National Quality Framework Submission: Royal & New Zealand College of Psychiatrists

Working with the community

• Executive Summary
• 1 About RANZCP
• 2 Introduction
• 3 Mental health and homelessness
• 4 Theoretical approaches to quality service delivery
• 5 Implementing quality
• 6 Quality frameworks in the health care setting
• 7 Quality and homelessness
• 8 Summary of recommendations

Executive Summary

The RANZCP welcomes the opportunity to discuss the development of a national quality framework to support quality services for people experiencing homelessness. Issues experienced by those who are homeless are complex and difficult to redress. As such, the examination of quality mechanisms that may be leveraged across sectors is a challenging, yet exciting task.

There is consistent evidence to support the finding that people who are homeless have a much higher prevalence of mental illness than the general population. It is well understood that people with a mental illness have a much increased risk of homelessness, that the mentally ill are very highly represented among the homeless population and that the circumstances of being homeless itself exacerbates or increases the risk of poor mental health. Psychiatrists and a range of other mental health and primary care professionals have a role in addressing this problem.

This proposal aims to overview some of the theory and examples of quality from:

• complex adaptive systems, as derived from theories such as systems theory, organisational theory and complexity science
• implementation models and current quality frameworks

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In a world with exponentially increasing information generation, it is important to focus not on the information itself, but how this information is translated to real world application. A robust and adaptive framework that addresses information and quality channels is the key to functioning high quality systems for those experiencing homelessness. As such, this proposal focuses on the development of quality and implementation processes.

Recommendations are outlined throughout, and at the end of this submission. In general, the RANZCP recommends a structured 'quality process' be developed that outlines broad aims for developing quality. Examining how services interact with each other and the broader context of service delivery, will identify barriers and enablers to quality. Developing implementation systems that do not rely on a single approach is also important to ensure uptake.

For further information contact

Jane London
Manager, Projects
Royal Australian and New Zealand College of Psychiatrists
309 La Trobe Street
Melbourne
VIC 3000

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1 About RANZCP

The Royal Australian and New Zealand College of Psychiatrists (RANZCP, the College) is the principal organisation representing the medical specialty of psychiatry in Australia and New Zealand and has responsibility for the training, examining and awarding the qualification of Fellowship to medical practitioners. There are approximately 3000 RANZCP Fellows representing eighty-five per cent of all practising psychiatrists in Australia and over fifty per cent of psychiatrists in New Zealand. There are branches of RANZCP in each state of Australia, the ACT and New Zealand.

Through its various structures, RANZCP accredits training programs and administers the examination process for qualification as a consultant psychiatrist; supports continuing medical education activities at a regional level; holds an annual scientific congress and various sectional conferences throughout the year; publishes a range of journals, statements and other policy documents; and liaises with government, allied professionals and community groups in the interests of psychiatrists, patients and the general community.

RANZCP is a leader amongst Australasian medical colleges in developing partnerships with consumers and family and other carers in respect to excellence of service provision. The Board of Practice and Partnerships includes consumer and carer representatives from a variety of backgrounds, who contribute extensively to the development and management of RANZCP programs and activities, and works together with the community to promote mental health, reduce the impact of mental illness on families, improve care options and supports, and ensures that the rights of people with mental health concerns are heard by mental health professionals.

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2 Introduction

The RANZCP welcomes the opportunity to discuss the development of a national quality framework to support quality services for people experiencing homelessness. Issues experienced by those who are homeless are complex and difficult to redress. As such, the examination of quality mechanisms that may be leveraged across sectors is a challenging, yet exciting task.

Working toward defining a 'quality system' is a significant challenge and the RANZCP commends the Australian Commonwealth Government, via the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) for commencing what will hopefully be an useful tool for the development of policy and programs that will assist people experiencing homelessness.

This submission is presented in three parts. This paper addresses broader quality and quality systems related to mental health and homelessness. The second paper, Which way home? (June 2008)¹ and third, Inquiry into homelessness legislation (August 2009)² explore issues specific to mental health and homelessness.

The RANZCP would welcome opportunities to further discuss the ideas outlined in all three of these submissions.

2.1 A Word on Quality

Quality is a slippery fish. Different sectors perceive it in different ways in different settings. A difficulty in developing a national quality framework for those experiencing homelessness is the application of a multi-sectoral approach. In responding to the Homelessness Working Group discussion paper, the RANZCP have predominantly drawn from quality development work in the healthcare sector.

