Using outcome measures to Improve Clinical Practice A Local Perspective

1
Using outcome measures to Improve Clinical
Practice A Local Perspective

• Peter Jeffrey, MH-OAT Coordinator
• GWAHS (Southern Eastern clusters)
• NSW, AUSTRALIA
• July 2007

Special thanks to Sam Grosvenor (GWAHS) for his
contribution to this presentation.
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The problem

• Clinicians are expected to
• routinely use a set of measures
• that they have not chosen but
• must complete.

• Often, completing measures is seen as a waste of
  precious clinical time.
• Measures may not even be looked at once
• completed. Why bother with a score?
• The stuff is never used or looked at anyway.

3
The challenge

• To help clinicians accept and understand that
  outcome measures can be clinically useful with
  assessment,
• care planning, review,
• relapse prevention
• and discharge.

4
Business Process

• Understanding the business process is critical
  for clinicians to understand outcomes and
  activity in the clinical setting.

5
MH-OAT

• The Mental Health Outcome Assessment Tool
  (MH-OAT) is a state wide initiative to improve
  the quality of mental health care in NSW
  (Australia).

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MH-OAT (cont.)

• It is a mandatory suite of standardised documents
  that involves strengthening MH assessment skills,
  training in standard protocols for assessment
  documentation, and training in using the standard
  measures implemented nationally (under the Second
  National Mental Health Plan).
• It is a process which aims to support clinicians
  in their provision of clinical care and to
  improve MH outcomes.

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The strategy a local perspective

• Increase clinical knowledge and awareness ?
  Ongoing targeted short training sessions.
• Strengthen clinical support and resources
  available ? Facilitator training for every
  team/unit. Develop procedure manuals.

8
The strategy

• Measure compliance with and quality of outcome
  completions ? Monthly file audits.
• Make sure that the data is looked at and
  reported. ? Provide ongoing feedback and
  encouragement to all clinicians and managers.

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strategies continued

• ? Give positive reinforcement and feedback
  through encouragement.
• At Team level
• MH-OAT Trophy
• which is awarded every
• 6 months for areas of
• team excellence or
• improvement with
• MH-OAT procedures.

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Further encouragement

• At Individual level
• Champion of MH-OAT
• Certificate of Achievement
• which is awarded monthly
• for individual efforts and
• excellence with MH-OAT.
• Both awards are presented at a ceremony with
  peers, and entered into a local staff newsletter
  - generally with a photograph of recipient(s).

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Strategy implementation (1)

• Targeted Training
• Weekly ongoing short (1-2 hrs)
• MH-OAT training sessions.
• 11 training and support available to all
  clinical staff as required.
• Other groups where clinical
• applications apply are also
• targeted for training input.

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Strategy implementation (2)

• Facilitator Training
• 46 staff nominated from
• 8 inpatient units and 10
• community teams.
• All surveyed as to training needs.
• Training and support is ongoing for this group
  and a MH-OAT Facilitator network has been
  established.

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Strategy implementation (3)

• File Audits
• Every team required to complete a predetermined
  number of file audits every month.
• These completed audits are checked by the Team
• Leader/CNC to address
• any issues arising.
• Audits then checked
• by MH-OAT Coordinator
• prior to batch entry onto
• computer by administration worker.

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Strategy implementation (4)

• Feedback
• Reports are generated and distributed for every
  team and unit to give feedback on
• Monthly file audits (numbers and file quality).
• Activity Collection Data for ambulatory hours
  entered onto the computer system.
• - Outcome measure data entered and comparisons
  across teams/services.

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Data Utilisation and Benchmarking

• Established frameworks and ongoing feedback can
  show how the data can be utilised.

• Benchmarking can assist areas and teams to
  realise what they can achieve.

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Using data for comparisons (NOCC Reports)
On total HoNOS scores GWAHS (SE) acute
inpatient figures are almost identical to the
national averages. - Plus some interesting
minor differences.
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What are the measures?
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The status of the Standard Measure in the
MH-OAT document set

• In terms of measuring outcomes, tracking progress
  and observing service patterns over time, the
  standard measures are the main source of the
  required information.
• In GWAHS, the standard measures are currently the
  only electronic computerised MH-OAT forms.

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MH-OAT document set

• The measures are reasonably easy to complete
  (unlike some of the other MH-OAT documentation)
  and do not require a lot of time, once clinicians
  are familiar with the task.
• Clinicians can enter the required data onto the
  computer system themselves and print out paper
  copies for the files, as well as produce
  graphical report summaries of results for reviews.

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Benefits of using Outcome Measures

• Validation of clinical impressions.
• A challenge to reconsider.
• Ammunition to argue for greater resources.
• Ammunition to reduce or question resources.
• A point of reference to gauge
• improvement or decline.
• A pointer for clinical planning
• and intervention.

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Overview of HoNOS -Health of the Nation Outcome
Scale

• HoNOS is a brief, reasonably comprehensive and
  reliable rating tool for Mental Health services
  used Australia wide ( abroad), which can track
  changes over time.
• It is mandated at all collection occasions.
• HoNOS can be viewed in relation to its subscales,
  individual items or as a total score.

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The HoNOS items 4 Subscales

• 1. Overactivity, aggression
• 2. Non-accidental self-injury
• 3. Problem drinking or drug-taking

BEHAVIOUR
IMPAIRMENT
4. Cognitive problems 5. Physical illness or
disability problems
6. Hallucinations/delusions 7. Problems with
depressed mood 8. Other mental and behavioural
problem
SYMPTOMS
9. Problems with relationships 10. Problems
with activities of daily living 11. Problems
with living conditions 12. Problems with
occupation and activities
SOCIAL
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Comparison of local GWAHS (SE) National HoNOS
collection data
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A convincing clinical outcome Comparison of
GWAHS (SE) Community Ambulatory Admission
Discharge Self-Rated distress levels with NSW
Average

• The GWAHS Ambulatory Care Admission K10 profile
  shows a very high level of very high distress.
• The Discharge profile shows a high proportion of
  Low Stress and a greatly reduced Very High
  Stress Level.
• The discharge profile is reasonably similar to
  the NSW population average. However, there is
  still evidence, for some, of higher than
  average discomfort and distress at discharge.

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What do we try to support encourage?

• Clinicians who care about people and about
  providing quality services.
• Widespread use of quality clinical data to inform
  clinical judgements and service planning.
• The vision of the National Mental Health Plan
  being implemented by all mental health services
  with a consumer and recovery focus.
• You can be a good clinician/ nurse/ practitioner
  without collecting data, you can be a better one
  when using outcome data.

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The results of local efforts
Comparison of statistics on MH-OAT documentation
compliance after ongoing implementation of local
strategies within GWAHS (Southern Eastern
clusters)
2005 NSW State Average 2005 GWAHS
2006 GWAHS

• Triage 45 - 45 - 75
• Assessment 72 - 63 - 75
• Physical 26 - 48 - 62
• Dev. History 25 - 45 - 52
• Cons.Recov.Plan 3 - 10 - 18
• Care Plan 30 - 50 - 55
• Review 27 - 35 - 42
• Discharge 67 - 63 - 55

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any questions?

• Thank you