined 28 areas of practice of inpatient care to which the standards may be applied. These areas of practice are admission procedures; diagnostic procedures; drug therapy and other physical treatments; nonspecific and specific psychotherapy; occupational therapy and work therapy; support for living accommodations and self-care; support for work, occupation, and education; support for social contacts and leisure; interaction with relatives; meeting of basic material needs; discharge procedures; handling of compulsory treatment; general medical care and liaison service; therapeutic relationships; treatment and care planning; time management; the therapeutic milieu; operational ward policy; teamwork in treatment; the information and communication system; the documentation system; organization and administration on the ward; management of staff; the hospital’s management structure; cooperation between management and clinical staff; public relations; advocacy of patients’ interests; and accessibility. (14,15,16)
In theory, each quality standard may be applied to each area of practice, so that each aspect of quality may be assessed in any given area. This two-dimensional model was then extended by a third dimension. For any application of a standard in an area of practice, questions may be asked on the level of the individual patient, the treatment unit (usually a ward), and the whole institution or hospital. For the patient, a distinction is made between the treatment process and outcome. (2)
1.2 Background of the study
Until the middle of the eighteenth century, there were hardly any special provisions for the mentally ill. In England the only hospital for these patients was the Bethlem hospital, founded in 1247.In most of the continental Europe, there was a similar lack of hospital provision; in the middle ages, hospitals in Spain were a notable exception(Chamberlain 1966).Nearly all mentally ill people lived in the community, often with help from Law provisions, or else they were in prison .In England the Vagrancy act of 1744 made the first legal distinction between paupers and lunatics, and made provision for the treatment of the latter. In response, private provisions for the mentally ill(madhouses-later to be called private asylums) were developed mainly for those who could pay for care, but also for some paupers supported by their parishes. At about the same time a few hospitals or wards were established through private benefaction and public subscription. The Bethel hospital in Norwich was founded in 1713.In London, the lunatic hospital was established in 1728,and in 1751, St.Luke’s hospital was founded as an alternative to the overcrowded Bethel hospital. Then, as now, the value of psychiatric wards in general hospitals was debated. (1)
Psychiatry in Bangladesh: Past and Present:
Bangladesh did not have any psychiatric services in erstwhile East Pakistan until 1957.During that time only available psychiatric facilities was forty cells of Dhaka Central Jail. There was no mental hospital in the East Pakistan though there was three mental hospital in West Pakistan at Lahore, Hydrabad and Peshwar. Psychiatric services was vary unsatisfactory in undivided Banglal. Only observational unit was established in Barhampur in Murshidabad which was abolished following decision of establishing a modern mental hospital in Ranchi, Bihar jointly by the Govt. of Bengal and Bihar. Remnants of those patients of Ranchi are still be to found in Pabna who were transferred in 1962 following establishment of mental hospital in Pabna. There was no psychiatric subject in medical curriculum except a few lectures which were given by a teacher of Jurispudence. The situation was similar in both West Bengal and in erstwhile East Pakistan.
All the countries of this subcontinent shared same ancient law – Indian Lunacy Act, 1912 with modification here and there. Though there has been lot of improvement both in treatment facilities, law etc. in all countries which comprised Indian subcontinent but in Bangladesh treatment facilities and legal framework is still struggling with primitive treatment facilities, ancient law and highly prejudiced medical profession. Result is the suffering of the people and erosion of prestige of medical profession in general in Bangladesh due to mechanical approach to the art of medicine.
