Quality improvement in health care organizations: a general systems perspective.

A systems analysis of healthcare organizations demonstrates that methods for improving quality involve the effective feedback regulation of key organizational performance parameters. Information flow is impaired in dysfunctional healthcare organizations, which often disregard significant clinical problems while preferentially tracking nonclinical indicators and clinical data considered most likely to meet the organization's standards. Such organizations thus achieve "pseudocompliance" with external requirements, but do not systematically work to improve the quality of clinical care or their performance as organizations. Efforts by government agencies and national organizations to foster quality improvement activities have had limited success precisely because local organizations perceive these efforts as externally imposed. Leaders' anxieties about their own and their organizations' autonomy, control, and performance can cause unwillingness to review data indicating performance problems, oversimplification of decision criteria, and reluctance to formulate meaningful conclusions and act on them. Contemporary quality improvement models, such as Continuous Quality Improvement (CQI) and Total Quality Management (TQM), reconnect leaders to their organizations' quality processes by emphasizing the leaders' roles in promoting quality as an organizational value, setting meaningful quality goals, and actively u sing information to improve organizational effectiveness.

Mental health treatment teams and leadership: a systems model.

Mental health treatment teams are living systems at the group level and comprise key productive subsystems of organizations providing mental health care. Effective treatment teams, like effective organizations, are anticipatory systems that contain subsystems that model and predict future system and environmental conditions and enable responses that increase system viability. A systems analysis of treatment teams highlights their potential instability due to their tendencies to regress toward dysfunctional partial systems and their active maintenance in nonequilibrium steady states with their organizational and external environments. Team subsystems are analyzed from the viewpoints of system processes and also with regard to individuals and their roles. Boundary processes are central to effective team functioning, assure constancy of team membership, and regulate the team's interfaces with its parent agency and with the external environment. Various causes and forms of disturbed information processing within hierarchical organizations are examined, and their effects at the treatment team level are discussed. The conclusion of the discussion focuses on team leadership and how leadership expands upon the concept of the decider subsystem to include role and personal factors to the team's leaders, and functions that are anticipatory and integrative in nature. Effective leaders must set appropriate thresholds for feedback regulation processes, and balance several pairs of seemingly opposing forces, including homeostasis and development, role differentiation and role overlap, and personal accountability and empowerment of others.

The vulnerability-stress model of schizophrenia: advances in psychosocial treatment.

Vulnerability models of schizophrenia are reviewed, along with psychosocial rehabilitation methods addressing functional abilities and social competence. Their relationship is discussed with a view to developing a framework in which biological and psychosocial approaches to schizophrenia can be integrated for purposes of effective clinical intervention. Such intervention is designed to improve social competence, cognitive appraisal, and coping skills for mediation of stress in vulnerable individuals.

Ethical issues for academic participants in state-university collaboration programs.

State-university collaboration programs often create ethical dilemmas for participants because of their conflicting values, goals, and expectations. Treatment and administrative staff in state agencies often seek to create an atmosphere of managed stability rather than fostering patients' autonomy. Academic participants in collaboration programs often feel impelled to change the system, even though the goal of collaboration requires them to find common ground with state agency staff. Academic participants must decide whether collaboration programs will contribute to needed reforms without overly compromising professional and academic standards. If they cannot endorse the values and quality of care provided in state systems, they must consider whether their participation should be conditioned on an agreement to work toward change. However, even in situations that are improving, clinicians must not let temporary compromises become permanent.

The mental health treatment team as a work group: team dynamics and the role of the leader.

Although treatment teams have been examined often in the mental health literature, this literature seldom addresses the crucial property of "teamness"--the key set of intangible phenomena that allow a team to function synergistically as more than the sum of its parts, and with a sense of team identity. In this paper, the concept of the work group is used to develop a framework for understanding the factors contributing to effective team functioning and identity, an their implications for the tasks of team leadership and sociotherapy: "the art of maintaining a social system in which the treatment of an individual patient can best occur" (Edelson 1970). Leadership activities that promote team cohesiveness and boundary maintenance are discussed, and suggestions are provided for ways in which the subjective experiences and emotional reactions of the leader and team members can be used to promote improved task performance and clinical care.

Toward the financial integration of public mental health services.

The public treatment of seriously mental ill patients continues to be frustrated by the lack of administrative and financial integration of state and community mental health services. Several states have initiated attempts to improve the cost-effectiveness of public mental health services through mechanisms that create financial incentives fostering community-based alternatives to psychiatric hospitalization. Examples of such mechanisms include capitation financing systems, performance contracts, regional mental health authorities, utilization review, and bed-targets. This paper reviews evidence supporting the need for and success of these efforts, and also addresses their limitations.

