Quality assurance in mental health-care: a case study from social work

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© 2001 Blackwell Science Ltd

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Abstract

The quality of health and social care is now a high priority for government, professionals, and the public. This is particularly true of mental health, where explicit standards lie at the centre of current policy, demanding the development of reliable means for quality assurance. These need to allow for the multiplicity of stakeholders in mental health-care, and their different constructions of ‘quality’. The challenges presented are illustrated by this account of an action research programme, which was developed to improve social work practice in a multidisciplinary mental health service, and evaluated using a case study design. An action research approach was chosen in preference to an ‘off-the-shelf ’ quality assurance system, because it possessed features that appeared to match the context of the work. It involved feeding back the findings of a baseline assessment of service quality to four teams of social workers, who used the information to select priority areas for improvement. An action plan was developed with them, and its implementation and impact were examined. Substantial improvements were observed in only one of the chosen target areas – the quality of case recording. For the other – securing the clients’ full involvement in their care plan – very limited improvements occurred. Interview data suggested that this was due to the presence of extensive organisational support for the first objective, but not the second. These findings suggest that while some features of action research can contribute to quality improvement, these must be incorporated into a more comprehensive programme of change, which commands the support of all the stakeholders involved.

Keywords:

action research, clinical governance, mental health, quality assurance, social work

Accepted for publication

18 May 2001

Blackwell Science Ltd

Quality assurance in mental health-care: a case study from social work

Christopher Ring

BA BM BCh DipSW Msc

Calderdale and Huddersfield NHS Trust, Huddersfield, UK

Correspondence

C. Ring Research and Development Department 3rd Floor, Staff Residences, Huddersfield Royal Infirmary Lindley Huddersfield HD3 3EA UK E-mail: [email protected]

Introduction

The last two decades have seen an increasing emphasison the performance of health and social services(Henkel 1994). This is attributable partly to central govern-ment’s concern to ensure value for money and containexpenditure, but variations in the range, quality, andcosts of care, and failures to protect vulnerable indi-viduals have also been significant concerns.

Measures to address these and other shortcomingshave been a prominent feature of the last decade. Whilemajor reorganisations of both health and social caretook place during the early 1990s, only recently has the

quality of individual care been systematically con-sidered. In 1998 the present government introducedclinical governance as the principal mechanism for qual-ity assurance in the National Health Service (NHS)(Department of Health 1998a, 1999a). This involves thedevelopment of national service frameworks, whichset standards for areas of clinical practice, and theestablishment of two bodies, the National Institute forClinical Excellence, and the Commission for HealthImprovement, to promote and monitor compliancewith these standards.

Social services departments are already subject to5-yearly joint reviews by the Audit Commission and

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Social Services Inspectorate, and the government hasnow published its strategy to address defects in thequality of social care provision (Department of Health2000). The main concerns include inconsistencies acrossthe country, and at local level, inflexibilities, lack ofresponsiveness, and failures of co-ordination. Thesewill be addressed by a much greater emphasis on train-ing for the social care workforce, and the creation of anew Social Care Institute for Excellence.

In the case of mental health services, not only day-to-day practice, but fundamentals of policy have also beensubject to extensive scrutiny. Current services, under-staffed and grossly over-stretched in urban areas, havebeen criticised from several perspectives, not least byservice users for being insensitive to their needs (Rogers

et al

. 1993). Confidence in mental health services hasbeen undermined by media coverage of homicides bymentally ill people, and ‘care in the community’ is nowat least partly discredited in the eyes of government andthe general public. This has culminated in substantialchanges to mental health policy (Department of Health1998b, 1999b).

However, expert enquiries into acts of violence andself-harm by people with mental health problems havealso cited failures of communication and poor pro-fessional practice as contributory factors (Ritchie andLingham 1992, Appleby 1997). Measures aimed atensuring safe and consistent practice, such as the ‘careprogramme approach’ (Department of Health 1991) havebeen patchily implemented. Failures of mental health-care may therefore be attributable as much to lack ofresources, and failure to attain accepted standards ofpractice, as to weaknesses in policy

per se

.Nevertheless, the new national policy (published as

the

National Service Framework for Mental Health

Depart-ment of Health 1999b) represents a significant change indirection, giving clear priority to safety and comprehen-siveness. Given its explicit statements of service aimsand standards, service quality and its assurance arenow embedded in contemporary mental health policy.

