Of significance in this listing is the recognition that not all activities are treatment specific. Many are devoted to organization maintenance, such as relations with the outside community and administrative business within. Later chapters elaborate on these services and incorporate them into the design of a decision support system.  As with the program elements, the four service groups represent a conceptual structure that can be used to categorize the activities or programs of a mental health organization. As the second dimension of the taxonomy, they can be grafted onto the first dimension to provide the schematic for much of the following material. This is presented in exhibit 2.

Advantages of the Taxonomy

The primary advantage of this schematic is to demonstrate the relationship between services and program elements. One point of view is that services are nested within program elements, but it is possible to examine either dimension independently. That is, one's interest may be only whether certain program elements exist within an organization or how many of them are identified. Switching to the other dimension, one may be interested in only the amount of direct service provided by an organization, which suggests that only the direct services column would be examined.⁽⁴⁾   At first glance it may appear that all program elements are engaged in the same services. This may be only partially true. It is expected that both direct services and administrative and support activities occur in these clinical program elements. However, it is not always expected that the other two services are nested within every program element. The most compelling case for this involves consultation and education activities. According to the taxonomy, these would be classified as consultation services. In the organization in figure 1, consultation was nested only in the ambulatory cost center. Therefore, if these activities were to be displayed in the schematic in exhibit 2, a case could be made that the consultation services would be entirely ascribed to the outpatient program element. No other program element is involved in such services.  One of the situations that this schematic also accommodates is the dilemma left open at the end of taxonomy dimension 1 - what to do with the staff, activities, and money associated with functions that are not clinical program elements. A chapter on financial data discusses the common convention of handling this as overhead and suggests that each organization have a documented method for how overhead is handled. Generally, it is distributed according to an allocation rule within the organization. Therefore, referring back to figure 2, those cells that are not covered by program element labels have their staff, activities, and costs distributed by some allocation method to the program elements.  In this way, all the costs, staff, and activities of a finance and accounting department could be considered an administrative and support service and allocated to the existing program elements. Further refinement is possible by considering service categories as well. For example, some aspects carried out in the clinical records department would be adjunctive (on behalf of patients) and the remainder, administrative and support services. Thus, that department could be distributed in two service categories and across all the program elements that applied.  Although this report does not suggest which allocation method should be used, it is the consequence of its application that is desired. What results is an accounting of 100 percent of the mental health organization. The taxonomy presented facilitates this. Emphasizing clinical factors first, it arrays the major clusters of clinical programs that are found across a universe of mental health organizations. It then recognizes that each program element has nested within it a range of possible activities and that these further assist in the selection of programs that are comparable. Finally, it offers a framework for accommodating other aspects of the organization that do not fit immediately within the program element/services framework. It accomplishes the latter by permitting these aspects to be allocated across both the program elements and the service dimension. In short, each organization should be able to account for all of its activities, staff, and monies via this taxonomy. At the same time, the organization should be able to come to a better understanding of what aspects of other organizations need to be examined if comparisons in data are to be made.

Summary

In order to circumscribe the universe of places to which a mental health decision support system is applicable, a functional definition has been developed. This specifies the characteristics such a setting must have in order to be included within the universe.  The issue of differentiation within this universe must then be confronted. The fundamental problem is that comparable content from a decision support system is meaningless if the settings that are being compared are completely unlike. A taxonomy concept has been offered. It is felt this taxonomy must be grounded in something relatively common to the universe of mental health organizations, must advance the task of developing a generic decision support system, and must aid in understanding and explaining differences between organizations.  After examining an organization chart as a starting place, two dimensions are offered. One dimension emphasizes the major clinical programs offered by an organization. Six clusters of program elements are detailed as parsimoniously encompassing the vast majority of clinical programs. To be labeled a program element, they have to be relatively identifiable in an organization's chart of organization. A second dimension covers types of services within the program elements. In order to eschew the problems inherent in a lengthy list of transaction or activity codes, four categories of services have been suggested.  The resulting schematic has both conceptual and practical applications. Conceptually, it provides a basis for identifying similar mental health organizations and aggregating comparable information on them. Practically, it provides a framework with which an organization can fully reflect the activities it accomplishes, the staff who accomplish them, the clientele it serves, and the costs of doing its business.

Chapter 3
Management and Decision Support in a Mental Health Organization

Managers of mental health organizations typically must keep a watchful eye on two differing goals that are often in conflict. The first goal relates to providing care and services to patients and clients who are mentally ill. Specifically, the managers may wish to provide the highest quality services in the quantity demanded by the clientele. In America of the eighties, where mental health programs primarily are supported by public funds or third-party payments, this goal must be tempered by pricing these services at a level that is acceptable to the payers, while demonstrating that the services produce a benefit. Consequently, a second goal emerges. Managers must also behave in ways that ensure the solvency and survival of the program. They must make intensive efforts to get reimbursed for services, endeavor to price these services acceptably, ensure that staff remain productive, identify and promote the benefits produced by their program, try to save costs where possible, turn a profit where appropriate, and otherwise keep the program liquid. If either of these two goals gets out of hand, it is suggested that the other goal suffers.  The standards against which service quality, service adequacy, or program solvency can be judged are usually referred to as performance standards. The MHSIP historically has not taken the position of establishing performance standards. However, the MHSIP does provide data-content standards, the individual items that ultimately lead to the construction of performance standards. Thus, the issue for this chapter is to come to some consensus on those areas of performance that are Critical for management attention so that subsequent chapters have a basis for offering content standards that are applicable to the performance areas. The two goals just noted, services and solvency, are the focus on which organizational performance is elaborated.

What Performance Areas Does a Manager Need To Know About?

As the previous chapters have attempted to clarify, the primary business of mental health organizations is to provide treatment and service to patients/clients who are mentally ill. This provides two starting anchor points. The terminology comes from a paradigm that is virtually lore in the mental health information systems field. These anchor points are who and what. They are usually linked as: who receives what.  Who refers to the clients or patients served by the organization and is elaborated by collection of demographic as well as clinical characteristics of this group. what refers to the services provided to the patients or clients and may be described generally as the program elements discussed in the previous chapter -quasi-specifically by classification of services into categories such as those in the previous chapter, or microscopically by detailing each specific transaction or activity administered.
Complications arise, however. If one focuses exclusively on services provided to the clientele, a substantial volume of work within any mental health organization can be lost. As noted in the previous chapter, this may involve activities related to clinical records, meetings, filing bills and tracking receipts, keeping the organization running, etc. Consequently, the what anchor point should not be interpreted solely as services to clients or patients. Keeping the business solvent and productive, while ensuring its survival means that other "what's" must be examined.
Furthermore, this leads to another performance area for elaboration, namely, the staff of the organization.  Someone must produce the what within the organization and, therefore, it is logical to ask about who is generating the product. In the terminology initiated above, this inclusion of a staff focus is linked as follows and as shown in figure 3. who receives what from whom.  Whom is usually elaborated within an organization by job titles or functions and may also be examined by the person's professional training. Like the client focus, demographic characteristics figure prominently, as does information essential to personnel functions, such as salary and payroll taxes. Whom also should apply to the full mental health organization and not only to those staff involved in providing clinical services.  These points made about the expansion of the what and whom dimensions are in keeping with the discussion near the conclusion of the preceding chapter. For the organization to account for all of itself, there must be a systematic way to embrace those activities and staff not directly associated with the taxonomy dimensions and to distribute them within the taxonomy. This allocation issue is visited later in the report.  Next comes a performance area that relates profoundly to the goal of organizational solvency and survival: cost. In competitive business, it is axiomatic that no enterprise lasts if what it produces costs more than what it takes in. As mental health organizations attempt to operate more like businesses, they keep a closer eye on the bottom line of cost. A later chapter makes clear that cost is driven by two of the factors that are noted in figure 3: what and whom. Costs in mental health, as in most human services, result basically from an interaction between the services in which the organization engages and the staff who are involved. In figure 4, the relation of this additional performance area to the original three is shown. The terminology expressing this is: who receives what from whom at what cost.
Finally, if a manager is to maintain a balance between supplying a sufficient quantity of quality services, at a price that ensures satisfactory survival of the program, one additional anchor is desirable. The outcome, benefit, or effect of the service is valuable information. This is frequently assessed in terms of either an improvement in the client's condition or a prevention of deterioration in clients status. However, examination of effects can also be extended to the nonclinical activities and staff of the organization. The terminology is modified as follows (the relation of this final performance area is shown in figure 4). who receives what from whom at what cost and with what effect.  This phrase is recognized by many individuals who have been involved in the design or acquisition of an information system for a mental health organization. It is felt by many to encapsulate the basic areas in which managers need information and, therefore, is used as an acid test for what a system should produce.

Why Do Managers Need To Know This?

In chapter 1, a fundamental proposal was offered: Managers are interested in making improvements in their programs and do so by making "rational changes based on good, data-based information about the operation of their programs." It is assumed that these improvements are targeted primarily toward realizing the goals of service and survival. These improvements are brought about by actions taken with the resources for which the manager is responsible. Four resource domains have been noted: patients, staff, money, and property. Five specific actions can be applied to these resources: acquire, distribute, monitor, account, and assess. This results in the matrix shown in exhibit 3.  Thus, a manager may determine that a program improvement can be made by changing behavior with respect to one or more of these actions, applied to one or more of the resource domains. For example, regarding the first cell in the matrix in exhibit 3, i.e., acquire patients, a manager may have evidence that there is an undersupply of new patients and that this is reflected by patients being treated too long or that the staff is not sufficiently productive. This may lead to an effort to acquire more patients. An advertising campaign, an appearance on a local radio talk show, or a contract with a local employer to provide employee assistance programs may be specific actions taken by management to acquire more patients or clients. Each cell can be examined in this fashion, as can scenarios in which multiple cells are targeted.  Although the buck ultimately stops at the executive director, CEO, or superintendent, in most mental health organizations, it is rare to find a single manager who assumes daily responsibility for all these actions. Management actions usually are divided and delegated as duties to others within the agency. Therefore, one finds acquisition functions variously distributed to boards of directors, directors of marketing, planners, recruitment specialists, and fiscal officers, as well as the CEO. Other actions are also delegated. Monitoring and accounting may often be delegated to those in charge of information systems, utilization review committees, ombudsmen, human resource managers, etc.

Exhibit 3. The association between management actions and resource domains in a mental health organization

Resource domains

In addition, the four resource areas to which these actions are applied are usually delegated. In many instances, almost all of a resource domain is under the responsibility of specialized managers. Therefore, one finds clinical managers, fiscal officers, property/maintenance managers, personnel directors, and even delegations within these management categories so that all the necessary actions can be carried out. All the individuals are legitimately involved in managing some aspect of the mental health organization. Consequently, they may all be viewed as part of the management team, even if many of these individuals do not regularly participate in the executive meetings in which official management decisions are made. However, it is primarily those managers with a responsibility for the clinical activities of the organization who are assumed to have an interest in this report. This narrowing of focus is deliberate, driven by the statement above that the primary business of these organizations is the provision of services to patients who are mentally ill.  Whether delegated or centralized, formally assigned or informally assumed, management requires action, action requires choosing, and choosing involves weighing accumulated inputs. As stated in chapter 1, how a manager mentally gets all these inputs, processes them, and weighs the risks associated with various alternatives is not the focus of this monograph. It is the position of the MHSIP that at least some of these inputs can be generically characterized as the performance areas noted in the previous section. A manager who has information about program clientele, staff, activities, costs, and impacts presumably has a substantial amount of the inputs needed to make the decisions and take the actions that will improve the performance of the program.  There are two general caveats, however. First, one might need some contextual information in order to make decisions. This might relate to policy, a recent historical event, the geographic area, a law, a cultural or demographic feature of the population served, etc. The MHSIP does not address these contextual factors. Information on them is too variable and, more to the point, they do not readily translate into data that can be formally entered into or derived from an organization's information system.  The second caveat is more pertinent to this report, viz, a manager's decisions benefit from comparable data. As the previous chapter emphasized, managers must have confidence that the data are in fact relevant and comparable. Some comparable data come from within the organization, e.g., data from a previous period or from an identical program element. The notion of corn-parable data taken from outside the organization is addressed in a later section, which deals with a broader system perspective. Leaving these concerns aside temporarily, the issue remaining is how the manager gets access to these kinds of information.

Where Does the Manager Get This Information?

Managers have numerous methods open to them for obtaining information on the performance of their programs. Meetings, observation, gossip, reports, and many other formal and informal sources are available to them. However, empirical data are the focus of this report. Therefore, it is assumed that formal, structured systems are preferred to provide managers with this empirical input. One label applied to such systems is management information systems. There is nothing particularly objectionable about this label; it has been used several times already. Nonetheless, it is felt that it fails to convey the decisionmaking and action-taking nature of management. As an alternative, decision support systems is used.  "Decision support systems . . . are computer-based information systems that are designed to support decision making and decision implementation" (LeBlanc 1987, p.73). Two unique features of this definition are worth noting:

The systems are computer based. The era of manually based information systems is rapidly disappearing. Cost and user-friendliness, once obstacles of genuine reckoning, are no longer substantial impediments.

The systems play a role in decisionmaking and implementation. They are not neutral in intent; they are not mere accumulation points for data.

Managers are expected to interact with these systems as they make decisions about their resources, including the monitoring and assessment of their use.  Managers, therefore, need to have access to decision support systems that provide them with empirical input formatted in a way they can use to make decisions about program operations. These systems should be able to provide information in areas specified in the stated paradigm: who, what, whom, cost, and effect. As stated above, a manager who has information about clientele, staff, services, costs, and impacts has a substantial amount of the inputs needed to make decisions about the resources of the program. The frequency with which this information is provided to the manager, its timeliness, and its degree of detail are local decisions, not within the scope of the MHSIP.

How Is This Information Available?

Independent Components Approach

The simplest approach to designing a decision support system that satisfies the conditions noted would be one where who, what, whom, cost, and effect constitute separate systems. It is not unusual to find multiple systems, each dedicated to only one function, within a mental health organization. This is especially true if one considers the match between these performance areas and the resource domains noted earlier. This can be noted as follows:

Resource area               Performance area                   System parallel                Patients                          Who                                           Clinical records

Staff                               Whom                                        Personnel

Money                            Cost                                          Accounting

Property⁽⁵⁾                      (Where)                                    Maintenance

Many mental health organizations operate with separate systems dedicated to these areas. The original statement of the MHSIP (NIMH 1983b) was based on such an approach: independent data components relating to organizations (a version of whom), clients (who), and staff (another version of whom) were proposed.⁽⁶⁾  At first glance, the approach is attractive. Data are available that are both relatively well-tailored and pertinent to one of the performance areas or resource domains. This implies quick retrieval of such information and, therefore, an ability to accelerate the decision-making process. But on further examination, this attraction begins to fade.  In the previous chapter it was suggested that for managers to make reliable comparisons, it was necessary to be able to categorize and allocate data about the organization's activities consistently. With a discrete systems approach it is extremely cumbersome to engage in this process of categorization and allocation. Data from the separate Systems have to be merged so that the who-what-whom-cost data can be distributed in the matrix shown in exhibit 2. If the systems are not carefully designed to permit this, the attempt to merge and combine data is time-consuming and error-ridden. This is hardly inspirational news to a decisionmaker who wishes to derive comparison data from such an in-house system or to know if comparison data from other programs are reliable. In addition, there is substantial inefficiency and overhead in maintaining this discrete systems approach. Data items may have to be keyed in multiple times in order to be posted to the respective system, and the generation of reports may take considerable time when multiple systems need to be accessed.
Even more important, however, is that such an approach is ultimately hindered by its descriptive limitations. That is, the types of information derivable from an independent systems approach are basically descriptive. They tell a manager about each of the performance areas, such as the types of patients being seen, types of staff employed and their stations, revenues and expenditures of the program, volumes of service being provided, and the impacts of the programs. This is useful, but most managers who are trying to understand cause and effect, to move a program in a particular direction, find the approach limited. With it, for example, one cannot address any questions that might require a crosswalk between these independent systems. This points to the fundamental problem of an independent systems approach: It confines a manager's ability to the description rather than to the analysis of program performance.  Although a clinical manager would undoubtedly find information useful about the demographic and clinical characteristics of the patients, without an ability to link this information with data from the other performance areas, it would be difficult to examine such questions as

What types of professionals are serving different patient types?

Does the payment source of the client affect the types or amounts of services received?

Do some clinical types show maximum improvement in functioning after limited, intensive therapy?

Are the staff in program X better at working with their clients than the staff in program Y?

Why do our costs per outpatient visit run 30 percent higher than the other outpatient program elements?

It is hoped that none of these questions is esoteric and that managers have had to confront analogous issues in making decisions about their programs. As the questions are considered, it should be apparent, at least regarding mental health organizations, that most management decisions require more than just descriptive information about production, distribution, or volume. While the latter can be exceptionally potent variables in many businesses, telling a great deal about success and solvency, they are potent only so long as they point in the desirable direction. When there is a failure, management in these situations inevitably turns to an analysis of contributing factors. For example,

Did problems occur with raw material supplies or costs?

What factor did labor contribute?

Was the product defective?

Were targets not met because of breakdowns in equipment or other maintenance problems?

Did customers find an alternate product that is better or cheaper?

Thus, even in business environments that rely on a small set of descriptive indicators, a time may arrive when such businesses need to analyze other factors that have contributed to their performance on this set of indicators. If these other data are not readily available from the business' information system, the decision-maker may make an educated guess, take a wait-and-see attitude, or do research that is costly and takes time.

Integrated Components Approach

In mental health businesses, there is not usually a clear bottom line tied to production or profit. It is generally acknowledged that a small set of indicators, especially narrowly defined indicators, is not sufficient. The reason for this is evident in the performance paradigm. As the paradigm was originally presented, the interdependencies between each of the performance areas were noted. Each interacts with the others. Ultimately, it is the full paradigm that must concern a mental health decisionmaker. This is true for any performance area one begins to analyze independently:

Effects do not occur without a patient, a provider, and an event; effects are also achieved at some cost.

There can be no patients unless there is a service provided to them and a staff that provides it; patients will not continue unless the cost of what they receive is reasonable and an effect observed.

A staff cannot provide a service unless there is a recipient for it; as they provide it, they produce a cost and an effect.