General systems approaches in mental health administration : developing state-university collaboration programs.

Developing state-university collaboration is the process of creating mechanisms to couple two systems for mutual benefit. Collaboration requires setting new organizational boundaries for both the state agency and the university and developing new patterns of information flow within and between the organizations. Each organization's homeostatic properties resist change; this resistance must be balanced by leaders' attention to the organization's developmental needs. The impact of collaboration increases tremendously after key thresholds of involvement are attained and a "critical mass" of faculty exerts a synergistic effect that shifts both the state agency and the university department to new functional states.

The Galt Visiting Scholar in Public Mental Health: a review of a model of state-university collaboration.

The Galt Visiting Scholar in Public Mental Health program was developed in Virginia to strengthen the relationships between the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services and the Commonwealth's three medical schools. We describe the development and evolution of this program and its accomplishments to date. Despite significant accomplishments, many of the key recommendations of previous Galt Scholars have not been enacted. The Galt Scholar approach of a consultant model is discussed and analyzed structurally using consultation theory. This analysis demonstrates both the potentials and limits of consultant models of state-university collaboration.

The link between fluid intake and weight gain in psychosis.

Diurnal weight gain was found to be abnormal among 44 of 77 institutionalized chronically psychotic patients. All patients were weighed and urine samples obtained weekly for 3 weeks at 7 A.M. and 4 P.M. Diurnal weight gain was normalized as a percentage by subtracting the 7 A.M. weight from the 4 P.M. weight, multiplying the difference by 100, and then dividing the result by the 7 A.M. weight. Normalized diurnal weight gain (NDWG) was 2.504 +/- 1.266% for the 44 study patients with abnormal findings, .631 +/- .405% for the 16 acutely psychotic controls, and .511 +/- .351% for 29 normals. Urine excretion was related (r = .476, p = .001) to NDWG in the subgroup of study patients with abnormal NDWG, consistent with the observation that their fluid intake exceeded fluid excretion in the afternoon.

Virginia's experience with state-university collaboration.

The development of an active collaboration between the department of behavioral medicine and psychiatry of the University of Virginia School of Medicine and Western State Hospital is described. The collaboration includes clinical research and opportunities for training residents and medical students. University faculty provide clinical and administrative leadership at all levels of the hospital's organization. The hospital's clinical functioning has improved through direct involvement of university faculty in patient care, and its recruitment of physicians and psychologists has increased due to expansion of academic opportunities and program improvements. The authors use examples from the collaboration experience to illustrate key issues, such as strong leadership, sufficient resources, and an understanding of systems factors, that are necessary to overcome resistance to change.

Seasonal stability of water balance among schizophrenic patients subject to water intoxication.

1. Diurnal weight gain, afternoon hyponatremia, and polyuria were assessed for one year among eight male schizophrenics subject to water intoxication. 2. The authors normalized the diurnal weight gain (NDWG) as a percentage by subtracting the 7 a.m. weight from the 4 p.m. Weight, multiplying the difference by 100, and then dividing the result by the 7 a.m. weight. 3. NDWG ranged between 2.69 +/- .99 and 3.34 +/- 1.32 percent (F [3, 5] = .885, p = .509) during the four seasons of the year. 4. The seasonal decrease in afternoon serum sodium compared to its morning counterpart ranged between 4.23 +/- 1.96 and 6.14 +/- 2.82 mmol/l (F [3, 5] = 2.212, p = .205). 5. Seasonal polyuria ranged between 8.2 +/- 3.5 and 8.8 +/- 3.2 liters (F [3, 5] = .228, p = .873). 6. Among schizophrenics subject to water intoxication, the seasonal stability in our three parameters of water imbalance suggest they may be used to follow patients with altered water homeostasis over time. This finding has both clinical and research implications.

Abnormal diurnal weight gain among institutionalized patients with manic-depressive spectrum disorders.

We found diurnal weight gain to be abnormal among 41 institutionalized patients with manic-depressive spectrum disorders. They were weighed at 7 AM and 4 PM weekly for three weeks. We normalized the diurnal weight gain (NDWG) as a percentage by subtracting the 7 AM weight from the 4 PM weight, multiplying the difference by 100, and then dividing the result by the 7 AM weight. NDWG was 2.216 +/- 1.513 percent for the study population, .631 +/- .405 percent for 16 young, newly admitted controls, and .511 +/- .351 percent for 29 normals. Abnormal NDWG may be an additional feature of manic-depressive spectrum disorders.

