Quality Indicators Workgroup Report

Linda Cabage, FPMHNP-BC; Katherine Darling, DNP, FPMHNP/FNP-C, APRN; Aparna Kumar, BSN, MA, MPH; Nicole Rozek-Brodrick, APRN, RN, NP; Laura Withorne-Maloney, RN, MSN, CNP
Advisor: Nancy Hanrahan, PhD, RN, FAAN

Objective:  Recommend a strategic direction for APNA Quality Improvement activities.

The Quality Improvement Workgroup recommends:  

  1. APNA place the consumers’ interest in quality improvement at the forefront of leading change and join SAMHSA in their Recovery Support Strategic Initiative.

Rationale: The consumer’s needs are the center of APNA quality initiatives and a patient-centered approach is at the center of concern for psychiatric-mental health nurses in all settings and specialties. The consumer is defined as the “patient” or “client” and their family or significant other. Partnering with people in recovery from mental and substance use disorders and family members to guide the behavioral health system and promote individual-, program-, and system-level approaches that foster health and resilience; increase permanent housing, employment, education, and other necessary supports; and reduce discriminatory barriers. A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.  

  1. APNA’s quality improvement initiatives focus on inpatient outcomes for psychiatric-mental health nurses and patients.

Rationale: It is important to note that two-thirds of all psychiatric-mental health nurses work in hospitals. Thus a focus on hospital quality improvement should appeal to a large group of APNA members. Furthermore, a recent report by the Institute of Medicine (IOM) on Value & Science-Driven Health Care asserts that improving the efficiency and effectiveness of hospital systems could reduce the cost of health care by 148 billion dollars; of which 68 billion is savings from unnecessary and preventable hospital readmissions. Preventable and unnecessary hospital readmission has become a widely used lever for withholding reimbursement thereby reducing costs and improving the quality of hospital care. By choosing to focus on quality improvement of hospital care, APNA--representing the largest employed workforce group in hospitals--could leverage psychiatric-mental health nurses into the forefront of quality improvement and cost savings! Many initiatives already well developed by APNA (e.g., safety: seclusion and restraints and staffing) could be reconceptualized as leading to this formal initiative.


In 2010, the United States adopted an unprecedented health reform policy that generated an imperative for lowering costs and improving outcomes (National Research Council 2011). Given the ubiquitous nature of mental illness and addictions, it is notable that quality improvement and quality metrics are undeveloped in the specialty of mental health and psychiatry. The following describes more explicitly the above two recommendations.

Patient-Centered Quality Improvement
Most Americans have a personal story to tell about a mental illness they themselves have experienced or an episode of a family member or friend. The story, in many cases, includes frustration about not finding appropriate treatment or fear of the consequences of being labeled as mentally ill. Treatment for mental illness is available and highly effective. Between 70 and 90 percent of individuals have a significant reduction of symptoms and improved quality of life with a combination of medication and psychosocial treatments and supports (Institute of Medicine, 2006). Each year the fallout from poor access to appropriate mental health care is disability, unemployment, substance abuse, homelessness, inappropriate incarceration and suicide causes. These consequences cause untold suffering for individuals and families and cost society more than 100 billion dollars each year. Systems for delivering mental health care are enormously wasteful, ill-targeted, inefficient, and unfair. The Quality Improvement Workgroup recommends that the APNA Board of Directors place the consumers’ interest in quality improvement at the forefront of leading change and join SAMHSA in their Recovery Support Strategic Initiative. The following strategies are recommended:

  1. There are many APNA recovery-centered activities. Gather these activities and reframe/rename them as APNA Quality Improvement initiatives. 
  2. Although APNA has a strong track recorder for including consumers, we recommend strengthening further the alliances with the following groups:
    1. NAMI (http://www.nami.org/)
    2. Federation of Families for Children’s Mental Health (http://ffcmh.org/)
    3. Mental Health America (http://www.nmha.org/)
    4. SAMHSA (www.samhsa.gov/)
  3. Promote the integration of recovery principles at conferences and other educational activities.
  4. Include consumers on the APNA Board of Directors, councils, and create a membership category for consumers.
  5. Require consumer membership and participation on all quality improvement initiatives of APNA.
  6. Consumers may be psychiatric-mental health nurses. Are they willing to identify themselves and become more active in consumer roles in APNA? What about a Psychiatric-Mental Health Nurse as Consumer Council?

