Measuring Behavioral Health Outcomes

By David W. Streem, MD

What do you need to implement a world-class outcomes measurement and quality improvement program?

Many providers, especially those in behavioral healthcare, may find the prospect of measuring outcomes intimidating, even frightening. We often pride ourselves on knowing our patients better than do other providers, and we may feel that measuring outcomes is unnecessary because our patients feel so familiar to us. We may think that if our patients are not doing well, we would have a strong sense of this without having to collect and analyze data. We all feel well trained and knowledgeable about the latest techniques.

But unless we have the opportunity to prove to ourselves, our patients and the public that our efforts produce the desired effects, we are working with untested theories and the value of our work cannot be determined.

In the future, demonstrating the value of the healthcare we provide will be an inescapable reality. While published studies for decades have analyzed the financial impact of screening tools and therapies, there now are tools that can assist the individual provider or small group in examining the effects of their efforts. Before any of these tools can be implemented, however, the provider must ensure that some simple traits are in place.

Without the following three principles firmly established in our minds, any quality improvement effort will be threatened as soon as difficulty appears.

Humility

The great organization must be a humble organization. The great professional must be a humble professional. We must always accept that we are not perfect and can do better. When we believe we are already as effective as we can be, innovation and quality improvement stops, because it must not be necessary.

As mental health professionals, we have close relationships with our patients, and those relationships last a long time. Many of these patients are very grateful for the support and guidance we provide. While these expressions of loyalty and gratitude can be satisfying, they also can distort our professional perceptions.

To be as effective as possible for the next patient we meet, we must perceive the effect of our involvement with patients as clearly as we are able, for good or ill. If we are truly humble, we are not concerned that our initial outcome measures may not turn out the way we hope, because we already accept that we are imperfect. Instead of being concerned, we must feel excited that we have found an opportunity to improve.

Curiosity

As behavioral health professionals, we tend to be curious about our patients ‒ their backgrounds, history, and why they chose this particular time to seek help from this particular provider. We should be equally curious about how to measure improvement in our patients reliably or how we might emulate others’ efforts in our field. If we are humble and curious, we want to know if our outcomes are as good as those of our colleagues and, if not, why not. Some variables that affect outcome are controllable; others are not. But often with enough curiosity and creativity, we can find ways to control the controllable aspects of our work.

Courage

If we look at the effectiveness of our own care, we will inevitably learn things that do not comport with our experience or training, or the advice of our mentors. We must then have the courage to change. We must be willing to change how we work and with whom we work.

Success may not come on our first attempt. A number of changes may be required to see the impact we hope for. But we must have the courage to question our beliefs about our work. The future demands it. So do our patients and those others who are paying for our services. And we should demand it as well.

Once these principles are established, often data collection becomes the greatest hurdle to overcome. Creating efficient ways of collecting data (either by patient self-reporting or entered by providers) permits rapid accumulation of information for analysis while posing a minimal burden.

Figure 1. Outcomes from Cleveland Clinic’s Alcohol and Drug Recovery Center (ADRC) partial hospitalization and intensive outpatient programs from July 1, 2013 through December 31, 2013, are compared with national figures across 32 states from the Treatment Episode Data Set (TEDS), most recently reported in 2005.

The Knowledge Program

Cleveland Clinic’s Center for Behavioral Health has worked with the Neurological Institute to develop the Knowledge Program, now part of Cleveland Clinic’s Clinical Systems Office. The intent of the Knowledge Program is to create a system that allows patients and caregivers to enter data for analysis of outcomes and quality improvement, research, and administration. The program permits data entry at the time of appointment, but patients also can access the system from their home computers and other platforms so that feedback can be received when it is more convenient, thereby improving compliance and the reliability of the data collected.

The Knowledge Program interfaces with the larger electronic medical record. The modern electronic medical record is so much more than a means to document encounters. It gives us the opportunity to collect, analyze and report data efficiently. In addition, a sophisticated, customizable electronic medical record system can reduce unnecessary variations in care and aid in teaching trainees and new hires. It can facilitate coding and reimbursement and reduce legal liability.

About the Author

David W. Streem, MD, is Quality Review Officer in the Center for Behavioral Health, attending psychiatrist in the Alcohol and Drug Recovery Center, and Assistant Clinical Professor of Medicine at Cleveland Clinic Lerner College of Medicine.

Suggested Reading

Cosgrove, T (2014). The Cleveland Clinic Way. New York: McGraw Hill.