DISCUSSION DRAFT DEVENTER, OCTOBER 2006 Consolidation of documents due for revision

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1 UNION EUROPÉENNE DES MÉDECINS SPÉCIALISTES DISCUSSION DRAFT DEVENTER, OCTOBER 2006 Cnslidatin f dcuments due fr revisin ARCHIVED: GENEVA, OCTOBER 2007 REPORT OF THE UEMS SECTION OF PSYCHIATRY Quality Assurance f Standards in Specialist Psychiatric Care INTRODUCTION This is a revised and cnslidating reprt based n the Charter n Quality Assurance in Medical Specialist Practice in the Eurpean Unin (March 1996) tgether with the three reprts f the Sectin f Psychiatry: Recmmendatins n Quality Assurance (Budapest, April 1999, revised Palma del Mallrca, Octber 2002); Quality Assurance f Standards in Specialist Psychiatric Care (Prague, Octber 2001) and Quality Assurance in Specialist Training in Psychiatry (Thessalniki, April 2002). The latter three reprts are nw all superseded by this current reprt. The Charter n Quality Assurance in Medical Specialist Practice in the Eurpean Unin (March 1996) defines Quality Assurance under the headings f: individual specialist; grup practice; hspital; prfessinal scientific rganisatins; EU member state r regin, and finally financing f quality assurance. Reference shuld be made t the afrementined riginal charter (March 1996) fr the relevant details. Quality f Medical Practice is the extent t which the ttal prperties f delivered medical care meet the current criteria and demands f medical care. The criteria in medical practice are based n cnsensus within the prfessin cncerning methd and utcme f prfessinal activities. Prfessinal criteria shuld be set by the prfessin n the basis f medical evidence n the basis f medical evidence r dcumented expert medical cnsensus. Prfessinal criteria are meant fr imprvement f medical care. They are nt meant fr cst reductin, but they might cntribute t it. Quality Assurance is a prfessinal cncept. It is the sum f the prcesses f assessing and stimulating the quality f medical practice by measuring utcme and cmparing it with current criteria and demands f medical care. It shuld ensure that medical activities are systematic and cntrlled. It shuld affect bth specialist and nn-specialist members f the medical cmmunity at different grades f experience, i.e. frm junir trainee t head f department, and every prfessinal wrking in health care. It can nly succeed if the individual dctr accepts that his/her practice shuld be pen t assessment by the prfessin, and t cmparisn with demands fr medical care and established criteria. It is a mral and ethical bligatin fr the individual specialist, but basically it shuld be a vluntary respnsibility. A specialist wh fails t meet this bligatin shuld receive cunselling by the prfessin, but shuld nt underg disciplinary actin. Prfessinal and scientific rganisatins are required t develp these quality criteria in their speciality and fr this purpse specialists must generate in their practice the instruments necessary t implement quality assurance prjects. Quality Assurance shuld als cver Pst Graduate Training and Cntinuing Medical Educatin. Participatin f medical specialists in cntinuing medical educatin prgrammes shuld be encuraged and registered. The recrds shuld be made available t the natinal prfessinal C:\Dcuments and Settings\JannaC\My Dcuments\JOANNA\U.E.M.S\Meetings\Geneva-Oct07\agenda items\s7-qa- final-n trk changes.dc

2 c-rdinating authrity where this bdy exists. A credit pint system perated by a natinal prfessinal authrity shuld be in existence t assess the participatin f the individual medical specialist in cntinuing medical educatin. The UEMS Eurpean Bards have the task t c-rdinate this system n a Eurpean level in each speciality. RECOMMENDATIONS ON QUALITY ASSURANCE SPECIFIC TO PSYCHIATRY Frm the afrementined Prague reprt (Octber 2001), gd quality f psychiatric practice means that every patient has the right t assessment, treatment and rehabilitatin, in lcally implemented treatment prgrammes, accrding t the best knwledge available. The starting pint can be the patient-flw (lgistics) frm the patient s pint f view, cvering the different phases in the curse f their disease and the prvisin f services. Five different phases can be recgnised: Referral phase Assessment phase Treatment and stabilisatin phase Transfer t ther services and terminatin f treatment Rehabilitatin phase Fr each phase, indicatrs (relevant pints f investigatin), standards f quality (defined acceptable levels and measures (instruments r mechanisms f quantificatin) shuld be identified. In quality assurance, measures traditinally cncern structure, prcess and utcme. In this wrk, utcme will be mst recmmended since it is f mst interest frm a patient s pint f view, and least dependent upn lcal traditins. Referral Phase Accessibility and availability f an ptimal level f effective care: Primary level: GPs must have access t and be able t cnsult psychiatric specialists/psychiatric teams, and t refer when needed. Scial Services must be cmpetent in supprting psychiatric patients needs in the cmmunity, in active cllabratin with psychiatric specialists and GPs. Secndary level: Psychiatric teams/specialists must be available fr emergency assessment and treatment arund the clck. Fr nn-emergency cases, an assessment must be btained within a week f referral. Tertiary level: When patient assessment, treatment and care needs cannt be met in the patient s hme, temprary placement in hspital beds shuld be prvided withut delay until the services can be prvided n a hme basis. The patient s dignity and integrity must be secured thrughut the hspitalisatin. Examples f Suitable Indicatrs: Primary level: GPs must have dcumented basic training in psychiatry GPs must have dcumented CME in psychiatry Time interval frm request t cnsultatin r referral Secndary level: All patients referred by GPs shuld be assessed and treated arund the clck in emergency cases, and within a week fr nn-urgent referral cases Tertiary level: - 2 -