Hospital Quality Improvement
There are many areas that could become the focus of APNA’s quality improvement strategic plan. We advise the APNA Board of Directors to focus attention on hospital quality reform for several reasons. First, workforce data shows that two-thirds of all psychiatric-mental health nurses work in hospitals. Second, inpatient services are currently being targeted for efficiency and cost effectiveness initiatives. For example, recently Medicare declared that significant savings can be had by decreasing the number of unnecessary hospital readmissions and prevent other admissions. Inpatient medical-surgical specialties are responding to Medicare cut; eventually, inpatient psychiatric services will be forced to observe and account for preventable and unnecessary readmissions. These pressures could further erode the support for quality inpatient psychiatric care that is already compromised from past administrative cost cutting strategies related to a reduction in the number of registered nurses and an increase unlicensed staff. Psychiatric-mental health nurses have experience the erosion of safety on inpatient units following these cuts.  

In the general medical sector, an understanding of patient safety has guided innovative interventions to prevent errors and lower the incidence of adverse events in general hospitals (Institute of Medicine, 1999, 2001). Similar progress has not been achieved in the specialty of psychiatry in these same settings. The focus on hospital patient and nurse outcomes provides important information about the effect of the organizational quality of inpatient care environments. Most psychiatric-mental health nurses know that there is wide variability in the quality of inpatient care settings. As APNA focuses psychiatric-mental health nurse attention on safe and quality care inpatient psychiatric care, quality improvement strategies and evidence-based practice will develop. Examples of quality indicators for patients include 30-day readmission, discharge planning and follow-up in the community; examples for psychiatric-mental health nurse quality indictors include adequate staffing levels, burnout, safe practice environments, and evidence-based interventions. These measures can challenge existing paradigms and clinical practice in psychiatric inpatient care.

The Quality Improvement Workgroup recommends that the APNA Board of Directors focus on inpatient outcomes for psychiatric-mental health nurses and patients.  The following strategies are recommended:

  1. Adopt a Quality Improvement Conceptual Model.  See Hermann, R. C. & Palmer, H. R. (2002). Common ground: A framework for selecting core quality measures for mental health and substance abuse care. Psychiatric Services, 53, 281-287.
  2. Establish an Institute for Quality Improvement where leadership and excellence in psychiatric-mental health nursing practice can become centralized.
  3. Form a Quality Improvement Workgroup that builds the expertise required to develop and promote a quality indicator through formal adoption at the national level.
  4. Identify an existing or developing psychiatric-mental health QI from another organization that APNA could support through collaboration; writing, field testing, and/or endorsement
  5. Identify a nursing organization and nursing related QI measure that has been proposed or submitted for evaluation by another group. Propose an expansion or extension of this existing QI into the domain of PMH nursing.
  6. Identify existing QI measures that have been endorsed and in the process of implementation by federal agencies or organizations and endorse these as a PMH professional organization.  Develop and submit nursing and/or consumer implications to these existing measures
  7. Identify current QI work being conducted within the APNA membership and develop a mechanism to support and endorse these efforts


Appendix A.  Quality indicators for Psychiatric Mental Health
Appendix B.  AHRQ National Quality Measures Clearing House
Appendix C.  SAMHSA QI webite
Appendix D.  SAMHSA Strategic Quality
Appendix E.  Tobacco as a Quality Indicator

Web Sources:

Nursing Alliance for Quality Care,  Mary Jean Shumann, Executive Director: http://nursing.gwumc.edu/researchinitiatives/nursingallianceforqualitycare
National Quality Forum:  http://www.qualityforum.org/Home.aspx
Agency on Healthcare Research and Quality: http://www.ahrq.gov/qual/measurix.htm
National Association for Healthcare Quality:  http://www.nahq.org/
Center for Quality Assessment and Improvement in Mental Health: www.cqaimh.org/index.html
National Database of Nursing Quality Indicators (NDNQI):  https://www.nursingquality.org/
American Nurses Association: National Center for Nursing Quality: http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality.aspx


Submitted to the APNA Board of Directors February 2012 
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