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3 Mental health and homelessness

Approximately 1 in 5 Australian adults will experience a mental illness in any given year and about 1 in 7 children and adolescents will experience behavioural or emotional problems over a 6 month period.³ Mental disorders are responsible for an estimated 11% of disease burden worldwide (thought to increase to 15% by 2020).⁴ The Australian Institute of Health and Welfare reported mental disorders to be the third leading cause of overall disease burden accounting for 27% of total years lost due to disability.⁵ Projections suggest that the mental health related disease burden will grow markedly as a proportion of overall disease burden.⁶ It has also been found that 24% of Australians with a moderate or severe disability also have a mental disorder.⁷ With regards to services, only 38% of adults and approximately 25% of children and adolescents experiencing a mental disorder seek assistance from a health service.⁸

The census in 2006 determined that approximately 106,000 Australians were homeless;⁹ a situation associated with poorer health, employment, relationships, criminal outcomes, and increased risk of alcohol or other drug disorders.¹⁰ It is not possible to say exactly how many of these homeless people suffer a mental illness although estimates are as high as 75%.^11,12 Mental illness is a significant factor in causing or maintaining homelessness with symptoms of mental illness often resulting in conflict with family, co-tenants or landlords, or preventing people from engaging fully in employment resulting in a loss of accommodation.¹³ Mental illness can also be caused or exacerbated by living homeless, with the constant social instability and potential for victimisation that often accompanies living homeless being highly traumatising. This can potentially trigger the onset or relapse of mood or psychotic disorders, particularly when coupled with substance abuse.¹⁴ Evidence has also shown that for people living homeless and experiencing alcohol or other drug disorders, over 60% develop their problem only after becoming homeless.¹⁵

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Homelessness and mental illness are not the same and are generally treated as distinct issues. Yet there is a strong correlations between the two issues and for those who experience both the risks to safety and recovery are greatly heightened. People experiencing combined difficulties are far less likely to participate in occupational and social pursuits or be in relationships than housed people living with psychosis.^16,17 Combined mental illness and homelessness is also associated with poorer engagement with mental health services or support.¹⁸. Accessing health services often only occurs in the event of a health crisis (eg. illness, assault or intended or unintended self harm) that require emergency, highly intensive and costly intervention through emergency departments and admissions into medical, psychiatric, or alcohol and drug units.¹⁹ As a result, the cost of care for people living homeless is significant and in many cases difficult to provide due to the severity of the presenting medical and/or psychiatric illness, often complicated by psychosocial and alcohol and other drug issues.²⁰

Currently, the delivery of care to those experiencing homelessness is fractured, often hidden (eg. the couch surfer) and, as a consequence, difficult to achieve. Development of a quality framework will assist in 'joining up' mental health care with services specifically directed at those experiencing homelessness.

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4 Theoretical approaches to quality service delivery

When reflecting on theoretical approaches to quality, there tends to be three generally accepted 'themes' that emerge:

• static change assumes that the environment in which care is provided is relatively ordered and predictable. Therefore, to promote quality one can focus on the health care provider via training and regulation (eg. quality assurance, standards)
• systems change, which is an interdisciplinary theory that recognises multiple components or groups that interact via a web of relationships. This recognises the fractious components of complex systems such as the healthcare sector. Quality is developed through various mechanisms within systems theory
• disruptive change is a relatively new theory that explores sudden and unpredictable changes, such as those that may occur as new technologies and policies arise with our current health reform agenda

In the development of the quality movement in healthcare, it is now generally accepted that a systems model is an appropriate approach to quality improvement. Conceived within the business sector, the 'system' concept has evolved through the industrial movement of the past century to create a model that focuses on consistency of purpose, and recognises interdependencies and interconnections within and between systems.^21,22

This model is particularly useful for the healthcare sector, which has numerous interconnections within and among care systems due, in part, to the non-linearity of use by consumers and carers. In addition to the changing journey of those using the system, healthcare is also unique due to the adaptive behaviour of healthcare providers and administrators. As noted by the Institute of Medicine, the 'unpredictability of behaviour in complex adaptive systems can be seen as contributing to huge variation in the delivery of health care'.²³ Of course, when accounting for not only the healthcare sector, but housing and emergency accommodation, government support services, employment, education, legal sectors and other services needed by those experiencing homelessness, the variation of the system increases exponentially.