This recitation can be continued, but it is hoped that the interdependency of each of these components is evident. Therefore, preferable to an independent systems approach is one that allows for these interdependencies to be readily examined. In systems design, this type of system is variously described as an integrated or relational data base. Such an approach is characterized by the following:

efficient input of the data (usually entered once);

the capability of merging data items whose combination pathways did not have to be spelled out a priori, i.e., not spelled out as part of the system analysis and design nor included in the routine programming code that operates the system;

relatively straightforward programming to achieve the combination;

flexibility in the preparation of specialized and ad hoc reports and analyses.

While these terms have been relatively common among system designers for several years, and while there is both hardware and software to accommodate the data processing, mental health programs appear to have made intermittent progress, at best, in implementing systems that can be characterized as integrated or relational (NIMH 1987a). At one time, NIMH was attempting to provide public-domain software that would operate on a wide variety of computers and meet these characteristics (Wurster and Goodman 1980). Funding limitations, rather than technical issues, halted progress.  This integration capability was judged by the Revision Task Force as absolutely essential to a redesigned MHSIP. Although the initial statement of the MHSIP proved invaluable in establishing and demonstrating the power of data standards for mental health information systems, with time, the limitations of an independent systems (components) approach became evident. For the reasons noted above, descriptive data are valuable, but limited. Therefore, the task force adopted as a working premise that the revised MHSIP would have to accommodate the progress and content of the initial MHSIP, but would also build toward a data base that was integrated and, consequently, useful to management decisionmaking.  This integration is achieved by focusing on one of the performance areas stated above, viz, the generic area labeled what. In subsequent chapters this is presented as an event component, and it serves as the keystone that unifies the other suggested components into an integrated whole. For an event component to function and for integration to be achieved, the MHSIP offers one unequivocal rule: Staff would be required to report on their activities. The task force saw no other mechanism by which information could be obtained that would allow the areas to be integrated. For some organizations this could be a major shift. For others, the rule would be pedestrian. Some activity report from the staff, in the form of a staff log, a service slip, or an administrative action that defaults their time to activity categories, would provide such essential information as:

staff identity

client identity (when appropriate)

type of event

location/place/program assignment of event

From these items, all of which are picked up in the later minimum data sets, it is possible to link data; derive costs; distribute activities, clients, and staff to program elements; and access data in each of the performance areas. All of these points are discussed in subsequent chapters.  The next task for this report is an elaboration on the specific content under the generic areas, and additional demonstration of the requirement that this content be integrated and useful to decisionmaking. The technology for such a system, its computer requirements, its file structures and software, the specific types of reports, the specification of frequencies or dates, and issues about legal or clinical procedures and policies are not covered. While these may be areas in which standardization is attractive, little evidence can be collected that the field has attempted to achieve commonality on any of them. Some of them involve concerns relevant to accreditation or eligibility for reimbursement. Others rely on market factors and shakeouts in the hardware and software industries. Agencies and vendors affiliated with those concerns may establish de facto standards. This version of the MHSIP does not venture into these areas.

Summary

As managers in mental health programs make decisions and take actions concerning their resources, they need access to empirical data that are pertinent to the management issue at hand. These data come from both the program itself and from other programs that are similar and comparable to the target program. Such data are best derived from ongoing systems within each organization that are explicitly designed to aid decision-makers. Thus, the derivation of the phrase: decision support system.  In designing these systems, several generic principles can be offered. A fundamental one is that the decision-maker must stay cognizant of a variety of performance areas, including patients, staff, services, costs, and impacts. Decisionmakers must understand that these factors interact. Most mental health managers do not have the freedom to focus on only one of these factors. If they try to narrow their focus, it is predicted that in order to remain viable, they eventually will be forced to consider the contribution of the performance areas they have tried to ignore. Therefore, any decision support system should be able to facilitate linkages among these factors, such that reasonable conclusions and hypotheses about cause and effect can be made by managers. The conclusions are the basis for the decision about what actions will be taken with which resources so that program performance can be altered. In order to make integrated information available to managers, it is necessary for staff to report on their activities and on who they served.

Chapter 4
Minimum Data Sets and Guidelines for Decision Support Systems

Justifications for the adoption of standards for mental health decision support Systems have already been presented. It was argued that such standards facilitate communication, judgment, and comparison. Standardization of content is feasible and is pursued in this section of the report. Standardization of systems that collect, report, and analyze the content is more difficult and is not pursued. Instead, system guidelines are be offered. This terminology distinction is not trivial and is further explained so that a common set of expectations pervades this material.

Minimum Data Items and Minimum Data Sets

Minimum data items refer to the specification and definition of individual data items that are identified as essential to the description and analysis of some topical area, viz, the program performance of mental health organizations. A collection of such items is referred to as a minimum data set. Items are identified for candidacy as minimum through the convergence of need, tradition, professional judgment, and empiricism.  None of these factors dominates, but each has a distinct role. Need is narrowly conceptualized here to mean items that are critical to the subsequent processing and categorization of the data. This might mean the name of an organization, a telephone number, or a code number for a record that allows follow-back for editing. Such items can be thought of as overhead, a necessary burden on the minimum data set in order to facilitate its collection or analysis.  Tradition identifies those items that are labeled as minimum due to the contribution of history, law, or idiosyncrasy of a given topic.

Professional judgment contributes or deletes items based on representative and informed experience and knowledge that such items are, are not, or will be important in addressing either a question in the topical area or the explanation of patterns in the data.

Empiricism, probably the least used, is based on tests using actual data bases that determine the extent to which an item contributes to the explanation of variance in the data base.

Regardless of the process by which an item enters the set of minimum data items, fundamental to the item's inclusion is the assumption noted above: Stated areas of mental health program performance cannot be satisfactorily described, analyzed, or explained without it. This description or explanation uses either the item alone or in combination with other items in the minimum set. The full set should have greater descriptive and explanatory power than the individual items.  Other characteristics of the minimum data items are also worth noting.

1. They are usually well integrated into the routine operations of the organization, such that they are collected or updated as a part of the clinical or administrative operations in which the organization is involved. If specialized data-collection initiatives are regularly required at the service-provider level, this calls into question either the inclusion of the item in the minimum data set or the quality of management in the organization.

2. Individual minimum data items can always be expanded or tailored to meet local needs. The specified basic categories allow one to expand any of them as long as the added details can be collapsed without belying the basic categories. For example, the basic categories "applicable" and "not applicable" could be satisfied by a local organization that actually uses a continuous measurement scale with values ranging from 1 to 10. The organization would have more information available to it than the basic categories indicate, but it would be able to satisfy them if it used a version of the following rule.

Scale values                     Basic data set categories

1-4                                     Applicable

5-10                                   Not applicable

3. The articulation of a minimum data set implies a hypothesis or set of hypotheses that the items presumably address. However, experience shows that in most instances of minimum data sets, the hypothesis is not stated, nor is it necessarily overtly evident. Systems designers know this principle well and are not free to ignore it. Thus, a conspicuous phase of system design is often labeled the requirements analysis or requirements statement: What does the system do; what reports are generated; what management actions are supported? Conventional wisdom suggests that these types of questions be answered clearly before a new system is purchased or an old one, redesigned.  The preceding chapters have presented the foundation of the hypothesis that drives the minimum data sets. Restated,

For managers of mental health organizations to make decisions about their program's performance and to take actions to ensure that services of acceptable quantity and quality are being provided in a manner that sustains the organization's solvency, these managers need to have data on who received what from whom at what cost and with what effect. These data must be comparable not only within the organization, but also with similar organizations so that the manager understands performance within a broader context.

In the next chapters of this section, each of the generic performance areas is described as a potential data component of a decision support system. In order to facilitate presentation, which is shown as minimum data sets, the performance areas are relabeled as follows:

Performance area                     Minimum data set

Who                                             Patient/client

What                                            Event

Whom                                         Workforce

Cost                                             Financial

Effect                                           (To be explained)

Minimum data sets should not be regarded as isomorphic with the full content of a decision support system or management information system. Every such system requires tailoring to accommodate local policy information that affects decisions; to address procedures that account for who has responsibility for and access to data; and to satisfy the culture of the organization, its clientele, and staff. Preceding chapters have suggested the generic areas and generic decisions that shape the minimum data sets that are presented later in this section.

System Standards vs. System Guidelines

Standards denote specificity. Quantities, values, terms, definitions, and concepts, all accepted as reference points for comparison, constitute standards. When dealing with minimum data sets, the employment of standards is reasonable. As one begins to consider how these items are collected within a service setting, and how they are maintained, retrieved, updated, and combined within a computer system, a far more formidable task becomes apparent. This task requires that the MHSIP define the frequency for the collection of data; the timeliness of the data; the quality-control procedures that designate acceptable completion rates or error levels; the file structures used to sustain, retrieve, and combine the data; the computer configurations able to match these requirements; the minimum and routine outputs that must be provided; and numerous other specifications.  These steps are possible and, for the organization involved in system design or acquisition, they are essential. For the MHSIP, however, they are daunting and, to date, unneeded. In addition, such specifications could unduly restrict service providers in their attempt to develop locally responsive systems. They could preclude system designers from incorporating state-of-the-art developments or from otherwise demonstrating their creativity.  Some would argue that there is a need for specificity in the system-design area, and they cite evidence that many State mental health authorities have shared requirements analyses and requests for procurements for systems. Nevertheless, for the present, the MHSIP approach has been to provide standards only for content and guidelines for systems. This means less specificity and only general suggestions about the nature of actual system operations. Some of these suggestions emerge in the data components below. A major guideline was inherent in the previous chapter, viz, that the system be integrated. However, the MHSIP has not established a standard that a relational data base design be used, nor a standard that separate data components be addressable with data base management software, nor any other standard for the system aspects. A later chapter comments on issues related to system operations as an organization shifts from a discrete systems approach to an integrated systems approach.

Summary

In order to build toward comparability, it is necessary to adopt conventions about terminology so there is some degree of certainty about how pertinent data were aggregated. Terms and their definitions that are suggested for inclusion in a mental health decision support system are labeled minimum data sets. Specificity about these minimum sets is possible and necessary. How these minimum items are included in actual practice implies that the MHSIP must also provide specificity with respect to systems for the collection, retrieval, updating, and analysis of the items. Historically, the MHSIP has held back in this area and has provided only general guidelines. That tradition is maintained in this document.

Section II

Decision Support Systems at the Organization Level:  Data Components and Minimum Data Sets for an Integrated System

Chapter 5

Patient/Client Data

In considering the nature of a data component for patient/client⁽⁷⁾ information, it is important to keep the concept of a minimum data set in mind. First, no effort is being made to describe the nature of the clinical record at the service-provider level. Local and individual clinical orientations, as well as legal considerations, must be given recognition and must take precedence. In addition, professional associations, especially those with an accreditation or auditing orientation, provide considerable guidance in this area. Second, the decision support system or information system does not supplant the clinical record. Rarely is there a need for these Systems to carry a substantial share of the information that is contained in clinical records. Although automated clinical records have a place as well as a history in mental health, they should be seen as a complement to a decision support system, i.e., as a source of data for the system. There is no need for 100 percent of the data in clinical record, automated or manual, to reside in a management information system. Third, in keeping with the management orientation espoused in the report, the focus is on those pieces of patient information that assist in the management of the organization, in answering the who part of the question in which decision makers are interested. It should also have some value in carrying out routine administrative tasks, especially in the preparation of reports.  As will become evident, the revised patient/client data set is quite similar to the earlier MHSIP version. The major change comes not so much from the items as from the possibility of linkage with other MHSIP data sets. Of major interest are the linkages with the event component. This linkage helps to profile service use by client type. When linked with the human resources component, the organization is able to analyze the types of staff serving subgroups of patients.

Definition of a Patient/Client

Registered and Nonregistered Clients

Mental health organizations inevitably encounter the situation in which services are provided to an individual, but they lack all the information on the person that would normally complete a clinical record, i.e., information that enables them to register the individual. This may be due to the nature of the contact; e.g., an emergency or a telephone contact, or the nature of the client, e.g., a desire to protect the patient; or the patient's unwillingness to provide essential information. In some organizations, services to persons on whom complete data are not available can absorb significant amounts of staff time. For statistical reporting purposes, these direct-care staff should receive full credit for their activities, including those clinical services provided to nonregistered patients on whom complete data may not be available.  For most organizations, patient/client refers primarily to those individuals who are registered with the organization. The distinction between registered and nonregistered clients is retained from the initial MHSIP:

Registered: An individual identifiable by actual name, code name, or unique identifier, who has a case record (medical record or clinical chart), and has received services from the organization...

Nonregistered: An individual who may or may not be identifiable by actual or code name or number, who does not have a clinical record, but has received services from the organization...(NIMH 1983b, p.51)

Registration does not necessarily mean the record that is opened must contain the name or other obvious identification of the patient, or that this identification is readily accessible by staff members. Systems designers can suggest mechanisms related to data coding or to access that permit reliable, unique identification, and restrict unauthorized access to identifying information on individuals receiving service. Even without these mechanisms, good clinical practices and staff professionalism can maintain confidentiality at the local level. This can be reinforced by appropriate regulation and law, usually required by each State.  Although full records cannot be maintained on non-registered clients, organizations should be able to determine the amount of service rendered to these individuals. It is also very useful to categorize these individuals by such variables as sex, gross age group, and general category of problem. This helps measure both the kinds of clients receiving services from the organization and staff productivity.  Whether or not an individual is registered is typically an organizational and clinical decision. In some cases, however, the patient decides. For example, an individual comes into a clinic, talks to a member of the staff about a mental health problem, but refuses to identify himself. The staff member may feel that a clinical service has been provided, but if the individual does not return and no identifying information is available, a record cannot be opened and the individual cannot be registered.  Organizations also differ in their rules about registration. Some organizations may choose not to register clients until diagnostic services have determined whether they can be appropriately served by the organization. Other organizations might register such clients, but discontinue the relationship or refer them if diagnosis suggests the organization cannot provide appropriate services. As a consequence of these varying rules, organizations could reflect very different numbers of nonregistered clients while providing essentially identical services.  For comparability of data across organizations, the following guideline is recommended: An individual seen by direct-care staff for the first time, on a face-to-face basis should be registered as a patient if

an appointment is made for another visit, or

the staff member expects the patient to return, or

the activity on this single encounter is judged by organization rules or therapist assessment as one of clinical significance.

A patient who is not registered during the first encounter should be subject to the above rules on subsequent encounters. Any individual charged for a clinically oriented activity should be registered. If an activity or procedure is significant enough to warrant payment, then on a clinical basis, it would seem significant enough to be recorded in a patient record. Once a record has been opened, the client should be considered registered.

Collaterals and Families

Another area that has proved troublesome in developing data reporting systems is the registration of collaterals. In treating an individual, a staff member may have to interview a relative or friend of the client. In this situation, the relative/friend would be recorded as a collateral in the client's record. This occurs very frequently in the treatment of children and can involve many interviews with one or both parents.  Confusion in recordkeeping may arise when contact with the collateral leads the staff to believe the collateral is also in need of treatment. A minimum organization policy should be to rely on the staff member to decide whether to (a) open a record on the individual and add a new client to the rolls, or (b) attempt to involve the collateral in couple, family, or group therapy in which the original patient also figures.  In some forms of family therapy, therapists often feel that the family is the client and that the treatment process should handle the family as an entity. This implies that a single treatment record for the family should be maintained. One solution is to maintain a single treatment record for the family, but to enroll or admit each member of the family as a patient, with a unique identifier. Each family member could then be independently included in a patient/client report, but a summary of services would show the number of individual, group, and family sessions.

Uses of Patient Data

In the paradigm presented in chapter 3, this data component is intended to assist the decisionmaker by providing information about the "who" element. Questions about the patient population are among the most persistent questions asked by managers, clinicians, researchers, and the public. The specificity of the questions varies, and there should be no expectation that the decision support system will be sufficient to answer all of them. This is especially true of those questions asked by researchers and the public.  On the assumption that the patient/client component is integrated with the remaining data components in a local decision support system, it is theoretically possible, when answering questions, to merge data from this component with data from the others. This ability can be critical for complex managerial analyses. A few such instances are noted below. The data exclusively from the patient component are also of extraordinary value in providing descriptive information. The repetitive set of concerns related to patient data follow.

Comparisons Between Patient Groups and the General Population

Not all mental health organizations accept among their goals the requirement that they target the general population in their area as their market. However, for organizations that are largely publicly funded, the matter of equity of access by all citizens is a critical concern.  Some of the most basic quest ions asked about the mental health services are related to how well all population groups are being served. For example, if the organization has a geographic area for which it is responsible, are clients coming from all parts of the service area? Are all age groups being served? Are minority groups receiving services? To what extent are indigent clients represented in the case load? These kinds of questions come from outside the mental health organization at least as frequently as from inside. In general, answers to these questions depend on comparing patient data with U.S. Census data. It becomes important, therefore, that items in the system be compatible with items collected for the census in order to make valid comparisons.

Comparisons Between Patient Subgroups and the Total Patient Group

Questions in this area deal with the differential characteristics among various subgroups of the patient population and their representation in case loads, program elements, or over time. These questions bear on both equality of access to services, epidemiologic concerns about greater need for service by some subgroups, and organizational goals that may emphasize some subgroups over others.  Do children, for example, experience longer periods of treatment in a program element than other age groups? Are divorced individuals more likely to be represented in a case load than single or married persons? Do clients from low-income families have similar experience profiles (e.g., type of program elements, length of treatment, prior care in the organization, referral patterns on discharge, etc.) to clients from higher income families? What percentage of clients have problems related to multiple disability areas, such as substance abuse and mental illness? Do patients with multiple disabilities exhibit different experience profiles than those disabled by mental illness alone? Are difficult-to-treat clients channeled through the organization in ways that raise questions about good clinical practices?
Answers to these kinds of questions are of keen interest to program managers when they are related to staff utilization or resource allocation within the organization. The study of the distribution and use of resources by various client subgroups is a necessary and useful part of organization management. In the data set below, references to the development of client typologies are intended to facilitate answering this set of questions.

