A Move to Judge Psychiatric Hospitals

Of all hospital services, psychiatric services may be less likely than most to be thought about in advance. If a family member needed to be hospitalized because of mental illness, would insurance coverage be the only consideration for choosing a facility? Is useful information about inpatient psychiatric care even available?

The usual answer to the first question is yes, at least in part because the answer to the second question is no. That's why the America's Best Hospitals psychiatry rankings rely solely on reputation among board-certified specialists.

A reader E-mailed us after the rankings came out last week. She suggested that when ranking psychiatric hospitals we should consider accreditation by the Joint Commission, the country's major healthcare accrediting organization. Wondering whether I'd missed a good information source, I went to the JC Web page and called up the accreditation quality report on a top psychiatric facility. (All such reports are publicly available at the site.)

What I found was that typical of mental health facilities with outpatient and inpatient care, the center is double accredited, in behavioral healthcare and as a hospital. But the 31 ways in which the facility is assessed are all related to patient safety, not to competence of care—whether there were programs to reduce infections, prevent falls, conduct a "timeout" before starting a procedure, and so on. And the only question with specific relevance to psychiatry is whether patients at risk for suicide were identified.

Safety is important, but it's only part of the picture, as is evident from the scrutiny the Joint Commission gives to community hospitals. I was able to download a 30-page accreditation quality report on MedStar Georgetown University Medical Center, a couple of miles from our offices, and find out how the hospital performed in dozens of life-and-death tasks such as making sure that hospital patients with pneumonia got a flu shot before they were discharged and giving patients having vascular surgery the right kind of antibiotic prior to the operation.

As it happens, the Joint Commission has wanted for a long time to judge psychiatric facilities on more than patient safety, and last month the group released a list of seven core measures that it wants to apply to free-standing psychiatric hospitals and acute-care hospitals with psychiatric units. The seven include hours of physical restraint use, the percentage of patients discharged on two or more antipsychotic medications, and—probably more telling—the percentage of patients discharged on multiple medications with adequate justification.

"We challenged the behavioral health field years ago to tell us what is it that can be measured that are good representative metrics, and it took this long to get there," says Jerod Loeb, the Joint Commission's executive vice president for quality measurement and research. With psych, as with rehab and a number of other specialties, what to measure and how to measure it "is not a matter of consensus," Loeb says.

That's an understatement. Celeste Miltown, who led the project to develop psychiatric hospital inpatient measures, says 150 were proposed, 18 were released for public comment, and those were pared down to the final seven. Unfortunately, she says, the list does not include any indication of whether patients got better or worse.

The seven-measure set will probably be part of the accreditation process by next April, although at least nine months of data must be collected before anything is made public. So the first results probably won't be out until 2010. That's a long time. But it's a start—"small baby steps," says Loeb—and it's long past due.