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Accreditation of acute in-patient mental health services

Published online by Cambridge University Press:  02 January 2018

Paul Lelliott
Affiliation:
Royal College of Psychiatrists' Research and Training Unit, Standon House, 21 Mansell Street, London E1 8AA, email: plelliott@cru.rcpsych.ac.uk
Helen Bennett
Affiliation:
Cardiff and Vale NHS Trust
Maureen McGeorge
Affiliation:
Centre for Quality Improvement, Royal College of Psychiatrists' Research and Training Unit
Trevor Turner
Affiliation:
East London and City Mental Health NHS Trust
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Abstract

Type
Editorial
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © Royal College of Psychiatrists, 2006

The difficulties confronting acute psychiatric wards have been extensively reported over the past 15 years. Recent surveys and reviews undertaken by national bodies suggest that 7 years after the publication of the mental health national service framework in England (Department of Health, 1999) these problems persist (Reference Marshall, Lelliott and HillMarshall et al, 2004; Healthcare Commission, 2005; Mental Health Act Commission, 2005; Sainsbury Centre for Mental Health, 2005). Table 1 is a summary of the issues raised by these reports and by other commentators.

Table 1. Summary of problems facing acute psychiatric wards

The focus has been on community developments
     Jobs in community teams more glamorous and better paid
     Wards seen as recruiting grounds for the community
     Managers’ attention on developing community services
     Under-investment in the physical environment of wards
The role of the acute ward is ill defined
     Dumping ground for people whose community care has broken down
     Very diverse casemix
     Function is an ad hoc mix of care, containment and accommodation
The environment is not therapeutic
     Staff with no time to deliver talking therapies
     Emphasis on pharmacotherapy
     Little input from therapists
     Limited access to day hospitals and no structured day
     Poor physical health care
Wards are dangerous and chaotic
     Violence and absconding everyday occurrences
     Staff always ‘fire-fighting’
     Zero tolerance cannot be enforced
     Substance misuse causes major problems
There is a lack of leadership
     The ward manager with little authority
     Multiple consultants admitting to one ward — none taking a lead
Trust management is obsessed with bureaucracy
     Paperwork taking staff away from patients
     Risk management is filling in questionnaires
There is a staffing crisis
     Problems with recruitment and retention; over-reliance on agency and bank
     Difficulties in releasing staff for training
     Low morale/high sickness rates
Bed management systems cause a problem
     Ward staff with little control over admission decisions
     Preoccupation with finance (preventing out of area placements) rather than quality

Acute in-patient psychiatry as a national priority

There is now a consensus among the agencies responsible for setting standards, overseeing patient safety and regulating healthcare in the UK that something must be done to raise the quality of acute psychiatric wards and to improve their safety - the two issues are strongly associated. The Department of Health has issued policy guidance (Department of Health, 2002a ); the National Institute for Health and Clinical Excellence (NICE) has published clinical guidelines on the management of disturbed behaviour in in-patient mental health settings (NICE, 2005); the National Patient Safety Agency has chosen safer wards for acute psychiatry as its first priority in mental health (Reference Marshall, Lelliott and HillMarshall et al, 2004) and the Healthcare Commission funds the national audit of violence in inpatient settings (Healthcare Commission, 2005) and is starting a national thematic review of the quality of psychiatric in-patient care in 2006. In Scotland, the Mental Health Director has asked the Scottish Division of the Royal College of Psychiatrists to convene a group to make recommendations about the way forward for acute in-patient services. In 2003, the All Wales Senior Nurse group presented its concerns about psychiatric wards to the Welsh assembly, via the Chief Nursing Officer.

Challenge of improving ward quality

The problem for the National Health Service (NHS) is not a lack of policy and guidance but the absence of effective mechanisms for bringing about meaningful service improvement. It has been argued that the sheer volume of guidance, and the accompanying micro-management from the centre through top-down performance management, are themselves barriers to change. This is compounded by the Government's repeated reconfiguration of services, and other NHS and local authority structures (Reference Smith, Walshe and HunterSmith et al, 2001). Long-term planning and sustained investment are difficult; the task for provider services has become to hit this year's target or meet this year's indicator, rather than address local, long-term priorities for service improvement. Inevitably national targets or indicators are often poor proxies for local service quality.

This performance management at a distance is somewhat removed from the principles espoused by the Department of Health for securing service improvement. These emphasise the importance of ‘putting patients and staff absolutely at the heart of the NHS… by giving greater authority and decision making power to patients and frontline staff’ with a Department of Health that ‘adopts a less hands-on approach with clear priorities, fewer targets and less guidance and instruction from the centre’ (Department of Health, 2002b ). These principles apply as much to mental health services as to other sectors of healthcare (Reference Kennedy and GriffithsKennedy & Griffiths, 2003).