Differential Use of Services Among Patient Groups

Questions in this area recognize that not all subgroups of clients need to use the same amounts and kinds of services. Service use as a measure can be direct (tabulating amounts of direct and adjunctive activities or units of service derived from the event component) or approximated by less direct measures (length of episode, intensity of service as reflected by program element exposure, disposition of the patient by the organization, etc.). Being able to profile service use by various sub-groups is of value in planning for services, i.e., ensuring sufficient service availability if high-need groups are well represented in the case load; for utilization review, i.e., determining if service use for differential subgroups parallels those suggested by the literature or professional judgments; and for understanding differences in the costs of various programs, i.e., those that serve the most disturbed patients are likely to have higher costs because of amounts of services provided and the personnel needs to deliver those services.  Although the field is not yet near the point at which systemwide standards of service delivery by patient sub-groups can be articulated, the availability of comparable data across the system creates de facto norms, providing an empirical beginning for such standards. It is predominantly in this area that concerns related to issues of prospective payment would occur.

Issues of Continuity of Care

A final significant use of client data appears to be on the ascent within mental health settings. This is the issue of ensuring continuity of care to clients, as they either move through a multiservice organization or reenter an organization at some subsequent time. Although the decision support system does not carry the burden of determining whether the patient has been served before, or of tracking the client through the organization during an episode, the system establishes the groundwork for this to be done. It does this primarily through the use of the patient-identification information.  A uniform policy with regard to client identification and authority to access client's data is helpful within an organization. It enables or encourages the clinical records system or the therapists to determine if other records on the patient exist within the organization, so that previous treatments or diagnoses are known. In addition, in large or geographically diverse organizations, such access may indicate if the client is under active care elsewhere within the organization and who is responsible. Such linkage checks may also flag a prescribed clinical linkage between program elements that has been made or has failed. In large organizations, the "loss" of patients in either of these ways has been known to happen. The data set recommendation for unique patient identifiers directly supports a focus on continuity of care for the patient within the organization.

Minimum Data Set

The following items constitute the minimum data content for the patient/client component of a provider-level decision support system. Each item is named, followed by either its minimum recommended categories or a brief explanation of its content. As noted in chapter 4, categories can be elaborated by the service provider depending on local needs. However, elaborations should always be designed to be collapsible into the minimum categories. This facilitates comparison of data with another organization or the reporting of comparable data to an auxiliary level. Comment sections follow the recommended categories. The comments are intended to explain the item further, discuss the importance or potential use of the data, or note advisable rules of interpretation.  Many mental health organizations also have responsibilities for patients whose principal diagnosis is alcohol- or drug-related. Efforts have been made to ensure the MHSIP data set is compatible with the data sets promulgated by the National Institutes on Drug Abuse (NIDA) and on Alcohol Abuse and Alcoholism (NIAAA). The details of the data sets of these Institutes should be given priority when a patient is to be reported to their data systems or when the organization maintains its substance abuse programs separately from its mental health programs. For patients with alcohol- or drug-related diagnoses treated in the mental health programs, the organization may wish to regard the NIDA/NIAAA data sets as a valuable complement of information to collect. The data permit comparisons with published reports from MDA, NIAAA, or comparable State agencies. The organization should check for the latest version of these data sets.

1. Organization Identifier
The 8-digit NIMH master facility code is recommended as the identifier.

Comment. Mental health organizations that are not aware of their NIMH-assigned facility code can obtain it from the Survey and Reports Branch of NIMH. If NIMH does not list the organization already, an identifier can be generated on request.  Because the first two numbers in the NIMH code string always identify the State in which the organization is located, it may be possible to drop these from the string for routine local operations and to develop a procedure to add them in automatically when preparing the data for external reporting purposes.  As unique patient data are maintained at the local level, it may not be necessary to have the organization identifier actually be a physical part of the data set. It is more important to be able to append this when reporting externally for statistical, billing, or other purposes.

2. Client status

Nonregistered - an individual who may or may not be identifiable by actual name or code name or number, who does not have a clinical record, but has received service from the organization

Registered - an individual identifiable by actual name, code name, or unique identifier, who has a case record (medical record or clinical chart), and has received services from the organization.
Comment: See text for comment.

3. Unique patient/client identifier
No minimum specifications

Comment. The organization should assign a unique identifier that enables the record to be identified and the data to be reliably associated with a particular individual. At the local level, this could be the patient name, a case number, the Social Security number, or other alphanumeric information. The identifier proves useful for follow back verification of information or editing of submitted data, and to access statistical information in other MHSIP components. The identifier should be stable from one reporting period to another in order to access that patient's information if the patient reenters the organization for service at a later time. In addition, it is useful to assist the organization in managing the patient's case and providing continuity of care within the organization and with other service providers.  The format specifications for a unique identifier may be established by an agency at the auxiliary level. This agency may be legitimately interested in, or legally responsible for, patients throughout many local organizations that constitute its domain of concern. Most often this auxiliary level is a State mental health agency, obligated by law to collect information by patient name or unique identification algorithm. The local level should honor these specifications. Aside from the legal consequences, this facilitates the subsequent reporting of data by local organizations, and facilitates the discharge of responsibility at the auxiliary level for continuity of care or linkage of clients with other organizations in the service area.

4. Date of most recent admission to organization
Month, day, year

Comment: This date is important for tracking the initiation of service for the current episode of care,⁽⁸⁾ as well as for calculating other measures used in figuring service contact and intensity.
In integrated systems of care, the client may be transferred out of one setting into another. This date of transfer in should be treated as a date of admission to the organization, because it implies that clinical responsibility for the patient has been accepted as of the transfer date.

5. Date of discontinuation/discharge/death
Month, day, year

Comment: While it is recognized that organizations vary considerably in their policies regarding when a patient's record should show a discharge or discontinuation from the organization, the standard established in the 1983 MHSIP has generally been accepted. Specifically, patients who have had no program contact in 90 days should be administratively discontinued. That is, even though the patient may not be available to participate in subsequent treatment planning, appropriate entries should be made in the record by the therapist responsible or by the organization, to close out that case from the current, active roster of clients.  Similar to the previous item, a client who is transferred out of the organization should be regarded as discontinued, and the date of (he transfer satisfies this item. Transfers within an organization, especially a multiservice organization, may be entered in the patient's clinical record, but they are not regarded as discontinuations or discharges under this item. Item 6, however, is relevant to this point.

6. Program element activity

This item refers to the program elements in which the patient has been/is active since the most recent date of admission to the organization, and the dates of the last service or discontinuation provided in each program element, as applicable:

Inpatient Month, day, year

Residential Month, day, year

Partial day Month, day, year

Outpatient Month, day, year

Case management Month, day, year

Emergency Month, day, year

Comment: Organizations that operate several program elements may provide services to a client in more than one of these during an episode. Often, the client remains enrolled in one of the program elements and is sent for service or transferred to another program element without formal discharge/admission or transfer in/out entries in the record. For a discharged patient, one of the dates in this item would correspond to the date in item 5.  A simple count of the applicable program elements in which the patient has been active during the episode of care provides a brief measure of service intensity; aids in understanding the costs associated with the episode; and facilitates a typology of clients that may have bearing on the severity of the problem.

7. Sex
Male, female

Comment: A patient's sex is a variable important in the epidemiology of mental illness and especially covaries with diagnostic clusters. In addition, as a demographic variable related to population characteristics, it reflects on the use of and access to mental health services by each sex. When linked with other data in the MHSIP data sets, it has relevance to issues of equity.

8. Date of birth
Month, day, year

Comment: Patient age is a variable important in the epidemiology of mental illness, and is associated with particular diagnostic clusters. As a demographic variable, it can be compared with the characteristics of the population area served, to assess issues of accessibility or unintended exclusion of age groups. When linked with other data in the MHSIP data sets, it has relevance to issues of appropriateness and equity of treatment.

9. Race⁽⁹⁾

American Indian/Alaskan Native - A person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition.

Asian or Pacific Islander-A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.

Black/African American - A person having origins in any of the black racial groups of Africa.

White - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Other-A default category for use in instances in which the patient is not classified above or whose origin group, because of area custom, is regarded as a racial class distinct from the above categories. Appropriate details should be maintained.

Comment: See next item.

10. Hispanic origin

Hispanic origin - A person of Mexican, Puerto Rican, Cuban, Central American, South American, or other Spanish origin or descent, regardless of race:

-Mexican/Mexican-American

-Puerto Rican

-Cuban

-Other Hispanic

-not of Hispanic origin

Comment: Items on the race and ethnicity of the clientele are important for both epidemiologic reasons and for comparisons with the population characteristics for the area served. Issues of accessibility, appropriateness of service, and equity can be examined.

11. Current marital status

Never married

Now married

Separated

Divorced

Widowed

Comment: Persons whose only marriage had been annulled are classified as never married. Individuals living as married are counted as married. Individuals reporting as separated (either legally or otherwise absent from their spouse because of marital discord) are classified as separated. Categories are compatible with the U.S. Census. Therefore, the item is of value in calculating rates of representation within an organization's case load in comparison to the overall population served. In addition, marital status has implications for prognosis (e.g., potential availability of a support system), and figures significantly in the epidemiology of mental illness.

12. Veteran status

Not a veteran

Yes, has served on active duty

Comment: A veteran is any person who has served on active duty in the armed forces of the United States, including the Coast Guard. Not counted as veterans are those whose only service was in the Reserves, National Guard, or merchant marines.  Veteran status may be associated with particular diagnostic clusters or presenting problems, and may also be a pointer for the need to check on patient history in other mental health service systems.

13. Legal status

Voluntary - a person who voluntarily seeks admission

Involuntary civil - a person committed for a non-criminal proceeding, whether for purposes of examination and observation or for treatment, either by a physician's certificate, a court proceeding, or police or related agencies.

Involuntary criminal - a person committed pursuant to one of the following:

- charges and/or convictions pending

- determination of competency to stand trial

- found "not guilty by reason of insanity" or "guilty but insane"

- determination of sexual psychopathy and related legal categories

- transfers from correctional institutions

Comment: The item is of profound importance to understanding variations in differential length of episode/contact with an organization or in the types of services a patient may receive. In addition, it helps to characterize important variations in patient mix across mental health organizations, which can explain staffing variations and cost differences.

14. Coded area of residence prior to admission to organization

Zip code and county code 

No fixed address

Comment: The address of the client's residence should be recorded in the original clinical record in sufficient detail so that it can be coded as above. In public organizations, the State mental health agency may promulgate a coding scheme for the State. However, it should be capable of providing the zip code or county code.  Most mental health organizations have a relatively targeted geographic area from which clients come. The item, therefore, is a de facto characterization of the service area of responsibility. This is sometimes referred to as the "market area." When further related to population characteristics such as those derivable from census data, viz, the Health Demographic Profile System (NIMH 1984a), the item enables the organization to check the degree to which patients come from areas within its service region that are associated with a high risk of mental illness.

15. Current coded area of residence

Zip code and county code

No fixed address

Comment: In addition to the comment on the previous item, also applicable here, patient residence may have changed in the period around the time of admission, or it may change during an episode of care. This information may be of value in understanding the case, in prognoses, or it may tell the organization that it must transfer responsibility of the patient to another setting.

16. Presenting problem(s) at time of admission

Each applicable category should be indicated.

Marital/family problem

Social/interpersonal (other than family problem)

Problems coping with daily roles and activities (includes job, housework, daily grooming, financial management, etc.)

Medical/somatic

Depression or mood disorder

Attempt, threat, or danger of suicide

Alcohol

Drugs

Involvement with criminal justice system

Eating disorder

Thought disorder

Abuse/assault/rape victim

Runaway behavior

Comment: The list of presenting problems is representative of the vast majority of descriptors used by mental health organizations to label or categorize the reasons why patients are entering for services. Many organizations find these listings to be as valuable as diagnostic groupings in describing their case loads. That is, they are used as both a complement and an alternative to diagnosis in presenting typologies for the clients served. Presenting problems are frequently used in the development of treatment plans, as they highlight salient areas for treatment and monitoring.

17. Diagnosis-admission, most current or updated, and discharge

Coding should be derived from the current Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association or the International Classification of Diseases (ICD).

If using DSM-III-R: Five digit code(s) for Axis I (clinical syndromes and V codes), Axis II (developmental disorders and personality disorders), and Axis III (physical disorders and conditions). For multiple diagnoses involving Axes I and II, the principal diagnosis should be noted. For multiple diagnoses within an axis, the diagnosis noted first is to be regarded as the one that is the focus of attention or treatment.

If using ICD-9-CM: Five digit code(s) for all diagnoses that apply, with the principal diagnosis (the one that is the focus of attention or treatment) listed first.

Comment: It should be assumed that the diagnosis appropriate to the type of record or report is provided: For a discontinued patient, the discharge diagnosis; for a recently admitted patient, the admission diagnosis; and for a census report, the most current or admission diagnosis. While a case can be made for reporting a diagnosis at more than one time point, a management use would need to be articulated.  The issue of concurrent disabilities among clients who are mentally ill is a critical one to many organizations. A count of such individuals is an important piece of descriptive information. The DSM multiaxial system obviates the need for additional, cumbersome coding to assist in the identification of patients with multiple disabilities. Of concern are such groups of the mentally ill who also are diagnosed with substance abuse problems, communication disorders, visual or hearing impairments, physical/medical problems, and those who are developmentally disabled or mentally retarded. If the ICD system is used, the recording of all diagnoses that apply similarly facilitates the identification of the multiply disabled.  The issue is not whether the organization assumes responsibility for services related to concurrent disabilities, but whether patterns of service use differ as a consequence of the disabilities. That is, the presence of multiple disabilities may account for unique referral patterns, for whether case-management action related to the patient is appropriate, and, significantly, for whether patients who are multiply disabled place greater demands on the resources of an organization than other patients.  For patients who are coded under alcohol or drug abuse disorders, it is advised that the data recommendations promulgated by NIDA/NIAAA be considered as an essential complement to the MHSIP data recommendations. Not only do these provide additional data of clinical relevance, but they will be of assistance in the case that specialized data reporting on these patients is required.

18. Severity of condition or level of functioning at admission

No minimum specifications

Comment: While partially redundant with a recommendation below to collect Axis V data, some indication of how dysfunctional the patient may be, that is, how incapacitated by the condition or symptoms, is considered important information. The ad hoc advisory group to the MHSIP commissioned a feasibility study to determine if there was an approach to the collection of data in this area that could be recommended for the minimum data set. It found no single approach that could be recommended at this time, but it did find substantial, worthwhile effort in mental health programs devoted to the measurement of the concept (Pokorny 1986). Therefore, it is recommended that organizations consider the collection of such data, but the MHSIP does not advise on the approach to be used.  Severity as a descriptor of the client population can be a potent piece of information. It maybe used to examine the level of care being provided to a patient or the appropriateness of the patient's placement. Severity is generally assumed to account for more variance in the resources consumed (e.g., the length of stay) by patients than do many other variables (Jencks et al. 1987). Thus, it may be associated with differences within and between organizations on costs, staffing configurations, treatments, etc. Level of functioning is often the concept organizations use when they are attempting to measure the change in their populations associated with the receipt of treatment services. That is, data on level of functioning are likely to be associated with outcome studies, and collected to show change in pre- and post-assessments. Because of design complications in these types of studies and the difficulties in making correct inferences, it should not be assumed that mere availability of these data for multiple time points permits outcome studies to be done.  Therefore, organizations considering the minimum under this item should adopt a measure of severity or functioning related to the patient's condition at admission. This provides useful data with which to describe the population served by the organization. There is much to be said for periodically updating this information during treatment. Clinicians in particular may find that in individual cases, a change in severity or functioning has clinical significance. Assigning a severity/functioning assessment at the time of discharge or administrative termination can also provide valuable descriptive data. The MHSIP remains wary about the use of these types of data in aggregate, however, especially to make claims about treatment or clinician effectiveness. Additional data and controls are needed before such statements can be made with certainty.

19. Chronicity of mental illness

According to a documented operational or functional definition maintained by the organization, patients can be classified as chronically (severely and persistently) mentally ill or not.

Yes, the patient meets the definition.

No, the patient does not meet the definition.

Not applicable; the organization does not maintain an operational or functional definition.

Comment: As this report is issued, a work group representing research, treatment, advocacy, and management issues relevant to this special clinical population is preparing a set of operational criteria that will better identify this group. One of the work group's concerns is that the criteria be useful and feasible for implementation at the service-provider level for inclusion in a decision support system. These criteria will be valuable in supplanting this item. Until their recommendations are available, the MHSIP would recommend that this population be identified by considering data from items 17, 18, 19, 20, and 22 of this data list, and the second item from the other recommended data list (see below).  It is strongly recommended that service providers significantly involved with patients who could be described as "severely and persistently mentally ill" be able to cite criteria that support the assignment of such a label. If these criteria are available, the organization may wish to replace the categories above with its criteria in the decision support system. if the data on this characteristic need to be reported externally, they can be reformatted to match the above minimum categories.  In the absence of a documented standard, it is recognized that the basis for comparing data on this item is compromised. However, the population is of extreme significance, while simultaneously presenting the problem of being more difficult to identify than other special populations (e.g., multiply disabled, children, frail elderly, homeless). In addition, there is every expectation that minimum criteria will be available shortly.

20. Eligibility determination

In reference to either the Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) programs of the Social Security Administration, the patient should be typed as one of the following.

Eligible and receiving payments

Eligible but not receiving payments

Potentially eligible, i.e., the case has not yet been submitted for determination or is in the process of determination

Determined to be ineligible, i.e., the case has been submitted and reviewed and a decision of in-eligible was returned

Not applicable

Comment: The degree to which a client is disabled by a mental illness is an important factor in the identification of the chronically, severely mentally ill. The more objective and uniform this determination of disability can be, the more valuable the information for use in the reliable, valid classification of the chronically mentally ill. The referenced programs of the Social Security Administration contain both criteria and a determination review that include mental illnesses among the disabilities that qualify a person for payments from these programs. Thus, patients who have been reviewed under these programs can be more confidently included or excluded from the count of persons with chronic mental illnesses. Furthermore, the patient's eligibility for these programs has income consequences for the organization, because reimbursement for services through Medicare or Medicaid may be possible. Payments to patients can also be used to provide residential care in noninstitutional settings.

