Data Standards for Mental Health

Decision Support Systems

A Report of the Task Force to

Revise the Data Content and System Guidelines of the

Mental Health Statistics Improvement Program

Walter A. Leginski, Ph.D.; and Colette Croze; John Driggers; Shirley Dumpman; Dennis Geertsen, Ph.D.; Edna Kamis-Gould, Ph.D.; M. Jo Namerow, Ph.D.; Robert E. Patton; Nancy Z. Wilson; and Cecil R. Wurster

U.S. DEPARTMENT of HEALTH AND HUMAN SERVICES

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration

National Institute of Mental Health

Division of Biometry and Applied Sciences

5600 Fishers Lane

Rockville, Maryland 20857

This monograph was written by Walter A. Leginski, Ph.D., Division of Biometry and Applied Sciences, National Institute of Mental Health. The concepts in the monograph were developed in collaboration with the members of the task force and in consultation with other experts in the field. Editorial management for the Mental Health Service System Report Series is provided by Sally A. Barrett.

All material appearing in this volume is in the public domain and may be reproduced or copied without permission from the Institute or the authors. Citation of the source is appreciated.

Suggested Citation
National Institute of Mental Health. Series FN No.10, Data Standards for Mental Health Decision Support Systems, by Leginski, W.A.; Croze, C.; Driggers, J.; Dumpman, S.; Geertsen, D.; Kamis-Gould, E.; Namerow, M.J.; Patton, R.E.; Wilson, N.Z.; and Wurster, C.R. DHHS Pub. No. (ADM)89-1589.  Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1989.  DHHS Publications No. (ADM)89-1589  Printed 1989
For sale by the Superintendent of Documents, U.S. Government Printing Office Washington. D.C. 20402

Foreword

The National Institute of Mental Health shares a commitment with mental health practitioners to a service delivery system that treats those with mental illness humanely, efficiently, and effectively. Thus, the Institute has an enduring interest in the operation of the service system and a commitment to facilitating improvements within it. These activities are reflected not only in the research portfolio of the Institute, but also in its capacity-building activities.  One of the Institute's longest and most successful capacity development partnerships has been collaboration with the Stale mental health agencies around the specification and adoption of data standards for the statistical systems operated by the States and the Institute. Collectively, this endeavor is known as the Mental Health Statistics Improvement Program.  This partnership is based on the shared assumption that one of the fundamental ways in which improvements can be made in service delivery is through examination of data on routine operations. The managerial and research implications of these data emerge quite clearly when uniformity in their content permits the data lobe compared across a number of settings. Through such comparisons of data, virtually every setting can serve as a site for field research, yielding ideas about exemplary approaches and emerging trends.  This monograph extends the prior work of the Mental Health Statistics Improvement Program.  For the first time, information systems that permit the linkage of data on patients, treatments, human resources, and finances are proposed as a standard for mental health service providers. All mental health programs, whether affiliated with State mental health agencies or not, can benefit from the application of these standards.  The guidelines documented in the monograph will enhance the availability of data that present opportunities for rational, beneficial change to be introduced in many mental health service delivery programs. The results will present challenges and opportunities not only for managers, but for clinical staff, researchers, policy makers, and consumers and their families.  The Institute has made a major commitment to the implementation of these standards in State programs. Through a competitive grant program, the institute is using fiscal year 1989 Alcohol, Drug Abuse, and Mental Health Services Block Grant set-aside funds for State implementation of the data standards. The present monograph will contribute to the success of these grants, as well as facilitate the data collection activities of other collaborators as the Institute works to implement these standards.

Lewis L. Judd, M.D.

Director

National Institute of Mental Health

Acknowledgments

The annual National Conference on Mental Health Statistics from 1986 to 1988 provided a forum for the Revision Task Force of the Mental Health Statistics Improvement Program to present its recommendations while they were in the process of being formulated. In discussion groups devoted to the recommendations and in evaluation feedback, many conference participants provided insights and guidance that were invaluable to the work of the task force. All the conference feedback was noted without identification; consequently, specific credit cannot be given. The members of the Revision Task Force are grateful to the many conference participants for their attention and thoughtful advice on the various proposals.  The concepts in chapters 12 and 18 had to be developed after the task force had formally disbanded. Throughout the development of these chapters, the senior author benefited from the generous advice and review of Ronald W. Manderscheid, Ph.D.

Task Force to Reconsider the

Minimum Data Sets and System Design Guidelines of the

Mental Health Statistics Improvement Program

Task Force Members

Chair, Robert E. Patton

Statistical Consultant

57 Tamarack Drive

Delmar, NY 12054

Colette Croze, Deputy Director for Community Program Operations

Department of Mental Health and Developmental Disabilities

401 South Spring Street, Room 400

Springfield, IL 62706

John Driggers

System Consultant

1808 Marydale Drive

Dallas, TX 75208

Shirley  Dumpman

Superintendent

Mayview State Hospital

1601 Mayview Road

Bridgeville, PA 15017

Dennis Geertsen, Ph.D. 

Chief, Center for Program Evaluation and Research

Division of Mental Health

1300 East Center Street

Provo, UT 84603-0270

Edna Kamis-Gould, Ph.D.

Acting Assistant Commissioner

Division of Mental Health and Hospitals

13 Roszel Road

Princeton, NJ 08540

M. Jo Namerow, Ph.D.

Research Consultant

National Association of Private Psychiatric Hospitals

Namerow and Associates

835 Light Street

Baltimore, MD 21230

Nancy Zurbuch Wilson, Director

Program Information, Evaluation, and Research

Division of Mental Health

3520 West Oxford Avenue

Denver, CO 80236

Federal Representatives

Walter A. Leginski, Ph.D.

Assistant Chief

Survey and Reports Branch

Division of Biometry and Applied Sciences

National Institute of Mental Health

5600 Fishers Lane, Room 18C-07

Rockville, MD 20857

Cecil R. Wurster, Associate Director for Program Development

Division of Biometry and Applied Sciences

National Institute of Mental Health

5600 Fishers Lane, Room 18C-26

Rockville, MD 20857

Ad Hoc Advisory Group

Mental Health Statistics Improvement Program

Fiscal Year 1989

Peter G. Beeson, Ph.D.

Director, Office of Planning

Department of Public Institutions

P.O. Box 94728

Lincoln, NE 685094728

Colette Croze

Deputy Director for Community Program Operations

Department of Mental Health and Developmental Disabilities

401 Stratton Office Building

Springfield, IL 62706

Robert Glover, Ph.D. Director,

Office of Mental Health and Mental Retardation

Department of Health

1101 Market Street, 7th Floor

Philadelphia, PA 19107

Dick Gregory, Ph.D.

Program Manager, Eastern Region

Department of Mental Health

P.O. Box 53227, Capitol Station

Oklahoma City, OK 73152

Michael F. Hogan, Ph.D.

Commissioner, Department of Mental Health

90 Washington Street

Hartford, CT 06106

Walter A. Leginski, Ph.D.

