IACAPAP Textbook of Child and Adolescent Mental Health

MISCELLANEOUS

Chapter

J.8

CLINICAL QUALITY AND PATIENT
SAFETY IN CHILD AND ADOLESCENTMENTAL HEALTH
2019 edition
Chng Soon Hian Jermain, Chan Mei Chern, Tina Fang &Daniel Fung
Chng Soon Hian Jermain
BSc
Executive, Department ofClinical Governance andQuality, Institute of Mental
Health, Singapore
Conflict of interest: none
declared

Chan Mei Chern MBA
Deputy Director (Operations),
Department of Developmental
Psychiatry, Institute of Mental
Health, Singapore
Conflict of interest: none
declared

Tina Fang MD
Director, Department of Clinical
Governance and Quality,
Institute of Mental Health,Singapore
Conflict of interest: none
declaredThis publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the editors or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2019. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Chng SHJ, Chan MC, Fang T, Fung D. Clinical quality and patient safety in child and adolescent mental health.
In Rey JM, Martin A (eds), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Childand Adolescent Psychiatry and Allied Professions 2019.

Quality J.8

1

IACAPAP Textbook of Child and Adolescent Mental HealthO

ne may wonder why there is a need to have a chapter on clinical quality
and patient safety in child and adolescent mental health. Surely, the verybasis of medicine is to provide good clinical care which is safe. Yet, asreported in the landmark 1999 book by the Institute of Medicine, To Err Is Human,
and later, in Crossing the Quality Chasm (Committee on Quality in Healthcare in
America, 2001), much harm has unwittingly resulted from health interventions
either directly through commission or indirectly by omission (Kohn et al, 2000).
The landmark book quoted that up to 98,000 patient deaths in the US were due
to medical errors every year, while James (2013) estimated that more than 400,000
premature patient deaths per year in the US were associated with preventable harm.
Regardless of the actual figures, it is worth noting that widespread patient harm by
medical interventions is an epidemic that must be taken seriously.
No estimates are available of children being harmed or having died as aresult of medical errors. However, many anecdotal accounts certainly point tothis occurring in children, who form a large proportion of any population. In
Singapore, for example, paediatric beds are just over 5% of total hospital beds andat the Institute of Mental Health (IMH), Singapore’s only psychiatric hospital,
there are 20 out of a total of about 2,000 beds.

Daniel Fung MBBS, MMed
(Psychiatry), FAMS
Chairman Medical Board,
Institute of Mental Health andSenior Consultant, Departmentof Developmental Psychiatry,
Institute of Mental Health,Singapore
Conflict of interest: none
declared
The following contributed to thewriting of this chapter, all from the
Department of Clinical Governance& Quality, Institute of Mental Health,Singapore: Lim SHI, Assistant
Director; Poremski D, Research
Fellow; Wei X, Senior Executive;
Ong GXJ, Senior ClinicalPsychologist. They declared noconflict of interest

In spite of best intentions, harm often results from therapeutic interventions.
As Donald Berwick (1996), a paediatrician who helped set up the Institute of
Healthcare Improvement in the US loves to quote, “every system is perfectly
designed to achieve what it was designed to achieve”. Healthcare systems are
driven by humans. The physician is the main driver of clinical assessment leading
to diagnosis. This is followed by treatment based on that diagnosis, in somesituations utilizing special skills led by clinicians, often a physician. These skills canbe physical, such as the surgical dexterity needed to excise or correct problematic
body parts, or analytic—helping patients understand their problems better andlearn effective means of handling them, often the case in mental health—or, indeveloping a system, understanding the family and therefore helping the family
work better, as is the case in child and adolescent mental health. The difficulty liesin the human element—humans are prone to error and errors are inevitable whenhumans are involved.
One problem is that physicians are trained to be perfectionists and may
sometimes see themselves as incapable of error (Perper & Cina, 2005). Healthcare
systems, because of the way they evolved, were never designed around this fact. Let
us examine the simple matter of medication. Physicians prescribe many drugs; newmedications are regularly developed, some have similar-sounding names and yet noattempt has been made to differentiate them. For example, the name clomipramine(used for obsessive compulsive disorder) is similar to chlorpromazine (used forpsychosis). If the medication ordering system is not properly designed, mistakes
when prescribing can easily occur. Some medications also look alike and patientsand pharmacists can easily confuse them.
This chapter is designed to help professionals working in mental healthto understand systems and how to improve them. It will introduce ideas aboutstandardizing care and the use of measures to monitor and improve quality. It
will also discuss culture of safety and innovation. As the county of Jonkoping in
Sweden frequently articulates to its staff, health professionals essentially have two

Quality J.8••

Do you havequestions?
Comments?

Click here to go to the
Textbook’s Facebook
page to share yourviews about thechapter with otherreaders, question theauthors or editor andmake comments.

2

IACAPAP Textbook of Child and Adolescent Mental Health

Aims of High-Quality Healthcare*
•
•
•
•
•
•

Safe: avoiding injuries to patients from the care that is intended to help them.
Effective: providing services based on scientific knowledge to all who could benefit
and refraining from providing services to those not likely to benefit.
Patient-centred: providing care that is respectful of and responsive to individual
patient preferences, needs, and values and ensuring that patient values guide all clinicaldecisions.
Timely: reducing waits and sometimes harmful delays for both those who receive andthose who give care.
Efficient: avoiding waste, in particular waste of equipment, supplies, ideas, andenergy.
Equitable: providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

*Committee on Quality in Healthcare in America (2001). Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington, DC: National Academies Press.

jobs, one is to do the work they are supposed to do, and the other is to improve it.
With this mindset deeply ingrained in their staff, Jonkoping has one of the bestrun healthcare systems in Sweden and an annual festival celebrating their systems
approach to healthcare improvement.

SYSTEMS THINKING
People can foresee the future only when it coincides with
their own wishes, and the most grossly obvious facts can beignored when they are unwelcome.
George Orwell, London Letter
A system is a set of interdependent elements interacting to achieve a common
result/outcome — a set of things that work together to achieve a goal. Quality is
the result of successful work within a system producing a good outcome. It is
achieved by individuals working in teams within well designed systems. Managing
quality requires planning and should not be accidental. As Edward Deming, aquality expert who helped design manufacturing systems said, “You cannot inspect
quality into the product, it is already there,” meaning that quality is not somethingthat inspection will produce; it is something that we must purposefully plan for.
Other processes within a particular system may be optimized (e.g., the car or
airplane frames are built and assembled perfectly), but if one process fails (e.g., theengine-building process), this can cause the entire system to fail catastrophically.
Yet we do not realize that unexpected, preventable adverse events—not due toillnesses—can occur in hospitals as often as 30% of the time (Chapman et al,2014; Classen et al, 2011). The problem is not human error, which is inevitable;
not having systems designed to prevent errors from occurring is the problem.
Another challenge is that we fail to recognize human error and mistakes
as a systemic problem, instead we tend to blame the “culprits” for not being
careful enough. One way to understand human error is through the science ofhuman factors. According to the World Health Organization (2011), humanfactors science is a discipline, comprising anatomy, physiology, physics, andQuality J.8

3

IACAPAP Textbook of Child and Adolescent Mental Healthbiomechanics, to understand how people work under different conditions. It looks
at three interrelated areas: the individual, the task, and the workplace. Human
factors science recognizes that humans are inherently fallible and the individual(who may be stressed, fatigued, have inadequate knowledge, etc), while trying tocomplete the task, interacts with the workplace (environment, culture, people,
equipment, etc) and these interactions may drive the human being to commit theerror. Relying on the individual to be more careful is simply insufficient to prevent
errors. Click here to learn more about this.
When we design a system, we need to recognize the importance of humanfactors. A good system is designed to eliminate or reduce human errors by making
it easier to do the right thing and harder to do the wrong thing. For example, if
a system allows medications with similar names to be prescribed without somechecks, errors can occur easily. Let us go back to the earlier example of clomipramineand chlorpromazine. A well-designed system would warn the prescriber whenchlorpromazine is incorrectly used for obsessive compulsive disorder. Thisadditional prompting makes it harder for the prescriber to accidentally prescribe
the wrong medication. This type of early warning is called clinical decision support.
Such support can be in the form of team members who help physicians, such as
pharmacists, or automation using information technology. By designing systems
around potential mistakes that humans make, errors can be reduced.
Edward Deming also introduced the System of Profound Knowledge in his
book The New Economics, where he viewed improvement through four lenses. Oneof the lenses—the “appreciation for the system”—highlights the importance ofsystems thinking. We shall examine his four lenses in the “improvement” section.