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Reflecting on the way in which smaller systems (microsystems) interact within the totality of the health system (macrosystem), an important distinction is the difference between mechanical and adaptive system design. Mechanical systems, even those operated by humans, are naturally predictable, and the alteration of a single component will generally yield a predictable result. However, adaptive systems rely on humans to not only operate, but interpret the system. Within a microsystem (eg. the ward of a hospital), this interpretation may not have a negative impact; yet, within a macrosystem variation of delivery of care, or gaps between microsystems can result in misuse, overuse or underuse of services.

Unfortunately, human behaviour in adaptive systems cannot be fully controlled or accounted for; one cannot simply 'replace a cog in the machine' to get a different output. This presents a unique challenge in healthcare, which is based on evidence defining standardisation, but in reality is also driven by consumer understanding and expectations, clinician knowledge and skills, health economics, geography, time pressures and other limitations.

Organisational theory arising from the study of adaptive systems, has delivered a number of conceptual frameworks that explore the dynamics of change. The zone of complexity²⁴, as illustrated in Figure 1, is a useful diagram when considering the macrosystem of healthcare, or with those experiencing homelessness.

Description of Figure

Figure 1. The Stacey Matrix and the zone of complexity.

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Using a matrix such as this as a direction tool, it is possible to reflect on service delivery within and between microsystems, and to decide which tasks or interactions can be, or are required to be, standardised. Within the example of those experiencing homelessness, interactions in each zone might be:

• Plan and control - example such as mental health assessment, therapeutic interventions, housing applicability assessments
• Zone of complexity - patient recall systems for those experiencing homelessness, access to private services, handover between inpatient and outpatient services, handover of information between crisis accommodation and psychiatric services
• Chaos - consumer willingness to engage with system, workforce strikes

By identifying and examining each of the macro and predominant microsystems that those experiencing homelessness interact with, one can begin to identify those interactions that are variable or relatively static. In turn, this will enable the development of appropriate programs and implementation mechanisms.

4.1 Recommendations

• In order to take into account the scope and diversity of service responses across Australia, the RANZCP recommends that a national quality framework for those experiencing homelessness be based on clear quality improvement mechanisms that identify:
  • service providers and the context of services (ie. constituent micro- and macrosystems)
  • services that can be standardised or those that need to remain flexible (ie. adaptive and mechanical processes and interactions)

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5 Implementing quality

As the traditional roles of the health practitioner, service provider, consumer and carer change, so do the mechanisms by which we implement quality information and processes. Previous activities focused predominantly on didactic education for individual providers and regulation for broader systems. However, advances in translational science have reframed the approach to ask, 'how do we translate evidence from the bench top to the bedside?' Or, in the case of those experiencing homelessness, the street corner.

In addition to the challenge of maintaining relevance to the changing roles of service providers, the information landscape has changed dramatically over last decade. Technological advancements mean that the rate by which evidence and information is produced is greater than the rate at which it can be implemented.²⁵ The recent paradigm shift from dissemination of information, to the facilitation of information use is vital to a useful and usable quality framework.

Appropriate implementation processes are of particular importance within the zone of complexity. The challenge is to deliver a solution that is implemented in a manner flexible enough to meet changing social, cultural, political and other contexts, whilst still retaining the core goal of the intervention. This means designing interventions that have different approaches for different audiences in different contexts to achieve the same thing.

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Within the health sector, seminal work by Professor Richard Grol succinctly outlines a range of strategies based on core assumptions about intrinsic and extrinsic reactive human behaviour in complex adaptive systems.²⁶ Intrinsic (internal) processes capture the motivation, interest, rationality and/or attraction of the clinician. Extrinsic (external) processes operate outside the clinician's control. These influences include regulation, financial incentives, social influences and organisational processes. Table 1 outlines detailed examples of the strategies that Grol has identified in relation to dissemination, adoption, implementation and maintenance of processes. Working from the belief that 'evidence based medicine should be complemented by evidence based implementation'²⁷, Grol is an advocate of identifying barriers to change within a particular context, and selecting a range of appropriate strategies aimed at overcoming these obstacles. Figure 2 outlines the Grol implementation process.

