Awad, A. G., “Evaluation of Quality of Care in Psychiatry”, Pergamon Press, Canada, 1980
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Quality is measured by evaluation - a judgement of the worth or value of something.
The first hypothesis, that medical care is now perfect, is rejected intuitively. The second hypothesis is that either the problem finding or the problem solving steps of the quality control procedure (or both) are faulty.
To be sure, fault can be found with our assessment methods:
- Medical audit or medical care evaluation has suffered from poor choice of study topic and objectives, poorly drafted or non-discriminatory criteria, and the desire of practitioners to paint a rosy picture when faced with the threatening task of self evaluation.
- Review of care in cases of extended hospital stay has been viewed as an administrative, cost-containment problem, rather than as a unique opportunity to identify quality problems.
- Due to the lack of objective methods, reviews of surgical cases, hospital acquired infections, ‘incidents’, ‘deaths’, and other groupings have failed to identify patterns of problems.
Sub-standard medical care might be due to
- lack of knowledge
- lack of performance
The problem solving activities designed to correct these two problems are
- continuing education
- credentialing
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Psycho-Social Assessment Proposal
Mental Illness is of grave concern around the globe today and has been for the past century. It is a mitigating factor for several severe social problems of our advanced western society and of primitive societies. Although there hasn’t been a direct link established, it has a relationship to the causation of wars. Something must obviously be done to address the issues of mental illness. The current ineffective solution is pharmacology. My bias solution would be to retrench all the psychiatrists and rid the world of all pharmacology for the field of mental illness, however this is irrational and subjective.
I do however propose a small scale ‘clinical’ trial of a psycho-social program. I have personally spoken to several psychiatrists, psych support staff and patients in hospital settings and out in the community. I believe that the psych staff are genuine in their motives to help the community, however they are slightly ignorant, unaware of the core issues that the patients are suffering from as a result from culture clashes, class barriers, varying attitudes to morals, ethics and lifestyle choices and general communication barriers.
I would like to propose to have select patients for two study groups of 40 males each, suffering from similar problems. Ideally we should cover the whole area of diagnosed patients, however aggressive patients with a record of assaults will prove detrimental to the study. I suggest the initial study be conducted for a group of males, as it is the males who are suffering the greatest from violent psychotic tendencies. Ideally it would be beneficial to have concurrent studies on women as well as they are suffering from neurotic tendencies too, however the program should be gender segregated for the sexual impulse issue. The patients should be selected carefully as the results are dependent on the motivations of the patients. They have to be willing to commit to a twelve month trial with a rigid, strict, structured program. I suggest to have one group to be subject current psychotropic medications, substandard housing, poor case management and irregular psychiatric reviews (the Control group), while the other group, given the radical Psycho-Social Assessment (PSA group) trial I propose. Ideally the women should be split up into two groups as well, run similarly and concurrently dependent on funding.
The Mission Australia Centre (MAC), Surry Hills, has the perfect infrastructure already established for a project of this kind. There are forty beds, individual rooms, lounges, kitchens and facilities of a five star standard. I propose that the PSA group receive absolutely no medication or ill treatment of any sort. Maladaptive behaviour is to be advised of in a written breach notice and verbally corrected twice for petty matters, then removed from the program if behaviour is inconsistent with the programs’ objectives. Serious behaviour problems, breaking of rules or failure to comply with the programs’ assessment should result in immediate removal from the program, as the defiant deviant would have a negative impact on the other members and it would be detrimental for the entire assessment.
No drugs or alcohol is to be tolerated within the program for the entire twelve months. As the MAC is situated within the heart of the drug and alcohol precinct, it would be difficult to maintain a zero tolerance policy. As patients’ walk around the corner, there are dealers, addicts, prostitutes, social and environmental surroundings that will have a negative impact on the program. To combat this problem, I suggest the irrational radical ‘lock down’. Eliminate all negative external influences. No psychiatrists! No dealers! No pimps!