QUALITY AND SAFETY IN MENTAL HEALTH
Improvement begins with I
Arnold H. Glasgow
Medical errors in psychiatry had received relatively little attention until an
investigative series published in the Hartford Courant, a US newspaper. The articles
reported that between 1988 and 1998, 142 deaths had occurred in the US during
seclusion and restraint in psychiatric facilities (Weiss et al, 1998). Those reports
were greeted by the psychiatry profession with the same scepticism and assertionsof inevitability that had characterized the reaction of other medical specialties toinitial reports of medical errors (Leape et al, 1993). Medical errors are not limited
to adults, they also occur in children but are underreported (Slonim et al, 2003).
Errors can happen anytime during the provision of healthcare and there aremany different ways of classifying them, one is to categorize them into diagnostic,
treatment, preventive, or other errors (Leape et al, 1993). Usually, errors are notisolated events but the result of ineffective systems, hence it is important to target
the root causes and error-proof the systems.
The Swiss Cheese Model (Figure J.8.1) provides a visualization of how
an error can occur. The stack of cheese slices represents an organization’s safetysystem, with each slice of cheese denoting a defence layer (for example, policies,
staff training, and environment) to prevent the error from passing through andQuality J.8

Ignaz Semmelweis“the Saviour ofMothers”
Semmelweis was a
Hungarian physician who
worked at the Vienna
General Hospital’smaternity clinic 1846–
1849. There, as elsewherein European and North
American hospitals,
puerperal fever, or childbed
fever, was rampant,affecting as many as 40%of admitted patients. He
was disturbed by thesemortality rates, andeventually developed atheory of infection, in which
he theorized that decaying
matter on the hands of
doctors, who had recently
conducted autopsies,
was brought into contact
with the genitals of birthgiving women during the
medical examinations at
the maternity clinic. He
proposed a radical handwashing procedure using
chlorinated lime.
At the time however, thegerm theory of infection
had not been developed
and Semmelweis’ ideas
ran contrary to medical
beliefs and practices. His
ideas were rejected andridiculed by the Viennese
medical establishment.
Quite unusually, his
contract was not renewed.
He died as an outcast in amental institution. Today,
his memory is honoured
by the name of the major
institution of medical
education in Hungary,
Semmelweis University.
Wikipedia

4IACAPAP Textbook of Child and Adolescent Mental Health

Figure J.8.1* The Swiss Cheese Model*Developed by James Reason; extracted from the Institute of Healthcare Improvement (IHI) Open School
Patient Safety 101: From Error to Harm.

resulting in an incident. The holes in each slice represent either existing latentconditions or active failures. When these holes “line up”, the error penetrates
through all layers of defence, resulting in an undesirable event.
Latent conditions are inadequacies in the processes, systems, or culture of anorganization. Possibly widespread across the entire organization, these “pathogens”
in the healthcare safety system can be invisible unless we look thoroughly. For
example, a gap in a hospital’s nurse training leading to nurses being unfamiliar
with operating infusion pumps because nurses “should have learnt that during
nursing school.”
Active failures are the unsafe acts of an individual leading to the incident.
The impact of these errors is usually evident. Example: a nurse who sets the wrong
pump settings for a patient.
It is important to note that when an error occurs, the conditions whichallowed the nurse to commit the error have to be examined. A common response inhealthcare is to punish the individual who committed the error. However, humans
are inherently fallible and prone to error. In systems thinking, examining thesystemic factors which allowed the human to commit this error is more effectiveat preventing the same error from recurring than punishing the individual who
committed the error—especially if another nurse can make the same error. Clickhere if you want to learn more about this.

Adverse Events & Root Cause Analysis
An adverse event is an unintended injury or complication that results in
temporary or permanent disability or death or increased length of stay in hospitalthat is caused by healthcare management rather than the disease process itself.
In Singapore, a serious reportable event is an unexpected occurrence, which may

Quality J.8

Root Cause Analysis
A root cause is a causethat once removed fromthe system prevents the
final undesirable eventfrom recurring. This is
an internationally usedmethod to identify systemic
causes of errors andadverse events. Its use
in patient safety incidents
and near misses has
been mandated by the
Joint Commissions, anaccreditation body for
healthcare institutions
originally from the US.
Other countries in Europe
and Australia have also
adopted this methodology.
The method is not a fixedrisk analysis formula but ageneral approach to help
identify means to deal withthe risk identified.

5

IACAPAP Textbook of Child and Adolescent Mental Health

Dealing with an Error Administering Medication
A 10 year-old patient was prescribed 0.5mL of risperidone but was administered adose 10 times higher by his caregivers in the step-down care facility. A root cause analysis
found that this error had occurred because the first digit of the dosage was partially obscuredon the medication label and there was a lack of communication of medication information to
the caregivers in the care facility.
This problem could be mitigated by encouraging staff to be “more careful” in the
future. However it was chosen to tackle the circumstances that made the error possible byestablishing labeling guidelines and providing medication information via a memo or a copyof the prescription to the step-down care facility. In this instance, embracing systems-thinking
helped to move beyond “blaming” and “shaming” to a more effective solution that is likely toprevent the recurrence of the same error.

Near Miss:
Mistaking the Heartfor the Head

involve death, major permanent loss of function, or major injury associatedwith treatment, lack of treatment, or delay in treatment of the patient’s illness orunderlying condition. Adverse events are usually detected through direct reports as
the events occur. Every serious reportable event should be assessed using the root
cause analysis methodology to identify causes or contributing factors which led tothe incident and provide recommendations and solutions to prevent its recurrence.
A good root cause analysis focuses on systems-related problems rather than on
human error. Click here for more information on root cause analysis methodology.
Near-misses are variations that do not affect an outcome but for which arecurrence carries a significant chance of a serious adverse outcome. Near misses
are worth measuring because they help identify worrying trends and are learning
opportunities to prevent an actual adverse event from occurring.
The international patient safety goals in the Joint Commission International
Accreditation Standards for Hospitals, 6th Edition (2017) addresses some of themost problematic areas in healthcare (see box in page 7). These goals provide theframework and impetus for hospitals to measure safety in these areas and to makecontinuous improvements to processes to safeguard the safety of patients.

Quality J.8

A patient was due tobe started on tricyclic
antidepressants. Becauseof the potential for
affecting individuals witha heart block, an ECG
was ordered prior to starttaking the medication.
However, the patient was
mistakenly sent to the ECT
suite.
Had the staff not checkedthat an ECT had notbeen ordered—it was an
ECG instead—the patient
would have undergone atreatment that she did not
require, with its potential
risks. It was noted thatboth ECG and ECT wereconsecutive entries in
the order menu; a small
misplaced tick could
have sent the patient
for an entirely different
procedure.

