Performance measurement is achieved by collecting data about the processes of care (services provided to patients and patient self-care activities) and about health outcomes (changes in patients' health status or health risk states attributable to processes of care). The performance measurement data is then presented in the form of a rate or score.

According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), behavioral healthcare organizations must measure performance in certain high risk activities. The topics/issues that must be measured are constantly undergoing revision by the JCAHO, therefore it is important to check the most recent accreditation standards to determine current requirements. According to the 1997-98 Joint Commission Standards for Behavioral Healthcare, the processes that must be regularly monitored and evaluated include those listed below:

• All adverse events or patterns of adverse events occurring during anesthesia use (including conscious sedation)
• Processes and outcomes related to behavior-management, to include when possible, perceptions of individuals served, families, and clinical staff.
• Processes and outcomes related to use of restraint and seclusion.
• Appropriateness of admission and continued stays (utilization management activities)
• Significant adverse drug reactions
• Processes and outcomes related to medication usage:

-     prescribing or ordering     -     preparing and dispensing
-     administering                   -      monitoring effects on individuals
(over time, each of these processes, if used in the organization, must be measured)

• Deficiencies, problems, failures, and user errors in safety management, life safety management, equipment management, and utilities management
• Risk management activities
• Quality control activities for the following services: clinical laboratory, nutrition services, equipment used in administering medication, and pharmaceutical equipment used to prepare medications (only those services provided in the organization).
• Information solicited from individuals served, families, staff members, and others about how well the organization is meeting their needs and expectations, how satisfied they are with the organization, and where the organization could improve.
• Competence of all staff, including licensed independent practitioners

In addition to the topics listed above, the Joint Commission requires that behavioral healthcare organizations collect performance measurement data for at least one individual-focused function and one organization-focused function. Over time, all major functions (as identified in the standards manual) must be measured. The organization's choice of performance measures should relate to their quality improvement priorities. Organizations should be measuring critical activities they feel are essential to meeting their quality objective, goals, and mission. The organization's leaders should identify performance measures that provide them with information about how well they are doing at meeting their quality goals. For example, if a goal is to provide seamless delivery of healthcare services across an episode of care data for at least one performance measure that evaluates success in achieving this goal should be collected.

Listed below are examples of performance measures that could be used to evaluate the quality of important functions and activities in behavioral healthcare organizations.

• Percent of patients (or their families/significant others) queried about advance directives on admission.
• Percent of patients with advance directives who have a copy of the directive in their medical record.
• Percent of cases lacking appropriate informed consent(s).
• Percent of cases in which the relapse prevention plan substantiates client collaboration.
• Percent of discharge summaries which include all required documentation. (organization to define required elements, e.g., for alcohol/drug rehab cases: client plan for attendance at aftercare groups, role of family involvement in continuing treatment, plans for aftercare attendance monitoring, next scheduled appointment time, referrals made to other agencies, etc.)
• Percent of patients for whom a follow-up appointment is scheduled within 2 weeks of discharge.
• Percent of patients/clients receiving appropriate consultations within 24 hours of admission or when there is a significant change in their condition (organization should define "appropriate").
• Average order-to-report times for diagnostic tests.
• Percent of cases in which diagnostic criteria are based on the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
• Percent of cases in which the family/significant other was involved at the appropriate stage of therapy.
• Percent of cases in which practitioners followed approved practice guidelines.
• Percent of patients with mental disorders who report acceptance/tolerance of their condition.
• Percent of home care clients being seen for mental health services who maintain a Global Assessment of Functioning (GAF) score of less than 70.
• Percent of ECT cases with adequate pre-ECT workup (organization should define "adequate workup", e.g., dental consultation, skull and spinal column x-ray studies, and electrocardiogram).
• Percent of cases in which restraint/seclusion is ordered more than once during hospitalization and the problem is not addressed in treatment planning.
• Percent of records of patients receiving biophysical rehabilitation, partial hospitalization, and residential treatment services that show evidence of:
  - activities are incorporated in the plan of care
  - documentation of patient's response to activities
  - periodic evaluation of patient's education achievement
  - vocational services provided to patient

• Average level of impairment in adult service recipients with substance abuse problems.
• Percentage of children with serious emotional disturbances placed outside the home for at least one month during the year.
• Percentage of clients with serious mental disturbances whose housing situations improve as a direct result of treatment.
• The percent of clients who report 6 months following treatment that alcohol, drugs, or mental problems no longer interfere with their productive activities.
• Substance abuse treatment completion rate for clients completing at least two face-to-face treatment contacts.

The book Performance Improvement in Psychiatric and Substance Treatment Services includes more than 150 examples of performance measures for inpatient and outpatient behavioral healthcare organizations. To learn more about this publication, visit the Brown-Spath and Associates' web site: http://www.brownspath.com or call (503) 357-9185.

© 1998 Brown-Spath & Associates.

To Learn More: Patrice L. Spath is available for inhouse presentations on health care performance measurement subjects. She can be reached (503) 357-9185; email: Patrice@brownspath.com