21. Source of referral (as arranged by one of the following):

Self

Family or friend

Police (except court or correction agency)

Court or correction agency

School system or education agency

Social service agency

Inpatient/residential organization (indicate specific type)

- State or county psychiatric hospital

- General hospital inpatient psychiatric program

- Other inpatient psychiatric organization Alcohol treatment inpatient/residential organization

- Drug abuse treatment inpatient/residential organization

- Nursing home, extended-care organization

- Community residential organization

- Other (detail should be maintained)

- Other referral source (indicate specific type)

- Multiservice mental health agency (including community mental health centers)

- Outpatient psychiatric service or clinic

- Private psychiatrist

- Other physician

- Other private mental health practitioner

- Partial day organization

- Shelter for the homeless/abused

- Alcohol treatment organization other than inpatient/residential

- Drug abuse treatment organization other than inpatient/residential

- Other (detail should be maintained)

Comment: This is valuable information in a marketing sense, as well as in a clinical sense. Managerially, it i prudent to know the sources that are referring patients to the organization. Such information is of value it'. taking actions in the resource acquisition area. Clinically, the source of referral is a variable of potential significance in developing a typology of clients and in under standing the course of the episode of illness, differences in utilization patterns, or the patient's prognosis.

22. History of use of mental health services prior to most recent admission to the organization

Previous treatment by mental health organization of any kind

No

Yes

If yes, previous treatment within the past year

No

Yes

If yes, previous treatment by this organization

No

Yes

If yes, program elements in which previous services were received (each applicable category should be completed)

Inpatient Yes/no/not applicable

Residential Yes/no/not applicable

Partial day Yes/no/not applicable

Outpatient Yes/no/not applicable

Case management Yes/no/not applicable

Emergency Yes/no/not applicable

Comment: Whether the client has had prior mental health treatment may serve as an important indicator of whether the patient has chronic mental illness, flag the organization that it may be valuable to seek information on the prior episode(s), and it could help to anticipate imminent and future use of services. The recency of the past episode(s) may also be of clinical value, but the time period may vary as a consequence of the disorder. A year is offered as the minimum, but the organization may find other time periods are advisable.  Within an organization, the linkage of data on previous episodes is frequently not done. This item reinforces the importance of examining the patient's prior care within the organization and noting the program elements in which the care occurred. This operation, as well as the data, may produce desirable efficiencies in staff time and clinical treatment.

23. Residential arrangement-admission, most current or updated, and discharge

The patient's usual residential situation or arrangement is classified as follows.

On the street or in a shelter for the homeless

Private residence/household

Other residential setting

Jail or correctional facility

Other institutional setting

Comment: It is assumed that the residential arrangement is related to the type of report or record. For discharged clients, the setting to which the patient is being released should be indicated. If the residential arrangement over time is to be reported, a management use needs to be articulated.  Availability of a support system is regarded as significant both in the etiology and prognosis for a mental illness. The residential arrangement provides a ready indicator for the potential for such a support network. It has at least face validity bearing on the stability or stressfulness of the patient's residential arrangement. Importantly, changes in a patient's residential arrangement during treatment are regarded by many clinicians as instances in which the client may need special attention due to increased stress.

24. Living arrangement-admission, most current or updated, and discharge

The patient's usual living arrangement is classified as follows.

Lives alone

Lives with relatives

Lives with nonrelated persons

Comment: It is assumed that living arrangement is related to the type of report or record. For discharged clients, the living arrangement to which the patient is being released should be indicated.  In conjunction with the previous item, an indication of the extent to which a social and support network is available to the patient can be derived. However, assumptions about stability and stress around different living arrangements cannot be made; they must be judged on an individual basis.

25. Expected payment source

None, organization to absorb total cost

Personal resources (patient's or patient's family)

Commercial health insurance

Service contract (i.e., contract with an employee assistance program, health maintenance organization, public mental health authority, etc., to provide mental health services under a written agreement on a fee-for-service, capitation, or lump-sum basis)

Medicare (Title XVIII)

Medicaid (Title XIX)

Veterans Administration

CHAMPUS

Worker's compensation

Other public sources

Comment: As part of the intake process, it is extremely common for prospective patients to be required to indicate how their bills will be paid. In many instances, and for many reasons, the source indicated early on is different from the source that actually pays. However, because of iterative billing, last-party-of-responsibility determinations, and the nature of reimbursement from many public programs, it can be quite difficult to indicate actual source of payment. Expected source of payment can be important information to help an organization describe its clientele. It also serves as a marker to determine if treatment strategies, amount of treatment, or assignment to particular types of staff correlates with expected payment source.

26. Discontinuation status

Transferred - responsibility for the patient officially accepted by another organization and patient transferred to that organization

Administratively discontinued (no contact with organization for 90 days)

Patient/client died

Patient/client terminated services against advice

Patient/client lost to contact

Discharged - treatment completed; no referral

Discharged - additional services advised; no referral

Discharged - additional services advised; referral made

Not applicable

Comment: Organizations may maintain many more options than this minimum listing. Patients who have eloped or are a.w.o.l. (absent without official leave) should be categorized under the "against advice" category. Patients on trial leave, weekend passes, etc., or who are otherwise assumed to remain under the clinical responsibility of the organization are not considered discontinued, i.e., the item is nonapplicable. They should not be reported in one of the discontinuation categories until the category is appropriate. Patients who are the organization's responsibility under a time-limited court order or service order and who then return to the responsibility of the originating agency may be counted in either the "transferred" or "discharged, with referral" categories. Which category depends on the nature of the arrangement or organization policies.  Organizations differ markedly on their policies regarding the issues of transfer, discharge, referral, and elopement. A client in one organization may be shown as transferred while the identical circumstance in a different organization is counted as a discharge with referral. This must be accepted. Nevertheless, these categories suggest potentially different cohorts of patients who may exhibit different patterns of service use, or follow particular paths through an organization or organized system of services.

27. Referral upon discontinuation

No referral (self, family, friend took responsibility)

Inpatient/residential care (indicate specific type)

- State or county psychiatric hospital

- General hospital inpatient psychiatric program

- Other inpatient psychiatric organization

- Alcohol treatment residential organization

- Drug abuse treatment residential organization

- Nursing home/extended care organization

- community residential organization

- Return to penal/correctional institution

- Other (detail should be maintained)

Other referrals (indicate specific type)

- Multiservice mental health agency (including community mental health centers)

- Outpatient psychiatric service or clinic

- Private psychiatrist

- Other physician

- Other private mental health practitioner

- Partial day organization

- Returned to court for adjudication

- Alcohol treatment organization other than inpatient or residential

- Drug abuse treatment organization other than inpatient or residential

- School system or education agency

- Social service agency

- Other (detail should be maintained)

Comment: As with the source of referral item, knowing the organizations to which patients are referred is valuable marketing information. It also may prove useful in utilization and quality-assurance reviews, in which patterns of use and case disposition can be examined in relation to clinical factors or potential patient typologies. In some instances lengthy treatments are also accounted for if one understands that appropriate referrals may not be available. However, the latter represents a type of important data that is not typically associated with a decision support system.

28. Current primary therapist or case manager

Name or identification number of organization staff who is currently the client's primary therapist, case manager, or advocate

Comment: Most organizations typically assign responsibility for each patient to a staff member of the organization. Some may actually build in administrative tension by having two different parties take responsibility for different aspects of treatment.  Being able to aggregate patients assigned to particular staff provides a useful report about current case loads and the types of clients assigned to types of staff. It allows a linkage to other MHSIP components, viz, event and human resources, to determine the degree to which the primary therapist, case manager, or advocate is involved in the provision of services. It is also recognized that ibis assignment shifts during the client's episode of care. The organization may find it useful to track this, but at minimum, the criterion remains the current responsible staff.

29. Date of report

Month, day, year

Comment: The report date allows for data to be aged and for other calculations using patient/client items such as date of birth, date of last service, etc.

Other Recommended Data Items

The following items are recommended for inclusion in a service provider's information system. They are not listed as minimum, however, because they are of less significance to decisionmaking or because of difficulties in specifying uniform categories. Like the previously mentioned items, basic categories have been specified for recording. This ensures that organizations collecting the data have a basis for comparison, while permitting them to collect more detail, if appropriate.

Diagnosis

Using DSM-III-R, Axes IV (severity of psychosocial stressors) and V (global assessment of functioning).

Comment: This not only provides a diagnostic profile on all five of the DSM axes, but also provides added useful additional data. Especially of value to the organization may be the use of Axis V as a de facto measure of severity.

Duration of disability

For patients who are disabled by their psychiatric condition, an indication of the length of time for which the disability has existed:

A year or longer

Less than a year

Not applicable

Comment: Disability is usually interpreted from the perspective of the patient being able to participate in work or work-like situations or being able to discharge major role responsibilities. This information is used widely as one of the considerations in identifying the severely mentally ill. It attempts to categorize whether the patient's psychiatric condition has disabled the patient for an appreciable period of time. Duration of disability figures importantly in the Social Security Administration's review under both the SSI and SSDI programs. It is not synonymous with the date for the onset of the patient's condition.

Handicaps/impairments (other than mental illness) at time of admission

Developmental disability/mental retardation 

Organically based problem in expressive communication

Blindness or severe visual impairment

Deafness or severe hearing loss

Nonambulation or major difficulties in ambulation

Moderate-to-severe medical problems

Comment: Each applicable category should be indicated. This item is offered because many mental health programs lack the diagnostic expertise to use the three DSM axes recommended in item 17 (above). This would result in loss of information about the multiply disabled.

History of use of mental health services prior to most recent admission to the organization

If inpatient, number of admissions:

Within the past year

Ever

Comment: The additional categories round out the data provided under item 22. The recency and total numbers of inpatient episodes contribute to the profile of patients who may be especially problematic cases and place special demands on the resources of the organization.

Education at time of admission

Never attended school

Special education

Preschool/kindergarten

Some elementary school (grades 1-7)

Completed elementary school (grade 8)

Some high school or vocational education (grades 9-11)

Completed high school or vocational education (grade 12 or high school equivalent)

Some college (less than 4 years)

Completed college (4 or more years)

Comment: For patients with special education, there may be an interest in obtaining additional information on the number of years in special education or the type of education provided. Educational level is frequently used in determination of socioeconomic level. The latter is strongly associated with epidemiologic patterns. Individuals with different education levels may show systematically different patterns of contact with mental health organizations, use different points of access, or show preferences for only certain types of program elements. These patterns may be judged clinically or financially unacceptable. Education levels may also be associated with particular patterns of service configurations provided to patients, which the organization may identify as potentially discriminatory or clinically questionable.

Employment⁽¹⁰⁾

Employed, including on vacation or sick leave

Part time

Full time

Unemployed

On layoff from job

Looking for work; available to accept a job during the past 4 weeks

In the Armed Forces

Not in the labor force

Homemaker

Student

Retired

Resident/inmate of institution

Other (e.g., volunteer worker, disabled)

Comment: Employment is correlated with socioeconomic level. The item may also play a role in understanding service patterns in areas marked by recent employment changes. It may also correlate with a number of other items such as severity of mental illness, eligibility determination, and expected payment source and, thus, contribute to the development of client typologies.

Annual gross income and number of dependents

Total annual gross household income, as well as the number of household members dependent on that income

Comment: These data are critical in determining socioeconomic level and would contribute to the development of client typologies that are fundamental to analyzing equity, patteflis of service use, and prognoses.

Income-principal source

Employment/wages

Public assistance

Other

Comment. See above comment.

Coverage

The MHSIP recommendation is that the items in the minimum data set be collected on 100 percent of the registered patients/clients of the organization, and as many of the items as possible should be collected on the nonregistered clients. The process of intake, registration, or admission is so routine in mental health organizations, and is the source for so many of the minimum items, that issues of burden evaporate. Other items in the minimum set are collected or updated at one time of service provision, during discharge planning, or as part of periodic reviews of clinical records. As noted elsewhere, how much of this information also besides in the clinical record, how much additional information is keyed into the decision support system, how frequently it is reported out, to whom it is reported, and in what style are issues for resolution within each organization.

Summary

The minimum data set for patient/client data:

1. Organization identifier

2. Client status

3. Unique patient/client identifier

4. Date of most recent admission to organization

5. Date of discontinuation/discharge/death

6. Program element activity

7. Sex

8. Date of birth

9. Race

10. Hispanic origin

11. Current marital status

12. Veteran status

13. Legal status

14. Coded area of residence prior to admission to organization

15. Current coded area of residence

16. Presenting problem(s) at time of admission

17. Diagnosis

18. Severity of condition or level of functioning at admission

19. Chronicity of mental illness

20. Eligibility determination

21. Source of referral

22. History of use of mental health services prior to most recent admission to this organization

23. Residential arrangement

24. Living arrangement

25. Expected payment source

26. Discontinuation status

27. Referral upon discontinuation

28. Current primary therapist or case manager

29. Date of report

Chapter 6

Event Data

Mental health organizations are service organizations. They exist to provide mental health services to patients. Their staff either provide services directly to patients or facilitate the provision of services to patients. To manage these organizations satisfactorily, it is not enough to know static pieces of information, such as the characteristics of the staff, the amount of service the organization provides, and the characteristics of the patients receiving the services - the kinds of data that were provided by the initial statement of the MHSIP. Not only are some key pieces of information missing, but one cannot address the relationship between these three sets of data.  Managers in mental health organizations need to be able to address: Who receives what from whom at what cost and with what effect. By accumulating and analyzing these data, rational and defensible decisions can be made about allocating staff and resources within the organization, meaningful evaluations of staff performance can be started, a basis for measuring treatment effectiveness can be developed, and a start can be made on discovering the most cost-effective treatment methods.  To move toward the availability of this type of integrated data, an event component is being introduced into the MHSIP. In addition to supplying data that reflect the activities and services provided, i.e., addressing the receives what performance area, the event component is the mechanism that allows linkage between the MHSIP components. Thus, it plays a dual role in the Program.

What Is an Event?

An event is characterized as

a transaction between a staff member of a mental health organization and a client in which a significant activity occurs;

a significant action by a staff member on behalf of a client, i.e., interviewing a collateral, providing various kinds of adjunctive services, and many case-management activities;

other actions by staff that facilitate the provision of services to or on behalf of patients, i.e., activities that support the continued operation of the organization.

The event data system refers to the method of collecting, categorizing and reporting data on the transactions that involve patients and/or staff members in a mental health program. At the service-provider level, it is intimately associated with billing, activity tickets, or staff logs - all methods widely used in mental health organizations to collect information on staff activities; what was received by, done for, or done to the patient/client, or what was done to support the organization itself.  In its simplest expression, an event is a therapy session with a staff member in an outpatient setting and an individual client. In more complicated situations, an event can involve more that one staff member, more than one activity, and more than one client. The latter might be the case in a partial day program element, in which the organized program of service entails a clinical team that provides a small group of patients with a service package; it might consist of group therapy, medication, rehabilitative skill training, and case management.

Event vs. Unit of Service

The latter example points to the need to distinguish an event from a unit of service. In chapter 2, a service was identified as a cluster of activities that shared similar targets, characteristics, or goals. A unit of service is usually a concept intended to categorize or measure production outputs or capacities and intimately associated with the costs of doing business and the way an organization prepares its bills.

For mental health programs, production is a reflection of full agency effort and, therefore, all activities must be factored into the agency's costs and reflected in the units that are billable. A billed unit of service reflects both clinical activities provided and activities that contribute to overhead.  Thus, units of service are aggregates of behaviors or actions that have the potential to be more discretely identified. For example, in the partial day program above, the unit of service may be a 3- to 5-hour partial day session with a group of clients. When a client or a third party receives a bill, it is for this unit of service. The billed unit of service reflects not only the distinct actions directed to the patients, but the actions that constitute the overhead costs of sustaining the program as well. These more distinct behaviors and actions constitute what is meant by events.  For a manager trying to understand agency effort and what constitutes the makeup of the organization's cost of providing a unit of service, it is necessary to know what events contribute to these units of service. It is important because organizations that appear to offer the same unit of service may find that such units are made up of quite different events. That is, two psychiatric inpatient settings may each agree that they provide a unit of service labeled a "patient-day," but what occurs during these units of service may differ substantially between the two settings. This variability can explain why costs differ, why patients do not move through one program as quickly as another, and why staffing configurations vary. In short, there is no guarantee that the concepts of unit of service or service production are similarly understood or decoded by mental health organizations. For standardization, additional abstraction or definition is required; hence, the event.  It was suggested earlier that similar measures of effort or units of service are distinguishing conceptual features of program elements, i.e., an inpatient program element produces different units of service than an outpatient program element. Accordingly, units of service must be differentiated by the program element to which they are ascribed. For the program elements identified in chapter 2, the units of service are:

Program element: Unit of service
Inpatient: Patient day - 24-hour period or any portion of the day during which a patient was the clinical responsibility of that program element.

Residential: Residential day 24-hour period or any portion of the day during which a patient was the clinical responsibility of that program element.

Partial day: Partial-day session - a continuous period, usually of at least 3 hours and always less than 24, during which a patient or group participates in the receipt of services from that program element.

Outpatient: Outpatient hour - a continuous period measured in fractions or multiples of an hour during which a patient or group participates in the receipt of services from that program element. Many outpatient program elements find it necessary to detail their units of service in fractions of hours because of the nature of their business (e.g., medication checks). An accepted convention in mental health service is that continuous service for a period of 45 to 50 minutes is usually rounded to 1 hour rather than reported as three-quarters of an hour.

Case management: Case-management hour - a continuous period measured in fractions or multiples of an hour during which a patient participates in or benefits from the receipt of services from that program element.

Emergency: Emergency hour - a continuous period measured in fractions or multiples of an hour during which a patient participates in the receipt of services from that program element. For comparability across emergency program elements, those elements providing emergency services as days (e.g., crisis stabilization for up to 72 hours) should have the ability to report their units of service based on an emergency-hour.

The unit of service is used managerially to compare and assess similar program elements on their productivity, potential productivity, or efficiency. These comparisons range in complexity from examining simple tabulations of numbers of units of service to complex ratios involving data from other MHSIP components. For example, units of service can be linked with staffing data as ratios of production to numbers of staff or to numbers of hours of staff (usually referred to as full-time equivalents, or FTEs). Units of service can also be linked to financial data to provide one of the most sought-after management measures in mental health: the cost per unit of service. More is be said about this in a subsequent chapter.