Quality assurance and mental health-care

Discussions of the quality of public services and how tosecure this are hampered by conceptual problems and aconfusing terminology, which is inconsistently used.Here, following James

et al

. (1992), I use the term ‘qual-ity assurance’ to describe: ‘those processes which aim toensure that concern for quality is built into services’.Quality assurance has a long history, originating duringthe 1940s in the manufacturing industry in the USA andJapan (Webb 1991). The experience gained and the tech-niques developed were progressively adopted in othercountries (including Britain), and applied to service

delivery in addition to manufacturing. During the last40 years a range of techniques has been developed,including statistical process control, quality circles, totalquality management (TQM), and the use of model sys-tems such as those developed by the British StandardsInstitute (BSI 1997). However, only in the last decadehave concerted efforts been made to apply qualityassurance to health and social care in the UK.

The experience gained to date has raised two issuesrelevant to mental health-care; one concerns the meansof quality assurance, and the other its ends. Regardingthe first, techniques such as total quality management(TQM) that have been extensively and successfullyapplied in the commercial sector (Morgan & Murgatroyd1994) encounter significant difficulties when appliedto the UK health sector, and must be adapted forthis purpose (Joss & Kogan 1995). These authors pro-posed a model which includes multidisciplinary leader-ship supported by specialist staff, and promotes thedevelopment of local systems with central oversight.

The subsequent introduction of clinical governanceis consistent with this, providing an overall frameworkfor continuous quality improvement, led by the ChiefExecutive and a senior clinician. It does not prescribe indetail how service quality is to be secured. However, itis explicitly restricted to health services, and no refer-ence is made to the analogous procedure of ‘best value’.This is the means by which local authorities are held toaccount for the quality and responsiveness of services,and will continue to be the instrument for improvementin social care provision at local level (Department ofHealth 2000).

The existence of separate systems jeopardises theprocess of setting and maintaining standards requiredto secure the quality of mental health services, asresponsibility for care lies with professionals employed(and often managed) by separate agencies. For instance,support of patients in residential care is often sharedbetween social work and NHS staff, co-ordinated usingdifferent procedures, and their employers are heldaccountable for performance by different mechanisms.

The second issue was identified by James

et al

.(1992), who, in an early review of quality assurancein social services departments, found a tendency toneglect the experience of the service user, in favour ofconsiderations such as ‘value for money’, or compliancewith policy objectives. More recently, Adams (1998)argued that the ‘new managerialism’, represented andreinforced by a regime of inspection and performanceindicators, emphasises accountability to state andemployer, rather than to the end-user.

In the case of mental health services, stakeholdershold differing views about what ‘counts’ for quality.While current government policy gives priority to public


Quality assurance in mental health-care


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safety and patient compliance (Department of Health1998b), available evidence suggests that service users’priorities lie elsewhere. Shepherd

et al.

(1995) comparedthe views of users, relatives, and mental health profes-sionals on which areas of care contributed most topositive outcomes for people with schizophrenia. Thelatter rated practical help (for instance with housingand finances), together with counselling and social sup-port, as having most impact. By contrast, professionals(especially doctors) considered professional support,treatment and monitoring, to be most effective in keep-ing patients well.

Other evidence suggests that service users valuehighly (but often lack) a choice of interventions andinformation about different options (Rogers

et al

. 1993);and the quality of the relationship with the care-giver isalso of central importance for many (Godfrey & Wistow1997). As Rea (1999) has pointed out, there are numer-ous difficulties in specifying and operationalising suchconcepts. Quality assurance may therefore need tosacrifice some precision and objectivity if it is to secureusers’ priorities for mental health-care.