Within mainstream and allied service providers for those experiencing homelessness, there will be different strategies that successfully address service provider and clinician intrinsic and extrinsic motivations. These will most likely be quite different depending on the sector and the level of autonomy that service providers experience. Grol's model is a good example of why a range of quality strategies need to be wrapped around a central quality framework.

5.1 Recommendations

• As each sector involved in service provision to those experiencing homelessness will differ in their capacity to deliver services, the RANZCP recommends that a quality framework implementation process should clearly identify relevant barriers and enablers within each service and the greater sector (ie. macro- and microsystems)
• The RANZCP recommends that an appropriate blend of implementation strategies be assigned to each quality framework component in order to maximise take up. As such, the college does not recommend a particular implementation channel; interactions within the micro- or macrosystem will define appropriate mechanisms
• Regulatory mechanisms, such as standards, are only one approach to quality. The RANZCP recommend a mixture of intrinsic and extrinsic factors be considered when designing an implementation process

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Description of Figure

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6 Quality frameworks in the health care setting

A framework is a hypothetical description of a system or process in order to address or examine complex issues. Frameworks are often seen as 'solutions' to a problem, when in fact, they simply allow users to gain objectivity and insight.

Below, examples of a number of mental health quality frameworks are outlined. In addition, the Royal Australian College of General Practitioners (RACGP) report: A quality framework for Australian general practice background paper, succinctly overviews international quality frameworks in the broader healthcare sector.²⁸

6.1 New Zealand Ministry of Health

Despite not having a quality framework, the New Zealand Ministry of Health released a National mental health information strategy in 2005²⁹ as a component of Te Tāhuhu - Improving mental health 2005-2015.³⁰ The purpose of this strategy is to identify and improve the use and application of mental health information at all levels of the mental health sector. Table 2 outlines part of the suggested framework for action, by clearly identifying the priority area or aim, along with the barriers, enablers and participants.

Following on from the information strategy was the Ministry's National mental health information strategy: Implementation plan 2006.³¹ This outlines the priority areas with a clear aim, actions and stakeholders.

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Description of Table

6.2 World Health Organisation

The 2003 World Health Organisation (WHO) Quality improvement for mental health³² is written as a policy and service guidance document and clearly places an emphasis on quality in order to maximise efficient mental health service delivery. This framework focuses on seven key components, or stages (Figure 3), to development of quality mechanisms for mental health service delivery:

• align policy for quality improvement
• design a standards document
• establish accreditation procedures
• monitor the mental health service by using the quality mechanisms
• integrate quality improvement into the ongoing management and delivery of services
• consider systematic reform for the improvement of services
• review the quality mechanisms

This framework was one component of multiple modules for policy makers aimed at improving mental health care. Other modules included financing, advocacy, information systems and area specific issues (eg. child and adolescent).

Description of Figure

Figure 3. WHO quality improvement model for mental health care

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6.3 Irish Mental Health Commission

In 2007, the Mental Health Commission in Ireland released a mental health quality framework (Figure 4), teamed with an incremental implementation plan. This quality framework is based around 8 'themes' that articulate quality care. The framework then outlines the standards that aim to fulfill themes via delivery of care, and the criteria by which these standards would be assessed.

Within the framework, there appears to be an emphasis on regulatory methods of quality assurance (eg. legislative requirements).

Description of Figure

Figure 4. Quality framework for mental health services in Ireland

When considering the proposed quality framework for those experiencing homelessness, a range of information elements need to be identified (eg. aims, systems involved, participants involved, implementation mechanisms and content). In reviewing international mental health and other health care frameworks, it is important to note that many of the proposed frameworks identify some components of a complete 'quality' cycle. However, none of the reviewed frameworks sketch an entire process: from defining quality goals, the basic rules that will govern the work, through to how it will be implemented. Unfortunately, we often see only sections of the journey.

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6.4 Recommendations

• The RANZCP recommend a detailed review of existing frameworks and quality improvement tools from each of the key constituent sectors be conducted. This will highlight the key concerns and needs of each sector, along with how each sector frames their enablers and barriers to quality

7 Quality and homelessness

Quality, as defined by those who interact with homeless and associated services, will differ depending on the experience of the individual, group or organisation. As such, defining what a 'quality service' looks like needs to be flexible and responsive. When considering the development of a quality framework, issues such as the key components of a quality system, the main participants or interactions, timeframes and the constituent sectors (micro- and macrosystems) are all extremely important considerations.

