Quality Assurance Initiatives in Psychiatric and Psychotherapeutic Care

for Depression

Experiences from the South-German QA project and the German Competence Network on Depression

Martin Härter and Petra Sitta

Stuttgart, 15.03. 2002

Regulations for QI

SGB V § 135a (Abs. 1), 2000

Care providers have an obligation for quality assurance and improvement along standards of evidence based medicine.

SGB V § 135a (Abs. 2)

Health care providers are obligated to participate in external quality assurance measures, especially if improvement of outcome quality is intended.

SGB V § 135a (Abs. 2)

Hospitals and other health institutions should implement and improve internal quality management, that guarantees the quality of care by a system of precise procedures and systematic measures and helps to improve it continuously.

Quality Management Projects in Psychiatry and Psychotherapy

I. Development of Inpatient Documentation Form (BADO)1993

II. Quality Circles in Outpatient Care1995

III. External Quality Assurance (Tracer Diagnoses)a) Depression (Baden-Württemberg)b) Schizophrenia (North Rhine Westphalia)1997

IV. Improvement of Inpatient Quality Management 1998

V. Development of Guidelines (schizophrenia, affective disorders etc.)1999

VI. Competence Networksa) Schizophreniab) Depressionc) Substance abused) Dementia 2000

Quality Assurance in Depression - Background -

„Quality Assurance in Inpatient Treatment

of Depression in Baden-Württemberg“

(Study Period: 1998-2000)

Work Group:Dr. R. Metzger, Bad Schussenried (speaker since 1997) Prof. Dr. R.-D. Stieglitz, Basel (2. speaker, 1994-1999)PD Dr. Dr. M. Härter, Freiburg (2. speaker since 2000)Dr. Ch. Hornstein, WieslochPD Dr. F. Keller, UlmDr. G. Schell, StuttgartDipl.-Psych. S. Stabenow, Karlsruhe (1994-1999)Dipl. Psych. W. Wiegand, ZwiefaltenProf. Dr. M. Wolfersdorf, Bayreuth (speaker, 1994-1996)

Initiator: Prof. Dr. M. Berger, Freiburg Support: Landesärztekammer Stuttgart

Project 3Quality Management in

Treatment of Depression

Subprojects 3.5, 3.6 and 3.7

(Study Period: 2000-2004)

Aims

Improvement of diagnostic and therapeutic quality

Development of process and outcome quality indicators

Internal quality assurance and external comparison of hospitals (bench marking)

Implementation and evaluation of quality manage-ment structures

Transfer into regular care ?

Clinics

South German QA project: n = 24

all psychiatric clinics in Baden-Württemberg

Competence Network Depression: n = 10

5 clinics in North Rhine Westfalia5 clinics in Baden-Würrtemberg and Bavaria

Service Profiling

Process

Outcome

Admission

Discharge

Course of treatment

• Sociodemographic characteristics (e.g. age, sex, marital status, level of

education, job situtation, living conditions, mother tongue)• Diagnostics (ICD-10, indication for inpatient treatment, reason for relapse/ disorder, family history of mental disorder)• Severity of disorder (HAMD, CGI, AMDP, BDI, GAF, attempted suicide, risk to

others) • Chronicity of disorder (duration, number of in- and outpatient treatments)

•Diagnostics (blood tests, ECG, EEG)•Pharmacotherapy (substance, dosage indication, duration etc.) •Psychotherapy (units of individual or group psychotherapy) •Other treatments (e.g. occupational therapy, music therapy) •Incidents (compliance, problems in psychotherapy, threats, attempted suicide)

•Therapeutic effectiveness •Change of psychopatholoy (GAF, AMDP, CGI, HAMD, BDI etc.)•Patient satisfaction (ZUF- 8, BBA)•Duration of inpatient treatment•Changes (job situation, personal situation, living conditions etc.)