The Rationale for Event Reporting

Unit of service measures are invaluable as management information. However, their aggregate nature can be a hindrance to decision makers because it tends to mask a considerable amount of detail. This detail can be critical in reconciling differences between similar program elements. Although knowing variations in patient types and the staff mix among these program elements is helpful, this information, too, can be limited. For managers to analyze performance, a more basic unit of measurement is required. This is where the event enters. The event is thought of as a more finite, specific piece of information that is usually based on the behaviors or actions of the staff of the organization. Furthermore, the behaviors of all the staff affect performance. While a manager's primary concern may be on transactions with a clinical orientation, in order to understand performance and costs, it is ultimately necessary to examine both services to patients and the activities of the staff.  Staff in many program elements who submit daily activity logs or service tickets are familiar with the notion of events and event reporting. Such tickets or logs frequently help to drive the billing system and are commonly associated with outpatient care. In other program elements, the idea that staff may be required to report, even on a sample basis, any detail about their activities may meet with resistance. Staff who do not get involved with actual clinical service provision, e.g., office workers, maintenance staff, administrators, etc., may view the suggestion that event data be collected from them as heretical. As this section attempts to clarify, all staff of the organization have to participate in event reporting. Some need to do this continuously, on a 100-percent basis; others need to participate only during sample periods.  As noted above, the event data system refers to collecting, categorizing and reporting data on the activities that involve patients or staff members in a mental health program. This event system is critical for a number of reasons. First, it is critical to the integration of data in an organization's decision support system. This is clarified as the chapter discusses the minimum data items to be included in event reporting. Task force members saw no mechanism other than event reporting that would permit this integration.  Second, an event data system is critical to understanding the unit of service. Events are the building blocks from which units of service are constructed. Some part of a unit of service for a program element consists of clinical transactions, either provided directly to clients or performed on their behalf. Other parts of the unit of service within a program element consist of behaviors that are nonclinical, e.g., administrative actions, reports, meetings, downtime, leave, etc. Still other parts of the unit of service consist of behaviors and actions that have been distributed or allocated to the program elements, e.g., the time used by a payroll office may be allocated to the program elements based on their number of employees, the dollar amount of their payroll, etc. All these behaviors and actions must be factored into units of service if one is to understand them as indicators of productivity, and if one is to understand their cost structures. Event reporting creates the mechanism by which staff can provide the detail needed for either the construction or the analysis of units of service in program elements.  Third, an event data system meshes well with a substantial volume of data collection occurring in many program elements. Probably the only exceptions are the inpatient and residential program elements. In most of the others, the collection of detailed information on the actions that transpire is quite common. This is attributable to such management actions as

acquisition, i.e., the intent to submit a bill for the service;

accountability, i.e., the need to satisfy a quality-assurance requirement or to make an entry into a clinical record;

monitoring, i.e., a tally of some type of utilization data.

In addition to these management needs, as more regulatory bodies are involved with mental health service providers, and as more auxiliary levels work with providers to supply additional types of information, the prevalence of event reporting is increasingly reinforced.  Finally, the relationship of staff, client, and activity, brought together by an event data system, is essential information when a manager of a mental health organization considers issues of cost, especially differential cost among similar program elements. Focusing on only one of these pieces of information may be inconclusive.  Differences attributed to different patient populations imply that needs for service and, thus, staffing types explain the cost variations.  Cost differences attributed to staffing configurations imply that the mixes are needed because of different treatment populations and their service needs.  Differences in service provision imply that patient needs and staff competencies account for the cost variations.  Unless the amount of time that types of staff are spending on different activities, with different clients, can be computed, the manager cannot understand how resources are being expended or why differences in resource consumption are occurring. It is only when these kinds of data are available and understood that the manager can sensibly propose alternative strategies. Otherwise, the manager experiments at random, by intuition, or accepts the patterns as they are.  In summary, a system to capture event data is well integrated with the performance paradigm spelled out in chapter 3. It fosters not only the integration of the various performance areas, but provides the manager with a base for analyzing performance so that necessary corrective action can be better targeted.

Efficiency and the Event Data System

An event has various attributes in addition to the who, what, and whom. These include the time the event took place, the place where the event occurred, the duration of the event, its cost, and the result. All of these important concepts have to be considered in designing a statistical system to provide the data needed to manage a mental health organization.  At the local organization level it is entirely appropriate to maintain considerable detail on events. This is the essential data needed for billing, clinical audit, and management analysis. In the explication that follows, this greater amount of detail is assumed. However, the examples are not meant to convey that as event data may be reported to auxiliary levels, the level of detail is constant. In order to keep this system reasonable and manageable, some condensation of detail is highly advisable, as event data move from the provider level to auxiliary levels. This becomes apparent in a later section dealing with data at the auxiliary level.  The event system is based on staff members reporting their activities. A major challenge in developing an event system is to design a method for staff to do this reporting with the least possible burden. The vital currency in any mental health program is staff's time, and the goal should always be to maximize the most productive use of staff time.  It would be ideal if data were available on each staff member in every program element for every activity performed for each working day. These data would include a code description of the activity, the identification of the patient or patients involved, and the identification of the place where the activity was occurring. Automation would be needed to handle such volume. Such a system would allow detailed summaries to be prepared with basic data about staff and patients that outline service costs, individual staff productivity, and many other analytic tabulations.  This ideal system, however, would require a substantial investment of staff time in recording and managing the system, as well as a major investment in computer hardware and software. The recommended details of event reporting that follow are an attempt to provide for as many of the values of this ideal event data system as possible, while minimizing the investment of staff time in recording and also minimizing the associated data processing costs.

Recommended Guidelines for the Collection of Event Data by Staff

These guidelines provide recommendations for the collection of event data by staff members of mental health organizations. They are specific to two groups of program elements, the components of which were defined above:

1. outpatient, case management, and emergency

2. partial day, residential, and inpatient

They are also specific for two groups of staff:

1. direct-care staff

2. all other staff

Direct-care staff includes all staff, professional as well as nonprofessional, providing direct or adjunctive services to patients as defined in chapter 2. Examples of these services include

diagnostic examination

a treatment session or visit involving a staff member and a client

dispensing of medication

an interview with a patient's family member

a group session with several patients and several staff members

the participation of a patient in an occupational therapy session

a dental exam of a patient

contacting of other programs and agencies to determine if they can provide a needed service to a patient

Note that direct-care staff also includes individuals providing adjunctive services. This includes a wide range of case-management services, such as arranging for the patient to receive services from another agency; trying to locate the patient; securing program entitlements, such as income maintenance, housing, or food stamps for clients; or any other service or intervention on behalf of a client. It also includes staff work related to the patient's clinical record, such as contacting family members to obtain patient histories and making entries related to the treatment plan.  Staff that meet neither of these criteria are referred to as all other staff. This includes office workers, administrative staff, maintenance staff, etc. For example, in the organization chart in figure 1, a consultation services component was shown. If staff assigned to this component provide only consultation and are never involved m direct or adjunctive care, they would be classified as all other staff.  Exhibit 4 summarizes the two dimensions of consideration. The following text elaborates on the details within each cell, and on various data collection alternatives.

Exhibit 4. Recommendations for the minimum recording of events by type of event, time period, type of staff Involved, and program element

Program elements

Outpatient, Case Management, and Emergency Program Elements

Direct-care staff includes all persons - regular employees, contract employees, trainees, residents, volunteers, and attending staff-who engage in activities directly with or on behalf of clients. The recommended guidelines for direct-care staff in these program elements require these staff members to maintain a log in which they record all their activities. This staff log would record each event, including the minimum data about that event, and it would be maintained year-round. It could provide the basis for a patient and third-party billing system. As a routine function of the local organization, schedule and activity forms could be designed and provided to the staff, which would substantially reduce the data recording involved.  The recommended guidelines provide that all other staff in these program elements maintain the same kind of log as the direct-care staff, but not all year-round. The recommendation is that these logs be maintained only for sample periods during the year. The exact frequency and length of the sample periods can vary depending on the degree of change in the program over time, the need for current data, the size of the program, and many other variables. One schedule that has been found useful is 1 week each quarter.

Partial Day, residential, and Inpatient Program Elements

The recommended guideline is that direct-care staff in partial day, residential, and inpatient program elements maintain staff logs for sample periods during the year. It is recommended they record all their activities during that period. During these sample periods, the concept of a unit of service should remain as described above, i.e., an Inpatient or residential day or a partial day session, but this is not a meaningful unit of time for staff to use in reporting their activities. The recommendation is that during the sample periods, staff use actual time it takes for the activity. It then becomes possible to move in one of two directions:

1. To pull together those reports from the direct-care staff that accumulate to represent a day or session (i.e., a unit of service in a program element) or

2. To remain on a discrete level and analyze gross units of service by smaller units of time/activity.

The recommended guideline for all other staff in these program elements is that during sample periods, a person who works in more than one program element records the hours worked in each program element. If the staff member works exclusively in one program element, a staff log need not be maintained. That person's time is automatically defaulted to the program element to which he or she is assigned, and the hours are allotted to the appropriate activity category.  In these three program elements, it is also necessary to maintain a patient attendance log. The expectation is that a patient attendance log is so fundamental that it probably would be available throughout the year. If not, it should be maintained at least to correspond to the sample reporting period. The log is used to provide the roster of patients to whom events may be directed. In some instances a patient may be in the log, but not identified in any of the staff event reports. Also, in some instances the event is directed to all patients in the log, and to list them uniquely on a staff person's log would be inefficient.  In the partial day program element, the log would list the unique identifier for each patient in attendance each day, as well as the length of time that the patient was in attendance. The remaining information about the activities the patient received or participated in would come from the staff logs.  In the residential and inpatient program elements, the log is also called a roll, roster, or census. It need only contain the unique identifiers of each patient and each day they are resident. Again, any remaining information about activities the patient received or participated in would come from the staff logs.

Justification for a Staff Log

The concept of event reporting is relatively straightforward. Managers are seeking basic data either on the services to patients or on the activities of staff. The mechanics of event reporting and the full use of event data are far more challenging than the concept, however. Minimally, one is seeking the association of a service event, the recipient of the service, and the provider of the service, i.e., who receives what from whom. This means there must be a method of making this association, and it must be built in to the mechanism for the collection of event data. The staff log is one such mechanism and is the basis for the event data system as it is described here. A staff log also provides a mechanism for gathering data on the events/activities of the nondirect-care staff. As stated earlier, the task force was able to conceive of no other mechanism than staff participation in the reporting of their activities that would make these data available.  The staff log must contain all the information about the event itself. The minimum content is described below. The log must also include identifiers of the staff member and the patient. However, there may be instances when the staff log does not contain patient identifiers, e.g., logs from administrative staff. Patient identifiers are needed on the staff log in order to bring together data about the patient and the staff with data about the event. Stated differently, it would be inefficient to require the staff log to collect data on patient characteristics repeatedly, or to include items about the staff person, when such data are already resident in the client and human resources components. By making the latter data accessible via the event report, they can be linked to data about the event.

Uses of Event Data

In programs or program elements that collect event data on a 100 percent basis, at least from direct-care staff, the most obvious use of data from the event component is for billing purposes. That is, the information can be obtained in a way that meets documentation or reporting requirements for the preparation and submission of a bill to the party responsible for payment. The other uses of data from an event component divide themselves into a dichotomy of event reports and event analyses.  Event report is the term used when tabulations, summary statistics, and even statistical analyses are confined to the data items in the event component. These data are obtained via the staff logs. Event reports might cover the number of direct events provided, the number of patients receiving group therapy vs. individual therapy, the ratio of direct-service time to intraorganizational support, etc. Event analysis is the term used when additional data are merged with the event report to conduct more probing analyses of the event and which require the linkage of event component data with data from other MHSIP components.

Event Reports

Event reports are summaries of the data items that constitute the component. Most often these are descriptive statistics used for monitoring. More elaborate statistics can also be applied, especially if the event data are thought of as a longitudinal data base (i.e., changing over time), or if a manager is making contrasts among comparable programs and needs more than percentage or tally data (i.e., assessment of differential performance). Whether descriptive or more analytic statistics constitute the event report, there are three general clusters of event reports possible: type, volume, and location. In practice, these usually are not separated, i.e., the most useful management reports include all three.

Type. This is the most fundamental dimension on which to distinguish event data within an organization. Type reports summarize the kinds of activities that go on within the organization, usually by the volume of such events, their location (e.g., in a program element), or both. Data on event type may tell a manager in a quick fashion if certain types of events are occurring, e.g., adjunctive services in a case-management program, administrative and support services in an administrative unit, diagnosis and assessment in a testing services program, etc. As noted, these reports usually have some data on volume or location. However, event type examined over time provides a change profile of the organization - how activities are added or dropped in response to environments, patient types, treatment philosophies, payment sources, or management actions.

Volume. Event reports focusing on volume present data on either numbers of events, the amount of time taken by selected transactions, or ratios contrasting different events, e.g., hours of direct service vs. scheduled staff time available. Volume reports presume that components of the organization have been clustered to be comparable either to one another or to other sources. Minimally, this implies that program elements are used to organize the information in the event report. As noted in chapter 2, comparing activity volumes across dissimilar program components is an empty exercise.  Volume reports also presume that type of event is an organizing factor for the report. With volume data added to type, management reports are far more useful and may begin to suggest to managers what patterns of production need management intervention. Volumes are usually judged against some standard such as past patterns or volumes across similar programs. Thus, the occurrence of occasional variations in volumes of events may not necessarily signal a manager that intervention is needed. A flu virus may affect a program element one month, resulting in lowered billable hours and increased administrative hours. Maintaining certain levels of productivity, anticipating slack or high-demand seasons, observing a marked or slow decline in particular activities in a program element, and noting other time- related patterns are made possible by examining event volume statistics over time. Many of these changes may be in response to management intervention and, therefore, become assessment reports. Others may be occurring because of subtle changes in patient types, staff morale, or inadvertent management action. These reports serve a valuable monitoring function. The more marked or persistent such volume differences appear, the stronger the need for the manager to investigate.

Location. Within an organization, location event reports attribute activities to particular components, as well as to physical sites in many cases. Some components of the organization may be expected to engage in the majority of their events in particular locations. For example, a case-management program element or a consultation and education service within the organization may be expected to provide the majority of their events outside of the organization. If a location event report reveals that the events are not occurring in the location expected - for example, 80 percent of the case-management events occur on site - it prompts the manager to examine the situation further, inquiring about the cause or the accuracy of the data.  Event reports combining data on location and event type can be quite useful for exception reporting, i.e., to detect the occurrence of events where they do not belong. Events that occur where they are unexpected or prohibited may be a sign of minor error in the system, or may be more serious and require management intervention. For example, staff in a consultation service might occasionally report that they provide direct service to a patient when they sit in on a therapy session. The addition of volume data enhances the value of these reports, especially for monitoring productivity of various organizational components. If the consultation staff report a direct-service event periodically, perhaps for 1 hour of a 35-hour week, this may be accepted. If the consultation service reports direct services for significant amounts of time, this may not be a situation a manager can accept sanguinely. As noted above, event reports are most useful when they combine type, volume, and location in one report.

Event Analysis

Event analysis refers to the generation of information reports based on the linkage of event component data with data from other MHSIP components. While additional MHSIP components on the workforce and finances have yet to be described, the concept of linkage can still be discussed. This linkage was described earlier in this chapter, and it is made possible by the fact that the event component includes data items that overlap explicitly with data items in the other areas. Therefore, in using the event data component, it is possible to exploit simultaneously the content in these other areas. The obverse is true as well, i.e., in using the other components, it is possible to draw on the content of the event data base.  Linkage with other data allows the event component to remain lean, while the value of the data expands exponentially. The types of reports possible with event analysis are exactly parallel to the basic information paradigm presented in chapter 3, viz, "who receives what from whom at what cost and with what effect". Whether the full paradigm is addressable depends on whether the organization has all of the information components in place with established linkage pathways. If these pathways exist, there are over 10 unique event analyses that can be generated from the four MHSIP data components, ranging from combinations of just two components to all four. Some of the more useful types of event analyses follow:

1. Patients/clients and services received - Typologies of patients can be developed using the patient component and might include target groups based on age or clinical characteristics. It is then possible to analyze the service or specific activities these groups receive (or benefit from) by type, volume, and location. Such data are useful for utilization review and quality-assurance monitoring, demonstrating accountability of the service program, decisions about the distribution of resources, and assessments about the suitability of these patterns.  Suppose that a provider operates a residential program for mentally ill young adults between the ages of 16 to 30, and observes that some residents are discharged after an average length of stay of 45 days, while the remaining residents have a length of stay at 150 days. Although the patient component alone would enable the manager to determine if there are clinical or demographic differences at admission between these two groups, linkage of patient data and event data would be of even greater value. This linkage might:

a. suggest a treatment model that could be used elsewhere,

b. uncover a pattern of service discrimination that requires correction, or

c. reveal problems both in efficiency and effectiveness, in which a service pattern is provided to a patient subgroup to which it is not appropriate.

2. Patients/clients and workforce - Because of cultural background, language skills, patient's diagnosis, or staff preparation, it is often assumed that certain staff/patient combinations are better than others. Event analysis provides a means of efficiently examining which staff are serving which patients. The manager may find evidence of desirable equal access by all types of clientele to all the direct-service staff. It is also possible for a pattern to emerge that the manager finds problematic, e.g., staff preferences that exert too strong a force on client assignment. Intervention or additional analysis may be necessary in the latter case.  The manager, for example, may inquire about the type of staff providing services to the two resident groups with different lengths of stay. This might reveal that

a. Certain staff identifiers are always associated with one of the cohorts.

b. The treatment teams for the cohorts are systematically different on some dimension, e.g., case managers and skill rehabilitation trainers might be present on the short length-of-stay cohort.

c. Some match between clients and staff on some dimension might appear to be related to treatment, e.g., the level of patient's disability might correspond systematically with the professional level of the staff, language skills of the patient and staff, ethnicity, etc.