History of psychiatry in Bangladesh began in 1957 when temporary mental hospital was opened in a ranted building in Pabna which was well known as ‘sitlai house’. Site of the permanent hospital was selected at Pabna and was located in the premise of an abandoned ashram of Shree Thakur which subsequently turned into 200 beded permanent mental hospital. First outdoor clinic was established in Dhaka Medical college in1964.Psychiatric outpatient was opened in IPGMR in 1972.A course specialization in psychiatry was started initially as diploma of psychological medicine(DPM) and subsequently for FCPS in psychiatry in1978.During the same period WHO was sponsoring a mental health project in Bangladesh and was holding workshop in collaboration with Govt. of Bangladesh with participants from medical administrators, teacher, psychiatrists, social workers, nurses etc. In 1978 outdoor clinics were opened in Mymensing and Chittagong medical college Unfortunately this had to be developed in some places due to paucity of manpower. Funds for mental clinics allocated in several plan periods were diverted for some other purpose at of the clinics which was built in Dhaka medical college hospital is an example. Stories were same regarding the fund allocated for mental clinics in Chittagong, Rajshahi etc. in various plan period. In pursuance of a decision in a W.H.O. seminar organization of training in mental health was established which was subsequently rechristened Institute Of Mental Health and Research. Then a separate and permanent institute for psychiatry was established at Sher–E-Banglanagar, Dhaka named National Institute Of Mental Health in 2001.We are gradually though slowly developing but we have to go a long way. Every field of psychiatry needs change and modernization. It may be noted that a well equipped psychiatric unit in general hospital with adequate physical facilities, appropriate personnel like psychiatrist, psychologist, social worker, occupational therapist can only function effectively both for training and service delivery. Future of psychiatry in Bangladesh lie in the development of integrated service delivery at the level of primary health care, development of general hospital psychiatry specially in teaching hospital, improvement of training facilities, development of skilled psychiatric manpower and modernization of Lunacy Act of 1912 and Pakistan Mental Health Act. (3)
The purpose of the study to evaluate the current services provided to the psychiatric patients of Bangladesh where many people even their family suffers for proper psychiatric treatment and diagnostic support. The service quality should be upto the mark so that it could meet the adequate requirement and increasing demand and people of our country can get standard psychiatric facilities.
1.3 Justification of the study
WHO has defined health as “a state of complete physical, mental and social well being and not merely an absence of disease or infirmity so that each citizen can lead a socially and economically productive life”, so mental health is one important component of health. Mental diseases are ancient one and any person can be suffer from such disease or disorder any time irrespective of age, sex, geographical and socio-demographic condition, environment, education etc. Though the actual scenario of psychiatric disorder and their magnitude is not identified in Bangladesh but trough a survey conducted by WHO we find that about !% of our total population are suffering from serious psychiatric disorder and 10% are with other mental illness. About 30% are at the risk of developing such diseases and 50% patients who are physically ill have psychotic symptoms. Unlike most physical diseases mental illness begins very early in life. Half of the cases begin by age 14; the prime of life, when three quarters have began by age 24.Thus mental disorders are really chronic of the young. For example anxiety disorders often begin in late childhood, mood disorders in late adolescence, and substance abuse in early 20’s.Unlike heart diseases or most cancers, young people with mental disorders suffer disability when they are in the prime of life, when they would normally be the most productive for the family, community and nation. Also major mental disorders cost the nation in lost earnings alone. Lost earning potential, costs associated with treating existing conditions, social security payments, homelessness and incarceration are just of the some of the indirect cost associated with mental illness that have been difficult to quantify.
Direct cost associated with treating mental disorders like medication, clinic visit and hospitalization are relatively easy to quantify, but they reveal only a small portion of the economic burden these illness place in the society. There are very selective hospitals and health personnel in Bangladesh who provide services for these patients. It is necessary to evaluate and explore the existing services are standard enough to meet the needs and requirement of the nation and society. The people of our country have every right to get accessibility to a standard quality of psychiatric services so that these people can lead a socially and economically productive life and can contribute in the prospects and economy of the country, even in the progress of the whole community. (22)
1.4 Limitation of the study
Due to the short time period and lack of fund and proper specialist guidance only a portion of inpatient services are studied in this study which are not sufficient to take a decision related to the quality of the total services provided by the institute. Even the complete inpatient services can not covered by the researcher like the physical facilities, cleanliness, food supply etc. Furthermore the outpatient services, the emergency services, specific therapy style and outcome, particular disease frequency and treatment outcome, patients’ satisfaction level, academic situation – all these chapter remain untouched which need proper assessment and evaluation. After complete evaluation, assessment and research among the whole services of the institute we can comment on the present quality status of the National Institute of Mental Health. We seek proper attention of government and particular authority for the evaluation and standardization of such hospitals and their services.
1.5 Research question
What is the quality of services provided to the indoor patients in National Institute Of Mental Health?
1.6 Research objectives
General objective
To assess the quality of services provided to the indoor patients in National Institute Of Mental Health.
Specific objectives
1. To assess the quality of treatment facilities for the indoor patients in National Institute Of Mental Health.
2. To identify the quality of diagnostic facilities available in National Institute Of Mental Health.
3. To estimate the manpower in indoor department of National Institute Of Mental Health.
1.7 Key variables
1.7.1 Dependent variable
Quality of inpatient services of National Institute Of Mental Health.