6

IACAPAP Textbook of Child and Adolescent Mental Health

Most common Serious Reportable Events in Mental Health Settings
Death or serious disability or injury:•
Associated with a fall•
Associated with an assault•
Contributed to by the use of restraint•
As a result of lack of treatment or delay in treatment•
As a result of suicide or attempted suicide

Mental health services have additional barriers to developing good quality
improvement systems due to:
•
•

•
•
•
•
•
•
•
•
•

StigmaMind-body dualism, which makes it hard for quality improvement
systems in general hospitals to be applied in a mental health setting as
the two systems differ because, in some aspects, medical practice varies
from psychiatric practice
The role of the government in monitoring the work
Legal and regulatory variations in mental health legislation regulating
involuntary treatment
The fact that multiple sectors are often involved (e.g., social services,criminal justice, education, etc.)
Different diagnostic systems and separate care-delivery structures
A more heterogeneous work force, greater solo practice, particularly inprivate practice settings
Fewer procedures that can be standardized
Different financing systems or different market structures
Less developed quality improvement and performance measures
Less linkage to information technology and innovations.

Failure Modes and Effects Analysis
While serious reportable event investigations and root cause analysis
methodologies are retrospective in nature, the Failure Modes and Effects Analysis
is used to prospectively look for potential failures (“failure modes”) within newlyconceptualized systems or processes, their associated consequences (“effects”), andthe elements which allow the failure to occur (“analysis”). An important feature ofthis tool is the managing of these elements—hence this tool itself can be thoughtof as a form of risk management. A Failure Modes & Effects Analysis comprises
the following steps (adapted from the National Healthcare Group Quality Resource
Management Department, The Failure Modes & Effects Analysis Handbook, 2018):
1.
2.
3.
4.
5.

Define the focus and scope
Assemble a multi-disciplinary team
Describe the process and sub-processes
Identify the potential failure modes
Identify the potential effects

Quality J.8

Serious Reportable
Event:
Fall From a Height
A patient had missed hisscheduled medical review
and was not rescheduled
for another. Two weeks
later, he climbed up thepartition in the day lounge
and jumped over to thevisitors’ lounge, landing
feet first before falling onto
his bottom, sustaining
multiple fractures.
Instead of blaming thestaff for not keeping
watch on the patient,
the investigationteam recommended
establishing a process
to prioritize the review ofpatients on a timely basis,including rescheduling thepatient if the initial planned
review was missed. The
gap above the partition
and the ceiling was also
closed across all wards
in the hospital to prevent
similar incidents.

7

IACAPAP Textbook of Child and Adolescent Mental Health

6. Identify the potential causes
7. Identify the current control measures
8. Conduct risk prioritization and criticality analysis
9. Formulate and implement new control measures
10. Conduct post-implementation review
11. Document Failure Modes & Effects Analysis and monitor.
Readers can find more information here. Examples of this tool in pediatrics
can be found here.

CULTURE OF SAFETY
Culture eats strategy for breakfast− Peter Drucker
A nurse heard that a patient wanted to die. She did not tell the doctor who
was going to discharge this young man because the doctor had previously scolded
her for interrupting his work. Subsequently, the discharged patient committed
suicide at home.
In this hypothetical example, the team’s culture of safety had a large impact
on the nurse’s decision to keep quiet. Traditionally, physicians are trained to beleaders of the medical team, while nurses are seen as subordinate to physicians.
As such, physicians are deemed more “powerful” compared to nurses. With thisin mind, it is easy to understand our fictional doctor’s and nurse’s actions. As
discussed earlier on systems thinking, we can design systems to make it harder for
staff to do the wrong thing and easier to do the right thing. However, underpinning
all these efforts is culture.
Culture points to a set of shared beliefs, values and goals. In the Joint
Commission International 6th edition (2017) Hospital Standards, a culture of safety

Information
Technology (IT)
System Glitch
In 2018, a glitch with
GPConnect – a clinicaland administrative
system that allows
general practitioners to
submit patient data to
the Singapore National
Electronic Health Record,
resulted in more than 830
patients receiving wronglylabelled medicine. One
patient was instructed totake 10 bottles of coughmixture each time insteadof 10mL, while anotherwas told to take two stripsof tablets instead of two
tablets. As a result, some
general practitioner clinics
had to contact affectedpatients to inform themof the error. The error
was caused by a plannedsystem update that hadgone wrong. This showsthat despite the use of
IT in preventing andmitigating errors, errors
can still occur.

Figure J.8.2* Culture of Safety Framework*Adapted from James Reason, Managing the Risks of Organizational Accidents

Quality J.8

8IACAPAP Textbook of Child and Adolescent Mental Health

Figure J.8.3* Code of Conduct for Safety. Guiding Principles for Each Sub-Culture*Adapted from James Reason, Managing the Risks of Organizational Accidents

is defined as “a collaborative environment in which skilled clinicians treat eachother with respect, leaders drive effective teamwork and promote psychologicalsafety, teams learn from errors and near misses, caregivers are aware of the inherent
limitations of human performance in complex systems (stress recognition), andthere is a visible process of learning and driving improvement through debriefings.”
It is a mammoth task to create and sustain a safety culture that embeds all theseelements but one way to start is to create a framework and code of conduct forsafety to guide staff. An example of a Culture of Safety framework (Figure J.8.2)
is adapted from James Reason’s (1997) book Managing the Risks of Organizational
Accidents and comprises five sub-cultures. Examples of desired behaviours arefurther illustrated in a code of conduct for safety (Figure J.8.3) for staff to relate to.
The interdependent subcultures are:
1. Informed. Risks, hazards and the rationale of policies and procedures
are understood by everyone. This translates into knowing why certain
things are done in a certain manner and for what purpose.
2. Just. A just culture promotes fairness and accountability. This will be
discussed in detail later.
3. Reporting culture. Near-misses, actual incidents, and unsafe conditions
are reported by everyone without fear of reprisals. Data from nearmisses are important, as they may indicate a gap within the current
system which warrants investigation. For example, an incident
reporting information system can be a one-stop portal for reporting.
4. Flexible. Everyone is encouraged to be adaptable and seek continuous
improvement in their work. Decision-making processes may varydepending on how urgent the decision is and the expertise of thepeople involved.

Quality J.8

9IACAPAP Textbook of Child and Adolescent Mental Health

5. Learning culture. Learning points from incidents and data are shared
openly. For example, a quality department tracks and disseminates key
incident reporting statistics throughout the hospital.

Speaking Up
A just culture is paramount to building a strong culture of safety. A justculture emphasizes accountability—everyone is held accountable for their actions.
Indeed, Sammer et al (2009) conducted a literature review and identified justculture as key for patient safety; those intending to report an incident may avoid
doing so if they perceive a potential punitive response or lack of due accountability
after their reporting.
In hospitals, “non-punitive response to errors” is often identified as an areathat needs improvement. To help address this, these hospitals may use the Incident
Decision Tree (Reason, 1997; Figure J.8.4). This decision tree allows investigators
to follow a structured track, ensuring that every incident is investigated in a fair,consistent, and unbiased manner. The decision tree helps to reinforce that staff canfreely report incidents and, if they are involved in incidents, they will be treatedfairly.
Going back to our nurse, what if she had spoken up? Surely this additional
layer in the Swiss Cheese Model would have reduced the likelihood of the patientcommitting suicide at home after discharge. The doctor may rebuke her for
speaking up—in which case, according to our incident decision tree, he would
be considered to have acted inappropriately and disciplined accordingly. So, why
didn’t she?
First, let us consider reasons for speaking up (respectfully, of course):• To stop a medication error• To explore a process for improvement (“flexible culture”), or• To clarify the rationale for certain procedures (“informed/learning
culture”).
In any case, speaking up benefits the speaker, patients, peers, visitors, andthe organization as a whole, and ultimately contributes to a strong culture ofsafety. Conversely, there are reasons why someone would hold back. For example,
Sammer et al’s 2009 study found that staff:• Were afraid of speaking up because it would damage their relationships
with others• Feared negative repercussions after they had spoken up, or• Felt the hierarchical relationships (for example, between doctors andnurses) impeded speaking up.
To address this, various languages that empower healthcare workers to speak
up, so that the team can take a step back before they proceed, were created. They
facilitate staff to speak up respectfully without coming across as overbearing. An
example used by IMH clinical staff is “CUS”:•••