3. Workforce and services provided - Because of the intimate association between staff effort and program costs, the overall productivity by staff is a perennial concern for managers. Event analysis permits a useful, discrete examination of staff involvement in particular activity categories. This provides the manager with opportunities to understand the nature of resource consumption within various programs. For supervisors responsible for personnel guidance and evaluation, these data are also invaluable. They not only provide documentation, but also help develop career paths, select in-service or extracurricular training, or nip problems before they become disruptive. Staff may gravitate toward certain activities because of their interest and talent in performing them. On the other hand, the same pattern could make some staff feel they are stymied, being unfairly treated, or that their skills are being misused.  In the residential example, the manager might inquire about the service profiles for similar groups of direct-service staff. The data could be by hours in activities or, more useful, by portion of the total time available in selected activities or services. Both averages and ranges of service for that group could be examined. The latter would suggest whether there is wide variability and, therefore, whether additional probing is needed.  A number of patterns might emerge, using the preceding example on length of stay.

a. Among the senior, higher trained, or team leader professionals, wide differences could occur in participation in direct treatment of patients.

b. Differential ranges of effort could be devoted to case management, clinical super-vision, and in-service training.

c. When activity profiles for individual staff are examined, similar professionals could show markedly different patterns, ranging from involvement in a wide assortment of activities to involvement in one or two categories.

4. Patients, services, and workforce interactions - Event analyses that seek to examine more complex interactions between the elements in the information paradigm can be daunting. They should be undertaken initially to understand the operation of the program, to suggest new configurations that might be more effective or efficient, or to investigate data patterns that cannot be understood otherwise. Managers will probably come to depend on them quickly. The fact that the event component makes them possible is the main point. The value of event analyses can be extraordinary, even if they are complex to do and to interpret.  Continuing with the above example, a manager who has observed such a marked difference in a program element probably would not waste effort with the piecemeal analyses suggested above. Although they are valuable in raising questions and demonstrating linkages between components, separate analyses rarely provide satisfactory explanations. As should be evident, however, an event analysis that links clients, staff, and activities quickly provides the manager with insights about the nature of performance or cost differences.  For the scenario created for the residential program, the following profile emerges:

a. The director of the residential program provides no direct services and distributes time between administration and community consultation. This director also maintains a private practice, and there is some concern that active management of the residential program is being ignored. Questions arise, therefore, about the actual nature of the community consultation.

b. The shorter length-of-stay cohort is served exclusively by one treatment team that is professionally staffed no differently than the treatment team serving the longer length-of-stay residents.

c. The shorter length-of-stay treatment team provides an intensive team workup on each of its new admissions and develops a treatment plan appropriate to the patient's strengths and problems. The latter is evident in that patients receiving higher amounts of individual and group therapy are rated as more disabled, and those receiving higher amounts of rehabilitative skill training and case management have been referred from an inpatient program. The latter group also exhibits the shortest length of stay.

d. The longer length-of-stay treatment team provides each of the patients with a similar profile of treatment, consisting of personal care provided by psychiatric nurses, recreation services provided by activity counselors, group therapy provided by social workers and weekly medication checks provided by a psychiatrist. This team, especially certain members, shows higher proportions of down time than the organization's standard, has above-average use of sick leave, and shows little diversity in the service categories used by individuals reporting.

Many other facets could be examined-in service training directed to team members dealing with various resident types; team meetings on patients; the amount of clinical supervision provided to lower level staff by more senior staff; types of referrals and placements for discharged residents; recidivism rates for the patients from the two teams; revenues generated by teams; time devoted to work with collaterals, etc. Although the example is fictitious, it demonstrates that an event analysis capability added to the MHSIP helps the manager explore all the areas of the performance paradigm without resorting to ad hoc data or anecdotal reports from staff or patients.  As noted, many unique event analyses are possible. In practice, not all of them are likely to be pursued as stand-alone reports. In remaining sections of this document, some of these analyses, made possible via event reporting, are reinforced.

Minimum Data Set⁽¹²⁾

The following items constitute the minimum data content for the event component of a provider-level decision support system. Each item is named, followed by either its minimum recommended categories or a brief explanation of its content. As noted in chapter 4, categories can be elaborated by the service provider depending on local needs. However, elaborations should always be designed to be collapsible into the minimum categories. This facilitates comparison of data with another organization or the reporting of comparable data to an auxiliary level. Comment sections follow the recommended categories. The comments are intended to explain the item further, discuss the importance or potential use of the data, or note advisable rules of interpretation.

1. Organization identifier

The 8-digit NIMH master facility number is recommended as the identifier.

Comment. Mental health organizations that are not aware of their NIMH-assigned facility code can obtain it from the Survey and Reports Branch of NIMH. If NIMH does not have the organization listed already, an identifier can be generated on request.  Because the first two numbers in the NIMH code string always identity the State in which the organization is located, it may be possible to drop these from the string for routine local operations, and to develop a procedure to add them in automatically when preparing the data for external reporting purposes.  As unique event data are maintained at the local level, it may not be necessary to have the organization identifier actually be a physical part of the data set. It is more important to be able to be able to append this when reporting externally for statistical, billing, or other purposes.

2. Date of event

Month, day, and year

Comment: The date of the event is a key variable so that an information system can properly handle, assign, and operate with the other data in the event file. For the analysis of data by reporting periods and for use in relational editing using data in other components -especially client and workforce components - the date is critical.

3. Staff member reporting

A unique identifier that can be used to associate the data in the human resources component or file with the staff member reporting.

Comment: As stated, this item provides the critical link to the data in the workforce file. See item 9 below for participation of other staff members.

4. Program element identifier and attendance logs

A code identifying the type of program element under whose auspices the event occurred. Recommended categories:

Inpatient

Residential

Partial day

Outpatient

Case management

Emergency

Not applicable - event did not occur under auspice of a clinical program element

A patient/resident attendance log must be provided for inpatient, residential, and partial day program elements for each day on which events are recorded.

Comment: As noted earlier in the chapter, events, units of service, and costs may be unique to each program element. Thus, it is important to be able to partition the data initially so that meaningful aggregations are possible later. Program element definitions were provided in chapter 2. For inpatient, residential, and partial day program elements, a patient attendance log for each day of event reporting must also be submitted. This lists all patients by unique identifier (see next item) on the rolls/census of the program element for that day. If patients attend the partial day program for variable lengths of time, the hours in attendance must be included. The unit of service count for these program elements (i.e., days or sessions) is derived from these logs. Organization components that do not have a clinical orientation must still be accounted for, and their activities and resources must be distributed. For this reason, when staff logs are being maintained by staff in parts of the organizations that do not meet the program element definition, a "not applicable" category allows them to default their activities. Subsequently, the organization may distribute their time according to its allocation rules.

5. Patient(s) Involved In the event

Unique identifier(s) that can be used to associate the data in the patient/client component or file with the patient(s) involved in the event.

Comment: This item provides the critical link to the data in the client component. Unique identifiers should be used under each of the following circumstances:

If the activity is with a patient or on behalf of a patient.

If more than one patient is involved, the unique identifiers of each patient should be recorded.

If the activity is not with or on behalf of a patient but involves an organization or association, codes for these organizations or groups receiving services should be developed. This guideline includes the service organization itself as well as its program elements or components.

If the patient has not been admitted to or registered with the organization, nor assigned a unique identifier, then the sex, approximate age, and presenting problem should be recorded.

6. Type of event

Individual mental health organizations maintain considerably different schemas for the classification of the activities of their staff. This is encouraged, as is a rich amount of detail that can be justified for management, billing, or clinical accountability purposes.  The categorization of events, transactions, or activities should be collapsible into the following recommended categories.

Direct-service events - face-to-face as well as other contacts (usually telephone) with patients/clients or groups of clients. Direct events are further categorized as to whether they are one of the following:

- Engagement and outreach events - activities usually directed to potential/nonregistered patients intended to establish trust and rapport, explain services and assistance available to the potential/nonregistered patient, and dispel likely or actual resistance on the part of the potential/nonregistered patient.

- Diagnosis and assessment events - activities intended to defame or delineate the patient's diagnosis and problems. These activities are used to document the nature and status of the recipient's condition in terms of psychiatric, psychological, interpersonal, somatic, social, or situational factors. They serve as the basis for formulating a plan for subsequent activities or services.

Diagnosis and assessment events usually include transactions such as examination (somatic or neurologic), testing, interaction, observation, interview, and laboratory work.

- Treatment events - activities based on the patient's diagnosis or problem intended to arrest, reverse, or alleviate the disorder or problem. Treatment events are most often provided in relation to a treatment plan and may be delivered to the recipient individually or as a group member.

Treatment events include such transactions as the administration of prescribed medications, medication checking and monitoring, behavior modification, psychotherapies, somatic therapies other than medications (e.g., electroconvulsive therapy), stabilization of crisis reactions or symptoms, social therapy (increasing patient awareness of interpersonal environment), and therapeutic education (information sharing or the development of recognition skills that help the patient to sustain adaptive functioning).

- Rehabilitation events - activities and services intended to train or retrain a patient to function within the limits of his or her original or residual disability. Rehabilitation events are most often provided in relation to a treatment plan and may be delivered to the recipient individually or as a group member.

Rehabilitation events include skill training in activities of daily living (e.g., personal grooming, eating) or instrumental activities of daily living (e.g., shopping, managing money, managing personal possessions, housework, simple meal preparation, use of public transportation); special education; vocational training; mobility restoration or improvement; and activities that assist the patient to participate in recreation or hobbies. Note: if the activity does not involve training in activities of daily living or instrumental activities of daily living, it falls into the next group.

- Personal care events - life support activities and services provided to meet the client's needs for food, shelter, and safety.⁽¹³⁾

Personal care activities include assistance in the performance of activities of daily living; providing meals, shelter, or a bed; protective oversight; or transportation.

- Adjunctive service events - activities on behalf of a patient/client who is not present.

The vast majority of the events in this category are related to case management. They involve staff assessment of a patient's need for other services, entitlements, or care that may not be within the authority of the organization to provide. Staff may then develop a plan for acquisition of these services, link the client to the service or otherwise refer them, advocate for the client, and monitor the client's receipt of and benefit from these services. In addition, adjunctive services may include work related to the patient's record; clinical consultation within the organization about the patient's diagnosis, treatment, prognosis, or referral; and the collection of additional information on the client.

- Consultation service events - activities that benefit another organization, association, or group.

The recipient of these activities and services is from outside the organization. The activities are intended to impart knowledge about mental illness and mental health that aids in prevention, recognition of mental problems, appropriate referrals and linkages to treatment sources, and general improvement of understanding within the community of mental illness and its treatment. These services are often labeled "consultation and education."

- Administrative and support events - activities for the benefit of the organization that cannot be assigned to a specific patient or agency.

Meetings, training, research, supervision, travel, vacation, sick leave, report preparation, down time, etc., usually fall in this category. It also serves as the default category for activities that do not fit into any of the above event categories.

Comment. The minimum categories echo the service taxonomy dimension provided in chapter 2. These categories capture generic activity clusters that can be used to describe and analyze service profiles by patients, staff, program elements, and organization, i.e., both event reports and event analyses, as described earlier. They also may provide much of the data needed for use in the financial component, presented below, to calculate the cost of providing a unit of service within a program element.  Of special concern may be the relevance of these categories to non-direct care staff. As discussed, if there is no management interest in knowing what makes up the employment time of these staff, there is little need for their participation in event reporting. For non-direct care staff with 100 percent of their time assigned to one unit, all their time maybe defaulted to the administrative and support event category. For example, the staff of the payroll office may not participate in event reporting for the sample period, and 100 percent of their time would be defaulted to a nonclinical care component, with the event type recorded as administration and support activities. If any of the nondirect-care staff spread their time among several components, e.g., maintenance staff, at a minimum they need to report their hours in these components.

7. Scheduled event

Event was scheduled, i.e., the activity, patient, and staff involved in the event were known at least 24 hours in advance.

Event was unscheduled, i.e., the activity, patient, and staff involved in the event were not known at least 24 hours in advance.

Comment. For many mental health agencies, the bulk of daily activity consists of planned events, i.e., those that are known about, planned for, or scheduled in advance. It may also be important for quality-assurance purposes to know if the event coincides with a critical date established by the treatment plan, a judicial agency, third-party payer, etc. Some volume of unscheduled activity is also to be expected. High incidence might suggest the need for closer management attention to treatment plans, adequacy of care, quality of the scheduling system, or other contributing variables. The following conditions are also of significance:

Nondirect care staff, such as administrative or maintenance staff, may not always know the specific activities they are to be involved in. However, in the event types in item 6, they do know they are administrative and support events. Therefore, it is anticipated that their time can usually be defaulted to scheduled events.

Staff involved in direct care may find unscheduled events in any of the event types.  In emergency program elements, unscheduled events may be the norm. That is, staff in these program elements may know that they are going to provide activities in advance, but usually the recipient is unknown. In emergency program elements with an inpatient focus, e.g., 72-hour crisis stabilization, events subsequent to the in-take assessment are probably classifiable as scheduled.

8. Event duration.

Actual time staff member was involved in the reported event in minutes and hours

Event canceled by staff

Event canceled by organization

Patient failed to show

Comment. Event duration is critical data for tallying staff time, amount of service received by patients, and for bill preparation. When multiple staff members are involved in an event, it is not intended that the amount of time be multiplied by the numbers of staff present. For example, the event duration of two staff members involved in 60 minutes of group therapy is 1 hour, although each staff person receives credit for 1 hour of a direct treatment event. When multiple clients are involved in an event, each client is credited with receipt of that amount of service, i.e., eight patients participating in 60 minutes of group therapy each are recorded as having received 1 hour of direct treatment. Bills are usually prepared from the latter perspective, i.e., the amount of service received by the patient.  When events are scheduled and the patient fails to make the appointment, staff productivity measures can be affected. These no-shows may vary by particular types of clients or events, and thus have clinical as well as administrative importance. Organizations may also find that some staff have above-average rates of client no-shows. Staff that cancel an above-average number of their events need to be looked at more closely. In addition, the cancellation of an event by the organization or staff may serve as a valuable management index at the local level. Frequent cancellation of events by an organization component may be a sign of mismanagement, poor scheduling, or resource problems.

9. Presence of other staff members

No other staff members involved in the event

Other staff involved in the event, with identifiers for each, including a special flag identifying the staff who is regarded as primarily responsible and accountable for the event, e.g., primary therapist, team leader, etc.

Comment. Only other staff who share in the performance of the event should be indicated. Staff who may also have been on duty or present physically, but not involved, should not be associated with the event. The special flagged identifier should only be used if the staff identifier in item 3 does not identify the primary staff. These data are needed for the correct preparation of billing information; for the correct tallying of events so that staff receive credit for their activities; and, in some program elements, for producing unit of service counts.

10. Location of event

Premises of the program element or the mental health organization

Other clinical setting

Patient's place of residence

Street or other public place

Other (detail should be maintained)

Comment. As payment authorities expand their definitions of where allowable services may be provided, and as mental health organizations expand their concepts of where they may provide services, it becomes important to attribute services to different locations. In addition, it is expected that locations vary systematically according to program element and type of activity or service.

Other Recommended Data Item

Presence of collaterals

The number of family members or significant others directly involved in the event

Comment: These are persons who are relevant in some way to the treatment plans of individual clients, not merely others who may be physically present.

Methods of Linkage

Two approaches to the linkage of event data with other MHSIP data components are viable. Neither is offered as a standard, but the implications for the degree of real integration in the decision support system are different. In the first, the staff logs themselves provide the critical data for specialized, ad hoc analyses. In the second, other files are enhanced with event information so that it is more routinely available for a variety of management and analysis questions.

A Temporary Event Analysis File

In the first approach it is probably best to think of a separate, new file being created. This is labeled an event analysis file and is a conceptual convenience, rather than a prescription that a system be constructed in this fashion. It can also be thought of as a temporary work file created to answer specific questions or to generate unique reports that require linkage of event, client, and/or staffing data.  The file begins with the staff log from which are obtained the recommended minimum data elements about the event, especially the unique identifiers of the patient and the staff. These identifiers are the mechanism for linking event data with the data on file for patients and for staff. If it is assumed that the latter also exist as separate files, the linkage can be thought of as a computer-based matching procedure, keyed on the appropriate identifiers. That is, all or part of the patient and staff data files can be linked with the event information file by matching the files on the identifiers common in each of the separate files. As this matched identifier is found, appropriate data from the client and staff components can be added to the new file.  Suppose, for example, the organization is interested in knowing if patients with particular diagnoses are systematically being channeled to certain clinical disciplines. To answer this basic question, two critical pieces of data need to be picked up for the new file. Beginning with the staff and attendance logs, a search of the staff and patient files proceeds. When a match for the staff identifier occurs, the data element on discipline/training of the staff is added to the new file. When a match for the patient identifier occurs, the patient's diagnosis or presenting problem is added to the file. Once the organization does this matching, it is possible to conduct an analysis pertinent to the above question. More data items could be factored into this analysis, or the analysis could be rerun if the initial findings raised more questions. A temporary event file could be created either to address an ad hoc question or to produce a routine report on the organization, either for internal use or for an auxiliary level. The important point is that the staff logs provide the basic event information, and client and staff data are pulled from those files as needed.

Enhancing Existing Files With Event Data

An alternate approach assumes that automated client and human resources files exist within the organization. The information collected by the staff log is distributed to each of these components rather than maintained in a separate or temporary file. Thus, when the staff log contains a patient's identifier, some information about that event, such as the staff identifier, the date, duration, type of event, etc., is added to that patient's automated file. Similarly, some of the information from the staff log is added to the staff person's automated file in the human resources component. For example, the type, amount (duration), and program element codes for the event could be added to the staff person's record, along with data on the cost per hour of that staff to the organization.  As various types of event analyses are done, information is retrieved from either or both of these components. Issues concerning staff productivity and cost can derive the bulk of the needed data from the human resources file, which has been enhanced with event and cost data. Issues about the types or amounts of activities received by clinical groups can be handled by the patient/client file, which has been enhanced with the event data. Finally, if the issue is whether certain clinical groups are receiving particular kinds of activities or services from one of the therapeutic professions, the analysis draws on both of the enhanced patient and staff files in order to accumulate all the needed data. This approach may require more storage space and cause small reductions in analytic speed, but as a primary advantage, it makes the event data more or less permanent within the files of the appropriate client and staff.  To summarize, in order to provide an analysis of who receives what from whom, three files - event, patient, and staff- are required. In preparing this analysis for a particular period of time:

the staff logs must report on all the events occurring in that period,

the patient file must include all patients who could have received service during the time period (normally, all patients on the rolls of the organization during that time period), and

the human resources file must include all staff members who could have produced any activity or provided any service to clients during the period.