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7.1 Key components of a quality system

Delineating key components (ie. 'issues' or 'domains' of quality), that are relevant to each of the constituent sectors would be useful. This will provide a clear indication of the key themes to be addressed and inform the aims or priority areas of the overall quality approach. It may also highlight issues of particular overlap or importance that may require a joint or significant strategy to resolve (eg. information flow between and within sectors).

There have been a number of reports and frameworks that have identified key components of quality, most notably the Institute of Medicine³³ and the RACGP³⁴. These elements include, but are not limited to:

• patient/consumer focus
• coordination of care across systems of care
• information technology and information management
• quality measurement and improvement
• behavioral health workforce
• team development
• competence
• professionalism
• capacity
• financing
• leadership

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7.2 Participants/interactions

Research indicates that for quality strategies to be successful, multi-faceted approaches aimed at different levels, dependent on audience, need to be adopted.35 Often strategies focus on only one party (eg. continuing professional development (CPD) for clinicians), whereas it should be focused at two or more parties (eg. CPD for clinicians, and direct marketing to consumers). Researchers and quality organisations have interpreted these participants in care slightly differently as can be seen in Table 3.^36,37,38

When considering the proposed quality framework for those experiencing homelessness, it is of particular importance to address issues between mainstream and allied services. Addressing this in either the framework, or associated implementation process/plan, may be an appropriate way to explore or represent the disconnect between these services. Implementing activities for these services will probably require different, yet complementary, dissemination and education activities.

Description of Table

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7.3 Defining quality service provision

As noted, defining a quality system will differ dependent on the individual or group using the system. The suggested key characteristics or quality service provision, as proposed by FCHSIA include:

• professional, objective and outcomes focused
• responsive and timely and relevant to the need of the client
• rights based, ethical, fair and equitable
• enables the client to participate in the decision making process and supports them to make their own decisions and achieve goals
• respectful to the client irrespective of age, gender, sexuality and gender identity, religion, race, language, country and culture of origin and for the consumer's relationships and networks
• delivered by a competent, trained and qualified workforce
• supported and enhanced through collaborative partnerships and networks with similar and allied service providers
• provided by organisations that have strong governance, organisational and financial management processes and systems in place

The RANZCP believe that these characteristics largely cover the elements of quality service provision that should be espoused by services (both mainstream and allied) providing support to those experiencing homelessness. However, a greater emphasis could be placed on: information sharing, where appropriate; collaboration; and, a recovery focus.

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7.4 Recommendations

• The RANZCP recommend that a four dimensional framework be explored, inclusive of key components/dimensions; participants/interactions; sectors (macro- and microsystems); and, time.
• Evidence shows that interactions tailored for a specific audience are more effective. The RANZCP recommend that careful consideration is given to all audiences, including national groups and policy makers.

8 Summary of recommendations

Theoretical approaches to quality service delivery

• In order to take into account the scope and diversity of service responses across Australia, the RANZCP recommends that a national quality framework for those experiencing homelessness be based on clear quality improvement mechanisms that identify:
  • service providers and the context of services (ie. constituent micro- and macrosystems)
  • services that can be standardised or those that need to remain flexible (ie. adaptive and mechanical processes and interactions)

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Implementing quality

• As each sector involved in service provision to those experiencing homelessness will differ in their capacity to deliver services, the RANZCP recommends that a quality framework implementation process should clearly identify relevant barriers and enablers within each sector and predominant microsystem
• The RANZCP recommends that an appropriate blend of implementation strategies be assigned to each quality framework component in order to maximise take up. As such, the college does not recommend a particular implementation channel; interactions within the micro- or macrosystem will define appropriate mechanisms
• Regulatory mechanisms, such as standards, are one approach to quality. The RANZCP recommend a mixture of intrinsic and extrinsic factors be considered when designing an implementation process

Quality frameworks in the health care setting

• The RANZCP recommend a detailed review of existing frameworks and quality improvement tools from each of the key constituent sectors be conducted. This will highlight the key concerns and needs of each sector, along with how each sector frames their enablers and barriers to quality

Quality and homelessness

• The RANZCP recommend that a four dimensional framework be explored, inclusive of key components/dimensions; participants/interactions; sectors (macro- and microsystems); and, time.
• Evidence shows that interactions tailored for a specific audience are more effective. The RANZCP recommend that careful consideration is given to all audiences, including national groups and policy makers.

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