Those who attempt to improve acute psychiatric inpatient services tend to seek the solution to the problem by looking elsewhere. There seems to be a prevailing view that if community care is working well and, in particular, if crisis resolution and home treatment teams are in place, the pressure on acute wards will be relieved and the problems will take care of themselves. This has not been the case historically (Reference Fitzpatrick, Thompson and HemingwayFitzpatrick et al, 2003) and is unlikely to be in the future. There is little empirical evidence that the reduction in bed usage reported by studies of intensive community care transfers to the real world. What has happened is that reduction in bed numbers, made by optimistic planners in parallel with or ahead of the introduction of ‘alternatives to admission’, has increased pressure on in-patient services. It has also led to the in-patient case mix becoming increasingly concentrated towards the more severe and is perhaps an example of when taking a systems-based approach to a problem has not worked.

Although in-patient care cannot be considered in isolation from other elements of acute psychiatric care, or from the interfaces with community services that affect admission and discharge, the focus of any quality improvement work has to be the ward itself. Attempts to improve quality have to work within the complex ‘black box’ that is acute in-patient psychiatry and have to look outwards from that perspective at the essential interfaces with other service elements.

There has been movement in this direction. Some wards in some regions have participated in acute care collaboratives. These follow an approach applied in the north of England, which was itself modelled on methods of quality improvement developed by the US Institute of Health Improvement (Reference GriffithsGriffiths, 2002). This approach uses a framework of measurable standards, and works through learning networks, to support front-line staff making incremental improvements in the quality of service. The same principles are applied in the National Audit of Violence which enables staff, service users and visitors to review a ward with the help of a template of standards, to share their findings and to create and implement an action plan for improvement. The last round of the audit included 120 acute psychiatric wards (Healthcare Commission, 2005). The Sainsbury Centre for Mental Health (2006) has also been piloting a practical approach to engage staff, patients and carers in making incremental improvements to acute psychiatric wards.

Why do we need an accreditation system?

An accreditation system is several steps beyond the acute care collaboratives, and formalises the approach to improving wards piloted by the National Audit of Violence and the Sainsbury Centre. The staff in wards that participate adopt a common set of national standards, work to demonstrate adherence to these and have the driver of passing accreditation to catalyse or lever change in the direction of improvement. Such a system could become a permanent feature of the landscape, unlike most national initiatives driven by the Department of Health and regulators, which are time limited. It could create an incentive for provider organisations to undertake a sustained programme of improvements to their wards, and enables sharing of good ideas between staff in different parts of the country. Furthermore, there is the potential to drive ongoing quality improvement by increasing the standards year on year, so raising the bar.

This approach has been successfully applied to clinics that administer electroconvulsive therapy (ECT); within 2 years, about 40% of all ECT clinics in England, Wales, Ireland and Northern Ireland have voluntarily enrolled with the ECT Accreditation Service (ECTAS), and many have reported improvements as a result (Reference Caird, Worrall and LelliottCaird et al, 2004; Reference Cresswell, Fortune and LelliottCresswell et al, 2006).

How does the accreditation service work?

Accreditation of acute in-patient mental health services (AIMS) is modelled on ECTAS. The system is standards based. Standards are graded into those that are essential if accreditation is to be achieved and those that, if met, are indicators of excellence. A period of self-review is followed by a peer-review visit by staff from other participating wards. Service users are involved, both as sources of information about the quality of the ward and as reviewers. Data collection is aided by carefully designed audit tools. The results are compiled into a report for the ward concerned that recommends actions where necessary. This report is the basis of the decision about accreditation status. As is the case with ECTAS, the accreditation decision for some wards is deferred, to give staff an opportunity to take corrective action to meet essential standards. Accreditation is for a set period of 3 years, but is subject to regular self-review and affirmation that the standards have been maintained. It is also expected that wards that are accredited demonstrate engagement in an ongoing process of improvement, working on areas that were highlighted during the review.

A set of principles underpin AIMS and differentiate it from centrally imposed inspection systems.

  1. Local ownership. Wards only participate if front-line staff and local service users agree. The local review process must be owned by front-line staff and must incorporate true peer review.

  2. Engagement. The system engages all relevant groups, including all staff that work on the ward, senior service managers and service users.

  3. Credibility. The accreditation process is transparent and the standards that underpin it are explicit. The steering group for AIMS includes service users, carers and representatives from the professional bodies whose members are most involved in in-patient care (British Psychological Society, College of Occupational Therapists, Royal College of Nursing and Royal College of Psychiatrists). In England, AIMS has working links with, but is independent of, the Healthcare Commission, the National Institute for Mental Health in England and the National Patient Safety Agency. In this way, it is anticipated that participation in AIMS will provide evidence of adherence to the requirements of national regulators. The AIMS standards are also informing national developments in Wales and Scotland.