3 Facilities fr extensive utpatient (r ambulatry) and hme treatment and care shuld be available When utpatient (r ambulatry) r hme treatment is unavailable, a sufficient number f hspital beds with physical standards crrespnding t the culture f the patient s hme shuld be available Prprtin f patients treated n an utpatient (r ambulatry) r hme basis versus hspital shuld be cmpared Others: Scheduled meetings between primary, secndary and tertiary services shuld take place t mnitr individual cases, as well as general aspects f exchange between services Shuld be discussed and decided upn lcally Measures: Simple standard prcedures as part f rutine wrk, preferably cmputer-based, shuld be implemented. Assessment Phase Assessment is carried ut as an interactin between the patient, the psychiatric specialist and the psychiatric team in cllabratin with relatives and significant thers. The psychiatrist makes the final decisin cncerning assessment. This shuld include details cncerning psychpathlgy, persnality traits (develpment, defence strategy, eg-strength), netwrk (the hme needs f minrs shuld als be assessed), scial develpment, present life circumstances, smatic histry, past and present, level f scial functining and psychiatric histry. Relevant available diagnstic tls, fr example psychmetric tests, neurimaging and labratry tests shuld be used. Examples f Suitable Indicatrs: Team dcumentatin f cmpetence in the abve-mentined areas Dcumentatin f standard prcedures fr assessment Availability f diagnstic tls, either n a rutine basis r, in specific cases, thrugh referral t mre specialised services Assessment f scial functining (e.g. Glbal Assessment f Functining, GAF) Cntact with family and/r significant thers Hme needs assessment f minrs At least 90% f all patients must see the psychiatrist during the assessment prcedure All staff wrking autnmusly must be licensed r authrised by a natinal r prfessinal bard Lcal guidelines fr assessment, based n natinal guidelines, fr majr diagnstic and prblem grups (prfessinally accepted state f the art guidelines) shuld be used Referral prcedures t mre specialised services At least 90% f all patients shuld be assessed with e.g. GAF Family and/r significant thers shuld be cntacted in at least 80% f cases Measures: Simple standard rutine registratins, preferably cmputer-based, shuld be part f everyday wrk

4 Treatment Phase Based n assessment, the treatment plan shuld be established in cllabratin with patient, psychiatrist and team, family and/r significant thers, where apprpriate. The psychiatrist has verall respnsibility fr the implementatin f the treatment plan and fr assessment f utcme. The treatment plan shuld actively cnsider the need fr bilgical, psychtherapeutic and psychscial treatment. Fr each treatment mdality, purpse, gal and time fr evaluatin shuld be dcumented. The individual treatment plan shuld be based n lcal and natinal guidelines. Each service shuld be cmprehensive and ffer a diversity f treatment pssibilities in the abve-mentined areas. Examples f Suitable Indicatrs: Lcally adapted guidelines based n natinal standards fr treatment fr majr diagnstic and prblem grups Dcumented individual treatment plan Dcumented patient invlvement in establishing the treatment plan Dcumented and authrised cmpetence in all treatment mdalities Balance between treatment needs and treatment capacity Outcme measures shuld be defined e.g. scales fr psychpathlgy and scial functining (e.g. GAF), side effects f treatment, user s satisfactin At least 98% f patients seen as in-patients r ut-patients fr seven days r mre shuld have a dcumented treatment plan with relevant treatment ffered immediately r within a lcally defined acceptable time span, accrding t assessment f needs At least 90% f patients shuld have dcumented active invlvement in establishing their treatment plan Lcal services, shuld have dcumented availability f the majr relevant bilgical, psychtherapeutic and psychscial methds fr all patients after prper assessment Transfer t ther services and terminatin f treatment Cntinuity f treatment shuld be ensured when a patient is transferred frm ne level f treatment t anther. Mutual agreements between the transferring and receiving levels shuld be dcumented. In rder t prevent relapse when treatment is terminated, there shuld be an agreement with the patient cncerning hw t recgnise warning signs f pssible relapse, and which specific service t cntact. Examples f Suitable Indicatrs: Dcumented agreement between transferring and receiving levels f treatment Dcumented agreement with the patient abut recgnising warning signs and which service t cntact 100% f patients transferred t anther service shuld have a dcumented agreement 100% f patients shuld have a dcumented agreement abut hw t recgnise warning signs and which service t cntact if needed Rehabilitatin and Re-scialisatin Prcess Rehabilitatin is a re-scialisatin prcess thrugh which the patient, relatives r significant thers are supprted t regain as much psychlgical, and scial autnmy and functin as pssible. The patient shuld be supprted t chse the relevant netwrk amng family, significant thers, and scial, educatinal, vcatinal and psychiatric services. Lst abilities which cannt be regained shuld be cmpensated. Supprt shuld be prvided t sustain - 4 -