I’m CONCERNED…“I’m concerned you did not change yourgloves…”
I’m UNSURE…“I’m unsure that what you are doing is appropriate
hand hygiene…”
STOP!... “Stop! You really should change your gloves…”

Quality J.8

10IACAPAP Textbook of Child and Adolescent Mental Health

Figure J.8.4* Incident Decision Tree

*Adapted from James Reason, Managing the Risks of Organizational Accidents. The decision tree examines the intent of the employee
involved, considers if the system contributed to the employee’s actions, and ultimately allocates the employee’s culpability.

Burnout
Most of us are in the healthcare industry to help others. It is this sense of
purpose and passion which drives us to provide the best care for patients. Despite
this, 33% of newly registered nurses seek another job within a year (Lucian LeapeInstitute, 2013), while about half of physicians reported at least one symptom ofburnout (Shanafelt et al, 2015). Burnout can be described as three inter-related
symptoms: emotional exhaustion, depersonalisation (detached feeling of self ), anda reduced sense of accomplishment, which leads to loss of purpose and meaning(Fung, 2018).
Burnout can be attributed to various causes. Stephen’s team (Stephen
et al, 2018) found that workload, work/life balance, cognitive dissonance, andclerical work contributed to physician burnout, while compassion fatigue, moral
distress, and work environment issues contributed to nurse burnout. In addition,
courtrooms (which focus on transparency) necessitate physicians’ ethical dilemmas
to be publicly debated. Since their decisions may be scrutinized, physicians become
increasingly defensive in their practice, adding additional stress to their alreadydemanding roles (Fung, 2018). In Singapore’s context, healthcare providers faceever-increasing expectations: to promote healthy lifestyles to prevent disease,provide high-value care, and reach out to communities (encapsulated in Singapore’s
Ministry of Health’s Three Beyonds) with an increasingly aging population.
Moreover, workplace violence also contributes to burnout – 70% of local hospital
staff had experienced physical abuse, and victims may suffer from physical andpsychosocial effects including depression and burnout (Tan et al, 2015). Lastly,
the stigma associated with mental illness often dissuades healthcare providers

Quality J.8

11

IACAPAP Textbook of Child and Adolescent Mental Healththemselves from seeking help due to fear of disclosing what they suffer from (Fung,
2018), further driving them to suffer in silence and eventually burnout (see also
Chapter J.12 of the eTextbook).
Burnout has severe consequences. Lower staff engagement (correlated withworse patient experiences), decreased productivity, and an increased incidence ofworkplace accidents come to mind. In terms of patient care, lower staff engagement
has been associated with lower quality of care and patient safety. Burnout itself
undermines healthcare providers’ empathy – which is crucial to deliver effective
person-centred care (Perlo et al, 2017).

Joy In WorkOne of the ways to address the burnout epidemic is the “Joy In Work”
concept from the Institute of Healthcare Improvement. The concept hinges on theprinciple of leaders and staff co-creating and co-designing solutions, so everyone
achieves their own joy in work (Perlo et al, 2017). It proposes four steps whichleaders can undertake to foster and nurture joy together with their workforce:
1. Ask staff, “what matters to you?” Leaders have to first engage staff tofind what truly matters to them in their work
2. Identify unique impediments to joy in work in the local context.
Leaders have to then identify the processes, issues or circumstances
which prevent staff from achieving these areas – the pebbles in the shoes(small impediments) and boulders (large systemic barriers)
3. Commit to a systems approach to making joy in work a shared
responsibility at all levels of the organization. Systems approach meansthat everyone, from leaders to clerical staff, have a role to play. Here,the designing of solutions together with staff is strongly encouraged.
Top-down approaches that neither consider staff’s opinions nor involve
their participation goes against the very notion of having joy in work.
4. Use improvement science to test approaches to improving joy in workin your organization.
The Institute of Healthcare Improvement’s framework for improving “Joy
In Work” summarizes nine components where senior leaders, middle managers,
and individuals can work together to achieve enjoyment (Perlo et al, 2017). Detailsof this framework are available here. Briefly, the nine components are:
1. Physical & psychological safety. Individuals feel physically safe in theirworkplace. They also feel psychologically safe enough to openly admit
mistakes, seek honest feedback, and are provided with support should
they be involved in an adverse event
2. Meaning & purpose. Individuals know their daily work contributes tothe organisation’s mission
3. Choice & autonomy. Individuals have the flexibility to complete tasks
the way they deem best
4. Recognition & rewards. Not limited to monetary rewards, leadersrecognise colleagues’ contribution and celebrate team accomplishments
5. Participative management. Leaders take into account inputs andsuggestions from colleagues when making decisions

Quality J.8

12IACAPAP Textbook of Child and Adolescent Mental Health

6. Camaraderie & teamwork. Leaders create conditions for teams to bondthrough social cohesion (i.e., team members feel supported, appreciateeach other, and feel part of the team)
7. Real-time measurement. There are feedback systems in the organisation
to monitor improvement efforts
8. Wellness & resilience. Individuals are able to “bounce back” after
setbacks, stress management, and general well-being
9. Daily improvement. Quality improvement methodologies are used totest and implement daily improvement efforts.

IMPROVEMENT
Not all change is improvement but all improvement ischangeAnonymous
Deming (2000) introduced the “system of profound knowledge” in his
book The New Economics, where he viewed improvement through four lenses:
1. Appreciation of the system (discussed in the systems thinking section)
2. Understanding variation (more on this in the variation section)
3. Psychology. Understanding and managing people’s motivations,intrinsic and extrinsic needs is key to driving efforts towards a common
goal
4. Theory of knowledge. A body of knowledge is formed with lessons
from “Plan-Do-Study-Act” (PDSA) cycles. This knowledge allows to
predict future tests which involve other theories or hypotheses (moreon this in the Plan-Do-Study-Act section).
Deming’s lenses allow us to view improvement holistically. All four parts
must work together to achieve improvement. For example, a team may schedulefamily meetings in the morning because it is the most convenient time to get theteam together, but it may be very inconvenient for families because of work andschool commitments, which may add to family stress. In this example, the team’s
psychology was addressed (intrinsic motivation for the team as it is convenient forthem), but the systemic viewpoint, or wider picture, was neglected.
The model for improvement shown in Figure J.8.5 provides a simple
framework for quality improvement (QI) practitioners. It asks improvement
leaders:••••

What are we trying to accomplish? (“What is the aim or purpose of
the project?”)
How will we know that a change is an improvement? (“What measuresor indicators need to be measured so we know if there is a change?”)
What change can we make that will result in improvement? (“Whatinterventions can be made to effect the desired improvement?”)
The “Plan-Do-Study-Act” (PDSA) cycle for continuous testing, analysis
and refinement follows these questions.

Quality J.8

13

IACAPAP Textbook of Child and Adolescent Mental Health

Figure J.8.5* A Model for Improvement.