1.7.2 Independent variable
Age of respondents
Sex of respondents
Religion of respondents
Designation of respondents
Experience of respondents
Admission procedure
Diagnostic facilities
Other laboratory facilities
Discharge procedure
Treatment facilities
Follow up care
Manpower facilities
Job satisfaction
Visitor’s restriction
Length of stay
Support services for rehabilitation of patients
Advocacy for patients
Recreation facilities
Supervision by management
Documentation and record system
Information and communication system
1.8 Operational definition:
Quality
The term refers to an attribute of goodness or degree of excellence of any work.
In patient department
That section of the hospital with all physical facilities ,regularly scheduled hours and personnel in sufficient numbers assigned to provide health care to the patients who are admitted and registered.
Standard
The precise count or quantity or model that specifies an adequate ,acceptable or optimal level of quality.
Quality of service
It is the effective health care to improve the health status and satisfaction of a population within the resources which society and individual have chosen to spend or that care or it means the degree of excellence of medical attention offered to patient by a hospital.
Utilization
Evaluation of the necessity, appropriateness and efficiency of the use of medical services, procedure or facilities.
Evaluation
Evaluation means whether or not the organization is meeting planned activities. Evaluation requires that goals, objectives and activities be translated into standard that provide the basis for comparing planned activities or the programs with actual performance.
Service facilities
It includes equipment, manpower and other facilities required for waiting, consultation, physical examination, diagnostic procedure and clinical care of patients. These facilities have got direct bearing on the overall management of patients and have impact on the quality of service as well.
Assessment
The identification and analysis of variety of factors that might explain function.
Service provider
Health care workers including doctors, nurses, other support stuffs like cleaners, word boys, ayas, security stuffs etc. as engaged in providing health care services for the patients of NIMH.
Problem
It is a question or difficulty which requires a solution. It is the gap between the desired and actual state of affaires.
A system
It may be defined as an aggregation of functional interrelated units designed to achieve predetermined objectives.
Efficiency
It refers to the measure of how economically resources are utilized to achieve predetermined objectives. It involves reaching end by only the necessary means or by the least wasteful use of resources.
Effectiveness
It is the relationship between an objective and the actual output.
Psychiatric Hospital
Hospitals specializing in treatment of serious mental disorder. They vary widely in size and grading.
Mental health law
Area of the law that is applied specifically to persons with a diagnosis or possible diagnosis of mental illness and to the people involved in managing or treating others in this situation. This includes area in both common law and statute law.
Community law
It is based on case law rather than statues, issues includes such concepts as insanity defenses, sane and insane automatism amongst other. The laws generally allow for compulsory treatment in a psychiatric hospital or in the community.
1.9 Conceptual framework
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Literature review
2. LITERATURE REVIEW
In Shorter Oxford Textbook of psychiatry the total management of psychiatric services in every type of psychiatric hospital and institute are described elaborately and stepwise. It describes the standard psychiatric services and treatment facilities. (1)
In Germany at the year of 1998 a study on assessing the quality of psychiatric hospital care was done to develop a tool for assessing the quality of psychiatric hospital care by a nonprofit organization which was commissioned by the German Ministry of Health. In this study a three-dimensional model was developed in which 23 quality standards may be applied to 28 areas of practice. For each application, question asked at four levels to stimulate ongoing quality management: the individual treatment process, the individual outcome, the treatment unit and the hospital as a whole. The authors provide sample questions to illustrate the approach. The quality assessment embodied in the model is comprehensive and addresses ethical issues, but it is also complicated and difficult to handle. Unlike model developed in the United States, it is not intended to be objective or standardized and it does not yield a score. To some extent, the model’s approach to assessment may reflect German cultural values and traditions. Although the manual has 373 pages, it does not give a specific definition of quality of hospital care or outline any implications for action. It provides guidelines for various potential users on how to assess the quality of a given hospital care procedure and how to ask questions about specific aspects of it. (2)
