There are a range of processes, systems and activities that affect the capacity of mental health service providers to implement the identified safety improvement principles.
Governance and leadership
Culture of continuous quality improvement
Consumer focus and value
Carer focus and value
Continuity of care
Information infrastructure for quality improvement
LegislationLegislation provides an important framework in which mental health services are delivered. Critically, it delineates between the voluntary or involuntary status of individuals, which is an important factor in how consumers and their carers experience the mental health system.
Between 1990 and 2000, each State and Territory developed and enacted mental health legislation consistent with the Model Mental Health Legislation and the United Nations' Principles for the protection of people with mental illness and the improvement of mental health care. Along with the Mental Health Statement of Rights and Responsibilities, is legislation that provides for minimum requirements for specific aspects of mental health care. While the precise nature of the safety measures and legislation varies between jurisdictions, the Acts regulate specific requirements in relation to treatment and interventions, such as electric convulsive therapy, seclusion, restraint and psychosurgery. They also include provisions for involuntary inpatient treatment and provisions requiring community-based treatment, such as provisions that can be used to require consumers to take specific medication whilst living in the community.
The National Mental Health Plan 2003-2008 acknowledges the need to review mental health and related legislation to ensure protection of the rights of consumers and the community.
StandardsThe National Standards for Mental Health Services were endorsed by AHMAC National Mental Health Working Group in 1996. Implementation of the National Standards for Mental Health Services involves formal in-depth review of mental health services against the Standards by an external accreditation body.
The Standards are a guide to high-quality service delivery and a key tool for continuous improvement, including safety improvement in mental health services (see appendix 5). Standard 2 specifically relates to the activities and environment of mental health services being safe for consumers, carers, families, staff and the community.
The National Mental Health Working Group also endorsed the National Practice Standards for the Mental Health Workforce in 2002. The Practice Standards were designed to complement the National Standards for Mental Health Services. They outline and address the shared knowledge and skills required when working in a multi-disciplinary mental health environment and supplement each of the professional groups' discipline-specific practice standards or competencies. The Standards apply to the mental health professions of psychiatry, nursing, psychology, social work, and occupational therapy (see appendix 6).
Other national standards, such as evidence-based clinical practice guidelines4, are also important for quality and safety improvement and systems need to be in place to use, review and update existing guidelines.
Top of page
Governance and leadershipGovernance, including clinical governance, is essential to improving quality and safety. Good clinical governance implies that there are well articulated processes for clinical performance and evaluation, clinical risk management, clinical audit, ongoing professional development, and full consumer and carer participation in quality improvement processes. Failure of a system to react appropriately to adverse events often points to inadequacies of leadership and accountability, and in particular to a lack of clarity about reporting processes.
Governance arrangements related to the provision of mental health care are complex. There are a variety of funding arrangements and responsibilities across a range of services and programs provided by State and Territory governments, the Australian Government and private sector organisations. Governing bodies are responsible for improving governance arrangements where these can further improve the safety and quality of mental health care.
Both clinical and managerial leadership is required to bring about change in organisations and to create a culture of quality improvement, including safety improvement. This includes actively supporting a range of quality and safety initiatives. Organisational safety initiatives encompass a range of strategies such as supporting risk management, adverse events and incident management and monitoring systems, workforce development and innovation, complaints mechanisms, information collection and performance monitoring, implementation of national standards, and external evaluation through accreditation and related in-depth reviews.
Culture of continuous quality improvementIntegral to continual quality improvement is the development of a respectful, transparent and just culture within which health care providers and others can report safety incidents without fear of inappropriate blame. The organisational culture needs to encourage and support reflective practice, learning from experience, use and dissemination of knowledge, partnerships with stakeholders and effective leadership in order to enable systematic improvement in service quality. However this can only be implemented once systems for adequately acknowledging and acting promptly on identified problems are instituted in mental health services within a governance framework, where responsibility, commitment and involvement in safe practice and improvement is identified at all levels.
Consumer focus and valueTo improve health outcomes, mental health services need to be responsive to consumers. This includes being sensitive to a range of individual needs, including needs related to age, gender, cultural and linguistic diversity, disability, and other health and dietary needs. Providing consumers with relevant information and opportunities to provide feedback, as well as access to advocacy and complaints mechanisms without fear of any form of retribution are necessary. Systems also must be in place for seeking consumer consent for sharing information with carers and/or family members to enable their participation in care planning.
