Developing a performance-driven culture in the children’s mental health system is a complex process that includes engaging, assessing, treatment planning, gathering data, measuring outcomes, and evaluating and continually improving care.
Although evidence-based practice (EBP) has become a norm, treatment-based evidence must also be considered given the multiple variables in play that do not adhere to the laboratory conditions within which EBPs were formulated.
For example, attention to crises and collateral contacts with family members and child-serving systems is essential to any credible children’s mental health service.
There are costs associated with collateral work and crisis intervention that must be quantified in determining appropriate rates of value-based payment.
At the same time that collateral and crisis work must be elevated in determining value, the use of evidence-based protocols cannot be overestimated.
Too often, evidence-based practices lack sufficient attention to (1) context (e.g. poverty, oppression, community violence, etc.); (2) the multiple intervening variables in a child’s life that are at play at any given time; and (3) the multidisciplinary and team-oriented nature of credible children’s mental health practice.
Gathering Data
A key source of information for this section was a presentation by Brianna O’Connor and Boris Vilgorin, NYU McSilver Institute, “Tools to support the development of a performance-driven culture,” July 25, 2017, at New York University School of Social Work.
In addition to paying attention to EBP and contextual variables, performance-driven organizations must consistently collect and organize data in order to measure the impact of their services The data may be guided by the following four questions: 1) What do we do well? 2)What impact are we having? 3) Why would anyone refer to us? and 4) What outcomes make us most proud?
Although we can describe outcomes anecdotally, measuring them by collecting data is essential to making the most powerful statement about the value of your service and what you do well. A good place to start is by gathering the data you already have. This includes:
- Who is served? This refers to data which offers an understanding of the population and demographics of those that seek your services with an eye toward any disparities around, for example, race, ethnicity, religion, socioeconomic status, language, disability status, sexual orientation, gender identity, etc.
- How are they served? This utilization data helps you see how your resources are being used, how productive you are in engaging those who need you and how well you sustain contact.
- How well are they served? This refers to outcome data that includes understanding whether people are getting what they need in a timely manner and whether progress is being made toward the goals of treatment. Standardized tests should be a part of the mix in determining progress.
- What is the cost of service? This has to do with cost and how effectively you are using your resources to support your mission. This should include the time spent on collateral contact, which can be especially costly in the children’s mental health system. The payer mix is also important to understand.
Measurement Criteria and Continuous Quality Improvement
It is best to select data that is likely to show change and success, using data that is measurable and actionable. For example, data that measures engagement and retention can lead to planning and action steps to improve practices that lead to children and their families staying in treatment.
Using a continuous quality improvement (CQI) model aiming at incremental change can help. This might include considering the following three questions: (1) how are we doing? (2) how do we know? and (3) can we do better?
A Plan – Do – Study – Act (PDSA) approach can then be used for implementing incremental change projects.
For example, at North Shore Child and Family Guidance Center we keep track of broken, cancelled and kept appointments. To improve our practice, we incorporated follow-up calls and then follow-up texts and discovered that texts have the greatest impact in improving rates of attendance.
Teamwork and Culture Change
Small teams of staff members developing time-limited changes projects work best. Having some institutional knowledge of group work planning and development is essential to developing successful teams that are problem-focused and do not collapse prematurely or endlessly flounder.
There are fundamentals to building a successful team that cannot be taken for granted. Most critical is proper planning, which includes clearly defining the needs to be addressed; formulating a clear purpose; affirming logistics that are acceptable to all team members and sanctioned by administration; and defining roles.
Time-limited cycles of up to four weeks in duration are best, so as not to schedule meetings that have no end in sight. The key to success is understanding that this is not a static process, but rather a dynamic one. The idea is not to seek perfection but to aim for continuous quality improvement.
Hearts and Minds
A performance-driven culture is about what you do well, how you will measure its value and success, and how you contract for value-based rates.
For many organizations this may represent a culture shift. Agency leadership is required to keep the momentum moving forward, continuing to educate staff members and bringing them on board with their full hearts and minds.
Mr. Malekoff may be reached at North Shore Child & Family Guidance Center, at amalekoff@northshorechildguidance.org.
