The fall and rise of TQM at a public mental health hospital.

BACKGROUND: Public mental health care is undergoing a period of fundamental change as it attempts to adapt to an environment characterized by increasing fiscal constraints, the need to demonstrate effectiveness of services, and consumer empowerment. Total quality management (TQM) provides a framework that enables mental health care to meet these demands. The author provides his perspective on a public, multipurpose psychiatric hospital's (Georgia Regional Hospital at Augusta) experience in making the transition from quality assurance to TQM. WITHOUT GOALS YOU CANNOT IMPROVE: Successful implementation of TQM rests on clinical staff's viewing TQM as a useful mechanism for achieving agreed-on patient/customer goals. Staff cannot simply do what they have been doing, but now do it better; there needs to be an understanding of what "better" means. TQM'S INTRODUCTION AND REINTRODUCTION: When first introduced in 1992, TQM was viewed by staff as the latest variant of quality assurance--and was therefore unsuccessful. When reintroduced in 1993, TQM contributed to the development of a psychosocial rehabilitation program. The staff's active involvement in establishing patient-specific goals was critical to the program's success. PERFORMANCE IMPROVEMENT: The hospital's Performance Improvement Committee has spearheaded the monitoring of treatment programs and the development of critical paths. In developing critical paths, the treatment team sets goals for patients' improvement both within the hospital and postdischarge and for treatment processes. SUMMARY AND CONCLUSIONS: The keys to a successful TQM program are effective leadership, a clear organizational mission, customer-oriented performance goals, staff empowerment, and the application of the scientific method to the workings of the organization.

The reported prevalence of physical and sexual abuse among a sample of children and adolescents at a public psychiatric hospital.

In this retrospective analysis of inpatient charts, a total of 298 children and adolescents admitted to a public psychiatric hospital over a 1-year period were examined for the prevalence of reported histories of physical or sexual abuse. Physical abuse was reported in 15% of the cases, while sexual abuse occurred in 13%. A variety of comparisons were made examining possible differences in gender, age, race, diagnosis, and personality trait disturbance among the abused and nonabused patients. Relative to known prevalence rates as reported to child protective agencies, physical or sexual abuse occurred much more frequently among our sample of patients, suggesting the need for careful assessment of such histories upon admission and during treatment.

Continuous quality improvement: conceptual foundations and application to mental health care.

Continuous quality improvement (CQI), a philosophy and a set of techniques for managing the quality of services in health care, involves procedures for defining an organization's goals and work processes and applying quantitative measures of quality focused on patient outcome. To successfully adapt CQI to specific mental health care settings, staff must understand the attitude, approach, and processes that distinguish CQI and must address the challenges of defining quality within mental health care and coordinating the efforts of multidisciplinary treatment teams. After detailing the development of the conceptual underpinnings of CQI, the author uses an example of implementation of CQI on a unit for chronic mentally ill patients at a state psychiatric hospital to show how these challenges can be addressed by reconceptualizing and specifying the treatment mission.

Self-harming behavior in incarcerated male delinquent adolescents.

This report describes self-harming behavior in males in a juvenile incarceration center. Three groups of adolescents were examined: self-harmers, those referred for a psychiatric examination, and the incarcerated general population. Compared to the general population, the youth in the two mental health groups were younger, had greater family needs, had more educational problems, were more likely to have escaped from a previous placement, and committed more rule violations. The self-harming group, when compared with the psychiatrically referred group, had a greater number of prior offenses, were more disruptive in school, performed worse on a problem-solving task, and committed more rule violations. Issues of psychopathology and treatment are discussed.

End stage renal disease and the marital dyad: an empirical investigation.

The psychological well-being of end stage renal disease (ESRD) patients and spouses was investigated from a dyadic perspective. The responses of patients and spouses from five groups of couples--illustrating different points in the progression and treatment of ESRD--were compared both across ESRD groups and between patients and spouses. Despite the fact that the ESRD groups reflected differences in illness/treatment intrusiveness, no significant differences were found between the ESRD groups, or between patients and spouses, in either marital relations or psychological well-being. However, while for all the participants marital role strain was a significant predictor of psychological well-being, the two dialysis groups evidenced significantly greater correlations between marital role strain and psychological distress than the nondialysis groups. These findings are interpreted as being consistent with a general systems theory approach to the conceptualization and treatment of chronic illness.

End stage renal disease (ESRD) and the marital dyad. a literature review and critique.

As medical advances have increased the expected longevity of ESRD patients, the familial elements of adjustment to this illness and its treatment regimen have become particularly important. Over the past dozen years, a body of literature has accumulated on the psychosocial adjustment of ESRD patients and their partners. In general, it has shown that each spouse's individual adjustment may be strongly influenced by the other's reactions to the illness. However, a good integration of an interpersonal framework has been lacking in most of these studies. This article reviews the area and offers methodological and theoretical suggestions for future investigations.