Planning for Quality Improvement
A Presentation to the World Health Organization
Symposium on Quality Improvement
H. Stephen Leff, Ph.D.
Department of Psychiatry, Harvard Medical School at
Cambridge Health Alliance
Human Services Research Institute
November 2, 2012
World Health Organization Planning Guidance Package – A useful
introduction to mental health planning
http://www.who.int/mental_health/policy/en/policy_plans_revision.pdf
Visions must be translated into plans with specific and quantitative goals and
objectives, strategies, targets and related quality improvement processes
Stakeholders experience and may be responsible for different aspects of
quality in different contexts
A Policy Ecology of Implementation.
Raghavan, R., C. L. Bright, et al. (2008). "Toward a policy ecology of implementation of evidence-based practices in public
mental health settings." Implement Sci 3: 26
질 What
향상Is Quality:
Improving quality animation
Quality Improvement:
Outcomes Is Moved
into Desired Range
and Variability
Minimized
Acceptable Variability;
Outcomes Is Moved into
Desired Range
Quality Improvement Is a Process: Common Representation of Continuous
Quality Improvement Process (PDCA)
소비자/환자
질 향상
현실적 목표
정책
욕구사정
이용 가능한 자원
정신보건서비스
지침
시스템 모니터링
욕구충족
성과
The Importance of Planning to Quality Improvement
according to the World Health Organization
To be effective, a vision needs “a detailed plan so
that…[it] can be implemented in a systematic
and well-coordinated way.”
“PLAN:” Quality improvement provides the arrows, A high
quality plan provides the target; Several arrows indicate
different quality improvement practices for different contexts
Mental Health System Planning: Like
Putting Puzzle Pieces Together
정책
Planning Begins with System Participants (Stakeholders)
Identifying Goals and Values
Quality Begins and Ends with Consumer: Example of a
Functional Level Scale For Needs Assessment
기능수준
Another Example of a Functional Level Scale For Needs Assessment:
Global Assessment of Functioning Scale
Example of Instrument for Translating Functional Levels into
Service Needs - 서비스 계획 및 평가 조사
Service Planning and Evaluation Survey (SPES)
기능수준
Clie nt ID:
Date :
Rate r Name :
RAFLS Rating
DMH Are a
Nat Svc Are a
RAFLS Rating
(A)
Se rvice Compone nt
(B)
Se rvice
Unit
(C)
Se rvice s Clie nt
Should Ide ally
Re ce ive
(Units/Mo.)
(D)
Units Actually
Provide d to
Clie nt
Use Code s liste d on
instruction she e t
(E)
Re asons for
Discre pancie s Be twe e n
Columns C & D
Re ason Code s (Column
E)
Hospital
정
신
보
건
서
비
스
If amount received was
less than the ideal:
1. Acute Inp atient
day s
1. C
1. D
1. E
2. Intermediate Inp atient
day s
2. C
2. D
2. E
1. Service does not exist
3. Extended Inp atient
day s
3. C
3. D
3. E
2. Service has insufficient
capacit y
3. Client was refused for
behavioral reasons
4. Inp atient Detoxification
day s
4. C
4. D
4. E
day s
5. C
5. D
5. E
4. Inabilit y t o pay
5. Inp atient Forensic Evaluation
5. Accessibilit y problem
Re side ntial
6. Language or cult ural
problem
7. Client refused service
6. Forensic Residential
day s
6. C
6. D
6. E
7. 8-16 Hour Residential
8. 24 Hour Intensive Staff
Sup ervision
day s
7. C
7. D
7. E
day s
8. C
8. D
8. E
9. Intensive Staff/ Sup ervision
10. M oderate Staff/
Sup ervision
11. M inimum Staff/
Sup ervision
day s
9. C
9. D
9. E
9. Clinician decided service
should not be provided
day s
10. C
10. D
10. E
10. Ot her reason not list ed
above
day s
11. C
11. D
11. E
12. Sup p orted Housing
13. Indep endent Living
w/Housing Subsidy
14. Indep . Living w/o
Subsidized Housing
day s
12. C
12. D
12. E
day s
13. C
13. D
13. E
11. Service subst it ut e for
ideal service
day s
14. C
14 D.
14 E.
12. Clinician decided service
should be provided
15. Sp ecialized Residential
day s
15. C
15. D
15. E
day s
16. C
16. D
16. E
day s
17. C
17. D
17. E
16. Nursing Homes w/M H
Cap acity
17. Substance Abuse
Residential
8. Family/ot her request
If amount received was
more than the ideal:
13. Client request ed service
be provided
14. Family request ed service
be provided
15. Ot her reason no list ed
above
Another Example of Instrument for Assessing Service Needs: The
Camberwell assessment of needs (욕구사정 ) short appraisal schedule
정
신
보
건
서
비
스
An Example of an Instrument for Measuring Services and Unit Costs
서비스 비용
정
신
보
건
서
비
스
Monitoring Transitions Between States: Particularly Useful
Way to Measure Outcomes for Planning - 성과
Functional Level 3
기능수준
Receive service
정신보건서비스
근거기반실천 / 근거기반진료
EbP System
Current System
FL1
FL2
FL3
FL4
FL5
5
10
65
15
5
FL6
FL1
FL2
FL3
FL4
FL5
FL6
10
60
20
5
5
Transition probabilities (추이확률)
Computer Simulation Makes It Possible to Project Service
Utilization, Outcomes, Service and System Costs Over Time
역동적 시뮬레이션 모델
서비스 비용
이용 가능한 전체 자원
정신보건서비스
성과
기능수준
시점
시점
•
C
Examples of Plan Results Produced by Simulation
근거기반실천 / 근거중심진료
정신보건서비스
“CHECK:” Monitoring System Performance – “Vital for Improving…”
국가정신보건정책과 계획에 대한
주의 깊은 모니터링과 평가는
서비스, 치료, 관리수준을
향상시키고 미래의 정책방향을
제시하기 위해 필수적인 것이다.
세계보건기구
Comparing Observed (“DO”) to Planned Results Starts
the PDCA Quality Improvement Cycle Again 시스템
모니터링 : 욕구충족
정신보건서비스
Less Residential
Treatment than planned
Less Rehabilitation than planned
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
45%
35%
30%
15%
10%
20%
15%
20%
Plan
Check
5% 5%
More Hospital than planned
More treatment
than planned.
The Link Between “Change Plan” and “Do:” Training
Change Plan
훈련
(Training)
Act
Check
Do