Additionally, brainstorming sessions were conducted with physician assistants, nurses, and residents to discuss options to improve the process and elicit a list of barriers.
Data Gathering
Several metrics were tracked to further understand the issue. Overall Press Ganey scores, in addition to admission and discharge subsection scores, were tracked for the 8 months prior to implementing the quality improvement procedures (March 2017-October 2017). Additionally, the treatment team members answered survey questions related to perceived patient understanding at the beginning of training sessions in the 5-week period immediately prior to implementing the quality improvement procedures. This survey was administered using a 6-point Likert scale, ranging from 1 (never) to 6 (frequently), and included the following questions:
- How often do you have to explain: (a) Request for Voluntary Admission form, (b) 72-Hour Rule, (c) Request to Discharge form?
- How often is there confusion about the 72-hour rule and RTD form once admitted to the adult inpatient psychiatric unit?
- How often do you need to re-explain the 72-hour rule and RTD form once admitted to the adult inpatient psychiatric unit?
In-depth interviews were conducted with 4 resident physicians, 4 physician assistants, and 3 nurses to identify specific shortcomings of the admission procedure. A key finding from these interviews was that some patients tended not to understand that the treatment team had 72 hours to respond to the RTD application. Instead, several patients had indicated that they thought that they could immediately discharge themselves since they were on the unit “voluntarily” or that they could categorically discharge themselves after 72 hours of being admitted. This feedback was crucial in determining the next steps that could be taken to minimize confusion.
Process Changes
In preparation for this quality improvement project, the language and layout of the Request for Voluntary Admission form was revised and approved internally by the hospital’s Forms Committee to emphasize the 72-hour rule and the process for completing a RTD form. Additionally, these interviews indicated that it was difficult to track patients who were admitted voluntarily versus involuntarily. To rectify this problem, a field was added to the electronic medical record system to include current psychiatric admission status, allowing the selection to be either “Voluntary” or “Involuntary.” This new field in the electronic medical record system gives nurses the ability to easily update legal status daily as appropriate, which minimizes the risk of information not being effectively communicated at shift changes, while also allowing various members of the treatment team to be updated on the admission status of each patient.
After reviewing data and obtaining staff involvement related to the problem, a new psychiatric admission and consent process was created. The new consent and admission process was characterized by a standardized procedure and scripted language to present to candidates for voluntary admission. The standardized procedure begins with the admitting staff member reading scripted consent language from a pocket card that includes 3 key points describing the voluntary admission procedure (see script in Figure 1). The first key point is to describe the 72-hour rule. Next, the staff member describes the purpose of the RTD form and shows an example to the patient. Finally, the staff member responsible for consenting describes the possibility of the patient being required to remain on the unit involuntarily in the event that he or she wants to leave before the treatment team sees fit and is deemed to be a danger to himself or herself or others.