Assistant Chief

Survey and Reports Branch

Division of Biometry and Applied Sciences

National Institute of Mental Health

5600 Fishers Lane, Room 18C-07

Rockville, MD 20857

Ted Lutterman

Director, Research Analysis

National Association of State Mental Health Program Directors

1101 King Street, Suite 160

Alexandria, VA 22314

Ronald W. Manderscheid, Ph.D.

Chief, Survey and Reports Branch

Division of Biometry and Applied Sciences

National Institute of Mental Health

5600 Fishers Lane, Room 18C-07

Rockville, MD 20857

Jonas Wailer, Ph.D.

Associate Commissioner for Planning, Evaluation, and Information Systems

Office of Mental Health

44 Holland Avenue

Albany, NY 12229

Nancy Zurbuch Wilson, Chair

Director, Program Information, Evaluation, and Research

Division of Mental Health

3520 West Oxford Avenue

Denver, CO 80236

Cecil R. Wurster

Associate Director for Program Development

Division of Biometry and Applied Sciences

National Institute of Mental Health

5600 Fishers Lane, Room 18C-26

Rockville, MD 20857

Alan L. Ziglin, Ph.D., Director

Planning, Evaluation, and Research Section

Division of Mental Health, Mental Retardation, and Substance Abuse

Department of Human Resources

878 Peachtree Street NE, Room 324

Atlanta, GA 30309

Other members of the advisory group whose terms were active during the deliberations of the Revision Task Force and the preparation of this report were Dennis Geertsen, Ph.D., Director, Program Evaluation and Research, Utah Division of Mental Health; and Lois J. Pokorny, Ph.D., Deputy Director, Office of Planning and Quality Assurance, Missouri Department of Mental Health.

A Guide to Readers
This monograph was written with several professional audiences in mind. The following suggestions identify the chapters that are considered to be of most interest or relevance to each of the groups of readers noted.

For all readers
It is suggested all readers be familiar with the two chapters that lay out the basic concepts that run throughout the monograph: Chapters 1 and 3.

Personnel within mental health organizations
Directors of management information systems, data processing, research, evaluation: Chapters 2, 4-10 are recommended. If these personnel also provide data for external reporting, chapter 12 is also recommended.  Directors of specific organization operations, e.g., clinical care, finances, personnel: Specific titles for chapters 5-8 should be examined for guidance.  Managers who want greater familiarity with the role of data and decision support systems within their organizations: Chapters 2, 9, and 10 are recommended. In addition, the uses sections in chapters 5-8 and the commentary following each data item in these chapters will prove useful.

Personnel within agencies that receive data from mental health organizations
Directors of management information systems, data processing, research: Familiarity with the full monograph is recommended.  Directors of specific programs within these agencies, e.g., human resource development, clinical care, quality assurance: Specific chapter titles from chapters 5-8 and 13-17 should be examined for guidance.  Executive directors of these agencies: Chapter 1 and the first sections of chapter 3 are recommended.

Researchers
The uses sections of each data chapter are recommended, as well as the commentary after each data item. In addition, chapters 2, 11, and 18 convey concepts that may affect a research agenda.

Contents

Foreword iii

Acknowledgments v

Task Force Members vi

Ad Hoc Advisory Group vii

A Guide to Readers ix

SECTION I. 

FUNDAMENTALS OF THE MENTAL HEALTH STATISTICS IMPROVEMENT PROGRAM 

Chapter 1. Data, Standards, Decisions, and the Mental Health Statistics Improvement Program 3

The Importance of Data? 3

Why Standards? 3

Why Compare? 4

What Decisions? 5

Why the Mental Health Statistics Improvement Program? 7

Summary 8

Chapter 2. What Is a Mental Health Organization? 9

Mental Health Organizations: The Provider Level 9

Evolving a Taxonomy of Mental Health Organizations 12

Summary 21

Chapter 3. Management and Decision Support in a Mental Health Organization 22

What Performance Areas Does a Manager Need To Know About? 22

Why Do Managers Need To Know This? 23

Where Does the Manager Get This Information? 26

How Is This Information Available? 26

Summary 29

Chapter 4. Minimum Data Sets and Guidelines for Decision Support Systems 30

Minimum Data Items and Minimum Data Sets 30

System Standards vs. System Guidelines 31

Summary 32

SECTION II.

DECISION SUPPORT SYSTEMS AT THE ORGANIZATION LEVEL: DATA COMPONENTS AND MINIMUM DATA SETS FOR AN INTEGRATED SYSTEM 

Chapter 5. Patient/Client Data 35

Definition of a Patient/Client 35

Uses of Patient Data 37

Minimum Data Set 38

Other Recommended Data Items 47

Coverage 48

Summary 49

Chapter 6. Event Data 50

What Is an Event 50

The Rationale for Event Reporting 52

Recommended Guidelines for the Collection of Event Data by Staff 54

Uses of Event Data 56

Minimum Data Set 60

Other Recommended Data Items 64

Methods of Linkage 64

Summary 65

Chapter 7. Human Resources Data 66

Who Are the Human Resources of an Organization? 66

Uses of Human Resources Data 67

Minimum Data Set 69

Other Recommended Data Item 75

Coverage 76

Summary 76

Chapter 8. Financial Data 77

Need for Financial Data and Data Standards 77

Nature of the Component 77

Uses of Financial Data 79

Minimum Data Set 83

Coverage 87

Summary 88

Chapter 9. Assessing Impact 89

Why Should Managers Assess? 90

What Should Be Assessed? 90

How Does the Decision Support System Aid Assessment? 93

Summary 94

Chapter 10. Issues In the Transition to an Integrated Decision

Support System 95

Attitudinal Issues 95

Technical Issues 98

Summary 100

SECTION III. THE AUXILIARY LEVEL AND THE NATURE OF A DECISION SUPPORT SYSTEM

Chapter 11. The Auxiliary Level and the Concept of a Mental Health System 103

The Auxiliary Level Defined 103

The Mental Health System 104

An Organization-Based Definition of the Mental Health System 107

Summary 109

Chapter 12. Models for Management Information and Decision Support Systems at the Auxiliary Level 111

The Need for Data at the Auxiliary Level 111

The Providers of Data 113

Four Models for an Information System at the Auxiliary Level 114

Summary 127

Chapter 13. Organization Data at the Auxiliary Level 128

Definition of an Organization 128

Uses of Organization Data 129

Minimum Data Set 132

Coverage 139

Summary 144

Chapter 14. Patient/Client Data at the Auxiliary Level 146

Uses of Patient/Client Data 146

Minimum Data Set 148

Other Recommended Data Items 156

Coverage 157

Summary 159

Chapter 15. Event Data at the Auxiliary Level 160

Uses of Event Data 160

Minimum Data Set 165

Coverage 170

Summary 173

Chapter 16. Human Resources Data at the Auxiliary Level 174

Uses of Human Resources Data 175

Minimum Data Set 177

Coverage 183

Summary 185

Chapter 17. Financial Data at the Auxiliary Level 186

Uses of Financial Data 186

Minimum Data Set 189

Other Recommended Data Items 192

Coverage 193

Summary 194

Chapter 18. Transition Toward an Integrated Decision Support System at the Auxiliary Level 195

The First Requirement: A Vision of the Decision Support System 195

A Model to Describe the Degree of Integration in the Decision Support System of the Auxiliary Level 199

The Model Considered for Multiple Auxiliary Levels and Mental Health Systems 204

Summary 208

References 209

Index 213

Section 1 Fundamentals of the Mental Health Statistics Improvement Program

Chapter 1 Data, Standards, Decisions, and the Mental Health Statistics Improvement Program

In order to provide better care to persons with mental illnesses, at least two major tracks of activity have to be maintained. One, clearly, is basic research on causes and effective treatments of mental illness. The second is continuing improvements in the system that provides services for those with mental illness. This monograph is pertinent to the second track of activity. Although it will not address the full range of possible system improvements, its contributions derive from a specific set of beliefs about how most system improvements come about.