A study on “Analysis of healthcare quality indicator using data mining and decision support system” was done in South Korea by the Graduate school of Health Science and Management in and Department of Quality Improvement of Severance Hospital under Yonsei University Medical Centre. This study presents an analysis of health care quality indicators using data mining for developing quality improving strategies. Specifically important factors influencing the inpatient mortality were identified using a decision tree method for data mining based on 8405 patients who were discharged from the study hospital during the period of December 2000 to January 2001. Important factors for the inpatient mortality were length of stay, disease classes, discharge departments and age groups. The optimum range of target group in inpatient healthcare quality indicators were identified from the gains chart. In addition, a decision support system (DSS) was developed to analyze and monitor trends of quality indicators using Visual Basic 6.0. Guidelines and tutorial for quality improvement activities were also included in the system. Among the 8405 patients, 4451 (53.0%) were male and 3954 (47.0%) were female. Patients who were discharged from Internal Medicine departments were almost three times (6109). Patients in age group of 41-60 had the highest proportion (31.3%). Among all disease classes, neoplasm had the highest proportion (28.8%). Disease classes with the proportion of less than 5% were grouped under miscellaneous. The decision tree for inpatient mortality had 17 statistically significant nodes at 5% level. About 170 (2.0%) were inpatient mortality cases. The most significant factor explaining the infant mortality was length of stay (LOS). Discharge departments were the next significant factors, followed by the age groups. (4)
A study named “The evaluation and medical service quality of inpatient department of public and nonprofit hospital” in Choungguing, China affirmed by the Health Bureau of Nanjing. This study construct the evaluation index system of medical service quality for inpatient department and employs the analytical hierarchy process to determine weights of forces based on the judgment of the specialists. Ten public and nonprofit hospitals in Nanjing have been studied; the result of evaluation of their medical service quality for inpatient department is gained, by using TOPSIS method and cluster analysis method. (5)
The Niagra Health System (NHS), Canada formed a quality improvement monitoring and reporting structure which is a series of linked committees and support departments. They developed a NHS quality reporting framework which serves to co-ordinate quality monitoring and reporting of information to continuously improve and enhance and to meet the Accreditation Canada standards. Now the quality framework is the foundation for the quality improvement throughout the NHS. They have utility management, laboratory accreditation, emergency preparedness, risk assessment tools, leadership walkarounds, automated unit dose drug system, medication unit dose, proper inpatient and outpatient services which are assured on the basis of their quality framework. (6,7)
A study was done by Department of Medicine and Prevented medicine, Uniformed Services University of the Health Sciences, Bethesda, USA named “Validity of the Department of Defense Standard Inpatient Data Record for quality Management and health services research”. Here the subjects were the patients whose inpatient charts were abstracted through the Civilian External Peer Review Program’s studies of acute myocardial infarction (N = 1,432) and 1993 review of the birth product line (N = 9,705). The ultimate result and analysis indicate that the Department of Defense’s SIDR (Standard Inpatient Data Record) is a reliable source of administrative data that compares favorably with traditional civilian quality management and health services research data sources, such as those from the Health Care Financing Administration and large insurers. (8)
National Centre for Workforce Analysis, American Nurses Association, American Academy of Nurse Practitioners jointly conduct a study to see the relationship between the nursing services with the quality of patient care and patients outcomes in acute care and nurse staffing strategies that improved patient outcomes. The result was that the higher registered nurse staffing was associated with less hospital related mortality, failure of rescue, hospital acquired pneumonia and other adverse events but the association is not necessarily causal. The effect of increased registered nurse staffing on patient’s safety was strong and consistent. Greater registered nurse hours spent on direct patient care were associated with decreased risk of hospital related death and shorter length of stay. No studies directly examined the factors the factors that influence nurse staffing policy. Few studies addressed the role of agency staff. No studies evaluated the role of internationally educated nurse staffing policies. (9)
Agency for Healthcare Research and Quality (AHRQ) of Utah Department of Health conduct a study on “Using Hospital Inpatient Discharge Data for Quality Improvement and Statewide Surveillance: AHRQ Inpatient Indicators.” Here the comparison of the risk adjusted rate for Utah inpatient discharge and the national rate from the AHRQ National Healthcare Quality Report. The results reflect the association of quality improvement of inpatient service with the increased discharge and short stay in hospital. (10)
Quality assurance project as proposed by the government of Bangladesh has an accreditation checklist for the Upajila Health complex for primary health care but no such criteria for tertiary level hospital and psychiatric care. Any further evaluation or study not yet performed to improve the quality of inpatient services of a psychiatric hospital or other tertiary level hospital. (11)