The event analysis is prepared by linking data from these three sources. ideally, this kind of system is based on computer files. The details of a computer system that can support these mechanics is beyond the scope of this publication. Mental health organizations have successfully operated such systems and have found them to be manageable. There is a cost in money, staff time, and management involvement for such a system to succeed and these must certainly be acknowledged. However, fundamental to the inclusion of an event component in the MHSIP is the belief that the benefits exceed the costs.

Summary

The minimum data set for event data is:

1. Organization identifier

2. Date of event

3. Staff member reporting

4. Program element identifier and attendance logs

5. Patient(s) involved in the event

6. Type of event

7. Scheduled event

8. Event duration

9. Presence of other staff members

10. Location of event

Chapter 7

Human Resources Data

Providing human services is labor intensive. The fundamental mode in which human services are provided has one provider interacting with one client for at least several minutes. As a consequence, it is usually necessary to have fairly sizable labor forces. In State governments, it is not uncommon for the mental health department to be among the largest of the State departments with a human services mandate. The delivery of mental health services, at least until the present, has not lent itself to many of the innovations that promise to reduce labor intensity, such as mass production, high technology, and automation. Consequently, a continued need is anticipated for large numbers of people to be involved in the delivery of these services.  Because of this labor intensity, the human resources side of the mental health enterprise has a special significance to managers: It is their biggest cost. Labor costs are typically cited as accounting for approximately 75 percent of the budget of mental health programs. Yet, it is the general sense of the field that managers tend to assign the lowest priority to examining data about the who dimension of the performance paradigm. This statement is based on the fact that in the original articulation of the MHSIP, a manpower component was included to provide better data in this area. However, of the three original components, this is the one that has received the least attention, and has had the most hesitant implementation history.  In 1982, the Mental Health and Human Services Program of the Western Interstate Commission on Higher Education (WICHE) received a contract to study the regional implementation of a human resources component in cooperating western States. The results of this effort have been fundamental not only in the revision of this component, but also, in subtle ways, to the more basic reorientation recommended for the MHSIP (WICHE 1984). Among the findings of particular significance to the task force were the following:

Several of the items as originally proposed, were not workable due either to their definitions, categories, or assumptions about the ease of data retrievability.

The component, when treated independently, did not have the same viability of either an independent organization or patient/client component; too many questions arose that required an ability to link human resources data with patient data or to better categorize workforce data within organizations.

The data set was unable to address frequently asked questions about mental health human resources because initial concerns about sensitivity or the negative impact on completion rates had led the MHSIP to exclude some items.

Each of these has been considered in the revised human resources component of the MHSIP.

Who Are the Human Resources of an Organization?

Workforce and staff will be used as synonyms for the human resources of an organization. However, those terms tend to apply more correctly to the individuals who receive a salary or some type of compensation from the organization. Human resources will refer to a broader complement. It covers all the individuals who, under the auspice of the organization, provide a service to the organization's clientele, support the administrative structure that provides services, or support the organization itself. Included are those who 

are employed by the organization, either fulltime or part-time, in direct-care or nondirect care services;

are volunteers;

are placed with the organization through a formal arrangement, such as a training program, internship, or residency;

provide services under a contractual or other administrative arrangement with the organization, e.g., interagency agreement or attending privileges, and who abide by the clinical and administrative rules of the organization as part of the arrangement.

Managers may be initially reluctant to acknowledge that this spectrum of individuals requires their attention, yet all of the groups listed contribute to the performance of the organization and share some responsibility in both its accomplishments and the costs of these accomplishments. Managers who are attempting to understand performance in order to improve it, ultimately must confront the role of each of these groups. A focus on only the employees provides substantial information and accounts for the bulk of the cost data. However, since most organizations have at least some complement from the other groups, a more robust analysis of performance and costs necessitates that all of the human resources be examined.

Uses of Human Resources Data

The questions that a manager has about the workforce are not confined to the two dimensions just suggested, viz, performance and costs. It should be apparent that answering questions in these areas will require linkage with data from the event and financial components. However, there are a number of descriptive questions that may precede or accompany performance and cost issues. A human resources data component can contribute to addressing these concerns.

The Composition of the Human Resources

The most basic questions managers will have about their human resources will relate to their numbers, distribution, demographics, training, and employment characteristics (NIMH 1987b). These pieces of data are critical in addressing basic management responsibilities, as recruitment, nondiscriminatory employment, standards compliance, and shortage areas. It is quite common for managers to regard these statistics as peripheral until a factor external to the organization such as an accreditation visit, a lawsuit, or the defense of a budget request spotlights their importance. Prudent management practices suggest relatively continuous examination of these statistics.  Size of the mental health human resource pool is variously measured as numbers of people or as the full-time equivalents (FTEs)⁽¹⁴⁾ available. The latter is an attractive conversion of raw numbers because it smoothes out certain anomalies that can be caused, for example, by a large number of part-time employees; by use of service contracts to employ scarce clinical professionals; and by part-time operation of some programs.   To make the data even more comparable, these numbers are often converted by using numbers of clients on the rolls (staff to client ratios) or use of civilian population figures (e.g., numbers or FTEs per 100,000 civilian population). While no widely accepted minimum staffing standards have been set for such figures, the data inevitably evoke public health concerns about how adequately patients and citizens are being served. An organization that has 1 social worker for every 15 clients would appear to provide its clientele with better potential clinical access than an organization with a ratio of 1 to 45.  Managers also need to know composition of their staff by such characteristics as training, degree, job assignment or function, demographic makeup or other category needed to answer management questions. These data can be tabulated either by numbers of persons or by FTEs. Such data may be needed to recruit particular kinds of personnel, to compare the human resources configuration of the organization with that of another, to complete a report to a funding agency, to calculate ratios or indexes, or to provide background information for additional querying.  In addition to knowing the size and makeup of the workforce, the manager may be interested in the distribution of these individuals within the organization. This is essential information, especially if one is to know areas/services/programs that are inadequately supplied. Such information is also valuable in a compliance assessment where certain staff configurations or intensities are needed for accreditation of a program type or to assess compliance to a staffing pattern intuitively expected because of the client population it serves or the cost data it reports. In some organizations, staff may not be dedicated to unique programs; they may split their time between several. If the latter situation exists on an as-needed rather than absolute basis, the data collected by event reporting will enable the organization to make an empirical determination of where staff are distributed by their actual time.  To repeat, data on the composition of the human resources of the organization are valuable for the manager. They assist in addressing a variety of questions about the nature of the organization. Some suggested applications are accreditation, access to care, equal employment opportunity demonstration, workforce recruitment, and relative comparisons with similar organizations. In addition, composition data are crucial in understanding event analyses as described in the preceding chapter. They provide a context for evaluating, probing, and understanding data which may show a manager patterns of performance, client movement, and cost that cannot be accepted at face value.

The Quality of the Human Resources

Quality of the human resources is not easy to assess, nor is it consistently judged. Some would assess it on the basis of staff qualifications such as degrees, amount of training, prior jobs held, continuing education endeavors, etc. Others feel these static measures are insufficient and look to on job performance to judge quality. Data on effectiveness, workloads, personnel appraisals, upward mobility, etc. are felt to be better indicators of the quality of the organization's staff. Measures of quality are made more difficult in mental health by the absence of standards. However, the MHSIP recommendations are able to provide some indexes that satisfy both static and dynamic orientations to quality assessment.  The static measures derive largely from the human resources data component and include comparisons about professional attainment, as measured by degree or advanced training, certification or licensure, years of experience in the field, and involvement in relevant outside activities (e.g., private practice or teaching). The dynamic measures derive from event analyses and could include the proportion of time in direct care or staff caseload, analyzed by an algorithm for the difficulty of the client (e.g., chronic recidivistic patients, dually disabled, low functioning level, etc.).  In addition, there are measures of human resource quality that are contingent on the citizens being served. A frequent assumption is that there should be some relationship between the demographic or cultural composition of the patients being served and the workforce that serves them. Language would be an obvious in-stance of this. Similarly, one could expect to observe systematic variations among the workforce depending on the clinical characteristics of the caseload. For example, one would expect to observe that physicians on the staff have a higher percentage of patients with diagnoses that respond to psychotropic medications than do clinical psychologists. Failure to detect these correlations between staff and client characteristics implies that the organization does not have a staff of the right quality, or that there is a problem with the deployment of the staff within the setting.  Whatever the nature of the question about the quality of the human resources of the organization, the value of comparable data and the importance of linkage of the data through event analysis should be apparent. The comparable data may be from similar organizations, or they may be population-based data that allow for the derivation of rates or comparisons of staff characteristics to these population characteristics. Even fuller use may be made of the human resources component via the event analysis capability. This allows the organization to tap into the data in the human resources file and address, at least somewhat, issues of staff quality derived from performance of the staff. This leads to a third use of workforce data.

Productivity and Performance of the Human Resources

A frequent concern of managers is whether staff are using their time efficiently. In mental health, this most often means: Are the direct-care and adjunctive care staff delivering a substantial amount of billable service? Linkage with other data components is the only mechanism by which questions in this area can be addressed:

If the concern is about the units of service delivered by the various professions, data from the event component are needed.

If concerns exist about staff costs relative to type of activity, data from both the event and financial components are necessary.

Data from the client component are needed to know whether desirable variations are occurring in the clinical profiles of patients served by the different core professions.

The absence of standards in the area of productivity makes judgment and interpretation somewhat subjective. However, many programs have established minimum productivity standards, and clinical staff are routinely monitored on this basis. The proposed data for human resources and the event analysis capability neither contain nor set recommended productivity standards, but jointly they facilitate the collection of data that either form an empirical foundation or permit a better degree of comparability across the mental health service system.
The linkage of workforce data with the other components also provides the manager with valuable information for training, personnel assessment, understanding staff burnout, retention of staff, and recruitment. Turnover among staff may be apparent from the human resources component alone, and most managers are able to spot problems with their staff well before the announcement of separation. However, linkage of staff data with client and event information can help the manager analyze these problems and plan an intervention. For example, a new organizational liaison may bring a new type of clientele to a setting, to which the existing staff have had little exposure. This could result in an increased stress level, leading to avoidance behaviors (staff cancellations of appointments) acting out (data errors), increased costs (frequent use of sick leave), or other manifestations. Solutions, such as in-service training, case consultations, or the need to acknowledge that staff are not prepared to deal with this clientele, can be entertained by an event analysis that focuses on staff variables.

Longitudinal Perspectives on the Human Resources

A final use of human resources data takes a longitudinal view. Such a perspective can be taken with any one of the previous uses. For example, a manager might examine how composition of the staff has changed over a period of years. This type of analysis may be done in response to a management initiative to reconfigure staff, foster growth of particular programs, decrease overhead, etc. If they are not done frequently by organizations, such analyses can lead to some surprising insights about declines, rises, and turnovers in professions or program areas (NIMH 1981b). Similarly, one could examine longitudinal changes in staff productivity or quality.
Longitudinal analysis on staff data can also be done on individual staff rather than on the collective workforce. Most of these analyses will depend on an event analysis capability rather than the human resources data component alone. This is made possible in that the minimum data set proposes a unique staff identifier be implemented that is stable from one reporting period to another. As noted previously, the staff identifier permits the linkage of human resources data with the other MHSIP components. Patterns over time for individual staff are valuable in personnel evaluations, developing career ladders, and spotting potential burnout before it becomes irremediable.

Minimum Data Set

The following items constitute the minimum data content for the human resources component of a provider-level decision support system. Each item is named, followed by either its minimum recommended categories or a brief explanation of its content. As noted in chapter 4, categories can be elaborated by the service provider depending on local needs. However, elaborations should always be designed to be collapsible into the minimum categories. This facilitates comparison of data with another organization or the reporting of comparable data to an auxiliary level. Comment sections follow the recommended categories. The comments are intended to explain the item further, discuss the importance or potential use of the data, or note advisable rules of interpretation.

1. Organization Identifier

The 8-digit NIMH master facility number is recommended as the identifier.

Comment: Mental health organizations that are not aware of their NIMH-assigned facility code can obtain it from the Survey and Reports Branch of NIMH. If NIMH does not have the organization listed already, an identifier can be generated on request.  Because the first two numbers in the NIMH code string always identity the State in which the organization is located, it may be possible to drop these from the string for routine local operations and develop a procedure to add them in automatically when preparing the data for external reporting purposes.  As unique human resources data are maintained at the local level, however, it may not be necessary to have the organization identifier actually be a physical part of the data set. It is more important to be able to append this when reporting externally for statistical, billing, or other purposes.

2. Staff/record Identifier

No minimum specifications

Comment: The organization should assign a unique identifier that enables the record to be identified and the data to be reliably associated with a particular individual. At the local level this could be the person's name, Social Security number, or other alpha-numeric information. The identifier is also useful for follow-back verification of information or editing of submitted data, and to access statistical information in other MHSIP components. The identifier should be stable from one reporting period to another.  The format specifications for a unique identifier may be established by an agency at the auxiliary level. This agency may have a legitimate interest in or be the official "employer" of all persons covered by the human resources component. Most often this auxiliary level will be a State mental health agency, obligated by law to collect this information by the person's name or unique identification algorithm. The local level should honor these specifications. Aside from the legal considerations, this facilitates the subsequent reporting of data by local organizations and facilitates the discharge of responsibility at the auxiliary level for payroll taxes, civil service matters, or other affiliation issues.

3. Date of report

Month, day, year

Comment: This is used as an anchoring point for aging the information provided, such as the number of years employed, age of the person, etc. It is also of value in linkage with the other components, especially for event analysis where knowledge of the human resources complement serves as a context for understanding production.

4. Date of birth

Month, day, year

Comment: The distribution of ages among the human resources of an organization is of significance to managers. This tells if the workforce is an aging one; implies whether fresh ideas or recent academic training experiences are being introduced into the programs; may suggest when retirements would impact the agency significantly; identifies where questions of leadership in a program may be of special concern (e.g., everyone is very junior or senior); and allows the manager to contrast the age of the organization's human resources with that of the population served.

5. Sex

Male/Female

Comment: In addition to its use for analyzing and reporting on equal employment opportunity issues, the sex composition of the human resources is of value in comparing to the sex composition of the client population and that of the population area served. Analysis of career opportunities and productivity by sex may yield some of the most challenging human resources management issues that the organization must confront.

6. Race

American Indian/Alaskan Native-A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition.

Asian or Pacific Islander-A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.

Black/African American-A person having origins in any of the black racial groups of Africa.

White - A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Other - A default category for use in instances in which the staff is not classified above or whose origin group, because of area custom, is regarded as a racial class distinct from the above categories - appropriate details should be maintained.

Comment: See next item.

7. Hispanic origin

Hispanic origin-A person of Mexican, Puerto Rican, Cuban, Central American or South American, or other Spanish origin or descent, regardless of race:

- Mexican, Mexican-American

- Puerto Rican

- Cuban

- Other Hispanic

Not of Hispanic origin

Comment: Items on the race and ethnicity of the human resources of the organization are important for both administrative and clinical reasons. Virtually every mental health organization will, at least occasionally, be asked to report these data for equal employment or nondiscriminatory employment practices. It was noted above that certain matches between direct-care workers and patients are often considered fundamental in arranging clinical treatment. Race and ethnicity are key dimensions of consideration regarding a match or compatibility between client and direct-care staff. Many managers consider these factors in recruitment, attempting to have a race and ethnicity mix among their human resources that is compatible with that of the community at large or with the population under treatment.

8. Date of employment/affiliation

Most recent date when current employment or affiliation with this organization began - month, year

Comment: The longevity of employees and other staff with an organization provides information to a manager indicative of staff quality, but it must be interpreted within an overall employment context. Where job opportunities are numerous, longevity can be interpreted positively, e.g., to convey job satisfaction, competitive salaries, and career stability. It seems most desirable for organizations to be able to demonstrate some balance between a cadre of employees who have been with the organization for some time and the addition of some new members to the workforce. If most employees are new (but the organization is not), the manager certainly needs to attend to this. The costs of recruitment and for the time for new staff to reach an optimum level of job proficiency would indicate that the organization is wasting valuable time and money.  In areas with high unemployment, longevity of staff may have less of a direct relationship to job satisfaction, salary scales, etc. Good management practices would suggest that the manager remain concerned about staff morale and job satisfaction and that he or she not exploit the lack of opportunity for employment elsewhere.
In addition to the employment and job satisfaction considerations, affiliation duration has other uses. In con-junction with the individual's birth date, this gives managers an ability to track the aging of their workforce and to anticipate patterns of retirement. Length of affiliation may vary by type of profession, training, and job functions. Productivity and involvement in particular patterns of services maybe related to the amount of time the person has been with the organization. It may also have a bearing on in-service and extracurricular training. That is, most managers are concerned about keeping the skills of the workforce contemporary. High proportions of staff who have longevity with the organization may raise questions about the training opportunities they have taken or been exposed to.

Note: For persons who separate from the organization and return subsequently, the most recent date of affiliation should be used.

9. Discipline/training/profession

From the following list, individuals self-select or are assigned to the one category that best reflects the major discipline, training, or occupation for which they have been trained or hired.

Psychiatrist

Other physician

Psychologist

Social worker

Clinical mental health counselor²

Substance abuse counselor

Other mental health professional

Mental health worker with less than a bachelor's degree

Registered nurse

Licensed practical or vocational nurse

Vocational rehabilitation counselor

Schoolteacher

Activity therapist (e.g., art, music, dance, recreational, or occupational therapist) Public, hospital, or business management/administration

Speech therapist

Dietician

Pharmacist or assistant

Dentist or dental assistant

Other physical health professional or assistant

Medical records administrator or technician 

Other worker (support, maintenance, administration)

Comment: This is a means of classifying the organization's human resources into categories that are at least historically meaningful. Data on this item will most frequently be used in developing distribution profiles or ratios that are felt to reflect on staff or program quality. Categorization by discipline or training, as its chief advantage, is readily understood by most workers in mental health settings and, therefore, it tends to produce reliable data. It then becomes easier to assign numbers to these categories (e.g., FTEs, numbers of people) that are useful in comparisons. A further use of these data might be to determine if functions or performance are correlated in any consistent way with professional groups or training backgrounds.

