As formerly practiced on the behavioral health unit described in this report, patients offered voluntary admission status to the inpatient behavioral unit often lacked complete understanding of the 72-hour rule and the process for requesting early discharge from the facility. We hypothesized that this led to the observed patient frustration and hostility, lack of trust in the treatment team, poor attendance and participation in group therapy activities, medication refusal, and overall decreased patient satisfaction. To address this issue, this pilot project was conducted to improve the voluntary admission process on the adult inpatient unit of a major academic medical center in North Carolina.
In April 2008, The Joint Commission’s Center for Transforming Healthcare embarked on an enterprise-wide initiative called Robust Process Improvement (RPI). RPI was developed as a blended approach in applying Six Sigma, Lean, and Change Management techniques to improve medical processes and procedures. RPI techniques were applied in this study to better define the problems related to inpatient behavioral health unit admission and discharge by collecting data, obtaining staff involvement, creating a solution, and monitoring for lasting benefit.
Methods
This quality improvement project took place at an 885-bed tertiary care academic medical center with Level 1 Trauma Center designation. Institutional Review Board approval was not required because this was performed as a quality improvement project rather than an experimental clinical trial and was not designed to create new generalizable knowledge.
The techniques used to improve outcomes on the inpatient behavioral health unit included Active Listening, Elevator Speech, Statistics, Cause and Effect Diagrams, development of a Communication Plan, Brainstorming, and Standard Work. Through interviews with physician assistants, nurses, and resident physicians conducted over a 1-month period, it became clear that there was confusion among patients surrounding the voluntary admission process, the process for requesting discharge, and the possibility of a voluntary admission being converted to an involuntary one. Active listening was used to better understand the opportunities for improvement from multiple perspectives through varying stages of the admission—from the consent process in the emergency department, admission to the unit, throughout the hospital stay, to the time of discharge. The following elevator speech was used to highlight the areas of confusion and the importance of implementing change with the team involved in implementing the new admission procedures:
Our project is about improving patient understanding of the voluntary admission process to the Adult Psychiatry Unit and the 72-hour rule. This is important because the present process leads to patient misunderstanding, discontent on the unit, resistance to provided therapies, and low Press Ganey satisfaction scores. Success will look like reduced patient confusion about the 72-hour rule, increased group participation, decreased patient-staff conflict, and improved Press Ganey scores. What we are asking from you is to use a standardized, scripted informed consent process, flow chart, and pocket card during the voluntary admission process.