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Benchmarking mental health care in a general hospital

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VOL: 99, ISSUE: 24, PAGE NO: 34

Anthony Harrison, MSc, DipN, RMN, is consultant nurse (liaison psychiatry), Avon and Wiltshire Mental Health Partnership NHS Trust, and Visiting Fellow, the University of the West of England, Bristol

Heather Devey, MSc, BSc, RN, is clinical project manager, Royal United Hospital Bath NHS Trust

Patient care can be improved by using benchmarking (Pantall, 2001). Since the launch of the clinical benchmarking initiative, The Essence of Care (Department of Health, 2001), a number of published examples have shown how this process has addressed qualitative improvements in patient care across a range of health care settings (Barber, 2001; Mason and Brady, 2003).
Patient care can be improved by using benchmarking (Pantall, 2001). Since the launch of the clinical benchmarking initiative, The Essence of Care (Department of Health, 2001), a number of published examples have shown how this process has addressed qualitative improvements in patient care across a range of health care settings (Barber, 2001; Mason and Brady, 2003).

The mental health benchmark (DoH, 2001) provides a framework for establishing and monitoring standards of mental health care. The benchmark enables practitioners, patients and carers to influence and participate in developing best practice that is linked to comparison and sharing. This particular benchmark also provides an opportunity for nurses working in a general hospital to focus on aspects of care that are often overlooked and that are frequently seen as having limited significance outside specialist mental health care settings (Teasdale and Mulraney, 2000).

Taking a joint approach

As part of a joint approach to benchmarking mental health care in the general hospital, two NHS trusts - Avon and Wiltshire Mental Health Partnership NHS Trust and the Royal United Hospital Bath NHS Trust - systematically identified good practice and developed guidance sheets to improve areas of poor practice. These were used as a mental health resource pack for the clinical areas of the general hospital.

In order to use the Essence of Care 'toolkit' effectively, it was necessary to work through the following stages of the benchmarking cycle:

- Establishing a benchmarking comparison group;

- Discussing and exploring the six elements of the mental health care benchmark;

- Identifying best practice;

- Scoring;

- Comparing and sharing scores;

- Developing and implementing action plans for practice improvement;

- Disseminating examples of good practice.

Establishing a benchmarking group

Clinical leads from each trust were identified to coordinate the benchmarking work and a multiprofessional comparison group was established. The overall aim was to improve the experience of mental health care for patients who were admitted to the general hospital.

The group was representative of clinical teams across the hospital and membership included nurses, medical staff, clinical managers, liaison staff for discharge and admissions, patients, and a carer representative. Mental health liaison nurses supported the group by offering specialist advice.

The coordinators felt that it was important to define ground rules for behaviour during meetings and establish boundaries about expectations and processes. The issues identified included having mutual respect, allowing expression of views not necessarily held by others, the importance of regular attendance, and a willingness to identify solutions to practice-based difficulties and not simply to repeat to colleagues problems that were already known about meeting patients' mental health needs.

Exploring the mental health benchmark

The mental health benchmark contains six elements or factors, each focusing on a discrete aspect of mental health care for patients admitted to, or attending, hospital (Table 1). All these factors relate to an aspect of assessment, in particular risk assessment, within the clinical setting. The first factor, orientation to the health environment, provoked much discussion among group members. It was finally decided that the term 'familiarisation' was preferred to 'orientation' because this acknowledged that some patients might not be able to feel fully oriented because of their underlying illness. For example, some patients with dementia might be able to develop an awareness and familiarity with their environment but, because of their condition, staff might not be able fully to orient these patients in the care setting.

After a preliminary discussion, the group decided that focusing on assessment was a key priority, both in terms of initial scoring and developing action plans to improve practice. This view is supported by current literature (Bridges, 2001; Brinn, 2000). After two meetings of the comparison group, key questions and discussion points relating to risk began to emerge (Box 1) and all members agreed that these questions should guide the subsequent scoring process.

Identifying best practice

The comparison group agreed that evidence of systematic risk assessment and patient need was required to demonstrate best practice. This needed to occur within a holistic assessment so that the mental health components were not seen simply as additional 'bolt-ons'.