Quality indicators / Patient Characteristics

Instrument Abbreviation Rating No. of items

Documentation Form Admission

(incl. CGI, AMDP, GAF)

DOCU-A Expert rating 27

Documentation Form Process

(incl. CGI, AMDP)

DOCU-P Expert rating 10

Documentation Form Discharge

(incl. CGI, AMDP, GAF)

DOCU-D Expert rating 29

Hamilton Depression Scale HAMD Expert rating 21

Beck Depression Inventory BDI Self-rating 21

Evaluation of Treatment Supply BBA Self-rating 22

Client Satisfaction Questionnaire ZUF-8 Self-rating 8

Assessment Tools

ICD-10 Diagnosis ofdepressive disorder

Yes No Exclusion from the study

Admission

Day 1-3

Process(weekly)

DischargeDay X

Patient: BDITherapist in charge: DOCU-A/ HAMD

Therapist in charge: DOCU-P

Patient: BDI, BBA, ZUF-8Therapist in charge: DOCU-D/ HAMD

Change in Diagnosis? Yes

Study design

EX

AM

PL

E

A 3 . G e s c h le c h t: m ä n n lic h w e ib lic h

A 1 . E in w e is u n g s m o d u s : o h n e P s ych ia te r, N e rve n a rz t,

P s ych o th e ra p e u t H a u sa rz t E ig e n e p s ych ia tr isc h e A m b u la n z K lin ik u m S o n s tig e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ u n b e ka n n t / u n k la r

A 2 . A u fn a h m e m o d u s : fre iw illig P s ych . K G / U B G B T G

A 4 . M u tte rs p ra c h e : d e u ts ch a n d e re M u tte rsp ra c h e , g u te

d e u tsc h e S p ra ch ke n n tn is se a n d e re M u tte rsp ra c h e , sc h le c h te

d e u ts ch e S p ra c h k e n n tn iss e sp ra c h lich e V e rs tä n d ig u n g a u s

a n d e re n G rü n d e n u n m ö g lic h , o d e re rsc h w e rt (g e h ö rlo s , a p h o n is ch o .ä .)

u n b e ka n n t / u n k la r

A 5 . A k tu e lle r F a m ilie n s ta n d : le d ig ve rh e ira te t in e h e ä h n lic h e m V e rh ä ltn is g e s ch ie d e n ve rw itw e t g e tre n n t le b e n d u n b e ka n n t / u n k la r

A 9 . W o h n s itu a tio n b e i A u fn a h m e : p riv a t: a lle in e / in n ic h t-th e ra p e u tis ch e r W G p riv a t: in F a m ilie /P a rtn e rs ch a ft (N e u fa m ilie ) p riv a t: b e i E lte rn (H e rku n fts fa m ilie ) in a n d e re r G e m e in sc h a ft (a u c h th e ra p e u tis ch e

W G o d e r p s yc h ia tr isc h e F a m ilie n p fle g e ) p syc h ia tris ch e Ü b e rg a n g s e in rich tu n g ,

p syc h ia tr isc h e s / g e ro n to -p s ych ia tr isc h e sW o h n h e im , A lte rsh e im , a n d e re s W o h n h e im

N o tu n te rk u n ft (z .B . A s y la n te n u n te rku n ft,F ra u e n h a u s , O b d a c h lo s e n h e im ,H o te lu n te rb rin g u n g , p riva te N o tu n te rku n ft),o b d a ch lo s , S ch la fs te lle

u n b e ka n n t / u n k la r

SS uu bb pp rr oo jjee kk tt 33 ..55 // 33 ..66B A S IS D O K U M E N T A T IO N (A u fn a h m e ) S . 1

A 1 0 . B e s te h t e in e g e s e tz lic h e B e treu u n g ? n e in ja u n b e ka n n t / u n k la r

A 1 1 . B e s itz t d e r P a tie n t e in e nS c h w e rb e h in d e rte n a u s w e is ? n e in ja u n b e ka n n t / u n k la r

G e b u rtsd a tu m :

. .1 9

A u sfü lld a tu m :

. .2 0

A 1 6 . H a u p tu rs a c h e n fü r E rs te rk ra n k u n g / R e z id iv : (M e h rfa ch ne n nu n g m ö g lich )

sc h w e re s o m a tisch e E rk ra n k u n g M a jo r L ife E ve n ts (z .B . T o d e in e s A n g e h ö rig e n ,

G e b u rt e in e s K in d e s ) b e la s te n d e F a k to re n im e n g e re n so z ia le n U m fe ld

(z .B . h ig h e xp re ss e d e m o tio n ) u n z u re ich e n d e V o rb e h a n d lu n g (U n te rd o s ie ru n g ,

ke in e p ro b le m s p e z ifis c h e P sych o th e ra p ie ) th e ra p e u tis ch e N o n -C o m p lia n ce u n b e ka n n t / u n k la r

A 1 7 . J a h r d e r e rs tm a lig e n p s yc h ia tr is c h e nA u ffä llig k e it: (Ja h re sa n ga be , gg f. ge sch ä tz t)

