Quality improvement initiatives of mental health services in Japan

Hiroto Ito, Ph.D.Department of Social Psychiatry

National Institute of Mental HealthNational Center of Neurology and Psychiatry

Japan, a leader of high quality products

High quality productsKaoru Ishikawa (1915‐1989), Fishborn diagramTaichi Ono (1912‐1990), TOYOTAAkio Morita (1921‐1999), Sony

1986: Imai M. “KAIZEN”1989: Berwick DM. N Engl J Med 320: 53‐6.2004: Liker J. “THE TOYOTA WAY”

“Quality” is a new conceptin Japanese healthcare organization*

1980’s: Self‐check manuals for hospitals

1987: A committee of Tokyo JCAHO (Joint Commission on 

Accreditation of Healthcare Organizations) 

1990: Japan Society for Quality in Health Care (JSQua)

1995: Japan Council for Quality Health Care (JCQHC)

1997: JCQHC start formal accreditation activities

*Ito H, et al. Int J Qual Health Care 10:361‐363, 1998.

Examples of Quality Improvement Initiatives

• Japan Council for Quality Health Care (JCQHC), 1997

• JCI Accreditation (2009‐)

• Clinical Indicators by National Hospital Organization (2010‐)

Challenges

• Bench‐marking systems in mental health field–“multi‐centre” quality improvement programs–especially for the process of care and outcomes

• Clarifying process of care–Using management techniques in Japan

Outline of my talk

1. “Mental Health Care KAIZEN projects”• Suicide prevention program in psychiatric inpatient care• Infection control initiative in psychiatric hospitals• Feedback system of quality of mental health care

2. Process‐visualization project in psychiatric services

3. Conclusions

Nation‐Wide Suicide Prevention Project in Stress‐Care Units

Shiranui Hospital(Fukuoka, 1989)

Nishi Hachioji Hospital(Tokyo, 1998)

*Soutce: Tokunaga Y (personal communication)

Matsubara Hospital(Fukui, 1997)

Kusatsu Hospital(Hiroshima, 2000)

Welfare Kyushu Hospital(Kagoshima, 1996)

Kansai Kinen Hospital(Osaka, 2003)

Kaya Hospital(Fukuoka, 2001)

Asaka Hospital(Fukushima, 2002 & 2008)

Iwaki Hospital(Kagawa, 1988)

Sawa Memorial Hamamatsu Hospital(Shizuoka, 2002)

Jindai Hospital(Aichi, 2002)

Toda Hospital(Saitama, 1986)

Nishiwaki Hospital(Nagasaki, 2001)

Narimasu Kosei Hospital(Tokyo, 2008)

Yonan Hospital(Gifu, 2006)

Hannan Hospital(Osaka, 1997)

Shinoda‐no‐mori Hospital(Chiba, 2007)

Uji‐Obaku Hospital(Kyoto, 2001 & 2008)

Goryokai Hospital(Hokkaido, 2004)

Iougaoka Hospital(Ishikawa prefecture)

Yahata Kosei Hospital(Fukuoka)

Hijiyama Hospital(Hiroshima, 2011)

Nosocomial Infection in Patients with Mental Disorders

1. Vulnerability to nosocomial infection– Poor self‐care– Closed environment– Older age

2. Potential transmitter of nosocomial infection– Delayed diagnosis– Uncooperative attitudes

Hayato Yamauchi, MD. (Saiki Hoyoin Hospital)

45 members from 36 hospitals

Infection Control Initiative by theInfection Control Association for Psychiatry (ICAP)* 

• Various training programs on Infection Control– Tuberculosis and scabies**– Appropriate use of antibiotics– Controlling the spread of infections

• Outcomes– Improved prevention of nosocomial infection – More infection control rounds

*Professor Noriaki Nukanobu (Hiroshima International University), et al. IHI, 2016**Others include HBV, HCV, HIV (acute patients) , influenza, norovirus, and O157 (long‐term care patients)

Feedback system of quality of mental health care: Concept

Diagnosis, Functioning level (eg. GAF), etc.

Seclusion/Restraint, etc.

