New Paper Proposes Framework for Eliminating Defects in Psychiatric Care

CLEVELAND – A new paper from the Department of Psychiatry and the Population Health program at University Hospitals (UH) Cleveland Medical Center, proposes a framework for eliminating defects in behavioral health treatment.

Entitled “Eliminating Defects in Behavioral Health Treatment,” the paper was published online on Nov. 19 in the journal Psychiatric Services and was written by Patrick Runnels, MD, MBA., Heather M. Wobbe, D.O., M.B.A., and Peter J. Pronovost, MD, PhD.

The authors cite that a large majority of defects are the result of system failures rather than due to the individual psychiatrist, and they propose that psychiatrists need to function as “systems engineers” to help eliminate these defects in healthcare organizations.

“The job of building and transforming behavioral health at the system level will require psychiatrists to adopt a new set of skills and a willingness to think differently about their identity as clinicians,” said Dr. Runnels, Chief Medical Officer, Population Health - Behavioral Health at UH and Associate Professor of Psychiatry at Case Western Reserve University School of Medicine.

“Beyond assessment and treatment skills, psychiatrists who act as systems engineers must be experts in quality improvement, implementation science, resonant leadership, and design-based thinking,” he said.

Dr. Pronovost, UH Chief Quality and Clinical Transformation Officer, said that they define “defect” as “anything clinically, operationally, or experientially that a provider would not want to happen, including in diagnosing, initiating treatment, adjusting treatment, nurturing therapeutic alliances at the individual provider and system level, and avoiding preventable service utilization.”

“The ultimate goal is to provide “defect-free care” that we believe will empower clinicians to engage in quality improvement initiatives at whatever level is most accessible to them,” said Dr. Pronovost.

“Despite our best intentions and efforts, defects happen every day in every field of medicine, said Dr. Pronovost, who is also Clinical Professor of Anesthesiology and Critical Care Medicine at CWRU School of Medicine. “Despite clear evidence-based screening tools and criteria for diagnosis, patients are rarely screened appropriately for common behavioral health issues, with barely half of identified individuals having received any care during the prior year and less than 15 percent having received appropriate evidence-based care. Even when prescribed a medication, only 23 percent of patients with depression received evidence-based psychopharmacology and appropriate symptom tracking.”

The authors trace defects back to incentives that are poorly aligned with goals, within and across health care systems, often leading to inefficient, suboptimal behavioral health care delivery. To a large extent, this deficit occurs because clinicians and the systems in which they practice are incentivized almost entirely by volume and throughput rather than by quality and outcomes.

They write: “Traditional payment models, information systems, and treatment paradigms fail to incentivize keeping people healthy, managing chronic conditions, or coordinating care across the continuum of services. This is not an indictment of clinicians, who are clearly motivated to improve the lives of the patients they serve. Nor is it an indication that high-quality work is not happening. Pockets of excellence are all around. A discussion with almost any psychiatrist will yield multiple stories highlighting the positive impact they have had on those they serve, stories that motivate them to continue their work as healers. Yet, despite clinicians’ best efforts, the constraints imposed by misaligned incentives negatively affect system design and lead to widespread defects in care.”

“Our observation and experience are that we providers have become so accustomed to working in low-reliability environments that we accept defects in the system as the norm. Indeed, most defects are invisible or are accepted as the cost of caring for patients with complex issues,” said Dr. Runnels.

In the paper, the authors provide scenarios to illustrate their points. In one such example, they describe a patient with major depressive disorder prescribed a starting dose of 20 mg of fluoxetine and scheduled for a follow-up appointment in four weeks. The patient picked up the medication but did not take the first pill for two weeks, then took two pills and stopped because of side effects. The patient called the office to report the trouble, but no one answered, and the phone call was never returned because no one checked the voicemail (no one had been assigned to check). When the patient arrived in the office four weeks later, the symptoms had not improved, and the patient ended up paying a second copayment of $50 to receive an alternative treatment. The patient described feeling angry with the system for not responding and for necessitating more time and money to receive the alternative treatment. The patient canceled the next appointment and did not return.

“If we instead made sure someone called patients one or two weeks after starting treatment and simply asked whether they had picked up the medication, tried it, and were still taking it, might we prevent this kind of outcome?” the authors ask.

They conclude with the belief that their framework to visualize and systematically eliminate defects in behavioral health care ultimately offers a hopeful approach to improving care—one that can drive large-scale success more effectively than trying to pick away at pieces of the system independently or berating clinicians about performance on individual quality metrics.

“This new narrative, which builds on much of the wisdom accumulated by our field over decades, can succeed only if clinicians see their core responsibility as focusing on eliminating defects and delivering the care that individuals with mental illness and addictions deserve, that clinicians are hungry for, and that payers increasingly demand,” they write.