10. Highest degree/education level as of date of report

Less than high school diploma or GED High school diploma or GED

Some education beyond high school but no degree

Associate degree

Bachelor's degree

Master's degree

Doctorate (e.g., M.D., Ph.D., Sc.D., J.D., Ed.D., D.O.)

Comment: This item is used primarily as an index of staff quality. Immediate supervisors might also find it useful for developing extracurricular training tracks and perhaps some in-service training. For example, many professions in mental health have annual continuing education requirements, which the organization could help to satisfy. It may also prove useful in understanding salary scales and job functions.

11. Country of highest degree

Name

Comment: Although this item may be used in conjunction with languages other than English, its primary value is as a recruitment index. Human resources or particular parts of the workforce composed of individuals who have been trained outside the United States can signal recruitment difficulties due to endemic personnel shortages or poor salary scale competitiveness. They may be correlated also with characteristics of the treatment population. When linked with other data through the event component, variations in service patterns or types of patients engaged may also be observed.

12. License/certification

Licensed to practice in this profession:

in this State yes/no

in another State yes/no

in another country yes/no

If a physician,

board certified in specialty yes/no

Not applicable

Comment: For disciplines and professions that commonly license or certify their members, this item serves as an index of staff quality. It is attractive because it relies on an external authority and implies both objectivity and uniformity in its determination.  Inclusion or this category is in recognition of an emerging specialty profession. Training programs are established and accredited that matriculate clinical mental health counselors as a unique professional group. Increasing numbers or them are being identified in the specialty mental health sector.

13. Employment/affiliation status with this organization

Salaried, payroll employee

- Full time (for definitional purposes, an employee scheduled for 35 hours per week or more)

- Part time (less than 35 hours per week)

Paid under contractual arrangement

Student, trainee, resident, intern

Volunteer

Attending (those with explicit privileges or credentials to admit patients to the organization for care and to provide service to them under the auspice of the organization, but who have a non-contractual, non-salaried relationship with the organization)

Comment: Organizations have many ways of ensuring that there are sufficient numbers of persons to provide services to patients and to sustain the organization itself. Employment is the most obvious. However, many of the human resources on which a report is critical may fall in some other affiliation category. It is important to know the spectrum of mechanisms by which the organization maintains its cadre of human resources, the numbers of people under each, and whether these affiliations systematically vary by professions or functions. It is also important to be able to analyze how productivity, service patterns, and costs may be affected by these configurations.

14. Hours typically scheduled each week within this organization (Include any normally scheduled overtime)

A 2-digit whole number

Comment: This is necessary information if one is to develop capacity measures regarding amount of total time available. In addition, since the definition of full-time or FTE differs (35, 37.5, and 40 hours are all documented definitions), knowing total hours and numbers of individuals allows for any of these definitions to be used.

15. Primary job function

The individual is assigned to the category that best describes the major function⁽¹⁵⁾ the agency expects that person to perform on a day-to-day basis. Only one category is assigned unless the person is officially assigned to functions that cover more than one of the categories listed (e.g., administration and direct care).

Direct or adjunctive patient/client care

Consultation, education, or prevention

Administration/management

Other job function (all other job functions in organization not covered above)

Comment: Knowing the basic function(s) the individual is expected to perform within the organization facilitates the correct linkage of the human resources data with either client or event information. That is, it is most appropriate to examine direct services productivity for those who have that function, and it would be inappropriate to link patient type to persons whose function was solely administrative. In addition, especially among some of the major clinical professions, the person's functions may not always be inferred from their training, e.g., a social worker who is exclusively a manager. Without knowing job function, attributions of productivity or analyses of type of patient served by various human resource subgroups would be difficult to interpret.

16. Experience

Prior to current employment or affiliation with this organization, total number of years worked in mental health

A 2-digit whole number should be sufficient; if 6 months or less, round down to zero; if more than 6 months, round up.

Comment: Staff experience is an index of quality. Al-though each work environment presents unique challenges, those who work in a mental health organization must not only understand special features of program operation, but must also face special issues of sensitivity and stress related to their exposure of some of the clientele. The amount of time the staff, individually or collectively, have worked in mental health environments reflects on their ability to perform in these settings. As with previous items on tenure, this item may also reveal systematic variations with regard to type of clientele engaged, productivity, or service patterns.

17. Languages other than English

Spanish

Sign

Other

Comment: The skills of organization staff to communicate with patients who are not able to use conventional spoken English can be an important asset to identify. Such skills are expected to be available in certain specialized mental health programs and in certain geographic locales. Thus, they serve as a program-quality index.  In addition, ability to use a language other than English may help to account for unique caseload or performance patterns of the staff.

18. Private practice maintained

An indication of whether the individual maintains a private practice in this profession.

Yes

No

Not applicable

Comment: This item is sometimes interpreted as an indicator of staff quality, i.e., that professional interest and ability is sufficient to enable the individual to sustain a private practice. Utilization-review uses might examine whether those with a private practice exhibit similar service patterns (length of service, referral on discharge, etc.) to those who do not maintain a private practice, assuming some comparability in the patients served. It could also be linked with affiliation status, especially for part-time and contract staff. Finally, if other indexes suggest that salary scales in the organization need attention, maintenance of a private practice relative to the person's salary could be examined.

19. University/college affiliation

An indication of whether the individual has an appointment or other affiliation with a university or college to do teaching or research at that institution.

Yes

No

Not applicable

Comment: This item is used primarily as a staff-quality index. In addition, there may be some relation between staff involvement in academic situations and the clientele of the organization. Referrals of unique classes of patients, clientele of a particular age group or presenting problem, or other service patterns maybe influenced by the affiliation.

20. Participation in job-related or career-development training

Since the previous reporting period or since the most recent affiliation date with the organization, an indication of whether the individual has participated in any of the following types of training intended to improve job performance, acquire additional skills, or satisfy a continuing education expectation:

- In-service training, i.e., sponsored by the organization, usually onsite and during work hours

- Extracurricular, i.e., sponsored by another organization, usually offsite, and release time from work may or may not be granted

- None

Comment: From the point of view of the staff person, receiving the opportunity and support for training to update or improve job skills maybe a key element in job satisfaction and longevity with an organization. Organizations and their clientele are not static. Participation in such training opportunities can result in increased productivity, improved ability to deal with patient groups that have presented dilemmas to the staff or the organization, or other positive outcomes. Some caution should be exercised, however, in the interpretation of the data, because all staff groups may not have equal need or be equally interested in training. Unless a link to performance can be justified, managers should not compel training merely in order to have high counts on this item. Programmed or self-instruction may fall under either training category.

21. Income from the organization

Actual or estimated income range for annual salary/reimbursement received from this organization, including overtime and bonuses, and excluding fringe benefits:

No income

$ 1-4,999 

5,000-9,999 

10,000-14,999 

15,000-19,999 

20,000-24,999 

25,000-29,999 

30,000-34,999 

35,000-39,999

40,000-44,999

45,000-49,999

50,000-54,999

55,000-59,999

60,000-64,999

65,000-69,999

70,000-74,999 

75,000-79,999 

80,000-84,999

85,000 or more

Comment: As noted in the introduction, the human resources of the organization are its biggest cost factor. Being able to attach an approximate salary figure to professional groups or analyze the proportion of salary going into direct-service functions versus other functions provides a manager with clear evidence of where the organization's financial resources are being invested. Hence, salary has high face validity as a measure of resource consumption and shares a logical relationship with expectations about productivity. Also, as has been suggested for many of the previous items, salary scales may be critical in understanding staff turnover or quality.

22. Fringe benefits value

As a percentage of the person's salary from the organization, the fringe benefits (contributions to retirement funds, health insurance, or life insurance payments, education benefits, participation in profit sharing, shares of stock, etc.) represent:

Not applicable/no fringe benefits

Less than 1 percent to 10 percent*

11 to 15 percent

16 to 20 percent

21 to 25 percent

26 to 30 percent

31 percent or more of gross salary

*A rounding convention should be assumed such that less than 0.5 is rounded down and equal to or greater than 0.5 percent is rounded up to the next whole number.

Comment: In some employment situations, fringe benefit packages are standard for all employees. In others, variations in these packages are ways of recruiting or retaining valued occupational groups. They may be used as negotiation points by individuals in these groups as well. Consequently, either for fuller understanding of personnel costs or to be able to analyze differential patterns of performance or organizational longevity, it is essential to have some estimate of the fringe benefits a person receives.

23. Separation date

If applicable, for the current reporting period, the month during which the relationship/affiliation between the individual and the organization terminated:

Month

Not applicable

Comment: This item is collected for persons who reported human resources data for a previous period or who joined or left the organization during the current reporting period. An exit date is as valuable for management analysis as an affiliation date. This permits a determination of actual longevity by individuals who have left the organization for whatever reason - retirement, termination for cause, end of training period, etc. Turnover among some staff groups may be markedly different than others and suggest to managers that additional probing is justified. Such turnover may mark a program with poor leadership, clientele that the staff are not adequately prepared to deal with, or noncompetitive salary. Turnover could even be an acceptable pattern (e.g., turnover among volunteers). Organizations may wish to consider expansion of this item to collect reasons for separation.  The separation date is also needed if one is to develop a picture of a human resource cohort for a given time period. This is most apparent in event analysis when it may be necessary to have a count and an identifier for every person who was on board at the time a particular event analysis or productivity ratio is being calculated. If there is a mismatch between the amount of activity and the number of staff responsible for that activity, some of the analyses and interpretations will be spurious.

Other Recommended Data Item

One additional item is suggested for inclusion in a local decision support system data base. The item is judged to have less widespread utility, and consequently, is not included in the minimum set.

Year of degree

A 2-digit code for year in which highest degree was granted.

Comment: The item can serve as a factor in profiles of staff quality, but can easily be displaced by information on continuing education or other training by the individual since the degree was granted. The year of degree helps to explain training patterns among more recently degreed individuals.

Coverage

The suggested definition of human resources intentionally covers the fullest interpretation of those who provide services in mental health organizations. The minimum set applies to all those who work in these settings. It is recommended that human resources data be collected annually. This is in recognition of turnover among the staff rather than the dynamism of the minimum data items themselves.  Many of the items recommended will be located in a personnel file, which the organization maintains on each individual. This is usually initiated when employment/ affiliation begins. It contains substantial additional data, such as home address, party to contact in an emergency, religious affiliation, vacation leave arrangements, name of insurance plan, etc.  Data in personnel files may not always be automated. For efficiency in the reporting of these data, and to avoid burdening staff with additional paperwork, automation of the more stable MHSIP data items should be considered. In such cases, staff would be required to supply a very limited number of items, such as private practice, their interpretation of their job function, or the updating of items that have changed since the last reporting period. The reporting burden on staff for this component would be minimal. Data would primarily be derived through data processing, involving personnel records, payroll, and any information on training that had been automated.  If the items have not been automated for convenient retrieval, all staff would need to complete some sort of survey questionnaire during a determined period of lime. Such a time period would he selected with the data collection under the event component in mind so there would be a high degree of correspondence between the staff in the two components. It is recommended that the organization make efforts to automate this information both to move toward computer retrieval of that data and to facilitate the event analysis capability.

Summary

The minimum data set for human resources:

1. Organization identifier

2. Staff/record identifier

3. Date of report

4. Date of birth

5. Sex

6. Race

7. Hispanic origin

8. Date of employment/affiliation

9. Discipline/training/profession

10. Highest degree/education as of date of report

11. Country of highest degree

12. License/certification

13. Employment/affiliation status with this organization

14. Hours typically scheduled each week within this organization

15. Primary job function

16. Experience

17. Languages other than English

18. Private practice maintained

19. University/college affiliation

20. Participation in job-related or career-development training

21. Income from the organization

22. Fringe benefits value

23. Separation date

Chapter 8

Financial Data

Need for Financial Data and Data Standards

When a manager of a mental health organization thinks about the management of resources, it is probable that money is the first resource that comes to mind. One of the most profound changes that has occurred in local mental health organizations since the 1970s has been the increased attention that managers give to their revenues and expenditures. Deficit spending and bailouts by the State mental health agency were once almost axiomatic in mental health organizations, especially those with a public, not-for-profit orientation that had high proportions of disadvantaged clientele. Most mental health agencies are currently under increasing pressure to provide and support quality services to the mentally ill and, at the same time, demonstrate solvency and fiscal accountability. For the latter, managers increasingly must monitor and contain the escalating costs of mental health services and conscientiously pursue reimbursement for these services.  This change has resulted in increased attention to financial data and a keen interest in comparability of financial data. For the most part, financial data in the mental health field have not been recorded and reported in a manner that facilitates comparing information across organizations or for aggregating financial information on organizations to describe systems of care. This has been unfortunate. Many mental health managers, both at the organization and auxiliary level, who have engaged in assessing a variety of methods for financing the treatment of mentally ill persons would find comparable information a valuable way to explore alternatives.  Because so little effort has been undertaken to set standards in the mental health field for documenting and reporting financial data, the MHSIP Advisory Group charged a task force to develop a recommended minimum data set in this area. Previously, financial data had been limited to gross reporting of revenues and expenditures at an organization level within the organization data component. This chapter is based on the recommendations of that task force.⁽¹⁶⁾ It attempts to integrate the recommendations into the performance model so that the question of at what cost can he addressed.

Nature of the Component

For the most part, recommended data elements for a financial data component have been drawn from two universally accepted summary financial statements: the statement of financial position and the income statement. Information from both of these financial reports is necessary for management of fiscal resources within an organization. The uses of these data are discussed in a subsequent section. Such information is also frequently requested by auxiliary levels such as State mental health agencies or corporate sponsors, that have administrative and/or funding authority and responsibility for organizations.

Statement of Financial Position

The balance sheet or statement of financial position -the accounting title preferred by this report - is a valuable piece of financial information typically produced on an annual basis. It includes three classes of information: assets, liabilities, and residual equity.

Assets are things of value that are owned and held by an organization. They are commonly divided into:

current assets - cash and other assets that can be converted into cash within a year; and

non-current assets - those that are expected to help provide services and help generate revenue for periods longer than a year.

Both types of assets can be further subdivided into several categories, usually on their order of liquidity (the relative ease of turning these assets into cash). These further categories are reflected in the minimum data set.

Liabilities, in an accounting sense, can be thought of as debts. They are commonly divided into:

current liabilities - debts that require payment within a year, which include such items as wages payable, accounts payable, and interest payable; and

non-current liabilities - obligations to be paid beyond a year, which include such things as mortgages and notes payable.

Residual equity is the residual claim on the assets of the organization by the community or the owners. Residual equity is the excess of assets over liabilities. It is commonly called the fund balance for not-for-profit organizations, and the owner's equity or stockholder's equity for for-profit organizations. Since residual equity is a derived variable, it is not included as a data element for reporting purposes.

Income Statement

The income statement is another major source of financial data. It depicts the financial activity of the organization for a period of time, usually 12 months, by means of its revenues and support and its expenses. As a general principle, a modified accrual basis of accounting is recommended for reporting revenues and expenses. A brief discussion of accrual vs. cash accounting is presented below.

Revenue and support are funds that increase assets or decrease liabilities. Revenue refers to funds earned. Support represents funds appropriated, granted, and/or allocated to the organization. They are commonly divided into:

operating revenue and support - income related to the delivery of mental health services, such as payments from clients or third parties; and

non-operating revenue and support - income not related to the delivery of mental health services, such as gifts, bequests, or capital gains.

Several categories of revenue and support are identified in the minimum data set. Of major significance is the recognition that revenue and support should either be tracked or allocated by program element.⁽¹⁷⁾ This is necessary in order to understand the cost structures of the organization.

Expense represents the other major section of the income statement. Expenses are a measure of the resources used by an organization. They can be subdivided into:

operating expenses-those associated with the delivery of mental health services, such as salaries and wages, supplies and inventory, utilities, and contracts for services; and

non-operating expenses-expenses not associated with the provision of services. These are difficult to classify because of the many types of arrangements established by organizations. One instance that occurs with some frequency is the establishment of a separate research enterprise that receives supportive funding from the organization and uses the organization's archival data base rather than doing de novo treatment research on mentally ill clientele.

As with revenue and support, resource use by program element should be tracked or allocated so that the cost structure of the organization can be understood.

Accrual vs. Cash Basis for Accounting

Fundamental to the preparation of financial statements in the distinction between the cash and the accrual methods of accounting. The cash basis of accounting is similar to what many people use for their personal checking accounts: Revenues are recognized when received, and expenses are recognized when they are paid. Thus, it focuses on the flows of the organization's funds. The cash basis of accounting has the major advantage of simplicity. Revenues are recognized only when cash is received from clients or others, while expenses are recognized only when the provider decides to pay them.

The simplicity of the cash method of accounting leads to several disadvantages:

1. It fails to match revenues and expenses and, therefore, may portray an inaccurate picture of how well the organization is using its assets to generate revenues.

2. It can result in wide swings in reported unit cost from period to period.

3. It raises serious reliability questions concerning comparisons of unit cost.

4. It does not recognize liabilities owed to others.

5. It leaves the financial statements open to questions of manipulation by management because the results of the cash basis of accounting are dependent only upon when cash changes hands, not when goods and services are actually exchanged or resources are actually used.

The accrual basis of accounting attempts to overcome these deficiencies by recognizing revenues when earned, liabilities when incurred, and expenses when assets are used or consumed. Thus, as opposed to the cash basis which focuses on the flow of funds, the accrual basis of accounting focuses on the flow of resources. It matches revenues and expenses; tends to narrow wide swings in unit costs that are not due to resource utilization; recognizes liabilities; and bypasses some of the management discretion available under the cash basis of accounting. The contrast between cost and accrual approaches is presented in exhibit 5.  The accounting profession has recognized the clear superiority of the accrual method of accounting for judging the financial condition of mental health organizations and for making meaningful comparisons among them. To the extent that local organizations or auxiliary levels have the flexibility to implement accrual accounting principles, the MHSIP encourages this as a standard practice.

Exhibit 5. Comparison of the cash and accrual bases of accounting