Another quality measures developed by the North Carolina Healthcare Quality Alliance (NCHQA) in 2010 which was established to improve health care for North Carolinians through promotion of evidence – based practice in primary care and measurement of health care quality using nationally recognized standards for care for specific health conditions. There is considerable scientific research into the design of measures to capture health care quality and numerous national organizations have developed and endorsed measures for preventive and acute care. Providers across North Carolina currently report data for quality measures as part of their participation in Community Care of North Carolina (CCNC) and/or as part of their agreements with state insurers. The implementation of the NCHQA will expand current reporting statewide and represents a significant initiative that can serve as a model to other states seeking to improve the health of their citizens through improved health care quality. Measures of quality have been chosen by the NCHQA partners to assess quality of care in the following five areas which represent a significant portion of health problems and health care expenditures among North Carolinas. Measures used in the NCHQA are based on nationally recognized evidence based standards such as those developed by the National Committee for Quality assurance and endorsed by the National Quality Forum (NQF) and which have been widely accept in the North Carolina Provider community. Assessment in progress regarding quality of care will be regularly conducted and will include critical review of the measures being used and the need to adjust them. But the extension of NCHQA to measures for other conditions and across the continuum of care is a long term goal. (12)
A study in Clearinghou was done titled “Hospital based inpatient psychiatric services: the percentage of patients discharged from a hospital based inpatient psychiatric setting with a continuing care plan created.” This measure is used to assess the percentage of patients discharge from a hospital based inpatient psychiatric setting with a continuing care plan created. Patients may not be able to fully report to their next level of care health care provider their course of hospitalization or discharge treatment recommendations. The aftercare instructions given the patient may not be available to the next level of care provider at the patient’s initial intake or follow up appointment. In order to provide optimum care, next level of care providers need to know details of precipitating events immediately preceding hospital admission, the patient’s treatment course during hospitalization, discharge medications and next level of care recommendations. (13,14,21,23)
Evidence supporting the measures of criterion of quality were a clinical practice guideline for other peer-reviewed synthesis of the clinical evidence and one or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal. Use of the measures is to improve performance. Currently it is used for routine use for internal quality improvement of hospitals, single health care delivery organizations. Here the target population were all patients age one year and older, either male or female and stratification by vulnerable population are children. (18,19,,21)
A survey was conducted by an independent research organization named the Picker Institute Europe, on behalf of the local hospitals and it is about the National Health Service Hospital and recent experiences of the patients in the inpatient and emergency department. The survey totally based on the patient’s satisfaction level about the quality care of the inpatient and emergency services of the National hospitals. (20)
On April 19, 2010, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would revise policies and payment rates for general acute care hospitals that are paid for inpatient services under the Inpatient Prospective Payment System (IPPS), effective for discharges in fiscal (FY) 2011 – that is, on or after October 1, 2010. In addition to promoting accurate payment for inpatient services to Medicare beneficiaries, the proposed rule strengthens the relationship between payment and quality of service by expanding the quality measures that hospitals must report in order to receive the full market basket update in fiscal year 2012. Under the Medicare law, hospitals that choose not to participate in the voluntary reporting program or do not participate successfully will receive an inflation update equal to the hospital market basket less two percentage points The proposed rule projects a market basket update of 2.4 percent, and, therefore, hospitals that do not successfully report the quality measures would receive updates currently projected to be 0.4 percent. (22,23)
A group of health professionals in the United States and United Kingdom commissioned with a similar task of developing an assessment tool would try to work out a rating scale that could be tested for its psychometric properties and could be used in an operationalized way. Such a scale would yield scores, like BASIS-32 does. Mental health professionals in quite a few hospitals have started to use the manual in line with the more or less established quality management procedures in each hospital. Although some positive experiences have been reported, a systemic evaluation has not yet been entirely done. (27)
The proposed rule does not substantively change the list of hospital-acquired conditions (HACs) in FY 2011, but describes the results of CMS’s evaluation of the impact of the existing policy on hospital practices and patient care.