5 functin, when needed. Training measures shuld be applied t help regain functin where pssible. Examples f Suitable Indicatrs: Dcumented rehabilitatin plan wrked ut in cllabratin with patient, the rehabilitatin team and the supprting netwrk Dcumented patient invlvement in netwrk planning Identified prfessinal respnsible fr c-rdinatin (e.g. case manager) shuld be appinted Outcme measures shuld be defined e.g. quality f life, satisfactin and level f functining Defined prcedures fr evaluatin and readjustment f plans Dcumented agreement clarifying respnsibility between scial and psychiatric services When rehabilitatin is required 100% f patients shuld have a dcumented rehabilitatin plan When scial services are part f the rehabilitatin plan, 100% f such patients shuld have a dcumented agreement 100% f patients shuld have an appinted prfessinal respnsible fr c-rdinatin The verall purpse f the abve standards is t imprve psychiatric services fr patients in the mst secure way pssible. Furthermre, this shuld cntribute t the enhancement f patient autnmy and satisfactin. Finally, these standards may facilitate the prvisin f services in the mst cst-effective manner pssible. RECOMMENDATIONS ON QUALITY ASSURANCE IN SPECIALIST TRAINING IN PSYCHIATRY In April 2002 (Thessalniki), the UEMS Sectin fr Psychiatry stated that gd quality in training f a psychiatrist means that every training prgramme shuld have defined gals, apprpriate requirements fr the training prcess and apprpriate means fr evaluatin. The aim f training is t achieve the necessary knwledge and clinical experience required t wrk as a specialist in psychiatry. It shuld enable subsequent CME, which is a life-lng learning prcess, cncerned with prfessinal as well as persnal develpment. The natinal requirements fr specialist training in psychiatry shuld be cmpatible with the UEMS Bard f Psychiatry Recmmendatins. An individual training prgramme aimed at fulfilling these requirements shuld be develped in cllabratin with, and apprved by, trainee, educatinal supervisr and training c-rdinatr. The natinal lgbk cmpatible with the UEMS Bard f Psychiatry Recmmendatins is a tl t secure prper training. It shuld be used by the trainee t recrd clinical and theretical training as described in the recmmendatins. The educatinal supervisr and the training c-rdinatr culd use the lgbk when assessing the trainee s prgress. The training c-rdinatr is respnsible fr the annual assessment f the trainee s prgress as well as the final evaluatin in the frm f a written reprt. The training c-rdinatr and the educatinal supervisr shuld have at least 5 years experience in specialist psychiatry and apprpriate training fr their task

6 Training institutins shuld be recgnised by an apprpriate natinal authrity. A distinctin shuld be made between institutins where cmplete training and where nly partial training can be prvided. There shuld be an effective and independent appeal prcedure fr the trainee wh wishes t express cmplaints r appeal against the decisins abut training matters. A natinal system fr regular scheme inspectins based n the UEMS Charter n Visitatin f Training Centres shuld be in existence. Based n the infrmatin gathered frm a questinnaire n quality assurance (Budapest, April 1999 and reviewed Palma de Mallrca, Octber 2002), the UEMS Sectin fr Psychiatry prpsed the fllwing recmmendatins as realistic t achieve by 2004: I Wrking grups n QA in all Natinal Psychiatric Assciatins (NPAs) shuld be established with the purpse f: frmulating QA plicies accrding t natinal standards stimulating the develpment f QA activities in prfessinal psychiatric bdies and in clinical psychiatric practice at a lcal level II III IV V NPAs shuld identify areas f pririty bth at a natinal and lcal level NPAs shuld start frmulating clinical guidelines n diagnsis and/r prblems frm within the areas f pririty Wrking grups at a lcal/clinical level shuld be established in the public sectr t identity lcal areas fr QA prjects e.g.: management f vilence, treatment with neurleptics, treatment withut cnsent, suicide preventin. Systems fr dcumenting activity and utcme measures (e.g. GAF) shuld be in place in the public sectr VI The abve mentined recmmendatins shuld als apply t private practice It is nw recmmended that all NPAs shuld audit the current situatin in their wn member states and take any necessary remedial actin t bring themselves int line with these recmmendatins