The following account of a small-scale quality assur-ance programme aims to explore the value of a particu-lar approach – action research – possessing featureswhich appear to address these issues. First, it describesthe approach and how it was implemented. Second, itevaluates the approach, using a case-study method.Some implications for quality assurance work in mentalhealth-care are suggested in the conclusion.

A quality assurance programme for mental health social work

The work described was undertaken within the mentalhealth division of a local authority housing and socialservices department providing services to an urbanarea with high levels of deprivation. Mental healthsocial workers were initially deployed in four unidis-

ciplinary teams, reporting to the social services commis-sioning manager, but based with their health servicecolleagues on NHS premises (Figure 1).

Plans were well-advanced to assemble full multi-disciplinary teams, including the social workers, and totransfer management responsibility for them to the localhealth Trust. This took place during the second year ofthe work described here. Preparations were also in handfor an inspection of the social services department in late1998, under the rolling programme of ‘joint reviews’ bythe Audit Commission and Social Services Inspectorate.

The quality assurance programme formed oneaspect of a systematic approach to improving servicequality in local mental health services. An earlier scru-tiny had revealed weaknesses in assessing the needs ofpeople with mental health problems, a failure to involvethem and their relatives in care planning, difficulties inproviding the help needed, and a lack of informationabout services.

As part of a plan to address these weaknesses, thelocal authority employed a quality assurance officer(the author). A number of approaches to qualityimprovement/assurance were explored for this pur-pose. These included QUARTZ, a system specificallydeveloped for mental health services, based on a setof schedules covering different aspects of the service(Clifford

et al

. 1989) and ISO 9002, a model system forquality assurance in service industries, which hadbeen adopted with some success in the local authority’slearning difficulties service. However, as both appearedto require co-operation across disciplines and agencieswhich could not realistically be negotiated, an actionresearch approach was selected in preference to these,for the reasons outlined below.

The term ‘action research’ was developed by thesocial psychologist Kurt Lewin in the 1940s during hiswork on industrial performance. While a concise defini-tion is elusive, action research addresses a problem byenlisting those involved in exploring its nature and

Figure 1 Management arrangements for mental health social workers before and after reorganisation.


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causes, and in developing and implementing solutions.Hart & Bond (1995) describe a number of features whichdistinguish the approach. Of these, four rendered itparticularly promising in the situation described: itinvolves a learning process; it has a clear problem focus;it emphasises involvement and improvement, and itincorporates a change intervention to address the prob-lem(s) identified.

Implementation

This involved four stages (Figure 2). A baseline assess-ment of social work practice was conducted in twoways. First, the views of a 1-in-3 random sample of thesocial workers’ clients were surveyed using a self-completion questionnaire, with a response rate of 48/85(48%). second, an audit was conducted by the authorof 43 case files, using a proforma to ascertain whetherspecific items of information, identified by the SocialServices Inspectorate as standards of good practice forcase recording, were included.

This baseline assessment revealed great variation inthe extent to which clients understood or felt part of theprocess of care planning; many could not identify theirkeyworker correctly; there was a lack of systematicneeds assessment; and the quality of case recording wasvery variable. However, a high proportion of clientsexpressed positive views of the relationship with theirsocial worker. These findings were fed back to the socialwork teams, who were asked to rank the identifiedweaknesses in order of importance. Their prioritieswere to address the quality of case recording, and tosecure greater involvement of clients in planning theircare. Targets and an action plan were developed forthese two areas, and implemented by the four teamsand the author during the following 8 months.

During this period a new case recording policy wasintroduced by the social services department, with asupporting training programme. The author, whodelivered this in the mental health division, used this

training to reinforce the importance of complying withelements of the action plan.

To complete the cycle of quality assurance, and toassist evaluation of the programme itself, a reassess-ment of practice was conducted 1 year after the baselineassessment, using two methods. Forty-four case fileswere audited by the author, including as many as pos-sible of those previously examined: closed files werereplaced by that of a current client of the same socialworker. An adapted version of the earlier proforma wasused. Fifteen social workers (out of a possible 23 whowere approached) were interviewed (again by the author)using a semistructured approach, covering knowledgeof the audit findings, recollection of the action planningprocess, changes in practice in the two priority areas,and influences on practice change.

