Improving Patient Safety for Inpatient Psychiatric Care

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Researchers argue that safety efforts have lagged for inpatient psychiatric care.

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Patient safety and quality of care initiatives have spread across the health care system. But similar efforts lag behind in areas where patients may be the most vulnerable—including inpatient psychiatric facilities.

Inpatients in psychiatric facilities receive care for mental health illnesses and yet they find themselves at risk of experiencing physical and psychological harm during their stay due to abuse, inappropriate restraint and seclusion, sexual assault, poor sanitation, and negligence.

In a recent paper, researchers argue that to be safe and effective, psychiatric facilities must adopt “trauma-informed care”—an evidence-based treatment framework that focuses on understanding and addressing the effects of patients’ trauma. Key principles of trauma informed care require that patients feel connected and informed and that staff members promote and protect patients’ autonomy. Importantly, adoption of the treatment framework is associated with a decrease in the use of restraint and seclusion.

Accreditation requirements for inpatient psychiatric facilities should include trauma-informed care measures, suggest Morgan C. Shields and Maureen T. Stewart from Brandeis University and Kathleen R. Delaney from Rush University. They also recommend using payment incentives to encourage patient-centered care, tracking and analyzing critical incidents in inpatient psychiatric facilities, and improving data collection and research on patients’ experiences.

Existing accreditation requirements, they argue, do not adequately support patient safety in inpatient psychiatry because they do not capture the trauma-informed treatment framework. For instance, the Joint Commission, which accredits most inpatient psychiatric facilities, focuses only on processes for restraint and exclusion, suicide screening, and physical environment. Shields and her coauthors did not find any additional language related to trauma-informed care or the need to create an organizational safety culture.

State licensing requirements for inpatient psychiatric facilities are similarly inadequate in promoting patient safety, argue Shields and her coauthors. States generally require psychiatric facilities to report complaints of critical incidents, such as abuse, neglect, and unexpected death. Yet Shields and her colleagues find that states often do not systematically track and report complaints, which limits state-level research on patient safety.

States also vary in how they make critical incident reports and regulatory violations publicly available, write Shields and her coauthors. For example, Massachusetts requires an interested party to fill out a public records request. The state then may provide the requested information as redacted pages rather than in an accessible database.

Data on patient safety in inpatient psychiatric facilities is also sparse, Shields and her coauthors say. They explain that, as a result, there is little empirical evidence on the scope of harm and patient experiences in these settings. The Agency for Healthcare Research and Quality, for example, commonly uses the Hospital Consumer Assessment of Healthcare Providers and Systems database to examine patients’ care experiences, but this database excludes psychiatric patients.

Furthermore, limited data can be gleaned from electronic health records (EHRs). The Centers for Medicare & Medicaid Services (CMS) excluded freestanding psychiatric facilities from its EHR incentives program, which dedicates substantial resources to help certain providers adopt EHR systems. As a result, only 15 percent of freestanding psychiatric facilities used even a basic EHR system in 2015.

To address these shortcomings, Shields and her coauthors offer several recommendations.

First, they suggest that accreditation organizations like the Joint Commission should broaden their standards to include trauma-informed care measures. Doing so would help move psychiatric facilities towards providing safer, evidence-based care.

Second, Shields and her colleagues recommend paying inpatient psychiatric providers based on how well they deliver patient-centered care, a process which would involve collecting data on patients’ satisfaction and experiences. Regulators could capture nuanced aspects of patient safety, such as psychological safety.

Shields and her coauthors note that CMS could require inpatient psychiatry facilities to measure and report patient experience data. They explain that payments incentives could then encourage safer care. The payments could also promote therapeutic staff-patient relationships in inpatient psychiatric facilities.

Third, facilities and researchers should conduct provider-level and system-wide research into the causes of harm in inpatient psychiatry, write Shields and her coauthors. They assert that facilities should conduct internal monitoring of critical incidents and states should track and report them.

Shields and her colleagues also assert a need for national-level monitoring. They suggest that CMS and the Joint Commission could require standardized reporting and receive critical incident data. They argue that greater transparency would also allow regulators to identify facilities that require intervention.

Finally, Shields and her colleagues call for improved research capacity. They argue that national surveys of hospital utilization and patient experiences should include inpatient psychiatric facilities and that CMS should support and encourage these facilities to adopt EHR systems.

These changes would encourage the creation of systemic data on quality, safety, utilization and payment to inpatient psychiatric facilities. Once data become available, Shields and her coauthors assert that research aimed at inpatient psychiatry safety and quality improvement should receive funding.

Shields and her colleagues’ paper appeared recently in the journal Health Affairs.