The syndrome of psychosis, intermittent hyponatremia, and polydipsia: evidence for diurnal volume expansion.

Seven patients (6 men and 1 woman, mean age 39.1 +/- SD 6.9 years) with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome) underwent serial determinations of serum sodium (SOD), plasma atrial natriuretic peptide (ANP), and urinary osmolality (UOSM) at 7 AM and 4 PM. There was a diurnal increase in ANP (7 AM 17.9 +/- 5.1 pg/ml and 4 PM 27.7 +/- 9.0 pg/ml, p = 0.02), a diurnal decrease in serum sodium (7 AM 141.1 +/- 1.7 mEq/l, 4 PM 129.9 +/- 3.2 mEq/l, p less than 0.0001) and no diurnal change in UOSM. The diurnal increase in ANP in the the PIP syndrome contrasts to the diurnal decrease in ANP reported in normal subjects. Our data, while preliminary, suggest that patients with the PIP syndrome have increased intravascular volume leading to ANP secretion, natriuresis, and hyponatremia.

Development of water dysregulation during Arieti's third stage of schizophrenia?

We found abnormal diurnal weight gain among 25% of acutely psychotic patients with schizophrenia and 68% of chronically psychotic patients with schizophrenia. They were weighed at 7:00 AM and 4:00 PM weekly for 3 weeks. We normalized the diurnal weight gain (NDWG) as a percentage by subtracting the 7:00 AM weight from the 4:00 PM weight, multiplying the difference by 100, and dividing the result by the 7:00 AM weight, NDWG was 0.93% +/- 0.89% for the 36 acutely psychotic patients and 2.2% +/- 1.5% for the 68 chronically psychotic patients (F = 25.297, p less than 0.0001). Drugs did not explain this difference. Our data, though preliminary, suggest that water dysregulation, as manifested by abnormal diurnal weight gain, develops in schizophrenia as patients progress into Arieti's third stage of this disorder. A longitudinal study design, rather than our cross-sectional one, would be necessary to assess developmental changes in schizophrenia.

Multiple versus single antipsychotic drug treatment in chronic psychosis.

Fourteen patients receiving multiple antipsychotic drugs in a state mental hospital long-term unit comprised the study sample. They completed a 1-year clinical trial to reduce such drugs to a single antipsychotic agent. Six of the 14 patients were successfully converted to a single antipsychotic drug without clinical deterioration. Eight patients showed marked psychiatric decompensation when converted to single antipsychotic therapy. Factors that may have contributed to this difference are discussed.

Survey of diurnal weight gain and urine volume in chronic schizophrenia.

We found diurnal weight gain to be abnormal among 39 chronic schizophrenic patients. The patients were weighed and urine samples obtained weekly for three weeks at 7 a.m. and 4 p.m. We normalized the dirunal weight gain (NDWG) as a percentage by subtracting the 7 a.m. weight from the 4 p.m. weight, multiplying the difference by 100, and then dividing the result by the 7 a.m. weight. NDWG was 2.075 +/- 1.331% for the 38 study patients, .631 +/- .405% for 16 acutely psychotic controls and .511 +/- .351% for 29 normals. Seventy-seven percent of the study patients had abnormal NDWG values and 62% were polyuric. NDWG related to urine volume (n = 39, r = .356, p = .026) with the variability in urine excretion explaining 13% of the variability in NDWG. We discuss factors that may have contributed to our findings.

Normalization of abnormal diurnal weight gain among chronically psychotic geriatric patients. Is abnormal diurnal weight gain a risk factor in chronic psychosis?

We studied 20 geriatric and 87 nongeriatric chronically psychotic male inpatients, 16 acutely psychotic male control subjects, and 14 male normal subjects. The subjects were weighed at 7 a.m. and 4 p.m. weekly for 3 weeks. We normalized the diurnal weight gain (NDWG) as a percentage by subtracting the 7 a.m. weight from 4 p.m. weight, multiplying the difference by 100, and then dividing the result by the 7 a.m. weight. NDWG was .509% +/- .337%, 2.209% +/- 1.529%, .631% +/- .405%, and .533% +/- .410%, among the geriatric men, nongeriatric men, control subjects, and normal subjects respectively. Differences in diagnoses and drugs did not explain these findings. We hypothesize that abnormal diurnal weight gain may be a risk factor for premature death among chronically psychotic inpatients.