This Fact Sheet discusses only the quality provisions of the IPPS FY 2011 proposed rule; separate fact sheets also issued today provide more detail on the payment and policy changes. The proposed rule does not substantively change the list of hospital-acquired conditions (HACs) in FY 2011, but describes the results of CMS’s evaluation of the impact of the existing policy on hospital practices and patient care. (28)
The Agency for Healthcare Research and Quality (AHRQ) in United States has a broad portfolio of mental health research. This report focuses specifically on AHRQ-funded research that has led to the development of programs, methods, and tools for evaluating and improving the quality of mental health services and improving the education of mental health professionals. AHRQ’s wide range of mental health research has produced
programs, methods, and tools that can improve the quality of mental health services. The PIC program allows people suffering from depression to collaborate in their care with their providers and has been shown to improve outcomes. Providers who treat schizophrenia patients have toolkits that use evidence-based treatment recommendations to assess the care and treatment they provide. AHRQ research supported the development of a simple tool to screen adolescents at risk for suicide. Research is also directed toward finding ways to evaluate and promote quality improvement programs for mental health services in school-based programs and MBHO’s. In addition, AHRQ’s research helps identify solutions that can improve education and training for mental health care professionals. (30)
The New Hampshire Department of Health and Human Services used the Schizophrenia PORT recommendations for key policy initiatives. The New Hampshire Division of Public Health used the PORT findings to highlight racial disparities in the provision of care, directly influencing New Hampshire’s Healthy People 2010 plan, which is aimed at
eliminating health care disparities. Partnering with the Dartmouth College Psychiatric Research Center, the Division of Mental Health restructured care protocol for patients with schizophrenia based on the PORT findings. The restructuring effort included the development of evidence-based toolkits for retraining community mental health staff. (32)
AHRQ-supported studies helped to develop a systematic approach to evaluating expanded school mental health (ESMH) programs in middle and high school and discovered that the costs of ESMH programs were low compared to the costs of programs in the community or private sectors.24 A cost-of-care evaluation conducted for one school mental health program found that clinician services cost less than $50 per hour–much less than private services, which were estimated to cost $100 to $120 per hour. A typical program provides assessment; individual, group, and family counseling; crisis intervention; prevention and case management activities; teacher consultation; and collaboration with school staff and the community. (30)
The RSQ was the result of a clinical practice guideline (CPG) program conducted at Children’s Hospital Boston.40 The program provided training to emergency room nurses on psychiatric issues such as how to perform patient searches, de-escalating techniques, and risk factors for suicide.40 At the beginning of the training, emergency room nurses at Children’s Hospital stated that they were uncomfortable dealing with children who had psychiatric problems or asking parents or children about thoughts of suicide.40 In addition, 94.4 percent of nurses stated that suicidal patients were the most difficult patients to treat40. Two years into the CPG program, nurses reported a significant increase in their confidence and less stress when dealing with psychiatric patients.
They also stated that they preferred using the screening tool to the previous method of simply judging when to ask about suicidal behavior.39,40 Parents also expressed relief that emergency room clinicians were asking about suicide. (31, 33, 37)
According to researchers funded by AHRQ, an ESMH evaluation plan should systematically measure the outcomes of the program’s goals, such as identifying emotional, behavioral, and academic problems early and improving school attendance. An AHRQ-funded study that used the Consumer Assessment of Behavioral Health Services (CABHS) prompted quality improvement efforts in several managed behavioral health care organizations. (34)
CABHS is based on CAHPS®a and was developed to collect ratings from consumers about services received from MBHOs.The survey assessed patient satisfaction in five commercial and five public assistance plans.5 Based on the results of these surveys, three MBHOs implemented quality improvement efforts. Based on the CABHS data collected in this AHRQ-funded study, along with data from a previous study using the Mental Health Statistics Improvement Program (MHSIP), researchers developed the Experience of Care and Health Outcomes (ECHO™). (35)
The ECHO™ 3.0 has two surveys–one for MBHOs and one for health plans. Both surveys ask the same questions, but the health plan survey includes questions about administrative services, such as filling out paperwork and finding information in written materials.42AHRQ cosponsored the National Conference on Behavioral Health Workforce Education in Annapolis, Maryland, September 10-11, 2001. The proceedings from this conference resulted in a special double-issue volume of Administration and Policy in Mental Health in May 2002. The proceedings present problems and solutions to
educating behavioral health professionals. (36)
Methodology
3. Methodology
3.1 Study design
Descriptive type of cross sectional study.
3.2 Study place
National Institute Of Mental Health, Sher-E- Bangle Nagar, Dhaka.
3.3 Study duration
January to June 2011.
3.4 Study population
All the Indoor Department health care providers – doctors, nurses, supporting stuffs of all ages including male and female at indoor department of National Institute Of Mental Health.
3.5 Sample size
The sample size could be measure as follows-
Z2pq
n = ————
d2
The sample size according to this equation is 384. But due to short period sample size will be fixed by convenient sampling technique into 60.
3.6 Research instrument
Questionnaire to health care providers
Observational Check list
3.7 Data collection technique
A questionnaire and a check list were designed to obtain required information. Questionnaires were used to obtained data from the respondent by face to face interview. The facilities related to psychiatric management at the inpatient ward were observed and recorded with the help of the check list.
3.8 Data collection procedure
The researcher herself attended the NIMH inpatient department for collecting data. One Questionnaire was used for each health care provider for data collection. The check list was filled by the researcher after observing the facilities directly.