The Importance of Data

Briefly stated, improvements occur mainly because decision-makers elect to make rational changes based on good, data-based information about the operation of their programs. Obviously, this is not intended to be a full theory for how systems of service change. It can be argued that visionaries and undesired publicity do more to change systems than do routine operational reports. However, unlike these more dramatic sources, the latter are constant and dependable sources of information available to managers. And, in contrast to anecdotal sources of information, these reports can be objective, reliable, and comparable - factors that can be crucial when a decisionmaker is trying to decide which option is better and which is worse.  The monograph attempts to present specific data that decisionmakers should consider. It will not focus on the process of making decisions. While decisionmaking theory is a field unto itself, the only aspect of the process relevant to these materials is that decisionmakers accumulate and assess various kinds of inputs that lead them to select one course of action over another. Any decision carries with it some element of risk. Consequently, decisionmakers are likely to try to reduce the risks inherent in choosing one alternative over another by accumulating a variety of inputs that might help them to assess their risks (Hildebrand and Ott 1987).  Empirical data are one such input. They are the input that will be emphasized throughout this report. Such inputs as political forces, crises, personal influences, past experience, intuition, and citizen action all play a role in decisions to change the mental health service system. While they are actively used by many mental health program managers, they are not covered in this document. It is important that this be recognized so that the monograph is not seen as naive or irrelevant for decisionmakers. A fairer assessment is that it is highly targeted to one of the sources of input that is considered when a manager is concerned with whether the program is doing an acceptable job of providing care to the mentally ill or whether it can do a better job.

Why Standards?

In the context of decision support systems, standardization refers to the field's general acceptance of concepts, quantities, terms, and definitions that serve as reference points against which comparisons can be made. Only occasional appeals for the development or adoption of standards pertinent to mental health data occur in the literature (Chang 1987; Laska and Craig 1982). However, in fields that have established standards, the absence of standards would make the conduct of business impossible. One does not usually think of contemporary chemists arguing about the definition of oxygen. Chemistry functions because it has accepted the periodic table as a statement of standards as well as an embodiment of theory. Standards accepted about U.S. electrical current mean that voltage, amperage, outlets, and plugs are so widely accepted that users of appliances incorporate them into their behaviors and do not have to worry about different standards with every use of an appliance or about moving from one locale to another. Designers of appliances benefit from these standards as well. Finally, when microcomputers and personal computers began to be widely available in the early 1980s, there was so little standardization that operating systems and software packages frequently were applicable only to specific pieces of hardware. The situation took only a few years to be corrected, and operating systems and compatibility across manufacturers became the norm.  However, in mental health it is extremely common for each service-delivery program to develop its own content for clinical records or its information system. If the program does incorporate standards, it is usually to comply with demands of a funding authority or an accreditation agency. This diversity, which has been commented on elsewhere (Zinober and Leginski 1984), creates problems for the aggregation of data across different programs - an activity occurring frequently in mental health either for external reporting or to compare one programs operation with that of another.  The adoption of standards permits communication, judgments, and comparisons. Communication is enhanced because standards provide clearer definitions of terms and concepts used in the conduct of the business. Judgments can be made against the standards - does an item, product, or degree of performance meet, exceed, or fail the test? And once standards are operationally in place, comparisons are possible by allowing the manager to aggregate data to foster an understanding of differential performance. While it is hoped the document will contribute in all of these areas, the latter effect is the one most highly desired. Comparisons and judgments about performance permit decisionmakers to make alterations in their service programs intended to improve their approaches to the care of the mentally ill.

Why Compare?

To some, the question "Why standards?" is less significant than the question "Why compare?" Comparisons in mental health service provision are important for theoretical and practical reasons. In regard to theory, Scott (1986) notes, "The theoretical models underlying and guiding our research on organizations have gradually shifted... from an emphasis on organizations as relatively independent entities to a view that stresses their interdependence with other units" (p.31).  This change is not of merely academic interest. It is assumed that most changes in social science theory reflect better understanding by experts of actual operations. The theoretical statement better explains what is observed: Organizational performance must be under-stood in a context.  For practical reasons, comparisons are important because it is extraordinarily rare in the American mental health system of the eighties to find an organization that is able to view itself with complete autonomy. For most providers it is essential that there be an awareness of organizations that are both complementary and competitive with them. Without this awareness, the program may provide duplicative services; may not know how to market what it does best; may not link patients with the right services; or may lose clients, staff, and financial resources if it does not acknowledge and somehow accommodate the existence of these other organizations. This requires knowledge of the performance of these other providers and, significantly, a comparison of performance if they are similar to the managers organization.  Such comparisons are not confined to the provider level. State mental health agencies and corporate sponsors also examine performance of organizations within a system of care to determine relative standings. States also make comparisons of their system of services with other States (NASMHPD, 1983, 1986). Competition alone is not the motivator for these comparisons. Knowledge of the availability and performance of other mental health resources may mean an opportunity to learn so that desirable changes can be made. It may also mean an opportunity to participate in a diversified network of services to meet the full range of needs of citizens with mental illnesses.  Thus, both in theory and practice, it is suggested that contemporary managers must attend to the environment of other settings and systems, as well as to the performance of the organization. Attending to this environment means a vigilance about process and a willingness to make frequent adjustments in order to improve performance (Jaeger et al. 1987). Data are one way to stay in touch with process and one way to assess the risks associated with deciding how performance can be improved. This monograph emphasizes the importance of empirical and comparable information in the form of standards for data content.

What Decisions?