  4. Responsiveness. Feedback to participating wards is prompt and includes advice and support about how to meet standards. Networking is encouraged through newsletters and an email discussion group.

  5. A focus on development. Although accreditation is only awarded to wards that demonstrate that they meet minimum standards, the purpose of the process is to support and help wards to achieve this.

The accreditation standards cover: physical environment and ward facilities; staffing (including leadership and training); care processes; factors relating to patient and staff safety; ‘the patient day’ and access to therapies; admission and discharge procedures; links with community services; and patient rights and safeguards, including the use of mental health legislation. The standards were developed through a structured process which started with a review of all documents containing recommendations that might be translated into standards (national reports, policy documents and guidance). The results were refined through an iterative process of consultation that involved all groups with a legitimate interest in acute in-patient services. Standards will be revised annually.

Update

To date, 21 wards have volunteered for the development phase. The first edition of the standards has been developed (http://www.rcpsych.ac.uk/crtu/centreforqualityimprovement/aims.aspx), and fieldwork to test the systems of data collection, through both self-review and peer review, was completed in June 2006, when recruitment of the first wave of wards into the accreditation process also started.

Conclusions

Since the quality of healthcare is determined by clinical staff interacting with patients, the healthcare provider organisation should do everything in its power to support and enable these staff to work as well as possible. This is sometimes lost when the agenda is set centrally and then handed down. AIMS is an attempt by the professions, working in partnership with service users, to reassert a leadership role in improving the quality of service. The mechanism by which it does this is to engage directly with the front-line staff responsible for delivering care.

Declaration of interest

AIMS is funded by subscriptions from participating mental health services. The service is managed by the Royal College of Psychiatrists’ Research and Training Unit.

Footnotes

This is the first of a series of papers on acute in-patient services.

References

Caird, H., Worrall, A. & Lelliott, P. (2004) The Electroconvulsive Therapy Accreditation Service (ECTAS). Psychiatric Bulletin, 28, 257259.Google Scholar
Cresswell, J., Fortune, Z. & Lelliott, P. (2006) Electroconvulsive Therapy Accreditation Service: First National Report (October 2003–October 2005). London: Royal College of Psychiatrists' Research and Training Unit.Google Scholar
Department of Health (1999) National Service Framework for Mental Health: Modern Standards and Service Models. London: Department of Health. http://www.dh.gov.uk/assetRoot/04/07/72/09/04077209.pdf Google Scholar
Department of Health (2002a) Mental Health Policy Implementation Guide: Adult Acute Inpatient Care Provision. London: Department of Health. http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4009156&chk=hdBfGn Google Scholar
Fitzpatrick, N. K., Thompson, C. J., Hemingway, T. R. E., et al (2003) Acute mental health admissions in inner London: changes in patient characteristics and clinical admission thresholds between 1988 and 1998. Psychiatric Bulletin, 27, 711.Google Scholar
Griffiths, H. (2002) Acute wards: problems and solutions. Psychiatric Bulletin, 26, 428430.Google Scholar
Kennedy, P. & Griffiths, H. (2003) Mental health ‘collaborative’ challenges care culture. Psychiatric Bulletin, 27, 164166.CrossRefGoogle Scholar
Healthcare Commission (2005) National Audit of Violence (2003–2005). London: Healthcare Commission. http://www.healthcarecommission.org.uk/assetRoot/04/01/74/51/04017451.pdf Google Scholar
Marshall, H., Lelliott, P. & Hill, K. (2004) Safer Wards for Acute Psychiatry: A Review of the Available Evidence. London: National Patient Safety Agency. http://www.npsa.nhs.uk/site/media/documents/1241_SWAP_ResearchReport.pdf Google Scholar
Mental Health ACT Commission (2005) In Place of Fear: 11th Biennial Report 2003–2005. London: TSO (The Stationery Office). http://www.mhac.org.uk/Pages/documents/publications/MHAC%2011%20TEXT%20FA.pdf Google Scholar
National Institute for Health and Clinical Excellence (2005) Violence – the Short-term Management of Disturbed/Violent Behaviour in In-patient Psychiatric Settings and Emergency Departments. London: NICE. http://www.nice.org.uk/page.aspx?o=244477 Google Scholar
Sainsbury Centre for Mental Health (2005) Acute Care 2004: A National Survey of Adult Psychiatric Wards in England. London: Sainsbury Centre for Mental Health.Google Scholar
Sainsbury Centre for Mental Health (2006) The Search for Acute Solutions: Improving the Quality of Care in Acute Psychiatric Wards in England. London: Sainsbury Centre for Mental Health.Google Scholar
Smith, J., Walshe, K. & Hunter, D. J. (2001) The “redisorganisation” of the NHS. BMJ, 323, 12621263.Google Scholar
Figure 0

Table 1. Summary of problems facing acute psychiatric wards

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