With 33 million Americans utilizing healthcare services as a means to manage mental health conditions and illnesses, adequate delivery of mental healthcare, treatment, and practice is becoming increasingly more important in the American landscape of wellness (SAMHSA, 2004a). The mental health system continues to be a challenging area of healthcare, due to: increased usage of coercion into treatment, diversity in care delivery systems, an unevolved quality measurement mechanism, and a drastically different business and marketplace infrastructure. These factors added to the, already, present stigma associated with mental health, culminates into an extremely perplexing subject of inquiry for advancing mental health services and delivery.
Equipped with this knowledge, an understanding of the complexities surrounding this issue, professionals can assess, identify problems, plan, intervene, and evaluate effectiveness in the forces of change for alterations in mental healthcare. This change can only happen from a productive, sobering critique of the mental health system and from the development of a specific, measurable, attainable, realistic, and time-bound (SMART) goal. This goal should draw from the Institute of Medicine’s (IOM) core healthcare competencies and employ knowledge, skills, and attributes (KSA) as a means to fashion that goal (“Improving the Quality of Healthcare, 2008).
In knowing the limitations and problems faced related to this topic, it is important to stay mindful that treatments exist that have proven to be effective. 21st century medicine, though continuing to evolve exponentially, has gifted evidence-based treatments that echo efficacy in each patient’s life they help improve. Research continues to maintain the delicate balance of genetic, environmental, biologic, and psychosocial factors implicated in mental wellbeing. This realization provides the rationale for short-term treatment of anxiety or the long-term treatment of schizophrenia or other chronic, mental conditions. These treatments are generally carried out through the synthesis of psychotherapy, pharmacological intervention, and psychosocial services.
Of course, varying issues in mental health (such as: bipolar disorder, major depression, or personality disorders) have unique regimens prescribed and tailored to meet the specific needs of the patient and the characteristics of the condition he/she presents with. With general regard to the topic, it is axiomatic that today healthcare professionals are more educated, better equipped with technology and its ability to deliver information instantly, and much more knowledgeable of evidence-based practice. Given these facts, one could assume that healthcare delivery, at least in the realm of mental health, should have a higher degree of effectiveness and adherence to treatments proven to work (“Improving the Quality of Healthcare, 2008).
Does the mental health system adequately stick to an evidence-based delivery of care? According to a meta-analysis, that reviewed multiple studies from 1992 until 2000, only 27% of the studies maintained an adherence to clinical practice guidelines, derived from evidence-based research (Bauer, 2002). Further studies continued to shed light on this horrid statistic. For instance, one study that measured the quality of American healthcare, in a variety of settings and specialties, it was found that patients presenting with alcohol dependence received care that was consistent with scientific evidence only 10.5% of the time (McGlynn et al., 2003). This demonstrates the failure of mental health delivery and the imperative need for treatments backed by medical science.
What is the effect of the mental health system’s inability to prescribe care consistent with the latest evidence-based research? The effects stretch from the personal tragedy of the patient to the social burden on a culture. One chart review of 31 random patients in state psychiatric hospital showed 2,194 medication errors over a total of 1,448 days (Grasso et al., 2003). The failure to identify proper alternative to restraint usage or to know when restraints are indicated could account for over 150 restraint-related deaths in America annually (SAMHSA, 2004b). Diagnostic failures, such as when to treat, how to treat, or even who needs treated, are impossible to quantify; but it is likely that this factor accounts for many deaths by suicide. Still, national, cultural, and social consequence can be much more staggering. Mental health conditions make up the number one cause for death and disability in American women and the second cause in American men.
Mental health ailments account for a large amount of absenteeism in the workplace, as well as impaired thinking and judgment, and critical mistakes on the job. Child welfare is even impacted, with 48% of child welfare services investigations having clinical implications for mental health care problems. In facilities housing youth that await mental health services, 48% of these facilities report suicide attempts among their youth (U.S. House of Representatives, 2004).
The social burden continues snowballing with an exponentially growing prison population, going from 601 persons in custody in 100,000 US residents in 1995 to one person in custody in 140 US residents (Harrison and Karberg, 2004). 16% of this population report a mental health condition or, at least, a history of a minimum of one night spent in an inpatient psychiatric unit (Mumola, 1999). The cost to society, in fiscal terms and cultural burden, are much greater than the cost of evidence-based treatment.