*Reproduced from The Improvement Guide: A Practical Approach to Enhancing
Organizational Performance, 2nd Edition. 2009. John Wiley and Sons (Langley etal, 2009), available here.
PDSA, a quality
improvement
methodology

Plan-Do-Study-Act (PDSA) Cycles
To improve healthcare, it is not enough to have good treatments thatwork—what we often call evidence-based treatments. These treatments should beapplicable in the real world in a safe, affordable, accessible, timely, and effective
manner. This kind of evidence-based delivery system can be evaluated using
improvement methodologies.
One of the basic improvement methodologies is the Plan-Do-Study-Act
model (for more information please click here). It provides a framework for
improvement, allowing teams to test changes on a small scale before implementing
them on a larger scale or in other services:
•

•
•
•

•
•
•
•

Plan theimprovement
Do the improvement
process
Study the results
Act to hold the gain
and continue toimprove the process.

Plan: identifying a problem, why practices need to change to solve theproblem, how this is to be achieved, how to implement and measurechange and when to start
Do. This is the action phase in which the plan is carried out, data iscollected and observations madeStudy: analysing the data, comparing it with expectations andsummarizing findings
Act. Adapting the changes and implementing them. A new cycle would
then start.

In the case example in page 15, the team used the Plan-Do-Study-Act cycle.
A flow chart of progress was constructed to identify key gaps. A patient focus
group was held to obtain feedback from 15 patients who had witnessed disruptive

Quality J.8

14

IACAPAP Textbook of Child and Adolescent Mental Health

Case Example
Johnny is a 10-year-old boy with an aggressive streak. He was admitted to hospitalfor nine days after staff at the children’s home where he was living were unable to containhis angry outbursts. One morning Johnny decided he wanted to leave the ward. He took
his bags, walked to the locked door and began kicking, banging and shouting at the door.
Ahmad, another inpatient, was annoyed by Johnny’s behaviour and punched Johnny in theface.
Over a 21-month period, the child psychiatric ward had reported 206 patient-related
incidents. The ward had one of the highest assault rates, five times higher than the rest of thehospital. A clinical practice improvement team was set up to find ways of reducing disruptive
behaviours in the ward by 50% within six months. Disruptive behaviour was defined as
aggression towards self, others, property, and the environment, which resulted in injury or
significant damage to objects. The team hypothesized that a reduction in patients’ disruptive
behaviour would lead to a reduction in assaults and self-harm (hospital quality indicators).

behaviours. A cause and effect diagram (click here to learn more about the cause
and effect diagram) and a Pareto diagram were constructed with three root causes
identified:•••Inability of patients to regulate their emotions when triggered
Lack of staff training in managing disruptive patients
Prolonged hospital stays due to lack of community support.

With the root causes identified, the team brainstormed and piloted various
interventions. For the first identified root cause (patients’ difficulty regulating theiremotions):••

Individualized behavioural modification programs were provided forthe disruptive children
A “cool down corner” was implemented to give patients alternative
ways of coping with stressors. This was a special place that promoted
de-escalation and regulation of emotions. The room contained items
to distract, soothe, and calm patients through sight, sound, and visual
aids. The goal was to help patients develop practical skills that could be
used in other settings and after being discharged. The use of the room
also enabled staff to de-escalate situations without the need to resort torestraint or seclusion. Unlike seclusion rooms, which are often sterile
environments devoid of any stimulation, this room offered adaptive
activities.

For the second identified root cause, members of the team who had
experience in managing disruptive patients shared strategies with the rest of thestaff and selected staff members attended external training in this area.
For the third identified root cause, discussions and case conferences wereconducted with step-down agencies to understand and address their needs, andtraining was provided for community partners to upskill them to better manage
patients following discharge.
With this multipronged approach, the ward saw an 80% reduction in
disruptive behaviour incidents. Beside cost savings, patients, caregivers and staff
reported an increase in satisfaction in the hospital stay.

Quality J.8

15

IACAPAP Textbook of Child and Adolescent Mental Health

Figure J.8.6 Pareto Diagram is a type of chart whose purpose is
to highlight the most important factors that can cause a problem.
Individual factors are represented in descending order by bars, and thecumulative total is represented by the line.
1098Number of Votes

93.9

8

100.0

100

80

81.8

60

6
57.6

4

4
30.3

2

0

Lack of Interesting
Structured Activties

40

2

Lack of Community Unwell Mental State
Lack of Staff
Support Leading toTraining on
Prolonged
Management of
Hospitalization
Disruptive Patients

Noise Pollution

Percentage (%)

10

20

0

Causes Disruptive Behaviour

Figure J.8.7 Cool Down RoomMeasurement
We must be clear about what we want to accomplish and how we willknow that improvement has occurred (meaning that results should be measured).
Measurement should be used to learn about the system rather than for reward or
punishment. There are three types of measures:•••

Outcome, which measures the variables the project or system aims toachieve
Process, which measures if certain processes are on track to drive thedesired outcome
Balance, which measures if interventions to one part of a system are
impacting other parts within the system. Balance measures are usefulwhen employing a system-thinking approach to avoid “patchwork”
solutions.

Quality J.8

16

IACAPAP Textbook of Child and Adolescent Mental Health

Figure J.8.8
Driver Diagram outlining the strategies used to reduce disruptive behaviour incidences in IMH’s child ward. The primary drivers drive the specific aim, while the secondary drivers contribute to the primary drivers. Change ideas are specific interventions which contributeto the secondary drivers.
Aim

Primary Drivers

Secondary Drivers

Occupy patients withmeaningful activities
Incident prevention &management
Reduce disruptive
behaviour incidences inchild ward

Tertiary Drivers (Change Ideas)

Update ward time-table with interesting
activities

Develop individualized behaviour modification
plan
Engage more volunteers to conduct activities

Train internal staff tomanage incidents

Share knowledge and skills within the multidisciplinary team
Attend internal and external lectures, workshop& courses
Organize conferences with external partners to
discuss discharge plan/datePatient support

Provide community support
to patients

Participate in field trips to other welfareorganizations
Train external staff to manage patients

We can make use of a driver diagram to determine which measures to track.
Figure J.8.8 depicts a driver diagram, using our case example as reference. It shows
the causal links between the aim, primary drivers, secondary drivers and the change
ideas. There are various ways this tool can be used. For example, the outcome
measure can track the aim, while the process measures can track the primary andsecondary drivers. Alternatively, if we were to embark on a smaller-scale QI project
which tests one change idea, the aim of that QI project itself could be an outcome
measure – whereas the various interventions being tested to drive the aim could betracked as process measures. For more information on driver diagrams click here.

Data
Data is captured in a number of ways. It can be in the form of outputs (suchas number of patients seen), or outcomes (such as whether patients are getting
better), or in the form of complications (such as medication side effects) or adverse
events. Trends can then be examined and compared over time. Comparing (orbenchmarking) consists of taking these data and comparing it either with similar
data in a different period or with data from other services, locally or internationally.
Data can be a collection of facts and figures that have little utility or, if
properly used, can be informative. Let us take the example of the number ofpatients seen in a clinic. One could use this as output data. A simplistic way ofinterpreting it would be to assume that seeing more patients would indicate that ateam is doing well because it has increased output. But whether patients are getting
better is unknown. Therefore, having a set of measures may be useful: have they
improved? Are there adverse outcomes?