Evaluation of the programme

Method

The purpose of the study was to evaluate actionresearch as a quality improvement tool, and to accountfor its impact on social work practice. Numerous influ-ences on professional behaviour were present in thiscontext, making it difficult to isolate the impact of theprogramme. A case study design was therefore chosenfor its evaluation (Yin 1994).

The details of this design followed Milne & Kennedy(1993), who examined the impact of performance feed-back upon professional behaviour in a mental healthday service. In this, they used measures of ‘awareness’,‘use’ and ‘consequences’ of the feedback. In the settingdescribed here, evidence was gathered in an analogousway on social workers’ learning, changes in practice,and perceived impact on clients. The design aimed todistinguish the impact of the quality assurance pro-gramme from the other influences likely to affect thesevariables. The evidence was gathered from:

•

the two file audits, which formed an intrinsic part ofthe programme and are described above: these wereused to assess changes in case recording.

•

a survey of social workers and team leaders 4 monthsafter the feedback meetings, to explore recall of thefindings of the client survey and file audit, andrespondents’ views on the importance and feasibilityof quality improvements in the ‘target areas’. Aquestionnaire was issued to 23 practitioners and fourteam leaders and was returned by 15 (56%). Theresponses were analysed by simple frequency counts.

•

the qualitative interviews conducted 8 months afterthe feedback meetings, with the 15 practitioners whoagreed to this (see above). The interviews exploredrecall of the initial evaluation findings, their views of

Baseline/(re-)assessmentof practice

Feedback to socialworkers and prioritysetting

Planning improvements incase recording and client

involvement

Implementationof action plan

Figure 2 The quality assurance cycle.

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the quality assurance process, associated changesin practice, and their explanations of change (or itsabsence). The four team leaders were also interviewed.The interviews were transcribed and coded by theauthor, using a set of codes developed from theinterview topic guide. The development of explana-tions for the changes in practice was based uponMiles & Hubermann (1984). This used an ‘explanatoryeffects matrix’ to represent the pressures for changereported by interviewees, and factors mediating theirimpact (Table 1).

Findings

Evidence of learning by practitioners

The findings of the baseline assessment (the clientsurvey and the first file audit) were poorly recalled bythe social workers, both when they were surveyed after4 months, or when they were interviewed after8 months. Most commonly recalled, by 7/15 (46%) atboth time points, was clients’ misunderstanding of thekeyworker’s identity and role. Weaknesses in needsassessment, and in case recording, were much less fre-quently cited as findings.

Poor recall of findings may be attributable to theinterval between performance feedback and the surveyand interviews, but may also reflect a failure to com-municate the findings effectively through the feedbackmeetings. The literature on performance feedback, andreports at interview, suggest there is considerable scopefor enhancing this process.

Changes in social work practice

The evidence of changes is derived from social workers’reports at interview, and the second file audit. For

case recording

, the target in the action plan was forpersonal details, contact persons, and key events to becompletely, accessibly, and accurately recorded oncase files.

A new ‘basic information sheet’ was introduced torecord both personal details and key events. The secondfile audit showed that 29/44 (66%) of case files includedthis. Twenty-five out of forty-four (57%) had been fullyor partly reorganised to comply with a new case record-ing policy, introduced by the department in preparationfor the forthcoming joint review. While not part ofthe original action plan, this does represent a positivechange towards compliance with an explicit standard.No improvements on ethnic record-keeping wereapparent. A number of other changes were cited bythe social workers at interview, mainly to comply withthe new case-recording policy. Independent evidence,also suggesting significant improvement, is that theSocial Services Inspectorate found that mental healthcase files were the best organised in the depart-ment (Social Services Inspectorate/Audit Commission1999).

On involving clients in the care programmeapproach, practitioners were expected to ‘maximise theextent to which client knows of care plan, understands,and agrees with it, [and to] record evidence of this’.

