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Executive Intervention Needed to Ensure Behavioral Healthcare’s Quality
It is time for an intervention. Our field languishes in a major deficiency: Few clinicians or programs measure their clinical outcomes. This lack of accountability damages the field and requires leadership.
One source of this failure is confusion about the type of evidence needed to ensure the quality of care—clinical trials vs real-world studies. We are stuck discussing academic studies rather than proving our field’s value every day. Solutions are waiting, but an executive-led intervention must get us moving.
Scientific Background
Randomized, controlled trials are the gold standard for academic research. Many people think it is the endpoint for proving the effectiveness of healthcare services. However, this is only one stage of evidence gathering to ensure care quality. Such research alone is insufficient. The final stage, “patient-focused” study uses data from real-world care to decide if this service is working for this patient.
This issue has broad relevance in healthcare, but our field has an especially rich history with it. We struggled for generations to find quick, effective ways to measure the impact of our services. We lack biological measures like other healthcare fields. Many became convinced along the way that our field did not need such measurement, and now that we have it, many will not use it.
When medication is given to a hypertensive patient, repeated measures of blood pressure help determine its effectiveness. This simple model can and should apply to our work. In behavioral healthcare, we now call this model “measurement-based care,” or MBC. While ready for broad implementation, it will take an executive intervention to break through our field’s self-defeating immobilization on MBC.
Historical Opposition to Measurement
Some experts minimize the value of assessing clinical evidence during the course of care. They seek to ensure quality strictly by validating treatments in research trials and then training practitioners to adhere to treatment techniques. Research may have high standards (e.g., controlled trials), but this does not ensure real-world outcomes. They fail to see real-world measurement as the last and highest quality bar.
Misunderstandings about measurement immobilize others who believe our work is either too subjective or complex to define progress and quantify results. Some support the mistaken idea that symptom relief is superficial as compared with the deeper changes produced by the best therapies. Some even insist that measuring results is a travesty brought on our field by those who are hostile to it.
Measurement provides a way to understand how clinicians are performing. Yet accountability is worrisome for some, and so measurement can breed mistrust. It cannot be denied that a small minority of clinicians in every healthcare specialty have subpar results warranting closer review and possibly corrective action. Yet these fears are overblown, and accountability is good for the field.
Accountability is an Executive Function
The chief executive is accountable for a program and its results. This responsibility may require gaining clarity about conceptual arguments like those described above. Clinical content does not cause an issue to be removed from an executive’s accountability. Many organizations have highly technical components, and executives may occasionally need to seek advice before final decision-making.
MBC services are widely available today, so technical capabilities are not a barrier to measurement. We can give clinicians real-time feedback on how clients respond to their interventions and provide reports on outcomes to all stakeholders. As our field integrates more fully into the larger healthcare industry, such reporting will be mandatory, and clinician resistance will be a management issue.
Know Key Findings and Simplify Data-Gathering
Executive interventionists have 2 preparatory tasks to tackle: 1) understanding the major findings about outcomes for psychotherapy--the most prevalent and costly service, and 2) engaging experts to simplify the data-gathering process—a significant source of resistance to MBC.
Three findings about therapy stand out:
- While therapy is remarkably efficacious, the variability in results is driven more by the therapist providing care than the techniques being used.
- No specific approach to therapy (not even widely studied cognitive behavioral therapy) is better than another, based on decades of studies across various types of problems and models of therapy.
- Giving clinicians feedback from ongoing measurement can improve their performance by as much as 25% and help them detect certain risks (e.g., premature termination by clients).
Researchers solved one of the missing links in MBC years ago—developing and analyzing client self-report questionnaires. We can now extract valuable information from brief measures (e.g., PHQ-9, GAD-7) and give clinicians actionable reports. One remaining weakness of MBC is the data-collection process. We ask clinicians and their staff to administer survey forms and transmit data to MBC systems.
Tech experts can help us automate this process. Data collection could rely on cell phones and other devices that use engaging consumer interfaces built with Alexa-type technology. Let us resolve this lingering weakness.
We are at a clinical impasse, and it is time for executives to intervene and move our field toward accountability.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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