Committed to quality improvement

According to the Mental Health Risk Retention Group (MHRRG), the most common liability claims made against community mental health centers (CMHCs) are related to sexual misconduct, patient violence, suicide, and medication errors. These claims can lead to expensive lawsuits, patient injuries, and damaged reputations.

Many underfunded and understaffed CMHCs, damaged by national budget constraints, don't have the necessary resources or manpower to implement company-wide quality improvement initiatives that can lessen or eliminate these risks. But Lakeside Behavioral Healthcare, based in Orlando, Fla., has created a company culture built upon quality improvement, which has led to their receipt of two Negley Awards in 2009 and 2010.

Lakeside's award-winning initiatives-“Minimizing Medication Errors” and “Preventing Sexual Misconduct in the Workplace”-are just small pieces of a broader quality improvement program, one that is rooted in Lakeside's organizational values and instilled in new staff members the moment they begin their careers at the CMHC.

Creating a system of quality care

When Diana Lee “D.” Jackson, vice president of quality and risk management, began her career at Lakeside in 1989 as the executive assistant to the executive director, Lakeside's 30 individual programs operated independently. These silos developed their own practices, processes, and standards for delivering care.

Jackson took over the quality and risk management department in 1992, just in time to spearhead Lakeside's accreditation process with the Commission on Accreditation of Rehabilitation Facilities (CARF).

“I went through all the offices and procedures for CARF, and I identified that every little program area did its own very unique thing,” Jackson says. “It was very repetitive for programs. They never communicated with each other.”

She recognized that the key to developing a system of care was to unite the different program areas under one company-wide approach, with one way of monitoring “what we did and how we did it.” Jackson created the Performance Improvement Committee (PIC), a strategic, governing body to oversee Lakeside's company-wide quality standards and practices.

With the PIC in place, Jackson established five additional standing committees (see figure). Each would oversee a specific aspect of the company and ensure organizational commitment to Lakeside's six Pillars of Excellence (Environment of Care, Professional Staff, Services to Clients and Families, Corporate Leadership, Resource Development, and Community Awareness) and to Lakeside's foundational values, or “Rocks” (Accountability, Customer Service, Communication, Teamwork). These five tactical committees are:

Consumer and Environmental Safety Committee. Representing the Environment of Care pillar, this committee is made up of representatives “from front-line staff to the vice president,” as well as the risk manager, says Jackson. Infection Control and CLIA/Waived Testing are sub-committees reporting to the Safety Committee.

Clinical and Ethical Practices Committee. This committee, made up of clinical supervisors, directors, and managers, represents the Services to Clients pillar and oversees company-wide practices for providing treatment. The committee evaluates each practice and then develops staff-education projects to improve them. Pharmacy, Training, Peer Review Teams, and the Psychiatric Emergency Interventions (PEI) Review Team are subcommittees reporting to this committee.

Compliance Committee. The Compliance Committee represents the Resource Development pillar, ensuring that contract regulations and rules are followed throughout the organization. Its subcommittees include the Service Event Review Team, the Contract Review Team, and Document Imaging.

Staff Relations Committee. This committee is responsible for maintaining the welfare, morale, and health of Lakeside's employees and holding up the organization's foundational values, or “Rocks.”

Privileging Committee. The Privileging Committee represents the Professional Staff pillar and oversees the privileging and credentialing process for all new, independent practitioners for Lakeside's hospital unit.

All tactical committees and sub-committees meet regularly, usually once a month. They review trends, identify problem areas, and recommend improvement activities, which are then reported back to the PIC monthly.

“One of the things that goes along with the PIC is the performance assessment system, which is a very intricate plan for how we measure outcomes for each of our clinical programs and the processes of each program,” Jackson says. “Each program has established a plan for their area, and they measure those on a monthly basis.”

From those measurements, the PIC creates detailed reports. Then, using data from the reports, the PIC identifies areas for strategic improvement. The result is a company-wide initiative, such as the “Minimizing Medication Errors” program.

All-line staff involvement

Though some committee assignments are position-driven, Lakeside opens up its committees to all staff members on a volunteer basis. With over 600 staff members and 30 program areas, the organization has found that this integrated committee system improves communication, keeps staff informed, and maintains a sense of togetherness.

“Staff are basically educated from orientation on about our performance improvement process and our pillars of excellence,” says Randy Hawkins, LMHC, NCC, director of quality health information services. “We never have to struggle to get people interested because it's an opportunity for them to voice their opinions and be part of the bigger picture.”

Staff are also encouraged to make quality improvement suggestions even if they are not involved in the PIC structure. Whenever a problem or opportunity for improvement is noticed, staff members are able to take these concerns directly to the appropriate committee for consideration. When warranted, ad-hoc, short-term performance improvement teams made up of front-line staff are then formed to assess the process in question and recommend improvements. The appropriate committee then approves the team's findings.

“The front-line staff, especially if they have a concern that really touches what they're doing, love to be on the performance improvement team,” Hawkins says. “They're able to really make a difference in their own work and the organization as a whole.”

The involvement of line staff in its quality improvement programs helped Lakeside's medication management and sexual misconduct programs stand out among the applicants for the Negley Awards, according to MHRRG president Nicholas Bozzo.

“They had a good diversification in both [2009 and 2010] in the level of people in the organization who were involved in making that best practice come to fruition,” he says. “It was not just senior management driving it down, nor was it people at the bottom of the organization trying to convince senior management they had to do it. It was a nice blend of both.”

This kind of ongoing, organization-wide improvement effort forms a solid defense against errors and litigation. Though Lakeside has not had a medication ordering error in three years nor any founded sexual misconduct allegations in the past two years, Jackson knows that it only takes one minor mistake to create a larger problem for any organization.

“You can do everything right and still end up having a problem,” she says. “But when you're defending yourself in litigation, the fact that you've done your due diligence and taken all these actions really does show to those judging the case that you've done everything you could to prevent this.”

Behavioral Healthcare 2010 July-August;30(7):29-30