The Helping Families in Mental Health Crisis Act (H.R. 2646), which passed the House in early July of this year, purports to address a cause of mass shootings by easing commitment processes for inpatient psychiatric treatment, among other provisions focused on expanding access to care for the most seriously distressed. Framing the need to improve the mental health system as a solution to violence is both stigmatizing and misinformed, as individuals with psychiatric diagnoses are more likely to be the victims of violence than the perpetrators.
Nonetheless, while the motivation is the wrong one, the passage of H.R. 2646 suggests there may be a window of opportunity for mental health policy reform. Such reforms should focus at least as much attention on the quality of inpatient psychiatric care, about which there is little systematic information, as they do on access.
In what follows, we describe the scant data available on the quality of inpatient psychiatric care and propose policy mechanisms that have been adopted in other parts of the health care system to promote improved quality of inpatient psychiatric care, monitor harm, and inform the development of best practices.
Value-Based Purchasing
Outside of inpatient psychiatric care, value-based purchasing has been implemented for acute general hospitals, physicians, and long-term care facilities. These measurement and incentive systems are now well established and cover process and outcomes of care domains, including patient experience as well as cost. But only recently did psychiatric inpatient facilities start to become subject to a similar kind of scrutiny and much work remains.
While the Centers for Medicare and Medicaid Services (CMS) has begun a pay-for-reporting program where hospitals are incentivized to report on a small number of core quality measures for inpatient psychiatric care, they are not yet incentivized to perform on these measures.
Moreover, the indicators lack meaningful assessment of patient experience and outcomes. Indeed, not only do psychiatric institutions lack the ability to track patient diverse outcomes at or after discharge, but also they lack a system to consistently and reliably track adverse events that arise during inpatient treatment. This is a particularly critical gap in light of evidence of injury and death to inpatient psychiatric consumers.
Recent Known Harms Within Inpatient Psychiatric Facilities
The largest supplier of inpatient psychiatric beds in the country, Universal Health Services (UHS), has been under continuous federal investigation regarding abuse, death, and fraud at many of their hospitals across the country. One UHS case was recently heard in the Supreme Court and involved the death of a teenage girl at a Massachusetts psychiatric hospital due to effects of medication that were administered by unsupervised and unlicensed staff.
Such reports are not confined to privately-owned facilities. For example, Tomah Veterans Affairs Medical Center, All-Saints Inpatient Mental Health Unit (a non-profit facility operated by Wheaton Franciscan Healthcare), and Rusk State Hospital have recently been subject to Federal investigations into unsafe clinical environments that resulted in significant patient harm.
Common themes of media reports of harm toward consumers of psychiatric facilities include suicide, lack of attention towards other medical conditions, inappropriate use of restraints, medication toxicity, physical and sexual assault, and lack of coordination at discharge. Youth and older adults have added layers of vulnerability and staff are also at risk for harm due to workplace violence.
Moreover, mainstream media accounts rarely touch on non-physical harm, such as emotional trauma, and are likely a small window into a much larger problem (Table 1). The facilities highlighted in Table 1 underwent local/federal investigation or civil litigation and were compiled to reflect the diversity in patient demographics, facility ownership, as well as the types of harm that have been reported in the media.
Table 1
| Hospital | Location | Summary of Harm |
|---|---|---|
| Arbour Health System, owned by Universal Health Services (see note 2) | National | Salient concerns across dozens of hospitals include medication toxicity, death, understaffing, fraud, lack of documentation, and staff training. |
| Bergen Regional Medical Center | Paramus, NJ | Over hundreds of known incidences of harm. Some accounts highlighted in the news article include a child being sexually assaulted by another child, an older adult with dementia having unexplained physical injuries, a staff worker assaulted by a patient, and a juvenile sexually assaulted by their roommate. |
| Commonwealth Health's First Hospital | Kingston, PA | A juvenile patient was sexually assaulted by another patient. |
| Northeast Florida State Hospital | Jacksonville, FL | The incident of focus concerned patient warehousing and inadequate transitions to housing and community supports. |
| St. Joseph Medical Center | Houston, TX | The specific incident of media attention concerned a patient who walked out of his room naked and was then tased, shot, and handcuffed by security officers. Investigations found issues with cleanliness, staffing, and patient rights. |
| Telecare’s La Casa Mental Health Rehabilitation Center | Long Beach, CA | There was a specific incident involving a patient suicide that made the news. Staff of the facility expressed that there is understaffing, poor training, and that the management is profit-orientated at the expense of safety and quality. |
| Timberlawn Mental Health System | Dallas, TX | Safety concerns included cleanliness, patient violence, suicide, lack of safety checks, and improper documentation. |
| Tomah Veterans Affairs Medical Center | Tomah, WI | A psychiatrist was overprescribing painkillers to patients, resulting in death. |
| Wheaton Franciscan Healthcare-All Saints | St. Racine, WI | Some instances of harm included adolescents being placed in the same unit as known sex offenders, sexual assault between patients, discriminatory admission practices, and management telling staff to falsify safety checks. |
Note 1. We used Google News to search for relevant news articles, using the following key words: inpatient, psychiatric, investigation, death. Out of 2,750 initial articles, 61 articles were included for analysis.
Note 2. There are dozens of UHS hospitals with reported harms. The table includes a sample of these.
While these anecdotes indicate the existence of harm, we know of no way to systematically assess the prevalence of adverse events within inpatient psychiatric facilities. While the states are largely responsible for regulating psychiatric facilities, the scope and intensity of these efforts vary such that data cannot be aggregated on a national level. In its role as a national purchaser, CMS requires hospitals to report deaths directly to regional offices only in cases that suggest involvement of specific restraint and seclusion techniques used during or prior to the death.
Those deaths in which restraint and seclusion techniques were not a contributing factor must merely be documented in an internal hospital log and made available upon CMS inspection. What is needed is not only broader quality performance measurement, but also a national surveillance system that would systematically track these various types of harm to patients and staff and would be made accessible to consumers, workers, regulators, researchers, and health care institutions.
A Policy Window To Improve Monitoring
H.R. 2646 calls for a “Center for Behavioral Health Statistics and Quality,” through which the Director is to establish surveillance systems to monitor key outcomes and conditions, such as the prevalence of psychiatric diagnoses, number of hospitalizations, housing, and criminal justice involvement. There is no explicit language, however, about using this system to monitor evidence-based quality indicators, harm, death, or patient experience associated with treatment in inpatient psychiatric facilities.
Given its existing charge, the proposed new Center would be optimally positioned to track adverse events and patient outcomes associated with inpatient psychiatric treatment episodes. Data collection and reporting are costly for both providers and regulators and adequate provisions must be made to ensure that the system is funded in a manner that does not inadvertently worsen access and quality. State and Federal regulators will also need to create mechanisms for holding psychiatric institutions responsible for the completeness and accuracy of data and ultimately for attaining acceptable levels of performance.
Policy makers and advocates are now waiting for the Senate to pass its version of H.R.2646, The Mental Health Reform Act (S. 1945). We urge policy makers to use this opportunity to make progress towards meaningful value-based purchasing reform by introducing a comprehensive and transparent surveillance system. Such a package of assessment, accountability, and surveillance will help to support regulatory and quality improvement efforts, and lay the foundation for ensuring that consumers have access to safe, high-quality inpatient psychiatric care.
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