It would be an oversimplification to leave management decisionmaking in mental health as just described - as judgments about whether the program is doing an adequate job or could do a better job. Some time must be taken to consider the types of decisions managers must make in operating a program or a system of care. This is necessary in order to get to a point at which one can begin to understand what data items are needed as input to the decisions so that the process of specifying standards for these specific items can be presented.  Before addressing what decisions managers must make, it is necessary to understand what responsibilities managers have. Managers⁽¹⁾ are responsible for the resources of their organization. In mental health this translates into responsibility for the financial assets of the organization, its property, the staff, and the patients.  Management decisionmaking centers around various actions that managers must take in relation to each of these resources.  The goals and objectives of the organization define the relative value of these areas and may, therefore, define which actions are important. For instance, if a primary goal of an organization is profit (to increase its financial assets), then managers may devote considerable amounts of time and behavior to this goal. It affects the types of staff they hire, and how they deploy, evaluate, and reward them. Managers might assess the physical plant relative to whether it conveys a sense of organizational prosperity. In addition, this goal affects the types of patients they might be willing to take on, the concern being minimizing bad investment by ensuring high volumes of paying clients.  On the other hand, if an organization promotes patient care as its most important goal, the needs of the patients might drive management actions. As in the previous example, staff configurations are considered, but in relation to patient needs rather than to finances. Patient's ability to pay may be secondary to their need for services. The quality of the physical setting is judged from the perspective of whether it is adequate for patient care and certification rather than as an end in itself. These examples are meant to contrast and clarify, not to convey which might be the better value and certainly not to convey that management must always single out only one of these areas.  No matter what resource is being considered, there are also consistent actions that managers must take. Actions mean not only behaviors in which the manager may engage, but also administrative manifestations of these actions such as establishing policy, documenting procedures, and delegating authority and responsibility. 

Five specific actions are proposed. As each of these is noted, consider the extent to which data-based operational reports can aid decisionmaking on each.

1. Acquisition - action taken to obtain or secure appropriate resources for the organization. Depending on the resource, this can mean obtaining financing, hiring staff, advertising one's services, contracting for services, establishing contracts with area employers to provide mental health services, or obtaining a Medicaid waiver to allow reimbursement for an otherwise excluded service.

2. Distribution - the allocation or parceling out of the resources within the organization. Frequently this is structured around budget preparations and appeals from programs within the organization. In other instances, there may be a formal methodology such as a regulation, an allocation formula, or a performance contract that determines resource distribution. Negotiation, historical patterns, and playing favorites are also methods for actions in this area.⁽²⁾

3. Monitoring - the maintenance of oversight on the use of resources within the organization. This is frequently the action most people see as management. It variously depends on the review of operational reports or other observation such as management by walking around. Many managers use a detection system, such as exception reports or the examination of key indicators. There is a considerable management literature in this area.

4. Accounting - the ability to document or acceptably demonstrate control over the use of resources. Usually this is thought of in a financial context - that ledgers, balance sheets, accounting practices, etc. are in place to document where the money comes from and where it goes. In addition, accountability actions can involve establishing stated policies about staff conduct, specific actions that must occur with respect to clinical treatment, or a certificate that life-safety standards are met. That is, managers must provide evidence of control over all the resources within the organization. It is interesting to note than managers at lower levels are required to account so that upper level managers can monitor.

5. Assessment -judgments about the application of both resources and actions. The word judgment is used specifically to convey that this action is value laden - a judgment is made against some criterion thought to be desirable, whether it is known only intuitively or specifically stated. Specific criteria should always be favored. While substantial literature on mental health is devoted to program evaluation, it almost always is focused on the patient resource. Managers have a broader responsibility and must also assess the other resources noted above. Of additional importance is that this action is applied to the above actions as well. That is, managers must assess their actions as well as their resources.  Assessments fall into two basic categories, depending on whether they are about resources or actions. First, from a manager's perspective, things either exist or are supposed to happen as a result of actions taken. These are referred to as compliance assessments. These might involve increased hiring of minorities, providing a monitoring report, redirecting resources, or changing a policy on a clinical or administrative matter. The manager will be interested in the degree to which there is compliance with the action and will probably demand accountability for noncompliance. At the provider level, it may often be that compliance assessments are done in response to some external authority rather than in strict response to internal decisionmaking.  A second kind of assessment relates to the resources and is labeled impact assessments. These also depend on observing some change or achieving a desired state as a result of the organization's resources. Most obvious might be a concern about impacts observed among the clients of the agency. Here arises one of the enduring concerns in mental health for the past 30 years: Did treatment make a difference? Staff performance and finances (i.e., cost effectiveness) are also judged from this patient impact perspective, but it is common for managers to expect staff growth to result in productivity increases and for increased financial resources to produce program growth or increased revenue generation.  Whether the concern is impact or compliance assessment, data fed back to the decisionmaker play a vital part in the assessment. A detectable change is expected and even managers who claim not to be especially interested in data can be observed to be quite interested in whether they are producing a change. Managers who are inclined to use data use them to evaluate the success of their decision and to help them manage the risks inherent in choosing one alternative over another.

Throughout the remainder of this monograph, these themes of data, standards, and decisionmaking will be revisited. Subsequent chapters show the transformation of these concepts into data content and systems that provide managers and decisionmakers with information that will assist them in taking actions.  As the above materials have been presented, they deliberately have covered a wide range of managers, from those responsible for a particular clinical unit within a mental health agency to those, such as county or State commissioners, responsible for an entire system. It is felt there is more commonality than discontinuity in the types of decisions these individuals make. Generally, it is the level of detail or aggregation that differs as one moves through this managerial hierarchy. However, as later material is presented, these various levels will be differentiated.

Why the Mental Health Statistics Improvement Program?