I propose that all the needs and wants (to a reasonable extent) of the patients be catered for. As in any hospital setting, sexual needs will not be catered for. From a psychological perspective, sexual activities during mental illness recovery (or any other time for that matter) is severely detrimental to the brain. Sexual abstinence is a golden rule for rehabilitation. If the patient wants a coffee; it should be provided. If the patient wants cake; it should be provided. If the patient wants a croissant; it should be provided. I am not advising to provide a five star catering service. I suggest to make all the ingredients required available in the pantry and provide the know how. Teach the patient how to bake a cake. It is not difficult. It might be difficult to whip up a five star curry at the start of the program, however if there are ‘able’, ‘component’ support staff available, it is a small goal. Enable! It may be a little extreme and irrational not to allow cigarette smoking, however the short walk to the super market to purchase cigarettes could prove detrimental to the entire project. Hence I recommend cigarettes be purchased and distributed accordingly.
The concept is not to detain the patients in a prison or hospital style regimen. The purpose is to provide a safe and nurturing environment, eliminating all possible risk factors. I re-iterate; drugs, alcohol, sexual contact, friends and family are all factors that could have a negative impact on the individual and the project. The control group will have contact with all these factors at free will combined with the medications and no education or training provided. At the end of the twelve months, the results will speak for itself. The patients are free to leave at any time they wish, however they will not be able to return. Once advised of the program structure, benefits, rationale, outcomes and infrastructure, the patients will not want to leave. There will be no reason to leave the building. Everything will be catered for.
I suggest, instead of talking to a normal psychiatrist, a team of able, component, trained psychoanalysts provide regular counselling for the patients. I propose a new approach as the old ways have proved ineffective in the long term. The counsellors have to spend a minimum of one hour a week every week for the entire year talking to each patient. In addition, there should be other support staff making their own assessments, and have team meetings on the progress of each patient. If funding is available, I propose a 24/7 CCTV documentation for security and future projects’ analysis.
The goal of life for the majority seems to be happiness. The common consent would be an attainment of sensual and material pleasures. Some philosophies might advise renunciation, however their ways are of a minority and are debatable. We live in materialistic world and require dialectic materialism in order to co-exist. Most people that have been through the psych system are not aware of what the world has to offer in terms of sensual and material pleasures and might be considered as disadvantaged. One might say this is achieved by employment, the pursuit of positive relationships and experiencing what the world has to offer slowly over time. To be able to purchase global goods and services requires a little bit of money, positive relationships require a considerable amount of communication skills and employment requires a whole array of skills. If we were to provide the PSA group with the skills required to secure employment, within an intensive twelve month training regime, placed into industry, closely monitored and supported, our mission would be just about complete. Money generated from the employment could be used to enjoy the luxuries of the world from where positive relationships could form. Our mission would be to provide the skills required by industry for average income satisfying positions within the twelve month clinical monitoring. As all the patients have different educational and work histories, it might be difficult to organise group programs. Hence each patient would have to be individually assessed, realistic goals determined and educational packages tailored to their needs.
I propose a daily regimen of up at six in the morning, lights out ten in the night. Morning exercise seven days a week. Cook their own breakfast and cleanup with support. Shit, shower and shave on a daily basis. Nine to five compulsory educational activities. Teachers, whether it be secondary, Tafe or tertiary, come in and provide in house support. Lunch and dinner cooked themselves with appropriate support workers to teach. Evening time; activities to develop hobbies should be scheduled. Whether it be music, jamming or writing, painting or knitting, there should be support workers to motivate and inspire the patients to develop skills. There should be no allowance for time to be wasted.
The results of this project will provide concrete data to evaluate the current theories on mental health treatment. As there has been no objective audits on the mental health system since the development of psychiatric medication, this assessment will prove beneficial to people suffering from mental illnesses all over the globe. The costs of mental health to governments will decrease greatly when this project is applied across the board. The stigmatic labels on the mentally ill will finally be lifted and a large number of welfare dependants stuck in the penitentiary systems, psych systems, unemployment lines, homeless shelters and brothels will be enabled to contribute to the economy. Reducing unemployment, cleaning up the streets, eliminating crime and violence, taking away the need to prostitute will raise general society morale, improve the societys’ productivity and raise everyones’ living standards!!