Only 6/15 (40%) of social workers cited one or morechanges in practice to support this aim: for instance,explaining the process of care planning (the care pro-gramme approach) to the client. However, the secondfile audit provided other evidence that changes incare planning had occurred. Nineteen out of forty-four(43%) showed clients’ comments recorded on the careplan, compared to 9/43 (21%) showing these 1 yearearlier – a significant increase (chi-square (2) = 4.24;

P

< 0.05). There was some evidence of other changes,e.g. a greater proportion of care plans had been

Table 1 Influences on case recording and client involvement in care planning reported* by social workers (n = 15) and their managers (n = 4)

Practice changes Pressures for change Mediating factors

Case recording Files better organised Aspects of the quality assurance programme including case recording training

Pressure of time/competing priorities

Key events more fully documented Influence of the SSD, and the SSI Climate of accountability, e.g. files’ accessibility to clients and other professionals

Lack of administrative and managerial support

Client involvement in care planning

Quality of written care plans significantly improved

Feedback from QA exercise Process and environment of the care planning (CPA) meeting

Only a few examples of changes in other aspects of practice

Apathy, antagonism, or inability of client to take part

* Pressures for change and mediating factors are only included if cited by more than four respondents.


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reviewed within the last 6 months: however, these didnot reach statistical significance.

Perceived impact on clients

A few interviewees believed that the quality assuranceprogramme had made a significant impact on clients,e.g. they might have received a better explanation of thesystem, or felt freer to discuss their needs. However,most social workers doubted that clients’ experiencehad changed. Because of this, a further client survey totest this was not considered justifiable.

Accounting for change – the programme and its context

The most striking finding from this evaluation is thatimprovements had been made in one of the target areasand not the other. While there were changes in theorganisation and content of the majority of case files,there was much less evidence of greater client involve-ment in planning their care.

At interview, 9 months after performance feedbackand action planning, social workers were asked toreport changes in the two areas of practice targeted,about the reasons for any changes, and factors whichhindered or helped practice improvement (team leaderswere asked specifically about the impact of the qualityassurance programme). Their responses were coded asdescribed above.

Table 1 summarises their reports at interview, distin-guishing: (a) changes in practice – both those reportedand those apparent from the file audits; (b) reportedreasons (‘pressures’) for change; and (c) factors mediatingthe impact of these pressures. Only items cited by four ormore informants are included in (b) and (c).

Case recording

Improvements in this area of practice were attributed toseveral factors by social workers and team leaders.These included the quality assurance programme, butfrequent reference was made to pressure from thesocial services department and less immediately, fromthe Social Services Inspectorate. An increased sense ofaccountability, both to colleagues and clients, was alsoreferred to. Training in good case recording practice, adepartmental initiative which was incorporated in thequality assurance programme, was repeatedly cited asan influence.

While several factors were cited as hamperingimprovements, some of these at least were within thepractitioner’s control, e.g. competing priorities andlimited time.

Client involvement in care planning

As noted above, only a few social workers reportedchanges to practice in the direction of greater involve-ment. They attributed these mainly to the quality assur-ance programme. Unlike case recording, there wasno evidence of other pressures for change. Also, twofactors were cited frequently as hampering this: the pro-cedures and environment of CPA meetings, and thereluctance of clients to be involved. These appeared lessamenable than poor case recording to energetic actionby the social worker involved. Weaknesses in this canbe addressed by greater care, or by taking the file home.Enlisting the client in formulating their care plandemands both the willingness of several parties, oftenwith differing priorities, to pursue this goal, and thetime and other resources to do so.

Placing the client at the centre of care planning, andaccurate and thorough case recording, are both coreprinciples in social work training and everyday prac-tice. Case recording improved to a much greater degreethan client involvement during the quality assuranceprogramme, although social workers ranked both ashigh priorities. The evidence suggests two explanationsfor this. First, substantial pressures besides the qualityassurance initiative existed to improve case recording,which was not the case with client involvement.Second, the latter is simply much harder to achievethan good case recording.