The Mental Health Statistics Improvement Program (MHSIP) is most often viewed as the codification of the recommended minimum content needed to facilitate mental health program management as well as the basic guideline for the system that is needed to collect and report this information in a way that will be useful in making decisions. The MHSIP manifests itself in at least four forms. As an ideology the MHSIP emerges clearly from a stream of thinking that combines the values of rationality and deliberation with those of action-taking. It anticipates relatively noble motives among decision-makers and data users and de-emphasizes self-interest or defeatist thinking about the value of mental health service programs. Empirical data figure importantly into this ideology. They are reflections of program performance and, therefore, contribute to management's changes in the system that provides services to the mentally ill.  Second, the MHSIP is a style of approach to an area of professional involvement and interest. The MHSIP grows out of a tradition of collaboration among individuals who are felt to have both insights about these data and rights to have their points of view considered. This tradition was first established between the National Institute of Mental Health (NIMH) and the State mental health agencies under a program called the Model Reporting Area. This was begun in the 1950s, when State psychiatric hospitals were the most significant source of service to the mentally ill. The program required that States agree to and demonstrate compliance with common data content and definitions in reporting their hospital data. These standards were established at annual meetings of MMH and those States participating or applying for acceptance in the Model Reporting Area program. These meetings later evolved into the National Conference on Mental Health Statistics, covering all States, which has a history of nearly 40 annual meetings.  Evolution of both the MHSIP and the National Conference continues and attempts to address individuals with a variety of data perspectives on mental health programs-service providers, academic researchers, advocacy groups, regulatory agencies, payers for services, vendors of information systems, etc. All those with an interest in mental health services information or who use such statistics, will find the MHSIP lays the groundwork for content; addresses questions of abiding and general interest; and provides a forum for discussions about the substance and technology of service data, as well as for its analysis and interpretation.  To enlist interest, another hallmark of the MHSIP style of approach is its reliance on volunteerism. There are neither inducements nor penalties associated with voluntarily subscribing to the principles of the program. The benefits are felt to lie in the acceptance of standards and the improved access to comparable data. But it is also recognized, as with the acceptance of standards in any area, that there are tradeoffs between the pursuit of creative autonomy and the restrictions inherent in accepting rules, definitions, norms and the other hallmarks that begin to characterize an area as a culture.  Third, the MHSIP is most frequently associated with documentation about the content of an information domain, specifically, the minimum data sets for the content of a mental health decision support system. In this form, the MHSIP provides statements of the minimum items that should be in such a system as well as their definitions or categories (NIMH 1983b). This content is used by system designers so that their systems are compatible and responsive to information requests dependent on this minimum content. It is also used in the collection of data from mental health organizations.  Minimum content is emphasized throughout this monograph and reflects the philosophical aspects of the MHSIP, i.e., that operational data produces improvements in service systems.  The content standards established by the MHSIP evolved from work begun in 1976. At that time an ad hoc advisory group that guided policy directions for the program determined that content should be established for three statistical areas: mental health organization data, patients/clients, and the workforce. Task forces were developed, minimum data sets proposed, and reviews and feedback gathered at several of the National Conferences on Mental Health Statistics. In 1981, these data sets were consolidated into a report recommending a design and content for a national mental health statistics system (NIMH 1983). This work was accomplished after input from almost 200 individuals who had involvement on some aspect of this product. In addition, every National Conference since 1977 has had an MHSIP track that provided input. The program and its content have consistently been characterized by this openness to collegial input.  Finally, the MHSIP manifests itself as a set of projects and operations. Most frequently, this involves data collection in which a wide array of organizational levels participate (see Manderscheid et al. 1987). In addition, the MHSIP enables networking. To date, this has been confined largely to State mental health agencies and shows up as the sharing of materials, such as design statements for major systems acquisitions, technical as assistance exchanges in which the experiences of one site serve as a positive object lesson to another, and other demonstrations of feasibility or usefulness of an approach or analysis. As a broader audience becomes involved in the MHSIP, it is hoped this set of operations and projects expands to include them or that they initiate their own exchanges in response to unique needs or interests.  An ad hoc advisory group shapes the policy and direction of the MHSIP and selects the projects and operations to be carried out. The group is currently composed of representatives from State mental health agencies and the National Institute of Mental Health. To date, these have been the most intensive users of the MHSIP materials. The advisory group is constantly open to input regarding the Program from those who subscribe to it.  The work reflected in this monograph emerged from a decision by the advisory group that the data standards articulated in the initial statement of the MHSIP (NIMH 1983) needed to be revisited. This necessity was stimulated not only by changes that had occurred in the mental health services delivery field, but also by the availability of computer technologies that permitted sophisticated processing of data at relatively low cost. In addition, an explicit decision was made by the advisory group that the statement of the MHSIP must focus on a broader constituency than that which was addressed in the first monograph.  As a result, a task force was convened and charged with reconsidering the data standards and recommending proposed changes to the system-design guidelines of the MHSIP. This task force, referred to in the manuscript as the Revision Task Force, submitted its recommendations and products to the advisory group. As the advisory group accepted or clarified the task force's proposals, the materials and concepts were taken to those who attended the National Conferences on Mental Health Statistics in 1986, 1987, and 1988. It is hoped that the report reflects the benefits gained from this type of open review. It is also hoped that users from many sectors, such as private psychiatric settings, psychiatric service programs of general hospitals, insurance carriers, researchers, advocacy groups, and others will find that the MHSIP addresses an important area. The increasing involvement of these sectors will extend these materials and add to their robustness.

Summary

This chapter has introduced some of the most fundamental assumptions behind the materials presented in the remainder of the report. As has been noted, a primary stimulus to providing better systems to care for the mentally ill is decisionmaking by managers to make informed and rational changes. Data describing the operation of their organizations are a critical input to these decisionmakers. The more reliably defined the data, the more certain the manager can be in comparing differential performance and deciding what performance is desirable or unacceptable. Decisions can then be made about both the resources and actions thought necessary to effect these system changes. The Mental Health Statistics Improvement Program is the label for the effort to develop and promote these standards and principles.

Chapter 2

What Is a Mental Health Organization?

A definition of a mental health organization is needed for two reasons. First, some boundary must be set that allows a determination to be made about whether a setting is or is not a mental health organization. Second, if a fundamental goal is to facilitate comparisons that help in the management of these organizations, it is critical that like is compared to like. Comparisons are baseless if common characteristics cannot be documented. Consequently, the task for this chapter is to provide a definition for a mental health organization and a taxonomy that assists in selecting comparisons that are valid and meaningful.  This section of the report focuses on settings that actually provide mental health services to persons with mental illnesses. These shall be referred to as the provider level or service delivery level. A later section shall deal with other organizations that are involved in mental health, which use information for comparison and management but are usually not direct providers of care. They, too, play a role in the MHSIP.

Mental Health Organizations: The Provider Level

Nominal vs. Functional Definitions

Two approaches are possible in developing a specific definition for these service delivery settings. The first is a nominal approach. It is widely used in identifying or defining health agencies, but has been rejected in favor of a less prevalent approach in which functional characteristics form the basis for a definition.  The original approach typically sets a definitional criterion based on a label or a set of labels. A user determines whether a setting meets the criterion or not. The label might cover a type of service provided (e.g., acute care), a target group (e.g., geriatric), or a characteristic of the setting (e.g., residential center). Specifically, a nominal criterion in mental health could be whether a place has in its title or name a phrase, adjective, or noun associated with the care of the mentally ill: mental health, psychiatric, psychological, mental illness, behavioral, etc. One could then begin a list of places that would meet this criterion, e.g., psychiatric hospital, mental health center, residential center for the emotionally disturbed, psychological services, and so on.  As stated, a nominal approach is not used. It has been rejected for a number of reasons. First, labels operate with different rates of success. At first glance, the labels above may appear reasonable, but in actual practice two contradictory problems emerge: They are too loose and they are too restrictive. Examples illustrate this point.

They are too loose. Applying the labels would include a great many organizations that do not actually deliver services, e.g., a county mental health board that primarily allocates money to fund places within the county that actually deliver services, a citizen action group with mental health in its title, a research foundation that funds others to do research on some aspect of this health area, etc. That is, even though fairly restrictive, the nominal approach may include places that are felt to be inappropriate at the provider level.

They are too restrictive. Settings complain that they have been excluded by the application of the labels and feel they should be included. Fictitious instances drawn from real names are the Yellow Door, Center for Wellness, Seek a New Horizon, Collingshead Lodge, or Preskot Prison. Nominally, nothing about these places suggests their involvement with the mentally ill. However, with investigation it becomes apparent that they should be counted because of their function, i.e., they serve the mentally ill.

