Assuring quality in community mental health centers. The need for psychiatric practice guidelines

Many have expressed concern regarding both the deterioration in the quality of patient care provided by CMHCs and the exodus of competent psychiatrists from them. Earlier efforts by the Joint Commission to serve as an accrediting body for CMHCs were ineffective. Two factors may well have contributed to this. First, the Joint Commission's community mental health "Principles" were not medically based and, therefore, may not have been sufficiently able to assure quality of care, especially for the seriously mentally ill. Secondly, the "Principles" did not enjoy widespread use among CMHCs. Heretofore, CMHCs have not been required to meet national accrediting standards to qualify for governmental and other third-party reimbursement. Tying reimbursement to a meaningful accreditation process, as is done for hospitals, would solve the latter problem. Redressing the former problem might be accomplished by incorporating guidelines for psychiatric practice, such as those proposed in this article, into JCAHO's and CARF's accreditation standards for CMHCs. Such standards would then, by linking authority to responsibility, provide the CMHC psychiatrist with a foundation upon which to reasonably practice and thereby assure quality patient care. Although 55% of CMHCs were headed by psychiatrists in 1971, only 8% had psychiatrist CEOs as of 1985. Although psychiatrists need not be administratively in charge of CMHCs, the importance of their clinical leadership role is undeniable. Yet, in many centers, this role has been sorely compromised. It is anticipated that a clearer delineation of the psychiatrist's and, more specifically, the medical director's role will benefit all involved: patients, families, psychiatrists, other clinical staff, executive directors, and CMHC boards of directors. Centers that have strong psychiatric leadership will clearly benefit in three ways: (1) liability risk will be kept to a minimum; (2) recruitment and retention of competent psychiatrists will be enhanced; and (3) with CMHCs remaining clearly in the medical mainstream, they will be assured of continued governmental and other third-party healthcare funding. O'Leary, President of JCAHO, writes the following: The Joint Commission has never placed a direct role in the development of clinical standards, and we do not intend to begin now. But we do urge appropriate specialty groups to establish this task as a high priority. While consensus standards are inherently imperfect, they do reflect unique collections of wisdom and experience.(ABSTRACT TRUNCATED AT 400 WORDS)