Ja h re s a n g a b e 99 99 u n b e ka n n t / u n k la r

A 1 2 . A rt d e s z u r A u fn a h m e fü h re n d e nZ u s ta n d e s : e rs tm a lig e s A u ftre te n e in e r

p syc h ia trisc h e n E rk ra n k u n g F o rtd a u e r e in e s la n g b e s te h e n d e n

Z u s ta n d e s V e rsch le ch te ru n g e in e s ch ro n isc h e n

Z u s ta n d e s W ie d e ra u ftre te n e in e s ä h n lich e n

frü h e re n Z u s ta n d e s d e u tlich e s A b w e ic h e n vo n frü h e re n

Z u s tä n d e n u n b e ka n n t / u n k la r

A 1 5 . In d ik a tio n zu r s ta tio n ä re n A u fn ah m e : (M e h rfa ch ne n nu n g m ö g lich )

E ig e n g e fä h rd u n g F re m d g e fä h rd u n g K rise n in te rv e n tio n g ra v ie re n d e B e e in trä ch tig u n g d e r L e b e n s fü h ru n g u n z u re ich e n d e a m b u la n te D ia g n o s tik - u n d

T h e ra p ie m ö g lich k e ite n ko m p le xe m e d ik a m e n tö se E in s te llu n g , a m b u la n t

n ich t m ö g lic h G e w ich ts ve rlu s t im R a h m e n e in e r p s yc h ia tr isc h e n

E rk ra n k u n g (-1 5 % ) M a n g e l a n fa m iliä re r / so z ia le r U n te rs tü tz u n g . S u b s ta n za b u s u s S o n s tig e s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

A u fn ah m e d a tu m :

. .2 0

lfd . N u m m er:

Baden-WürttembergFreiburg(2001) N= 210 (1999) N= 1718 (2000) N= 1091

Age (years): 49,4(18 - 86 years)

55,7 53,0

Women (%): 63 68 65

German (%): 93 91 90

Living situation: 57 % family36 % alone

69% family27 % alone

66% family30 % alone

Employed (%): 45 36 37

Patient Characteristics

4

6

12

5

48

64

79

32

2

29

0 10 20 30 40 50 60 70 80 90

Others

drug abuse

lack of support

loss of weight

not controllable in outpatient care

insuficient outpatient diagnostics

severe impairment of social functioning

crisis intervention

risk to others

risk to himself

(Multiple choice)

Freiburg (2001), n= 383

Indication for inpatient treatment (%)

3

44

32

42

13

54

28

32

16

47

31

3

15

0

10

20

30

40

50

60

slightly ill moderatelyill

manifestlyill

seriouslyill

extremly ill

Freiburg 2001 (N= 383) BW 1999 (N= 1716) BW 2000 (N= 1254)

Indication correct ?

Severity at Admission - CGI (%)

V 5. T h erap eu tisch e M aß n ah m en : ke ine (M ehrfachan tw ort m ög lich ) G ep lan t B egonnen / läu ft B ee nde t

S ozia lbe ra tung E rgothe rap ie A rbe its the rap ie P hys io therap ie M usik therap ie K unst-/G esta ltungsthe rap ie S port-/B ew egungs the rap ie A lltagsprak t.T ra in ing A rbe itsve rsuch /S ta rth ilfe K ogn itives T ra in ing S onstige :

V 1. G esam tb eu rte ilu n g d er Z u stan d sän d eru n g : N ich t beurte ilba r Zustand is t seh r v ie l besser Zustand is t v ie l besser Zustand is t nur w en ig besser Zustand unverändert - Zustand e tw as sch lech te r - Zustand is t v ie l sc h lech te r - Zustand is t seh r v ie l sch lech te r

V 4. D iag n o stisch e E rg eb n isse: ke ine

Labor unau ffä llig pa tho log ischD rogenscreen ing

unau ffä llig pos itiv

E K G unau ffä llig pa tho log isch

E E G unau ffä llig pa tho log isch

C C T/M R T unau ffä llig pa tho log ischLum balpun ktion

unau ffä llig pa tho log ischLeis tun gsd iagno stik /N europs ycho log ische D iagn .

unau ffä llig au ffä lligP ersön lichke itsd iagn ostik

unau ffä llig au ffä lligS erum sp iegel:________________ the rap . B ere ich zu n ied rig zu hochS onstiges : _____________________

unau ffä llig pa tho log isch

SS uu bb pp rr oo jjee kk tt 33 ..55 // 33 ..66

BB AA SS IISS DD OO KK UU MM EE NN TT AA TT IIOO NN ((WW oo cc hh ee nn --VV ee rr llaa uu ff ))