3.10 Sample technique
No statistical sampling was done among the health care provides of inpatient department of NIMH as the researcher wanted to cover all the professionals working in inpatient department of NIMH. So, convenient sampling technique was applied for this study.
3.11 Data processing and analysis
Both the check list and questionnaire were pre tested and finalized. During data analysis study objectives were kept in consideration. Frequency table were made for each variable and cross tabulation were also made for some related variables. Chi square test was done for comparison. Data will be processed and analyzed by using SPSS (Statistical package for social science) software.
Results
4. RESULTS
Evaluation by the check list
Hospital records:
Number of patients admitted per month: 200 – 250/month
Number of patients discharge per month: 200 – 230/month
Bed occupancy rate: 95% – 97%
Male : Female bed occupancy rate – 140:60
Average hospital stay of a patient – 30 days
Diagnostic facilities:
Admission procedure
- Completed within 30 minutes of arrival of patient.
- Filling of forms, examination and treatment sheet – properly done.
- Separate recording and reporting forms and register – maintained.
- Confidentiality and preservation of records – maintained.
Diagnosis:
- Proper physical and mental examination – present and applied.
- Common laboratory investigation facilities like blood, urine and imaging, ECG etc – present and used.
- Necessary psychiatric investigation facilities like EEG, CT scan, MRI etc – present and used.
Discharge procedure
- Patient discharged with proper diagnosis
So, available diagnostic facilities present in NIMH is satisfactory and the use of these facilities are near to standard.
Treatment facilities:
- Normal physical treatment facilities – present and used.
- Specific psychiatric treatment facilities like psychiatric drug therapy, cognitive therapy, electroconvulsive therapy, psychotherapy, counseling, occupational therapy and rehabilitative therapy etc – present and used where needed.
- Treatment care planning and teamwork for treatment, accessibility care – present but not sufficient.
- Available essential drugs but supply is not adequate.
- Support for living, accommodation, self care, education and rehabilitation – present but support for work and occupation are not adequate and support for social contacts is absent.
- There is no provision for recreation or leisure time and advocacy for patients.
- Other common facilities like hygiene, emergency light, ideal waste disposal, infection and injury prevention – on practice but 24 hours emergency ambulance service is not available on regular basis.
We can see that, more emphasis on medicine supply is needed. There is also no 24 hour emergency service which should be ensuring for better management of patients. Other treatment facilities are near to standard.
Manpower facilities:
- No .of medical officers attending per shift – 10/12 at morning shift, but 1 at evening and night shift.
- No. of Nurses attending per shift – 12/15 at morning shift but 5 at evening and night shift.
- No. of security guards working per shift – 8 at morning shift but 5 at evening and night shift.
- No. of cleaners working per shift – 4/5 at morning shift but 3 at evening and night shift.
- No. of ward boy attending per shift – 8 at morning shift but 5 at evening and night shift.
So, overall the manpower is not enough for 200 patients who are admitted in this hospital.
- Co operation between management and clinical stuffs- present.
- Communication and information system – poorly established.
- Public relation present but not satisfactory.
- Visitor restriction is also not a satisfactory level due to lack of manpower.
- Supervision by the hospital administration is done only once in a week which should be increased.
The most important drawback in NIMH is it’s limited manpower. Though the institute is 200 bedded but the manpower present here can serve 100 patients properly. So, every staff has to do double work which obviously hamper the quality of services.
Figure 1 Distribution of respondents by age
The Bar diagram shows the frequency of the age group of the respondents. Among the 70 respondents 15 are in the age group of 20- 30, 48 are in the age group of 31- 40 and the rest 7 are in the age group of 41- 50
Figure 3 Distribution of respondents by experience
The above bar chart shows the total experience of the respondents. Here 17 respondents have 0-5 years work experience, 27 respondents have 5-10 years work experience and 26 respondents have more than 10 years work experience.
Figure 4 Distribution of respondents by experience in NIMH
The bar chart shows experience of the respondents in NIMH. 32 respondants had Upto 5 years work experience and 38 respondents had 5-10 years work experience.
Figure 5 Opinion regarding indoor facilities utilization
The pie chart shows the opinion of the respondents about the indoor facilities utilization. According to 34.29% respondents facilities are proper utilized and 65.71% respondents think that facilities are under utilized.
Table 1 Distribution of respondents by religion
| Religion | Frequency | Percent | ||
| Muslim | 53 | 75.7 | ||
| Hindus | 16 | 22.9 | ||
| Christian | 1 | 1.4 | ||
| Total | 70 | 100.0 | ||
The table shows the frequency of the respondents according to the religion. Here we can see that among the 70 respondents Muslims are 53 i.e. 75.7%, Hindus are 16 i.e. 22.9% and Christian is 1 i.e. 1.4%.