Your hospital

Average

Controlledrange

Your hospital Average*Feedback using eCODO system (seclusion/restraint and other quality

indicators) NCNP: National Center of Neurology and Psychiatry

Every 3 months Time

Benchmark(international)

Data inpu

t at h

ospital

Second

ary an

alysis of “an

onym

ized

” da

ta

Feed

back to

 hospital

Goa

l settin

g at hospital

percen

tage

A ten-year activity using electronic Coercive measures Database for Optimization (eCODO)

2006

2007

2008

2009

2010

2011

2012（3 hospitals）

2013（6 hospitals）

2014（6 hospitals）

2015

Multi-center peer review(February)

Regional exchange in Osaka(November)

Training program(June)

International exchange(Finland)

Start of the project

eCODO edge server (ver.1)

eCODO edge server (ver .2.0)

NCNP introduced eCODO system (October)

eCODO edge server (ver .2.1)

eCODO edge server (ver .3.1)

Psychiatric Electronic Clinical Observation(PECO)

Outline of my talk

1. “Mental Health Care KAIZEN projects”• Suicide prevention program in psychiatric inpatient care• Infection control initiative in psychiatric hospitals• Feedback system of quality of mental health care

2. Process‐visualization project in psychiatric services

3. Conclusions

Tools for Standardization‐ Clinical Pathway for inpatient ‐

Phase 1 Phase 2 Phase 3

Outcome

Pharmacological intervention

Psycho-social intervention

Preparation for discharge

…

“Chain model” clinical pathway

Overview pathway

Clinical Pathwayfor early stage after discharge

Clinical Pathway for

maintenance stage

Clinical Pathway for inpatient

Phase1 Phase2 Phase3

“comorbidity” concept

Index condition

Comorbidity

Comorbidity ComorbidityDepression Dementia

Comorbidity Comorbidity

Hip fracture…Ex. complications

(nephropathy, neuropathy, retinopathy)

Cancer, Stroke,Acute myocardial infarction,or Diabetes

Multimorbidity in ageing societyCombinations of 3 diseases*

Diabetes (774,100: 56.9%)

Hypertension(1,090,200人: 80.1%)

Hyperlipidemia（838,200人: 61.6%）

30,200 (2.2%)

391,600(28.8%) 139,900

(10.3%)

212,400(15.6%)

457,300(33.6%)

101,400(7.4%)

[Total] 1,361,400

28,600(2.1%)

*Japan Patient Survey (2008)Tsushita K, et al. 2014 (in Japanese)

1 disease:   11.7%2 diseases: 78.0% 3 diseases: 10.3%

“Clinical care is often fragmented, involving both primary care and multiple secondary care specialists who may not be communicating effectively” with each other, and “there is a clear need for integrated care of multiple conditions”  [1, 2‐5].

1. Smith SM, et al. BMJ 345: e5205, 2012.     2. Stange KC. Ann FamMed 10: 2‐3, 20123. Bayliss EA. Simplifying care for complex patients. Ann FamMed 10: 3‐5, 2012.4. Kamerow D. BMJ 344: e1487, 2012.   5. Smith SM, et al. Br J Gen Pract 60: 285‐294, 2010.

“Web model” needed for integrated care*

Low

High

High Low

Chain model

Hub model

Web model

Level of predictability

Ex. internal medicine, rehabilitation, psychiatry, palliative care processesCase manager coordinates sub‐processes

Ex. chemotherapy processesGantt charts

Ex. multimorbidityChange from ‘time’–task matrix 

into a ‘goal’–task matrix

*Modified figure by Kris Vanhaecht, et al. Int J Care Pathways 14: 117–123, 2010.

Level of agreemen

t

Index condition

Web model: Personalized Notebook for patients with multimorbidity*

・・・

PersonalizedNotebook

using

Initially registered as

<Dementia><Depression><Diabetes><Heart disease><Schizophrenia><Stroke><…>

Hypertension

DepressionDiabetes

Cancer

Heart disease

Schizophrenia

Stroke

Dementia*Developed in collaboration with<Six national centers>NCC: National Cancer Center NCCV: National Cerebral and Cardiovascular CenterNCNP: National Center of Neurology and Psychiatry NCGM: National Center for Global Health and MedicineNCCHD: National Center for Child Health and Development NCGG: National Center for Geriatrics and GerontologySource: Ito H, et al. Shakai Hoken Jyunpo 2531: 10‐14, 2013 (in Japanese).