Quality J.8

17IACAPAP Textbook of Child and Adolescent Mental Health

Employing data as an indicator of performance is starting to be used widelyin psychiatry and behavioural health. Some commonly used indicators include
the rate of falls, suicides, assaults, choking episodes, adverse events, readmissions
to hospital (within a specified time frame, usually 30 days), and mortality perhospital days. Some common indicators and their use can be found at the following
websites (click on the name to access):
•
•
•
•
•

The Joint Commission International (JCI). International Library of
Measures
Organization for Economic Co-operation and Development (OECD).
OECD Health Statistics
The Australian Council on Healthcare Standards. Australasian Clinical
Indicators Report
National Health Service (England). Statistics
Ministry of Health Singapore. Statistics

The following indicators are used in child and adolescent psychiatry services
in Singapore:
•
•
•
•
•
•
•

Falls
Assaults
Episodes of restrain
Readmissions to hospital
Average length of stayAdverse events
Bed occupancy rate

Regular and continuous measurement of important indicators specific to
psychiatric practice is the best method to obtain accurate data. Data collection
can be done in a number of ways. One way is to embed these indicators as partof regular practice. This can be done by including relevant rating scales or formsin everyday practice or using technology to capture data in systems, automating
measurement and analysis. A more traditional form of data collection is via audit,
to measure outcomes through sampling. Feedback from patients and families isalso useful data. In many hospitals, adverse events and near misses are reported
and captured. A newer approach to identifying adverse events is through the useof “trigger” tools that are part of auditing electronic medical record systems. Clickhere to view a tool developed by the Institute for Healthcare Improvement.
Once data are regularly measured and monitored, problems worth addressing
can be identified. Problems worth solving are those that:•••

Occur frequently
Result in severe adverse outcomes such as death or disability
Significantly concern staff and patients.

Variation
Moving on to Deming’s second lens (understanding variation), continuous
improvement in healthcare systems requires measuring and understanding ofprocess variation. Variation is always present in any measurement – it can be

Quality J.8

18

IACAPAP Textbook of Child and Adolescent Mental Healthvariation from one period to the next, or between different instruments. A key
concept in quality improvement is that variation comes from two sources:••

Common cause variation. This is the “background noise” that is inherent
in the system and cannot be eliminated. It affects all outcomes. For
example, the average length of stay of patients discharged from achild psychiatry facility typically exhibits random month-to-monthvariation, even in the absence of any significant change in system
performance or patient profile.
Special cause variation. This is the part of variation that is unusual, andtypically not part of the system. For example, in manufacturing this
could be related to a defect in raw materials, or equipment breakdown.
Special cause variation can represent both process improvement or
deterioration. For example, during a period of bed shortage, physicians
are compelled to discharge patients sooner, resulting in a decline inlength of stay.

A system that has only common cause variation is said to be stable and incontrol. A system with both common and special cause variation is said to beout of control. However, a system which is out of control is not necessarily a badthing. This is because in improvement work, when interventions are tested, there
are three possible outcomes:• The intervention does not produce significant change (i.e., systemremains stable)• The intervention produces undesirable change, or• The intervention produces desirable change.
In order to reduce common cause variation, the process can be examined. For
example, establishing clinical guidelines for specific psychiatric conditions maylead to a reduction in variation in length of stay. To better visualize the changes
and its associated variations, QI practitioners typically plot control charts totrack their measures.

Control Charts
A control chart is a chronological plot of measurements of a variable overtime – the most common examples in healthcare include waiting times, medication
error rate, number of falls, readmission rates, number of adverse events, length ofstay, etc.
Control charts can alert us when a significant shift in the process occurs
and when actions need to be taken. This prevents over- or under-reaction to thedata. There are many types of control chart, depending on whether the measure
is discrete (also called “attribute” data) or continuous (also called “variable” data).
They differ in how the standard deviation is estimated. Nevertheless, the same rules
apply to all control charts. Interested readers may refer to the texts by Montgomery(2009), Murray & Provost (2011), Ryan (2011), and Woodall et al (2012).
In summary, control charts can yield much insight into the performanceof a process, and can tell us if the tested intervention produces a desirable change(i.e., improvement) with minimal mathematical complexity. However, how do wedetermine the value of interventions?

Quality J.8

Click on the image below
to go to IHI’s video library.
Control charts are describedin the section “Whiteboard
Videos”

19IACAPAP Textbook of Child and Adolescent Mental Health

Value
Assessing the impact of a new intervention will eventually, regardless of theevaluation method, lead to questions of value—does this new program add value
to our services? This often goes beyond mere cost because advances in healthcare
tend to be more effective but also more expensive. As a result, health economists
usually consider the degree to which society assigns value to a given outcome tojustify the added expense.
Unlike cost, which can be derived quite objectively, assigning value is moredifficult. Estimating value is largely subjective and various stakeholders may havedifferent opinions, leading to different valuations. An entire branch of healtheconomics is devoted to the concept of value, preferences, and the greater public
good.
Dartmouth Medical School developed the idea of a value compass forhealthcare (Nelson et al, 1996). This compass is similar to a directional compassthat has four points—four aspects of healthcare processes that measure quality:
•
•
•

•

North: functional status, risk status, and wellbeing
South: costs (both direct and indirect)
East: satisfaction with the care. In children and adolescents, satisfaction
may be tempered by what the caregivers and other responsible adults
want, and this is usually a balance between the patient, the family andtheir concerns
West: clinical outcomes.

These four aspects provide a balanced yet comprehensive measure to monitor
quality in healthcare.

Cost Effectiveness
Clinical trials of mental health interventions often prove efficacy without
providing information about real world effectiveness. Analysis of cost effectivenesstakes into account the cost of the intervention in relation to the clinical benefit.
Quality of life in mental disorders is an important aspect, beyond improvement ofclinical symptoms. However, most mental health outcome measurement focuseson symptom amelioration with little consideration of its impact on functioning.
Measurement of the quality of life is therefore necessary. Additionally, with therapid advances in modern medicine, most people recognize that no healthcare
system in the world is able to commit to every intervention available. Needless tosay, governments and policy makers are constantly faced with difficult decisions
about the allocation of scarce financial resources. Hence, it makes sense to focus oninterventions that will improve individuals’ quality of life the most.
Economic evaluation of healthcare interventions is one of the tools that
help guide decision making in this challenging environment. The concept of
Quality Adjusted Life Years was originally developed to measure effectiveness or
improvement for cost effectiveness analysis (Weinstein & Stason, 1977). Thisapproach takes into account both quantity and quality of life. The former isexpressed in terms of life expectancy or, alternatively, whether the individual is deador alive. The latter embraces the entire spectrum of an individual’s life, not only
their health status, and consists of a range of components such as an individual’s

Quality J.8

20

IACAPAP Textbook of Child and Adolescent Mental Healthphysical, social, and cognitive wellbeing. Several instruments have been developed
to measure Quality Adjusted Life Years in the young such as:•••

EuroQol-5-Dimensional-Youth (EQ-5D-Y) (Wille et al, 2010)
Assessment of Quality of Life (AQoL)-6D (Moodie et al, 2012)Child Health Utility 9D (CHU9D) (Stevens, 2012).

Economic evaluations are now well documented in a range of populations
and healthcare systems. For example, the use of EuroQol-5-Dimensional-Youth toassess cost effectiveness in mental health conditions such as depression, psychosis,
and severe and complex non-psychotic disorders in adults (Subramaniam et al,2013); the Self-Reporting Questionnaire 20 items in adult community mental
health services (Harpham et al, 2003); SF-6D and EQ-5D in a study of adults withschizophrenia (McCrone et al, 2009); Youth Outcome Questionnaire 30.1 (YOQ-30.1) in children with ADHD, adjustment disorder, bipolar, post-traumaticstress disorder, and psychotic disorders (Dunn et al, 2005); and EQ-5D for severe
dyslexia in children (Hakkaart-van Roijen et al, 2011).
While recognizing the usefulness of economic evaluations in allocating
scarce resources, it should be emphasized that such measurements are seldom
available for mental health populations, especially in children and adolescents.
This is surprising given that more than half of mental disorders start in childhoodor adolescence and persist through adult life, affecting individuals’ functioning andproductivity over the lifespan (Kim-Cohen et al, 2003).

