PATIENT INFORMATION

McLEAN HOSPITAL QUALITY IMPROVEMENT

The McLean Hospital Quality Improvement Program provides direction and support for the organization's commitment to design, measure, assess and improve its performance in concert with the Hospital's mission of excellence in patient care, teaching and research. The Quality Improvement Program is designed to maintain and enhance patient, staff and visitor safety and to improve the environment of care.

To promote and provide the coordinated, ongoing and systematic measurement and improvement of the organization's performance and patient outcome.
To provide a coordinated and integrated system for hospital-wide assessment and improvement of interrelated governance, management, safety, support and clinical care processes that affect patient outcome including standards compliance.
To assure the provision of a comparable level of care for all patients with the same health problems and acuity.
To promote the safety and well being of patients, staff and visitors through loss prevention and risk reduction activities.
To promote effective and efficient utilization and integration of services.
To provide a database to assist the Credentials Committee and Department Heads in the review of the performance of members of the Clinical Staff. This review includes delineation of clinical privileges and appraisal of those individuals not permitted to practice independently.
To provide for the identification of continuing education needs.

PROGRAM FUNCTION

The Quality Improvement Program is intended to ensure an organization-wide systematic process for the design, measurement, assessment and improvement of the organization's performance. The Continuous Quality Improvement Program is carried out via collaborative multidisciplinary work groups.

McLean Quality Measurement and Reporting Activities

McLean Hospital's Department of Mental Health Services Evaluation reports on quality indicators to support McLean administrators and clinicians in their quest to furnish the best patient care. McLean's quality measurement efforts help strengthen our relationships with patients and other constituencies and help enhance our care through targeted feedback to clinical programs and administrative leadership McLean's quality indicator reporting is comprised of three levels of patient care reporting:

BASIS-24 outcomes measurement
Patient "Perceptions of Care" measurement
Administrative indicator measurement

BASIS-24 is a twenty-four item self-report questionnaire given to all inpatients on admission and discharge to assess treatment outcome by measuring symptoms and functional difficulties. Upon viewing aggregate results of the change in score from admission to discharge, McLean administrators and clinical leaders can assess the degree of patient improvement across each patient care unit and the hospital at large.

The Perception of Care survey is McLean's tool for measuring patient satisfaction and obtaining feedback on service quality.

McLean also reports on what we term "administrative indicators," which include statistics on medication errors, patient assaults, restraint/seclusion, and readmissions. We report data as a percent of patient days.

Results for some indicators are transmitted directly to the Joint Commission on Accreditation of Healthcare Organizations as part of their requirement that all psychiatric hospitals collect and report on quality indicators.

The Department of Mental Health Services Evaluation also assists other psychiatric health care organizations with quality measurement. If you represent a health care organization interested in knowing more about McLean's quality measurement services to other psychiatric facilities, please visit the McLean BASIS plus™ web site for details.

McLean Hospital
115 Mill Street
Belmont, Massachusetts 02478

Tel: (617) 855-2424
Fax: (617) 855-2948
Email: spereda@mcleanpo.mclean.org