A second reason why a nominal approach has been rejected is that a label conveys a degree of uniformity that is often unjustified. The label "hospital" can cover the types of acute care/surgical service settings most people would think of. But it might just as easily apply to long-term stay facilities that focus on rehabilitation or care to persons with head trauma, to places that serve the psychiatrically ill, or even to veterinary settings. Thus, while a label may serve as a rough type of screener, unless one pursues further information, the label may lead to the assumption that all those settings to which it applies can be compared or otherwise thought of as similar. Experience has shown this assumption is usually faulty.  A third reason stems from a frequent solution to the dilemma just posed. In order to make a set of nominal criteria effective, either more labels are added or one finds that the labels actually begin to analyze the functions of the setting. Suppose one adds other service-oriented labels that are quite commonly associated with mental health organizations, such as rehabilitation, outpatient, shelter, or group home. It should be apparent that with the addition of these labels, one can begin to do a better job of delimiting a universe of settings that provide mental health services. But one also runs the same risks as earlier, viz, over inclusion and potential exclusion.  If the solution has been to explore the functions of the organization, it must be asserted that this is no longer a nominal approach to definition. What frequently happens in practice is that nominal criteria are applied only loosely. If their application leads to the suggestion that the organization should be counted into the universe, a set of decision rules is often evoked. These decision rules apply to characteristics of the organization that are more than nominal - they depend on an understanding or analysis of the functions or activities the organization carries out. A set of such decision rules might be determined by asking,

Were the patients mentally ill and how was this determined?

What percentage of the patients were mentally ill, and what types of mental illnesses were prevalent among them?

Did the setting actually provide mental health services?

Was it staffed by psychiatrists or other mental health professionals, and were they involved in the delivery of specialized services to these patients?

These types of questions are no longer confined just to the use of labels or descriptors. More problematic is that when these types of decision rules are a part of a nominal definition, they are often used informally, tacitly, or inconsistently.  As a basis for classification, nominal approaches that permit tacit criteria to be used cannot be accepted. Their use results in unstable and unreliable boundaries for a domain of study. If one is concerned with reliably classifying whether places or things are in or out of a universe, a nominal approach should be viewed with suspicion. There should be clear evidence that the labels alone work sufficiently and that no additional criteria are evoked.  Although widely used in defining universes to be considered in health research, it was felt a nominal approach carried too many liabilities. The alternate approach used by the MHSIP is a clearly articulated functional approach to definition. This presents a set of decision rules that are to be applied. It states the activities that must be observable or the extent to which a place must meet these rules before it can be counted in. From the existing MHSIP (NIMH 1983b), the functional definition of a mental health organization has been incorporated.


Functional Definition of a Mental Health Organization

A mental health organization must have five characteristics:

1. Formal establishment by law, regulation, charter, license, or agreement

2. An established organizational structure, including staff

3. A primary goal for all or part of the organization of improving or maintaining the mental health of its clientele or seeking to prevent impairments to mental health from developing

4. A clientele with psychiatric, psychological, or associated social adjustment impairments

5. Provision of mental health services

Such locations and settings as psychiatric hospitals, psychiatric outpatient clinics, psychiatric partial hospitalization programs, multiservice mental health programs, and many others clearly meet the definition. However, a part of another kind of agency can also be a mental health organization, according to this functional definition. For example, a separately organized psychiatric unit in a general hospital can be such an organization, as can the psychiatric service program of a health maintenance organization, if it is separately organized.  All five characteristics must be met for a place to be classified as a mental health organization. Two instances clarify this. First, emphasizing characteristics 3 and 5, the provision of mental health services must be a primary goal for all or a specific part of an organization for it to be included. Such an instance occurs in the separately organized psychiatric unit in a general hospital. However, a general hospital that treats mentally ill persons on its regular wards, in scatter beds, but does not have a separately organized psychiatric unit is not a mental health organization. The provision of mental health services does not automatically make an organization a mental health organization; the other criteria must be met.  The second instance emphasizes characteristic 4. Specifically, the presence of mentally ill individuals in a setting without the inclusion of the other characteristics does not make an organization a mental health organization. A licensed and staffed residential setting that provides room and board to mentally ill people and also provides counseling or other mental health services to its residents meets the definition of a mental health organization. If it does not offer counseling or some other mental health service, but only room and board, then it does not fit within the definition. The presence of mentally ill individuals within an organization's clientele does not automatically make it a mental health organization; the other criteria must be met.  The functional characteristics specified above can be translated into a definition of a mental health organization:

Any administrative and functional structure of one or more service-providing units and a grouping of persons within this structural entity, defined by law, charter, license, contract, or agreement to provide mental health services to persons for the purpose of preventing, identifying, reducing, or stabilizing mental disabilities.

The importance of this definition cannot be overemphasized if later discussions are to be understood and found satisfactory. It sets the boundaries on the universe of settings, places, facilities, and organizations to which these materials are felt to apply. Those settings that do not meet the definition may find these materials of interest, but they are not within the domain of the MHSIP.

Who Applies the Definition?

Most users find this functional definition specific and meaningful. They are able to recognize readily whether an organization meets or fails to meet the criteria. For other users, the definition is not fully satisfactory because of ambiguities or omissions. For example, nothing is said about the degree or kind of mental problems that the clientele may have. Consequently, organizations that deal with severely disturbed patients, as well as those dealing with groups that have been labeled the "worried well" may meet the definition. For some users, this range of settings may be problematic.  Also, nothing is said about what constitutes a mental health service. This is necessary because of the extraordinary complexity of this issue and because neither the field itself nor payers for service agree on what constitutes a mental health service (Meyer 1985). It is recommended that these ambiguities and omissions be tolerated. As concrete and identifiable problems with the definition are demonstrated, resulting from philosophy, implementation efforts, or an empirical demonstration of its faults, the definition can be incrementally modified.  The question remaining is, Who should apply this definition? A first layer of application of the definition is self-selection. This may be either organizational or individual. That is, a setting may determine that it meets the functional definition and that the materials and concerns expressed in this report are relevant and should be accommodated. On an individual level, someone with management responsibilities in a setting may decide the definition is relevant and, therefore, that some attention should be given to the materials.  A second layer of application is discussed in a later section of the report. This is application by the auxiliary level. It is apparent that there are levels that are usually organizationally separate from these provider mental health organizations. Typically, they do not provide mental health services, but are intimately linked to the provider level by nature of funding, legislation, history, ownership, management, collegiality, or regulation. This may be a Federal Government agency, a corporate sponsor, a county funding administration, a State mental health agency, an insurance payer, a national organization, etc. This level is referred to as the auxiliary level to imply that its role is not exclusively oversight, but, as frequently, involves assistance and advocacy. It is assumed that agencies at the auxiliary level are interested in defining mental health organizations so that they know how many are in their universe of concern, and so they can make other uses of the information about them. Clearly, a State mental health agency (SMHA) is a major focus for such concerns, as may be a clearinghouse for information on where particular types of services can be obtained.  It is recommended that if there is uncertainty about whether a place is a mental health organization - and that this determination is critical to a policy matter relating to the numbers of such places or to an administrative matter, such as licensing or financing-the SMRA ultimately make the determination.

Evolving a Taxonomy of Mental Health Organizations

The functional definition sets the boundaries for what organizations fall within the universe of settings. However, a second goal of this chapter is to suggest ways in which like organizations can be identified so that comparisons can be meaningful. If one is interested in understanding further the operation of these organizations and accounting for variations between them, some additional classification is required. Such classification schemata are usually referred to as taxonomies. A substantial amount of conceptual work, involvement with relevant constituencies, and testing is needed before a formal taxonomy of mental health organizations is possible. Presenting a preliminary classification basis and the reasoning behind it is the remaining task of this chapter.  In looking for a basis for a taxonomy, the task force felt several criteria had to be considered:

The basis for it could not be too abstract - it had to be understood by a wide and disparate audience.