V 6. P sych o th erap eu tisch esH au p tverfah ren :

K e ine P sycho the rap ie T ie fenpsycho log ische Therap ie K ogn itive V erha ltensthe rap ie G esp rächspsycho therap ie

nach R ogers In te rpersone lle P sychother ap ie D ia lek tisch -behav io ra le

Therap ie nach L in ehan C lin ica l M anagem ent S onstige :

____________________(b itte angeben) unbekannt / unk la r

V 7. An zah l P s ych otherap ies itzu n gen : E inze lterm ine : G rup penterm ine :

V 2. D iag n o sew ech sel? N eue H auptd iagn o se:

ne in ja F ___ ___ . ___ ___

V 3. A M D P - P sych isch er B efu n d - nicht beurte ilb . n ich t vorh . le ich t m itte l schw er

1 . B ew usstseinsstörung en 2 . O rien tieru ngsstörung en 3 . A u fm erksam keits-/G ed .s t. 4 . Form a le D enkstö run gen 5 . B efürch tung en u nd Zw änge 6 . W ahn 7 . S innes täuschun gen 8 . Ich -S töru ngen 9 . S töru ngen der A ffek tiv itä t 10. A n triebs- un d P s ych om ot. S t. 11. C ircad iane B eso n derhe iten 12. S uiz ida litä t 13. Frem dg efährdu ng

G eb urtsdatum :

. .19

W oche

vo n: b is :

A usfü lldatum :

. .20

lfd . N um m er:

EX

AM

PL

E

%

2,4

86

82

85

52

35

24

10

13

5

9

0 20 40 60 80 100

none

ECG

EEG

Lab

AD Level

CCT/NMR

Drug screening

Personality

Neuropsychology

Lumbal puncture

others

Diagnostics (Freiburg 2001, n= 401)

Medication

97 93 97 94

33

51

27

5462 59 55 59

0102030405060708090

100

Freiburg BW Freiburg BW

AD Neuroleptics Others

1999 2000

Psychotherapy

Freiburg 2000N= 145

BW 1999N= 1718

BW 2000N= 1254

Psychoeducative Group 57,2 24,7 28,6Relaxation Therapy 75,2 48,3 45,2Cognitive Behaviour Therapy 48,3 28,1 25,0Interpersonal Therapy 37,9 7,1 5,7Humanistic Therapy (Rogers) 3,4 11,9 12,7Analytic Therapy 0,7 15,3 16,2

NO Psychotherapy 12,9 36,6 36,6

0,3

10

17

41

30

0,4 1 3

18

49

29

0,2 1 3

18

52

25

0

10

20

30

40

50

60

a lot worser worse unchanged little better much better a lot better

Freiburg 2001 n= 377 BW 1999 n= 1711 BW 2000 n= 1249

Problems ?

Clinical Global Impression Discharge (%)

Admission Discharge mean (SD) mean (SD)

Freiburg 24,7 (11,6) 12,1 (11,1)(2001) N = 210

Baden-Württemberg 27,3 (11,2) 11,1 (9,8)(1999) N= 1587

Baden-Württemberg 25,7 (11,4) 10,7 (9,4)(2000) N= 1157

Psychopathology - Beck Depression Inventory

Duration of Inpatient Treatment

Days (mean)

61,4 62,5

69,3

58,8

50

55

60

65

70

75

1999 2000

Freiburg Baden-Württemberg

41,2

6,8

6,6

5,9

5,5

5,3

10,6

0 10 20 30 40 50

Psychotherapy

To feel unterstood

Distance from home

Medication

Talk with nurse

Contact with other patients

Visits from family/friends

Baden-Württemberg: n=473,categories >5%; BBA

The most important for me was .......

Evaluation of treatment by patients

Quality of treatment

48,9 48,9

0,4 0,64,3

66,2

28,8

2,3 5,5

68

26,1

0

10

20

30

40

50

60

70

80

bad less good good excellent

Freiburg n= 131 BW 1999 n=1340 BW 2000 n=948

Client Satisfaction Scale: ZUF-8

Did you get the treatment, you wanted?

