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Learning from top performers

February 1, 2008
by Susan L. Rushing and Paul M. Lefkovitz, PhD
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Texas community mental health centers work together to address differences in use of state hospital beds

Texas has ten state-operated psychiatric inpatient hospitals with a total of 2,477 beds. In a growing state with increasing demand for psychiatric services, it is important that these critical public resources are used judiciously. The task of managing state hospital bed utilization belongs to the state's community mental health centers, most of which serve as local mental health authorities that approve admissions and coordinate lengths of stay.

Together, the centers have successfully managed to keep statewide bed utilization below 100% of authorized capacity. However, an examination of bed utilization patterns showed significant variance among the centers, with some exceeding their allocation and others utilizing far fewer beds. Concerns surfaced that the centers exceeding their allocations might face possible financial sanctions. The Texas Council of Community Mental Health & Mental Retardation Centers, the statewide trade association that works on behalf of the community centers, agreed to sponsor a more formal study to determine if best practices for managing state hospital bed utilization could be identified.

Process Benchmarking

A method known as process benchmarking1 was selected as the vehicle for the investigation of best practices. Process benchmarking is a technique that employs benchmark data as a starting point in identifying promising or best practices. Process benchmarking was developed by Behavioral Pathway Systems. The Texas Council and BPS entered into an agreement to conduct a series of process benchmarking projects, commencing with the utilization of state hospital beds.

Process benchmarking is based on the simple premise that top-performing organizations use different methods than other organizations, which account for their notable level of performance. Process benchmarking systematically contrasts the strategies used by top-performing organizations with other organizations’ strategies. Those tactics that prove to distinguish top performers from others are regarded as potential best practices.

Process benchmarking typically is conducted in workshop-type settings with the aid of anonymous audience-polling technology. Participants come prepared with their organization's measured performance in the designated domain of inquiry. First, top performers are identified. Then a series of questions is posed about strategies and factors that might drive high levels of performance. Question by question, the responses of top performers are compared quantitatively with those of the other organizations. The strategies that prove to distinguish top performers from the others are considered indicative of potential best practices. These promising approaches are discussed by the group in detail.

Making the Process Work

To prepare for the process benchmarking exercise, a small work-group was formed from within the Texas Council's membership in fall 2006. It included representation from the leadership groups for behavioral health, quality management, and CEOs. The group met several times via teleconference and identified potential practices that could contribute to low utilization of state hospital beds. These were distilled into a Guide for Participation, which was distributed to registered attendees several weeks before the scheduled process benchmarking exercise. Attendees were asked to obtain the data required to answer each question in the Guide and bring the data with them to the workshop.

Process benchmarking workshops were conducted on two occasions. In the second exercise participants used electronic audience-polling technology. This technology proved to be very beneficial in that it made participation anonymous and streamlined the process by obviating the need to conduct hand tallies after each vote. Most importantly, however, the audience polling database permitted post-hoc analysis of the data, which proved to be key in bringing about the insights that ultimately materialized.

The process identified 13 factors related to state hospital bed utilization. These factors fell into three clusters. The first cluster was clinical management. Five clinical management practices were found to distinguish low state hospital bed utilizers from high utilizers. For example, having center psychiatrists routinely talk to ER physicians about individuals being considered for admission was identified as a potential best practice for centers. That factor and the other four potential best practices were actionable tactics that could readily be adopted by centers.

The second cluster involved the interface between the centers and the state hospitals. Four factors distinguished low versus high bed utilizers. For example, it was found that the degree of agreement between the center and the hospital on the date of the client's discharge was a key factor that distinguished low bed utilizers from high utilizers (low utilizers and the state hospital agreed more often). All of the factors identified within this cluster would require coordinated efforts between the centers and the hospitals to bring about improvement.

The third cluster was related to external factors and community resources. Again, four factors distinguished low versus high bed utilizers. One powerful factor was found to be the presence of a psychiatric unit (other than a state hospital) within a 45-minute drive of the service area that was accessible without regard to ability to pay. The majority of centers with low state hospital bed utilization had such a resource available, in contrast to none of the centers with high state hospital bed utilization.