Patient Reported Outcome Measures
Patient reported outcome measures include a vast array of self-reported
tools. These measures have not been used consistently in psychiatry because
patients may lack insight. As such, an external assessment of an individual’s state
has conventionally been considered to hold more merit than the individual’s selfreport. However, greater efforts are being made to expand routinely collected data
to include patients’ judgements of their own condition.
Patient reported outcome measures have been shown to be more robust
predictors of future psychiatric rehospitalisation than more “objective” forms ofdata (Shadmi et al, 2018). Quality of life scores, as reported by psychiatric patients,
self-reported functional ability, and symptom interference have been shown tosignificantly predict the risk of future psychiatric hospitalization.
Interest in obtaining patients’ perspective has extended into various
paediatric disciplines (Bevanset al, 2010; Edbrooke‐Childs et al, 2017). Children
as young as five have been shown to be able to complete accurate reports of their
quality of life, when given age appropriate tools (Varni et al, 2007).

QI BY INDIVIDUAL PRACTITIONERSIndividual practitioners can use the above-mentioned QI principles in their
daily work. Referring to the IHI Model for Improvement in Figure J.8.5, oncea target has been established, individuals must measure their work in order totest interventions using the Plan-Do-Study-Act model. For example, individual
clinicians can measure patient outcomes or satisfaction over time to determine
if their work or changes in their practice are leading to the desired outcomes.

Quality J.8

21

IACAPAP Textbook of Child and Adolescent Mental Health

These activities are increasingly being used in some countries for re-certification
purposes.

SPREADING AND SUSTAINING IMPROVEMENT
The success of a QI project will provide the impetus for wider implementationof the changes at other departments or units. Spreading the changes yields greater
returns on initial investment and creates a renewed sense of satisfaction and pride
when changes are being adopted elsewhere.
There are various components to consider when spreading. The Institute of
Healthcare Improvement’s Framework for Spread (Figure J.8.9) describes them.
In essence, leaders have to ensure that spread efforts are aligned to organizational
goals and appropriate “sponsors” identified to drive such improvement.
Once the improvement has been spread, the improvement team should
ensure that the improvement is sustained. Unfortunately, teams are often set up to
temporarily work on a problem and the initial gains achieved are lost when the teamdisbands. An improvement process that pays no heed to creating conditions for
spreading and sustaining the changes will be unable to hold the gains; sustainability
does not happen automatically after the improvement is made. Instead, sustaining
improvement requires planning to change the backbone of the process after
the project has come to an end. This may involve standardization of processes,
documentation of associated policies, procedures and guidelines, measurement
and review to ensure changes become incorporated into daily practice, training andeducation of staff, and sharing of measurement and status of initiatives (National
Healthcare Group Quality Resource Management Department, 2017).
Figure J.8.9 IHI’s Framework for Spread.

Quality J.8

22

IACAPAP Textbook of Child and Adolescent Mental Health

Table J.8.1
In his book Diffusion of Innovations, Everett Rogers (2013), wrote that changes
are adopted by different individuals at different speeds. He introduced the following categories
of “adopters”
Category

Characteristics•

Innovators

Risk-takers open to new ideas and concepts or who
may themselves be the originators of such ideas
and concepts
May not have sufficient influence over the general
population to serve as change champions• Minimal persuasion

Not as open as innovators, but are still willing to try
out new ideas with a bit of convincing
Possible opinion leaders, useful for propagatingchange as change champions• Explain and provide packages tospread new ideas• Minimal data to assure

Wait for confirmation of the idea’s effectivenessfrom the early adopters
Willingly adopt the idea once they are convinced• Share successful stories of how theidea helped others• Show evidence of the idea’s
effectiveness••

Sceptical of new ideas
Tend to stick to the old ways of doing things since
they are already “good enough”• Utilize change champions for peer
influence• Show evidence of the idea’s
effectiveness• Share statistics on how many people
have already embraced the idea•

Traditionalists who take time to accept new ideas,
they will only adopt the new idea when there are noother alternative
Possible opinion leaders, who can shut down ideas
quickly• Utilize change champions for peer
influence• Eliminate existing processes to ‘force’them to adopt the new idea

•
•

Early
Adopters

Early
Majority

Late
Majority

Laggards

Engagement strategy

•
•
•

•

INNOVATION
Innovation can be defined as “the intentional introduction and application
within a role, group, or organization, of ideas, processes, products or procedures,new to the relevant unit of adoption, designed to significantly benefit theindividual, the group, or wider society” (West, 1990). This definition encompasses
the three key components of innovation: novelty or new idea, an applicationthat can be implemented, and that it is beneficial. In healthcare, the need forinnovation is complicated because it needs to be safe and beneficial in ways that are
ethically acceptable. Because innovation involves risk, this balance is important.
When looking at innovation in healthcare we refer for the most part to biomedical
innovation, new treatments and technologies that achieve better outcomes. Thereis also health systems innovation that targets improvements in efficiency and cost
reduction, resulting in better use of resources (Ellner et al, 2015). These innovations
are particularly important in creating better value for patients.
One example of innovation is the tele-dermatology service introduced to
IMH patients in 2006. This joint collaboration with the National Skin Centre

Quality J.8

23

IACAPAP Textbook of Child and Adolescent Mental Healthmeant that IMH patients need not travel for their dermatology consultations,instead they are reviewed by dermatologists via webcam in the comfort of theirwards. By combining technology and innovation, this managed to bring value topatients and staff alike.
Another example of innovation is RegnaTales—a series of six mobile gameapplications developed to motivate, engage, and equip children and youths withanger management, problem-solving, and social skills through interactive andgamification elements. RegnaTales was developed based on the Social ProblemSolving Skills Training Program for anger management (Ooi et al, 2015), which
follows closely the cognitive-behavioural framework. Through RegnaTales, a muchlarger population—both clinical and non-clinical—can be reached. More details
on the effectiveness of RegnaTales can be found here.

CONCLUSIONS
Quality is never an accident; it is always the result of highintention, sincere effort, intelligent direction and skilful
execution; it represents the wise choice of many alternatives
William A Osler
Improvement science is new to healthcare largely because healthcare is
generally resistant to change. This is the unfortunate effect of the noble tradition of
medicine where physicians are taught early that there is a specific way in which to
do things that has been handed down for many years. Some of these methods aresupported by little evidence. For example, doctors are traditionally taught to takea good history, perform a physical examination and then conduct investigations.
With the advent of new technologies, this may not necessarily be the most efficientor cost-effective method, yet few studies have explored this. Quality improvement
has moved many industries towards achieving perfection by error-proofing systems
rather than relying on flawed human approaches. We are not proposing radical
change, without concern for safety, but to study the systems we have today and to
improve them.

••

Do you havequestions?
Comments?

Click here to go to the
Textbook’s Facebook
page to share yourviews about thechapter with otherreaders, question theauthors or editor andmake comments.