48,1 48,1

1,97,4

59,1

31,5

1,36,1

59,1

33,5

3,8

0

10

20

30

40

50

60

70

definite not not to allintents

in generalyes

definite yes

Freiburg n= 131 BW 1999 n= 1317 BW 2000 n= 935

Client Satisfaction Scale: ZUF-8

Summary

structural quality indicators fo inpatient treatment stronger control for indication (inpatient treatment) necessary

process quality comparison of diagnostic procedures (necessity?) long mean duration of inpatient treatment remarkable differences in medication and psychotherapy relevance of psychotherapy for patients

outcome quality high effectiveness for inpatient treatment relevant percentage of „unchanged“ patients (chronic depression) high patient satisfaction

Quality Management Projects in Psychiatry and Psychotherapy

Conclusions:

+ QA in psychiatry is possible+ Attempt to implement QA area-wide / regional+ Participation of all psychiatric hospitals in Baden-Württemberg+ Development of documentation forms+ Development and implementation of the concept of benchmarking

- no project evaluation- representativity of data is limited (selection of patients?)- data only at admission and discharge- low establishment of QM-measures in clinics- clinical relevance ?- transfer in regular care ?

Exp.group:

5 hospitals

Contr.group:

5 hospitals

InterventionBaseline Post -intervention treatment/evaluation

T0 T1

Training; Involvement of QM-structures, areas of

intervention (benchmarking based)

2002

T0 T1

T2

T2

Continuous trainingOngoing

benchmarkings

n=150 pat./hospital

n=150 pat./hospital

n=150 pat./hospital

n=150 pat./hospital

Initial Bench-

markings

No intervention

2003

Step 3 Step 4 Step 5 Step 6

T0 T1 T2

T0 T1 T2

3.5/3.6 Time schedule - Main study

Quality Management Projects in Psychiatry and Psychotherapy

Preliminary Conclusions:

+ planned total-survey in clinics+ reduced and adapted documentation materials+ testing the effect of QM-structures

- motivation of staff, documentation load for physicians- data for clinical decision making ?

Quality Assurance Initiatives in Psychiatric and Psychotherapeutic Care

for Depression

Experiences from the South-German QA project and the German Competence Network on Depression

PD Dr. phil. Dr. med. Martin Härter and Petra Sitta, Dipl. Psych.

Martin_Haerter@psyallg.ukl.uni-freiburg.de

Selected Publications

• Härter, M., Vauth, R., Tausch, B. & Berger, M. (1996). Ziele, Inhalt und Evaluation von Trainingsseminaren für Qualitätszirkelmoderatoren. Zeitschrift für ärztliche Fortbildung und Qualitätssicherung, 90, 394-399.

• Reuter, K., Mager, A., Härter, M., Kern, I. & Berger, M. (1999). Qualitätszirkel in der stationären Versorgung. Ein Pilotprojekt an der Universitätsklinik Freiburg. In M. Härter, M. Groß-Hardt & M. Berger (Hrsg.), Leitfaden Qualitätszirkel in Psychiatrie und Psychotherapie (S. 91-102). Göttingen: Hogrefe.

• Härter, M., Stieglitz, R. & Berger, M. (1999). Qualitätsmanagement in der psychiatrisch-psychotherapeuti-schen Versorgung. In M. Berger (Hrsg.), Psychiatrie und Psychotherapie (S. 1001-1014). München: Urban & Schwarzenberg.

• Klimpel, M., Schüpbach, H., Groß-Hardt, M. & Härter, M. (2000). Implementierung von Qualitätszirkeln im Krankenhaus aus arbeits- und organisationspsychologischer Sicht. Gesundheitsökonomie und Qualitäts-management, 5, 157-162.

• Härter, M., Bermejo, I., Aschenbrenner, A. & Berger, M. (2001). Analyse und Bewertung aktueller Leitlinien zur Diagnostik und Behandlung depressiver Störungen. Fortschritte der Neurologie und Psychiatrie, 69, 390-401.

• Tausch, B. & Härter, M. (2001). Perceived effectiveness of diagnostic and therapeutic guidelines in primary care quality circles. International Journal for Quality in Health Care, 13 (3), 239-246.

• Keller, F., Härter, M., Metzger, R., Wiegand, W. & Schell, G. (2001). Prozess- und Ergebnisqualität in der stationären Behandlung ersterkrankter und chronisch depressiver Patienten. Krankenhauspsychiatrie, 12, S50-S56.

• Härter, M. & Stieglitz, R.-D. (in Druck). Qualitätsmanagement in Psychiatrie und Psychotherapie. In H.J. Freyberger, R.-D. Stieglitz & W. Schneider (Hrsg.), Kompendium der Psychiatrie, Psychotherapie und Psychosomatischen Medizin. Basel: Karger.