+Life style monitoring+Advance directives

Depression and other chronic diseases (meta‐analysis)*

Unh

ealth

y lifestyle

Dementia

Vascular

Alzheimer type

Diabetes Depression

StrokeLacunar infarction

Atrial fibrillation

Hypertension1.59 [1.29‐1.95] 2)

2.52 7)

1.657)

1.39 [1.17‐1.66] 1)

2.38 [1.79‐3.18]1)

10% (recurrent: 1/3) 8)

10%8)

*Meta analysis/systematic review.1)Lu FP, et al. 2009 2)Sharp SI, et al. 2011  3)dChang‐Quan H, et al., 2011  4)McGuinness B et al., 2009  5)Power MC, et al. 2011  6)Kalantarian S, et al., 2013  7)Diniz BS, et al. 2013  8)Pendlebury et al., 2009  9)Makin SD, et al., 2013 10) Mezuk B et al., 2008 11)Pan A et al., 2012   12)Nouwen A, et al., 2010   13) Rotella F, et al., 2013   14)Ayerbe L, et al., 2013   15)Dong JY, et al., 2012  16) Nicholson A, et al., 2006     17) Van der Kooy K, et al., 2007      18) Peters SA et al.,  2014   19)Peters SA, et al., 2014   20)Petgen T, et al., 2012

20 [9‐33] %9)

1.38[1.22‐1.56] 6)

Not significant5)

1.4～1.610‐11)

1.15 (2008)10)1.24 (2010)12)1.29 (2013)13)

1.29 [1.25‐1.32]14)1.34[1.17‐1.54]15] 

Myocardial infarction

1.81  [1.53‐2.15]16)1.60 [1.34‐1.92]17)

Coronary artery18)F: 2.82 [2.35‐3.38]M: 2.16 [1.82‐2.56]

F: 2.28 [1.93‐2.69]M: 1.83 [1.60‐2.08]19)

Adherence/ exercise / diet/ alcohol consumption/ sleep/ other lifestyles

Decline of renal function

CKD guide2012

1.39 [1.15‐1.68]20)

Death

Fishbone (or Ishikawa*) diagram

Polypharmacyof

Antipsychotics

PatientNursePhysician

MethodSystem

Insufficient timeto assess patients

Insufficient physician

Insufficient supervision

ReluctantTo change

Reluctantto changemedications

Chronicdisease

Fear of relapse

Attitudes not to follow guidelines

Ito H, Koyama A, Higuchi T. Br J Psychiatry 2005.Goh YL, Seng KH, Su A,  et al. Permanente Journal 15: 52‐56, 2011.

Rotation of physicians

Fee‐for‐service

Limited incentives

Limited alternatives

No practical guideline how to decrease numberof antipsychotics

*Kaoru Ishikawa, PhD. (1915 ‐ 1989)

Professor, Faculty of Engineering The University of Tokyo

Quality Management Innovations

Unit transition of 10 inpatients*

A: Main routI: Sub rout(seclusion/restraint)

Case [1]：Unit A1→A2→I2→A2→A5[2]：A1→A2→I1→A2→I1→I4→A2→A4→A5[3]：A1→I2→I3→I2→I3→I4→I3→I4→A2→A5[4]：A1→I3→I4→I3→I2→I4→A2→A5[5]：A1→I2→I3→I4→A2→I2→I4→A2→A5[6]：A1→I2→I3→I4→I3→I4→A2→A4→A5[7]：A1→I2→I1→I2→I4→A2→A3→A5[8]：A1→I2→I1→I2→I3→I4→A2→A5[9]：A1→I3→I4→I3→I4→A2→A3→A4→A5[10]：A1→I2→I3→I4→I3→I4→A2→A4→A5

*Satoko Tsuru (University of Tokyo)

Conclusions

• Quality issues: multi‐dimensional

• Quality improvement stages

1. In‐hospital quality improvement

2. Multi‐centre activities

3. International platform