Quality J.8

24

IACAPAP Textbook of Child and Adolescent Mental Health

REFERENCES
Batty MJ, Moldavsky M, Foroushani PS et al. (2013).
Implementing routine outcome measures in childand adolescent mental health services: from present
to future practice. Child and Adolescent Mental Health
18:82-87.
Berwick D (1996) A primer to leading the improvement ofsystems. BMJ 312:619-622.
Bevans KB, Riley AW, Moon J et al (2010). Conceptual andmethodological advances in child-reported outcomesmeasurement. Expert Review of Pharmacoeconomics &Outcomes Research 10:385-396.
Cappelleri JC, Zou KH, Bushmakin AG et al (2013). PatientReported Outcomes: Measurement, Implementation andInterpretation. CRC Press.
Chapman SM, Fitzsimons J, Davey N et al (2014). Prevalenceand severity of patient harm in a sample of UKhospitalised children detected by the Paediatric Trigger
Tool. BMJ OpenClassen DC, Resar R, Griffin F et al (2011) ‘Global trigger tool’
shows that adverse events in hospitals may be tentimes greater than previously measured. Health Affairs
30:581-589.
Committee on Quality in Healthcare in America (2001).
Crossing the Quality Chasm: A New Health System
for the 21st Century. Washington, DC: National
Academies Press.
Deming WE (2000). The New Economics: For Industry,
Government, Education. MIT Press
Dunn TW, Burlingame GMM, Walbridge M et al (2005).
Outcome assessment for children and adolescents:
Psychometric validation of the youth outcome
questionnaire 30.1. Clinical Psychology andPsychotherapy 12:388-401.
Edbrooke‐Childs J, Barry D et al (2017). Patient reported
outcome measures in child and adolescent mental
health services: associations between clinician
demographic characteristics, attitudes and efficacy.
Child and Adolescent Mental Health 22:36-41.
Ellner AL, Stout S, Sullivan EE et al (2015). Health systems
innovation at academic health centers: Leading in a
new era of health care delivery. Academic Medicine.
Fung D (2018). Creating value and valuing creation: caring
for our doctors. Singapore Medical Association (SMA)
News, pp 5-7.
Hakkaart-van Roijen L, Goettsch WG, Ekkebus M et al (2011).
The cost-effectiveness of an intensive treatment
protocol for severe dyslexia in children. Dyslexia
17:256-267.
Harpham T, Reichenheim M, Oser R et al (2003). Measuringmental health in a cost-effective manner. Health Policy
and Planning 18:344-349.
James JT (2013). A new, evidence-based estimate of patient
harms associated with hospital care. Journal of Patient
Safety 9:122-128.

Quality J.8

Joint Commissions International (6th Edition) (2017).
Governance, Leadership and Direction-Intent of GLD.13
and GLD.13.1, pp 230.
Kim-Cohen J, Caspi A, Moffitt TE et al (2003). Priorjuvenile diagnoses in adults with mental disorder:
Developmental follow-back of a prospectivelongitudinal cohort. Archives of General Psychiatry
60:709–717.
Kohn LT, Corrigan JM, Donaldson MS (2000). To Err is
Human: Building a Safer Health System. Washington,
DC: National Academies Press.
Langley GJ, Moen RD, Nolan KM et al (2009). The
Improvement Guide: A Practical Approach to
Enhancing Organizational Performance, 2nd Edition.
2009. John Wiley and Sons.
Leape L, Lawthers AG, Brennan TA et al (1993). Preventing
medical injury. Quality Review Bulletin 19:144-149.
Lucian Leape Institute. (2013). Through the Eyes of the Workforce- Creating Joy, Meaning, and Safer Health Care.
National Patient Safety Foundation.
McCrone P, Patel A, Knapp M et al (2009). A comparison of
SF-6D and EQ-5D utility scores in a study of patientswith schizophrenia. Journal of Mental Health Policy
and Economics 12:27-31.
Montgomery D (2009). Introduction to Statistical Quality
Control. Hoboken, New Jersey: Wiley.
Moodie M, Richardson J, Rankin B et al (2010). Predicting timetrade-off health state valuations of adolescents in four
Pacific countries using the Assessment of Quality-ofLife (AQoL-6D) instrument. Value Health 13:10141027.
Murray S, Provost L (2011). The Health Care Data Guide:
Learning from Data for Improvement. San Francisco,California: Jossey-Bass.
National Healthcare Group Quality Resource Management
Department (2018). The Failure Modes & Effects
Analysis Handbook. Singapore: National Healthcare
Group.
National Healthcare Group Quality Resource Management
Department (2017). The NHG Quality Improvement
Toolkit. Singapore: National Healthcare Group.
Nelson EC, Mohr JJ, Batalden PB, Plume SK (1996). Improving
health care, part 1: The clinical value compass. Joint
Commission Journal on Quality Improvement 22:243–
258
Ooi YP, Ang RP, Lim-Ashworth N (2015). Effective Anger
Management for Children and Youth-The Manual.
World Scientific.
Perlo J, Balik B, Swensen S et al (2017). IHI Framework for
Improving Joy in Work. Cambridge, Massachusetts:
Institute for Healthcare Improvement.
Perper JA, Cina SJ (2005). When Doctors Kill: Who, Why, andHow. New York: Copernicus Books, p111.

25

IACAPAP Textbook of Child and Adolescent Mental HealthReason J (1997). Managing the Risks of Organizational Accidents.
Ashgate.
Rogers E (2003). Diffusion of Innovations, 5th Edition. Simonand Schuster.
Ryan T (2011). Statistical Methods for Quality Improvement.
Hoboken, New Jersey: Wiley.
Sammer CE, Lykens K, Singh KP et al (2009). What is patient
safety culture? A review of the literature. Journal of
Nursing Scholarship 42:156-165.
Shadmi E, Gelkopf M, Garber-Epstein P et al (2018). Routine
patient reported outcomes as predictors of psychiatricrehospitalization. Schizophrenia Research 192;119-123.
Shanafelt TD, Hasan O, Drybye LN et al (2015). Changes inburnout and satisfaction with work-life balance inphysicians and the general us working population
between 2011 and 2014. Mayo Clin Proceedings
90:600-1613.
Slonim AD, LaFleur BJ, Ahmed W et al (2003). Hospitalreported medical errors in children. Pediatrics
111:617-621.
Stephen S, Steven S, Namita SM (2018). Leadership Survey:
Immunization Against Burnout. NEJM Catalyst, 1-13.
Stevens K (2010) The Child Health Utility 9D (CHU9D). A
new paediatric preference based measure of healthrelated quality of life. PRO Newsletter #43. May
Subramaniam M, Abdin E, Poon LY et al (2013). EQ-5D as ameasure of programme outcome: Results from theSingapore early psychosis intervention programme.
Psychiatry Research 215:46-51.

Quality J.8

Tan AL, Chia GSZ, Ng BY et al (2015). Violence against
healthcare staff – A multidimensional problem. Annals
Academy of Medicine 44:511-513.
Varni JW, Limbers CA, Burwinkle TM (2007). How young canchildren reliably and validly self-report their healthrelated quality of life? An analysis of 8,591 children
across age subgroups with the PedsQL™ 4.0 GenericCore Scales. Health and Quality of Life Outcomes 5:1.
Weinstein MC, Stason WB (1977). Foundation of costeffectiveness analysis for health and medical practice.
New England Journal of Medicine, 296:716-721.
Weiss EM et al (1998). Deadly restraint: a Hartford Courant
investigative report. Hartford Courant, October 11-15.
West MA (1990). The social psychology of innovation in groups.
In MA West & JL Farr (eds), Innovation and Creativity
at Work: Psychological and Organizational Strategies.
Chichester, UK: Wiley, pp309-334.
Wille N, Badia X, Bonsel G et al (2010). Development of theEQ-5D-Y: A child-friendly version of the EQ-5D.
Quality of Life Research 19(6): 875-886.
Woodall W, Adams B, Benneyan J (2012). The use of control
charts in healthcare. In Faltin W, Kenett R & Ruggeri
F (eds), Statistical Methods in Healthcare. Hoboken,
New Jersey: Wiley, pp253-267.
World Health Organization (2011). Topic 2: What is humanfactors and why is it important to patient safety? In:
Patient Safety Curriculum, Multi-Professional Edition.

26