Table 2 Distribution of the respondents by designation
| Designation | Frequency | Percent | |
| Doctor | 26 | 37.1 | |
| Nurse | 38 | 54.3 | |
| Support staff | 6 | 8.6 | |
| Total | 70 | 100.0 | |
The above table shows the frequency of the 70 respondents regarding their designation in NIMH. Among them doctors are 26 i.e. 37.1%, nurses are 38 i.e. 54.3% and support staffs are 6 i.e. 8.6
Table 3- Respondent’s opinion about the time of admission
| Time for admission | Frequency | Percent | |
| 30 min | 45 | 64.3 | |
| 30min-1hour | 24 | 34.3 | |
| more than 1 hour | 1 | 1.4 | |
| Total | 70 | 100.0 | |
The above table reflects the opinion of 70 the respondents about the time of admission in NIMH. 45 respondents i.e. 64.3% think that admission time is within 30 minute, 24 respondents i.e. 34.3% say that the time is between 30 min. to 1 hour and the remain 1 respondent i.e. 1.4% thinks the admission time require is more than 1 hour.
Table 4- Respondent’s opinion about easiness of admission
| Answer | Frequency | Percent | |
| Yes | 35 | 50.0 | |
| No | 35 | 50.0 | |
| Total | 70 | 100.0 | |
The table shows the opinion of the 70 respondents about the easiness of the admission procedure in NIMH. 35 respondents i.e. 50% think that the admission procedure is easy enough but the remain 50% i.e. 35 respondents think that it is not easy enough for the public.
Table 5 – Response about the planned admission list
| Planned admission list | Frequency | Percent | |
| Present | 15 | 21.4 | |
| Absent | 55 | 78.6 | |
| Total | 70 | 100.0 | |
The above table showing the response of the 70 respondents about the presence of planned admission list. Among them 15 respondents (21.4%) think that planned admission list present in NIMH but 55 respondents (78.6%) know that there is no planned admission list in NIMH.
Table 6- Respondent’s opinion about the admission process
| Organization of admission process | Frequency | Percent | |
| Fairly organized | 60 | 85.7 | |
| Very organized | 10 | 14.3 | |
| Total | 70 | 100.0 | |
The above table describes the opinion of the 70 respondents about the admission process. 60 respondents (85.7%) marked the admission process as fairly organized and 10 respondents (14.3%) marked it as very organized.
Table 7 Respondent’s opinion about changing admission date
by the hospital
| Change admission date by hospital | Frequency | Percent | |
| YES | 30 | 42.9 | |
| No | 40 | 57.1 | |
| Total | 70 | 100.0 |
The table shows the opinion of the 70 respondents about the change of admission date by the hospital administration. Here 30 respondents (42.9%) think it is changed by the hospital but 40 respondents (57.1%) think that it is not changed by the hospital.
Table 8 Respondent’s opinion about satisfactory follow up care
| Satisfactory follow up care | Frequency | Percent | |
| Yes | 69 | 98.6 | |
| No | 1 | 1.4 | |
| Total | 70 | 100.0 | |
The above table shows the opinion of the 70 respondents about the follow up care. 69 respondents (98.6%) told that the follow up care is satisfactory in NIMH and 1 respondent (1.4%) told it is not satisfactory.
Table 9 Respondent’s opinion about possible better care
| Possible better care | Frequency | Percent | |
| Yes | 69 | 98.6 | |
| No | 1 | 1.4 | |
| Total | 70 | 100.0 | |
The above table describes the opinion of the 70 respondents about the possibility of better care or services in NIMH. Here 69 respondents (98.6%) think that the services can be better than present but only 1 respondent (1.4%) thinks it is not possible
Figure 6 Opinion about appropriate diagnostic facilities
The pie chart shows response of the 70 respondents about the diagnostic facilities in NIMH whether it is appropriate or not. 60% respondents think the diagnostic facilities are appropriate for the diagnosis of the patient but 40% think that it is not appropriate.
Figure 7 Opinion regarding discharge patient with diagnosis
The pie chart reflects the opinion of the 70 respondents about the discharge of the patient from NIMH with appropriate diagnosis or not. 98.57% respondents said that the patients are discharged with appropriate diagnosis but 1.43% said that patients are not always discharged with appropriate diagnosis.
Table 10 Re