When considering the IOM’s core healthcare competencies relative to this topic, it seems that the most fitting one is: “employing evidence-based practice”. With only 27% of mental health cases adhering to evidence-based guidelines for practice and management of mental health conditions, it is clear that this competency is one in which the mental health field could strive for better compliance. By employing evidence-based practice, then the best outcome is maximized for the patient (Finkelman, 2012).
As one seeks to derive a SMART goal from a core competency, it is important to pinpoint knowledge, skills, and attributes (KSA) as related to the competency. In this case, the appropriate KSA would be: utilizing evidence as a guide for practice. By guiding practice with evidence, then one can help decrease readmission rates and be sure that the patient is getting the best, evidence-based treatment tailored to his or her condition. This improves patient outcome, thereby improving patient satisfaction. This KSA is important across the professional spectrum and demands interdisciplinary compliance, whether one is a nurse, therapist, or psychiatrist. Keeping this in mind, the construction of a SMART goal should include a multidisciplinary perspective (Chamberlain College of Nursing, 2014).
Coalescing all the hitherto mentioned data and concepts, my SMART goal is: I will work to assess adherence to evidence-based treatments in my facility’s psychiatric unit, by working with the quality department to review the three, most common reasons for admission in 2014, reviewing peer-reviewed articles and resources related to evidence-based treatment in those conditions, and reviewing facility data to determine a compliance rate for evidence guided practice. This is to be accomplished by December 31st, 2014. The first step in any process is assessment. By gathering data and deriving a baseline, this provides a starting point and a means of measurement for improvement in the future. This is a crucial step and, thusly, a great beginning SMART goal.
In order to achieve a goal, one must construct a plan of action. Step one: meet with the quality department, present hitherto mentioned statistics, and make case for intervention by November 24th, 2014. Step two: meet the following day, November 25th, 2014, to research the three, most common reasons for admission to the psychiatric unit. Step three: review peer-reviewed articles and resources related to the evidence-based treatment of those conditions, by November 30th, 2014.
Step four: review facility data related to patient care and whether or not evidence-based treatments were followed in cases involving the three, most-common reasons for psychiatric admission in 2014, by December 15th, 2014. Step five: gather data and determine a compliance rate, or the percentage of cases, involving these three conditions, in which evidence-based treatment guidelines were followed. This should be accomplished by December 31st, 2014. This data can be useful in developing more SMART goals in the future, especially for the following year. This also provides a measurable starting point for evaluating future interventions’ efficacy.
In conclusion, mental healthcare delivery continues to be a complex issue with multiple factors that inhibit effective care. The results of poor mental healthcare can be disastrous, with effects stretching from patient trauma to societal detriment. One way to curb these negative effects is to increase compliance of evidence-based practice in the treatment of these conditions. This is no small task. As such, a SMART goal should focus on the first step: assessment.
This assessment should be further specified, as the spectrum of mental illness is far too broad, into the three, most-common reasons for psychiatric admission. This hones the focus of research on the largest populations seeking treatment at this facility. By utilizing the quality department, there is a guarantee of resources, experience, and expertise necessary to achieve the goal. The derivation of a compliance score provides a baseline for gauging future policy change and intervention. This is the perfect beginning point to formulate future goals and maximize patient care.
Bauer MS. 2002. A review of quantitative studies of adherence to mental health clinical practice guidelines. Harvard Review of Psychiatry 10(3):138–153. Chamberlain College of Nursing (2014) NR447. Change, decision making and goal setting (week 3 lesson). Retrieved from: http://nursingonline.chamberlain.edu Finkelman, A. (2012) Leadership and management for nurses: Core competencies for quality care (2nd ed.). Boston, MA. Pearson Grasso BC, Genest R, Jordan CW, Bates DW. 2003. Use of chart and record reviews to detect medication errors in a state psychiatric hospital. Psychiatric Services 54(5): 677–681. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series . Washington, DC: The National Academies Press, 2006 . McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. 2003. The quality of health care delivered to adults in the United States. New England Journal of Medicine 348(26):2635–2645. SAMHSA (Substance Abuse and Mental Health Services Administration). 2004a. Results from the 2003 National Survey on Drug Use and Health: National Findings. DHHS Publication Number SMA 04-3964. NSDUH Series H-25. Rockville, MD: SAMHSA U.S. House of Representatives. 2004. Incarceration of Youth Who Are Waiting for Community Mental Health Services in the United States. Committee on Government Reform, Minority staff. Special Investigations Division. [Online].
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