Positive consumer participation in mental health services can also be assisted through implementing processes that ensure participation in planning, implementation, evaluation and quality improvement. These include individual care planning, and the routine implementation of consumer self-report outcome measures and consumer perceptions of service quality measures 5. Consumers must be provided with appropriate support as needed.
The participation of mental health consumers, as full partners, in their health care is expected in all treatment settings. This is an evidence-based practice and one of critical importance. Identifying and addressing stigmatising attitudes and cultures of control within mental health services that undermine this valuing of consumers is essential to a recovery oriented mental health service.
Top of page
Carer focus and valueMental health services need to be responsive to carers and families of mental health consumers, unless there are clear, specific and documented reasons for not involving them in a consumers care such as the consumer does not consent to their involvement. This includes being sensitive to a range of individual needs, including needs related to age, gender, cultural and linguistic diversity, disability, and other needs. Providing carers with relevant information, opportunities for feedback on progress and enabling their participation in care planning when informed consent is provided by consumers. Systems also must be in place for seeking consumer consent for sharing information with carers and/or family members to enable their participation in care planning.
Positive carer participation in mental health services can also be assisted through implementing processes that ensure participation in planning, implementation, evaluation and quality improvement. These include the routine implementation of carer 'burden of care' measures, carer perceptions of service quality measures 6, and individual care planning where the consumer consents to such participation. Carers must be provided with appropriate support as needed.
Continuity of careContinuity of care is a cornerstone of the National Mental Health Strategy and the National Standards for Mental Health Services and a specific focus of the Australian Health Care Agreements 2003-2008. Safe and quality care for people with mental disorders and mental illness cannot be achieved without effective processes for continuity of care, especially given the episodic nature of mental illness. Continuity of care means continuity between different elements of mental health services (inpatient and community), between mental health services and other acute and primary health care services, including emergency departments, as well as with other service sectors such as drug and alcohol, disability and housing etc. It means not only continuity across the course of illness, but also in recovery and coordination of services across the consumer's lifespan and life circumstances. It requires an integrated specialist mental health system with appropriate inpatient-community and public-private links.
Clear protocols and processes that facilitate continuity of care are very important, including high-quality discharge planning. Improving systems and ensuring continuity of care, particularly within a sector that increasingly focuses on care within the community, is essential for improving the safety and quality of mental health care for consumers.
WorkforceThe knowledge, skills and attitudes of the mental health workforce are crucial to providing safe mental health services. Mental health services need a mix of professions and skills, and to foster a team approach to service provision. The workforce needs to be skilled in quality improvement processes and be able to access appropriate clinical supervision, support and professional development. The workforce needs to be trained in safe work practices, adverse events identification and incident prevention, monitoring and management processes. Such training and work practices need to be supported by management.
The National Practice Standards for the Mental Health Workforce are being implemented to: promote best practice; guide and support clinical supervision and mentoring; structure continuing education and curricula development; assist in recruitment and staff retention; and complement other competency standards.
'Investment in the workforce is essential'. This principle underpins the National Mental Health Plan 2003-2008 and acknowledges that 'the supply, distribution and composition of the mental health workforce are fundamental to quality services'. 7
Top of page
Information infrastructure for quality improvementInformation infrastructure that supports the collection, interpretation and use of relevant information is essential to quality improvement. Recent significant changes to the information infrastructure in public specialised mental health services and private hospital mental health services has led to standardised processes for data collection at assessment, review and discharge. This information is clinically useful as well as providing information on outcomes at the service level. The availability and use of comparable data enables monitoring and evaluation of service performance and outcomes, and provides opportunities for benchmarking.
Service level research and evaluation for quality improvement is also important, and can make effective use of routinely collected information for development and dissemination of evidence-based best practice. Participation in collaborative research and evaluation should be encouraged and should use available information sources for local quality improvement. Health service research and evaluation can support safety improvement, for example, through clinical audits that focus specifically on the priorities identified in this plan and other locally identified safety issues.
4 For example, RANZCP Clinical Practice Guidelines.
5 At a minimum - as based on the work of the Information Strategy Committee and its development and implementation of National Outcomes and Casemix Collection and key performance indicators.
6 At a minimum - as based on the work of the Information Strategy Committee and its development and implementation of National Outcomes and Casemix Collection and key performance indicators.
7 National Mental Health Plan 2003-2008, p 11.