It had to identify those critical dimensions that had the best explanatory power, i.e., that explained the variations between facilities fairly, well.

The taxonomy also had to reflect the scientific principle of parsimony, i.e., be brief yet inclusive

It had to translate into a feature that would be useful in furthering the development of decision support system.

The organization chart was selected as the starting point.

The Organization Chart

If, as the definition states, the organization is formally established and has one or more service-providing units, it has an organization chart - some actual or conceptual schematic that shows the organization's component parts and their relation to one another. An organization chart for a fictitious mental health provider program 15 shown in figure 1. Although the chart has been made somewhat complex to facilitate subsequent examples, is not totally unrealistic.
This organization has an administrative level that carries out much of the business side of the facility, i.e., most of the staff in these functional areas are not involved directly in patient/client care. The organization sustains three major service-providing units: inpatient care, ambulatory care provided in three different settings, and a program of services to patients in community setting.  In addition, because of geography, the organization operates a program in a satellite location that offers all three of the above services within one program. Depending on the preferences of the organization or an auxiliary level, the organization depicted in figure 1 might be labeled either a hospital (because of the inpatient program) or a multiservice mental health organization. Each of the boxes in the organization chart has assigned functions to perform, staff to perform them, and other resources (notably space and money) to make performance possible. Resources within the organization may be distributed on the basis of these boxes, and information may be collected from the various departments in order to monitor and account for the use of resources. This concept provides an important beginning for an organization taxonomy, because it demonstrates that even within an organization, differentiations are needed. Not all of the programs will be comparable to one another. They have different functions; their patients require different types and intensities of treatment; they require different resources; and their productivity is measured in different units (e.g., a day vs. an hour of care vs. a payroll cycle vs. a monthly information report).  Most organizations recognize this and group these noncomparable programs into more comparable units so as to better manage them. These major subdivisions are conceptualized as cost centers, components of a mental health organization to which relatively dedicated resources are assigned. Such components perform relatively unique activities or produce relatively distinct products. In the sample, the major cost centers have been outlined in bold.  However, as the sole basis for developing an organization taxonomy, any organization chart is problematic. The most obvious reason is that not all facilities organize themselves in the same fashion. Settings that are simpler than the one in the example have fewer cost centers, while other settings may offer the identical services, but configure them completely differently. A second reason is that boxes in an organization chart may actually mix up a number of categories that need to be separated in order to obtain information that is comparable. This is true of functions, staff, patients, space, and frequently, dollars. If one's goal is to derive normative data or other empirical standards against which managers can contrast their program's performance, the data must be derived or aggregated in a way that ensures it is reasonably comparable. Failing that, the justification for the use of standards for content of decision support systems is considerably reduced.  To convey this situation better, the organization chart is translated into a matrix in exhibit 1. The cost centers have been arrayed down the side, and a variety of mental health setting functions displayed across the top. If the function is carried out even partially in that cost center, a mark has been placed in the appropriate cell.  Examination of the marked cells suggests that there is not a great deal of uniformity in this matrix. This is problematic for two reasons:

1. The comparability of information is critical if it is to be useful managerially. Activities or programs defined differently provide no basis for comparing them. This means discussion about the activities is subject to misinterpretation - each party decodes the information according to idiosyncratic experience. More important, it means that a manager attempting to use normative data or information from a different program to compare performance, data, cost, productivity, or any derived measure of the organization can have little confidence that like is being compared with like.  For example, in the sample organization, the ambulatory program contains a number of activities that other organizations might choose to configure differently. They may feel that partial day programs are sufficiently different from outpatient programs and that the two should not be under a common clinical program. Thus, if the sample organization were reporting on its ambulatory program, mixed within the information would be data on partial day activities, outpatient services, and consultation activities. This would be useless or misleading comparison data for another organization that has chosen to structure its ambulatory program to include only outpatient services.

2. This matrix fails to meet an important criteria noted earlier, viz, it does not provide a basis for development of a generic decision support system. If one were attempting to derive principles for the design of such a system, a much lighter degree of uniformity would be required. Without such uniformity, an efficient decision support system could not be suggested. One would need relatively uniform data content and a system design for the collection or processing of data that could be applied throughout the organization.

If the matrix in exhibit 1 were the basis for the system, much of the content and design would be uniquely tailored to individual cost centers. The only functions that appear to be uniform are administration/support and involvement with clinical record keeping. Using another of time criteria mentioned in the introduction to this section, it is arguable whether these functions explain much of the variation between organizations. Few managers make critical decisions based on such information, and most of them cannot afford to forgo information about the activities of their staff, the characteristics of their clientele, and the financial viability of their operations.

Taxonomy Dimension I - Program Elements

In short, a conceptual structure is required that is either much simpler or more uniform than that provided by an organization chart. This structure should be recognizable to the field, flexible, and sufficiently generic to accommodate most actual organization configurations, and it must be meaningful in how it organizes data. Diffused through the organization chart and the matrix are two critical dimensions which provide a basis for just such a conceptual structure. The first dimension is that of a cost center.  It is essential that one be able to propose internal structures for mental health organizations that characterize the uniqueness of the functions performed, the staffing involved, the types of clientele served, the product delivered, and the resources assigned and consumed. Since the function of mental health organizations, as defined, is to deliver services, the cost centers that are of fundamental importance are those that have a clinical orientation, i.e., those that provide clinical services.  Clinically oriented services are those that provide a specific patient, family, or group with diagnosis and prognosis of the recipient's mental health status relative to a disabling condition or problem, and where indicated, provide the recipient with treatment and/or rehabilitation to restore, maintain, or increase adaptive functioning. Clinical services are distinguished from other services by their emphasis on identification and remediation of specific mental or emotional problems, conditions, or diseases. This clinical emphasis means that organizational segments that deal with nonclinical activities, such as administration, physical plant maintenance, dietary operations, relations with the community, etc., are not part of this core.  The core set of cost centers employed to characterize a mental health organization is derived from a concept proposed in the original MHSIP, that of a program element. A program element is a conceptual convenience for labeling and for facilitating the derivation of comparable information about mental health programs. Program elements are conceptualized as clusters of major clinical program areas within mental health organizations that are relatively homogeneous with respect to one or more of the following:

the types of functions they perform

the staffing intensity or type needed to perform them

patient/client groups that would be assigned to or treated in the area

the types and relative amounts of resources needed

the outputs produced

One approach to the identification of such program elements is empirical, i.e., the use of a technique, such as a cluster analysis or a factor analysis, to identify aggregations within organizational settings that have relatively low within-group variance and that might maximize the between-group variance. While such an approach is attractive, it is a major undertaking, and the literature in this area is simply too thin to use as a foundation.  An alternate approach has been used by the task force, that of professional judgment. The previous MHSIP provides the starting point for this identification. However, in recognition of changes that have occurred in the industry, the original program elements are not regarded as immutable. The task force identified six program elements that account for the substantial volume of clinical activity carried out in mental health organizations. The six program elements, each with distinct functional characteristics follow:

1. Inpatient - 24-hour care in a hospital setting.

2. Residential - Overnight care in a residence that is also responsible for either an intensive treatment program or supervised living and other supportive mental health services. Common names for programs often providing these kinds of services include residential centers for emotionally disturbed children, halfway houses, community residences, shelters, hostels, and supervised apartments. The crucial factor is not the name of the program element, but what kinds of services are provided. More than room and board must be provided for it to be a residential program element in a mental health organization.