The benchmarking work has, therefore, been able to inform another trust-wide project that is revising the hospital's standard nursing assessment documentation and care guidance.

Included in the definitions of best practice were: using appropriate risk screening tools; having access to specialist mental health advice and assessment; and identifying referral and care pathways for patients with specific mental health needs. Although the project initially focused on nursing documentation, the benchmarking process provided an opportunity to develop a multiprofessional approach to assessment.

Scoring practice

Using each benchmarking factor as a guide, the practitioners returned to their clinical areas to score current practice. This information was then used to establish baseline scores for risk assessment practice across the hospital. Subsequent re-scoring, using the same process, has highlighted qualitative developments in practice, and specific improvements have been identified in the assessment, planning and delivery of mental health care (Box 2).

Comparing and sharing scores

There was little surprise among the group members at the relatively poor practice that had been identified during the initial scoring phase, and members were frank about the difficulties that meeting mental health needs can present for both the organisation and individual practitioners.

The scores were recorded, and provided a baseline against which to measure future practice. Each representative gave a justification for the score he or she gave to a benchmark statement, and this information was used to inform the generation of ideas for addressing some of the problem areas, as well as to clarify the aspects of mental health care that needed to become the focus for quality improvement.

Care guidance sheets on assessing and planning care

By adopting a facilitation role, the group coordinators helped members to think through ideas for improvements relating to each element of the benchmark. One of the most pressing concerns identified was the need to address the issue of risk assessment for patients with mental health needs admitted to the general hospital. To provide a focus for this work, the group identified five commonly encountered mental health problems experienced by patients in the hospital:

  • Self-harm and suicidal tendencies;
  • Depression;
  • Psychosis;
  • Acute confusion;
  • Alcohol dependence.
As a way of developing a more comprehensive and systematic approach to risk assessment for patients with those common problems, a small subgroup developed a series of assessment and intervention guidance sheets for staff assessing, planning and providing care. These were intended to complement existing care guidance in the hospital and were developed with input from both mental health and non-mental health staff. Each guidance sheet was developed with reference to the relevant literature and in addition provides examples of further in-depth reference material.

The benchmarking process has raised awareness among group members of the importance of addressing mental health needs in the general hospital. As a consequence, the comparison group coordinators have been able to take advantage of the enthusiasm for improving practice. For example, although the development of specific care guidance was partly informed by contemporary literature on good practice relating to specific aspects of care (Harrison, 2001; Kadum, 2001), it was also based on the group members' reflections on practice within their clinical area during the initial scoring phase. This vital feedback has further informed the development of the care guidance.

To ensure that the guidance sheets become a focus for assessing and planning care, they are included as part of a mental health resource pack for each clinical area in the general hospital. The guidance has been issued as a paper, folder-based version and is also available to practitioners electronically via the trust's intranet. Funding from the Foundation of Nursing Studies was used to produce the packs and to develop the materials to a high standard.

Dissemination of results

It is important to disseminate the results and outcomes of a benchmarking exercise so that best practice can be shared and standards can become more equitable across similar clinical settings.

The dissemination strategy adopted by the comparison group highlighted the following issues:

- Networking with other local trusts to share experiences of benchmarking mental health;

- Giving presentations to local quality forums;

- Publishing in both trusts' internal newsletters the work done and the developments arising from it;

- Using educational events to highlight the benchmarking work and the practice-based developments;

- Organising poster displays throughout the trust;

- Undertaking a series of presentations to the trust boards, trust governance groups and professional forums.


The benchmarking process was used to evaluate standards of mental health care within a general hospital. As a result of the exercise, comparison group members were able to pinpoint a number of factors that should make the benchmarking process a success, namely, to:

  • Identify individuals who have an interest in the issue and are, therefore, more likely to see the work through to its conclusion;
  • Involve all levels and grades of staff;
  • Encourage honesty and constructive feedback from comparison group members;
  • Actively involve patients and carers; their input into the identification of problems, clarifying work priorities and developing action plans allows changes in practice to remain patient focused;
  • Support staff throughout the scoring and re-scoring processes while acknowledging that poor practice can be difficult for them;
  • Focus on developing solutions to problems, rather than simply restating long-standing difficulties;
  • Take time to disseminate and publicise the work and improvements that result.
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