Discussion

The introduction argued that quality assurance inmental health-care presents two particular challenges:the complexity of the service system and the differingperspectives of stakeholders about what ‘counts’ forquality. Does the experience recounted here suggesthow these may best be addressed?

The difference in programme impact between thetwo areas chosen for quality improvement suggests thatsupport from the wider organisation is essential forchange. For case recording, the existence of an immin-ent review by the Social Services Inspectorate, andpressure from middle management within the localauthority, encouraged social workers to change theirbehaviour in ways which coincided with that requiredby the quality assurance programme.

By contrast, the failure to make substantial gains ininvolving clients in their care planning also suggests theimportance of wider organisational support. In thisarea, no pressures for change apart from the internalquality assurance programme were perceived by inter-viewees. Attempts by the author (a social servicesemployee) to secure support from senior clinicians and




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managers with responsibility for quality in the partnerhealth Trust, had limited success.

A recent evaluation of FACE, a quality assessmenttool specifically developed for use in mental healthservices, confirms the value of such support in bringingabout improvements in the quality of care (McGilloway

et al

. 1999). Using this in a range of mental healthcaresettings met with varying degrees of success. The crit-ical variables affecting implementation appeared to bemanagement involvement, staff ownership, and theattitude of psychiatrists.

The importance of establishing a culture of qualitythroughout the organisation is also demonstrated byexperience gathered from other areas of health andsocial care. Three years’ experience of joint reviews ledSocial Services Inspectors to the view that, ‘qualityinitiatives restricted to specific services are less likelyto be effective than programmes which address the effect-iveness and culture of the whole organisation’ (SocialServices Inspectorate/Audit Commission 1998, p. 46).Garside (1998) argues that healthcare quality improve-ment requires a ‘vision’ of what is to be accomplished;change must be supported organisation wide, andfocused attention is needed on the implementation ofchange. A recent review of approaches to promote theuse of evidence by healthcare practitioners alsoconcluded that successful strategies for change in thiscontext were likely to be broad based and multifaceted(NHS Centre for Research and Dissemination 1999).

The implication of the present study and other workis therefore that quality assurance needs to be sup-ported throughout the system of care. In the case ofmental health, which requires the co-ordination ofinterventions from several organisations, a commonapproach to quality assurance is therefore needed.Where management arrangements for social care inmental health are transferred to the NHS, quality assur-ance may be subsumed under clinical governance. Thisis likely to emerge in some areas, but is less than idealin view of its tendency to exclude non-clinical interven-tions which clients consider important.

This is one aspect of the second challenge to qualityassurance in mental health: the differing views aboutwhat ‘counts’ for quality. Users tend to rate practicalhelp and the quality of relationships as most important,whereas professionals value treatment and monitoring(Shepherd

et al

. 1995, Godfrey & Wistow 1997). Unless adebate between these and other legitimate stakeholderstakes place, decisions on which aspects of a service willbe subject to quality assurance are likely to be taken byprofessionals and managers.

This quality assurance programme did start toaddress the issue. Action research emphasises theinvolvement of stakeholders in defining problems, and

identifying solutions. The programme involved socialworkers in identifying the areas to be addressed, agree-ing standards of practice, and suggesting means toattain these. While it did not involve service users (ortheir relatives) at this stage of the process, there is thepotential to do so. If this can be realised, then theirviews about areas where quality is paramount can betaken on board. In practice, this might mean that clients’concern to maximise their income is recognised by aquality standard that ensures that all have access towelfare advice and opportunities for paid work if theydesire this.

It is salutary to recall that quality assurance is ameans to better mental health care. Even within circum-scribed areas, gaining agreement on what this means,how it may be secured, and delivering this, emerge asmajor challenges. Limited initiatives such as thatdescribed here, do allow others to learn from theirshortcomings. The experience gathered highlights theimportance of a negotiated and developmental approach,endorsed by all the stakeholders, at all levels of theorganisations concerned. While this may sound uto-pian, it appears to be essential for quality assurance tomake any real difference to the experience of peoplewith mental health problems.

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Quality assurance in mental health-care: a case study from social work