3. Partial day - Structured programs of treatment, activity, or other mental health services provided in clusters of 3 or more hours per day. These programs are often called day treatment, partial hospitalization, partial care, psychosocial rehabilitation, and activity centers.

4. Outpatient - Programs of mental health services provided to clients on an hourly schedule, on an individual or group basis, and usually in a clinic setting. Services such as screening, crisis intervention, and psychiatric treatment can be included.

5. Case management - Programs characterized by individualized attention emphasizing some type of intervention or participation in the natural environment of the patient involving one or more of the following activities (Kanter 1989):

a. outreach, engagement, or assessment of the patient and subsequent planning for a range of services, entitlements, and assistance;

b. brokering, coordinating, or advocating for the range of services needed;

c. clinical intervention with the patient to assist adaptive functioning in the environment;

d. monitoring receipt of service and/or patient's response to services.

6. Emergency - Programs that provide immediate and short-term services to patients experiencing psychiatric emergency or crisis situations. This covers telephone counseling, immediate services, and referral services.

A primary criticism that is leveled against the program elements is that they have been defined too broadly. For example, the MHSIP originally proposed two residential program elements, characterized as either treatment or supportive, with the differentiation based on the intensity of supervised treatment delivered. Or, the partial day program element could distinguish partial day programs that deliver active treatments from those that provide structured activities to the clients. The problem for the task force was that virtually every one of the program elements could be so "refined," and no end was in sight. Consequently, the principle of parsimony seemed best advised. The fewest categories that accounted for the widest inclusion have been offered.  If these six program elements are applied to the organization in figure 1, it is possible to relabel many of the boxes associated with clinical services with one of the program element identities. This is shown in figure 2. Later chapters explain what happens with regard to the staff, activities, and money associated with those boxes that retain their labels from the original figure.  As noted, professional judgment of the task force fostered the selection of these program elements as the dimensions that largely satisfied the criteria that had been set out. Particularly salient are the criteria

allowing for meaningful aggregations of comparable data;

explaining differences in program costs and productivity reasonably well;

forming a basis for additional development of a generic decision support system for the local level.

It was the experience of the task force that there is a reasonable history or weight of evidence for these program elements. The field is dynamic, however, and revisions to the list are needed periodically. Although current data bases have been insufficiently exploited to test for these distinctions on an empirical basis, empirical research is favored for developing these distinctions.  Many managers who encounter the program element listing for the first time are puzzled about what to do when they offer a service that matches one of the program elements but is not separately organized, i.e., is not a cost center. This is a common situation. For example, every clinical program in a mental health organization may offer emergency services, but that organization may not have a cost center it would label an emergency program element. Or, the activities described for the case-management program element may simply be diffused into the organizations outpatient services. In these settings, the program element dimension creates confusion because it does not suggest how they should handle these features.  The solution is a two-part suggestion. The first part is an advisory decision rule and the second part depends on a dimension of the taxonomy yet to be discussed. As to the decision rule, If the organization offers a set of services that matches one of the program element definitions but does not conventionally aggregate these services into a cost center, the organization should not artificially create a program element in order to demonstrate adherence to this listing. This does not necessarily mean that the organization "loses credit" for these services or that comparability decisions are jeopardized. This is so because of the second taxonomy dimension.

Taxonomy Dimension 2--Services

In introducing the program element concept, it was noted that differences should be reasonably apparent on such dimensions as

staffing, e.g., professional qualifications or intensity of staff coverage;

types of clientele, e.g., a psychiatric or functioning characterization of the patient that suggests a best match with the types of treatments offered in a program element;

services, e.g., types, intensities, or configurations of services provided in the elements;

products, e.g., the units used to measure output or productivity of the program element;

costs, e.g., the dollars attached to one of the measures, but usually linked to products in the form of a cost per product unit such as a day of care, an outpatient visit, an emergency contact, etc.

Although any of these might be eligible for an additional taxonomy dimension, only one appeared to be workable. It was the task force's judgment that staffing and clientele simply had too little commonalty across the programs with which members were familiar. They did not make reliable bases for the additional dimension. On the other hand, products and costs appeared to be relatively "high end" concepts - sophisticated measures requiring a substantial working knowledge of program operation, data aggregation, and linkage ability, and ultimately, dependent on staff and services data for their derivation. This left services as the remaining candidate. Since the program element was based on clusters of clinical programs, the addition of services as a second dimension was attractive.  One encounters immediate dilemmas, however. First, the concept of service is not a very uniform concept in mental health. Not all mental health organizations offer the same menu of services. Some, like the fictitious one in figure 1, may offer a wide array of services. Others, which specialize, may offer services of only limited types to patients with selected diagnoses. Also, "services" as a term in mental health is used to cover everything from specific procedures to units of measure (units of service) to programs of care (residential services). Because there are so many interpretations of service, dilemmas may arise as one attempts to aggregate specifics, such as activities or organized programs, into more general categories.  As an alternate to service, the notion of an activity or transaction might be possible. However, as noted above, there is not a great deal of agreement on what activities constitute a mental health service. Some third-party payment programs reimburse an activity as mental-health related, whereas in another jurisdiction, the same activity is excluded. This situation is quite common m the Medicaid program. In addition, the naming conventions for activities are not nearly as well agreed upon as names for major clusters of clinical programs. This is especially true as one moves away from somatic treatments, such as psychotropics or electroconvulsive therapy, to treatments involving verbal exchange or rehabilitation involving an instrumental daily activity. Thus, one can have little confidence in activities as a basis for comparability.  These dilemmas can be resolved if parameters are set out that suggest how activities aggregate into more comparable groupings or if service is used to apply to something more operational. Thus, it should be apparent that an order of abstraction is needed for this dimension that will overcome or accommodate these problems. Such a dimension was provided by work from a definitions manual (NIMH 1980b), stimulated by work of the mental health program of the Southern Regional Education Board (SREB).⁽³⁾  The activities performed by the staff of a mental health program element fall into one of four general categories labeled services. Each service category shares similar characteristics or goals. The four service categories are

1. direct services - face-to-face as well as other transactions (usually telephone) with patients/ clients or groups of patients/clients;

2. adjunctive services- activities on behalf of a patient/client who is not present;

3. consultation services - activities for the benefit of another organization, association or group;

4. administrative and support services - activities for the benefit of the organization that cannot be assigned to a specific patient or agency. Meetings, training, research, travel, down time, etc., fall in this category. It also serves as a default category for activities that do not fit under the above.

Exhibit 2. Critical structural dimensions for understanding the comparability of mental health organizations based on clinical programs and the services provided

Service areas