Report from the supervision of mental healthcare for children and young persons at Møre og Romsdal Hospital Trust (Helse Møre og Romsdal HF)

The Office of the County Governor in Møre og Romsdal (Fylkesmannen i Møre og Romsdal)

Summary

The Office of the County Governor of Nord-Trøndelag, the Office of the County Governor of Møre og Romsdal and the Office of the County Governor of Sør-Trøndelag performed a supervision of mental healthcare services for children and young persons at Møre og Romsdal Hospital Trust’s Clinic for children and young persons, BUP Molde (hereafter referred to as BUP Molde) between 14 and 16 May 2013.

The supervision covered the health trust’s outpatient activities.

The principal objective of the supervision was to review whether the health trust ensures that the patient pathways provided by these services are characterised by:

• satisfactory levels of progress and continuity,
• satisfactory quality in the work, including interaction with the patient, parents (or guardians) and municipal primary services, as well as (if applicable) schools/the Educational and Psychological Counselling Services (known as PPT) and the child welfare services.

Patient pathways can be divided into the following four phases, all of which formed part of the supervision:

• receipt and evaluation of referrals,
• assessment and diagnosis,
• treatment,
• conclusion and follow-up of the treatment.

Three non-conformities were noted during the supervision:

Non-conformity 1

Møre og Romsdal Hospital Trust does not ensure that receipt of and evaluation of referrals by BUP Molde complies with the requirement to collect supplementary information or with the requirement to document medical assessments.

Non-conformity 2

Møre og Romsdal Hospital Trust does not ensure that patients referred to BUP Molde are given the required healthcare within the stipulated time limit for receiving treatment.

Non-conformity 3

Møre og Romsdal Hospital Trust does not ensure that assessment and diagnosis at BUP Molde are sufficiently multidisciplinary, and that a diagnosis is made as soon as the assessment process is concluded. The health trust has not set any targets for how much time may normally elapse before a diagnosis is made.

Children and young persons with mental health illness constitute a vulnerable patient group. Early intervention has great potential in terms of preventing subsequent mental illness. It is therefore unfortunate that BUP Molde is not of the size or managed in a manner that ensures that patients are treated within the stipulated time limits. Furthermore, it is unfortunate that BUP Molde has failed to establish a system of standardised practice that results in the quickest possible making of diagnoses/conclusions in all six assessment areas with a view to commencing treatment as soon as possible, and based on multidisciplinary assessment and comprehensive approach.

The management of BUP Molde has implemented a number of procedures that are not followed. There is a lack of control procedures to monitor this. Practice varies, both among teams and within some of the teams. As a result there is a risk of inequalities occurring in the quality of service delivered in patient treatment at BUP Molde.

Date: 2 July 2013

Mona B Parow
Audit leader

Åse Hansen
Auditor

 

1. Introduction

The report is drawn up following a system audit at Møre og Romsdal Hospital Trust in the period 19 February 2013 – 2 July 2013. The audit forms part of the planned supervisory activities which the County Governor of Møre og Romsdal, the County Governor of Nord-Trøndelag and the County Governor of Sør-Trøndelag are performing this year.

Section 2 of the Act relating to Public Supervision of Health and Care Services gives the Office of the County Governor the authority to supervise the county’s health services.

The objective of the system audit is to assess whether the organisation complies with the various legislative requirements in its internal control (quality management) activities.

The audit comprised assessing:

• what measures the organisation has implemented to uncover, correct and prevent any violation of the law in the areas covered by the supervision,
• whether the measures are monitored in practice and, where necessary, corrected,
• whether the measures are adequate to ensure compliance with the legislation.

A system audit is performed by reviewing documents, carrying out interviews and other forms of investigation.

The report concerns non-conformities that were uncovered during the audit and therefore does not provide a complete appraisal of the organisation’s performance within the areas covered by the supervision.

• Non-conformity is the failure to comply with requirements laid down in or in pursuance of laws or regulations.
• Notes refer to conditions that are not in conflict with requirements defined in or in pursuance of the law or regulations, but where the supervisory body wishes to point out there is potential for improvement.

2. Description of the organisation - special issues

BUP Molde has four departments. In this organisational structure, the Children's and Young Persons’ Psychiatric Outpatient Clinic (BUP Outpatient Clinic) comes under the Department for Mental Healthcare for Children and Young Persons. The hospital trust has four outpatient clinics. These are located at Volda, Ålesund, Molde and Kristiansund hospitals respectively. This supervision was performed at the Outpatient Clinic Molde BUP. The outpatient clinics are led by their department heads and section leaders. Department heads and section leaders report to the clinic director. BUP Molde is currently headed by an acting section leader.

BUP Molde employs 41.5 full-time equivalent positions for professionals and four office staff. One professional position is currently in the process of being filled. As a result of employees training to specialise in their discipline, two professional positions are currently seconded to a different section.

The outpatient clinic is organised into a total of five teams: three teams covering different geographic areas; one team for small children, and one emergency team. Each team has a team co-ordinator. The team for Molde currently does not have a team co-ordinator.

The outpatient clinic runs its activities within ordinary working hours. There is no duty rota system. Any requirements for help after 4 p.m. are routed via the municipal medical emergency services (usually the on-duty G.P.) and, if required, the emergency unit at Ålesund Hospital.

In 2012, BUP Molde received 592 first-time referrals. This is up 103 patients compared to the preceding year. The rise is most marked in the team dealing with the inland region and the team for Molde. From 1 January 2013 to 19 March 2013 there were 131 first-time referrals. 29 of these patients were rejected. At the end of the above period, 92 patients continued on the waiting list. As per 14 May 2013, the waiting lists presented to the auditors indicated that there were 18 cases in which patients had not been given treatment within the stipulated time limit at BUP Molde. Most of these were part of the Molde team's case load.

3. Performance of the audit

The system audit comprised the following activities:

The notification of the audit was sent on 4 March 2013. A list of the documents the organisation has sent to the auditors in connection with the supervision is supplied in the chapter Case documents.

The pre-audit meeting was held on 4 April 2013.

The opening meeting was held on 14 May 2013.

Interviews
Twelve people were interviewed.
A list of the documentation that was reviewed during the audit visit is provided in the chapter Case documents.

The closing meeting was held on 16 May 2013.

4. What the supervision covered

The supervisory body has appraised whether the specialist health service, through systematic governance and management, ensures that children and young persons are provided with medically sound mental healthcare. Children and young persons are mostly in the age group from newborn to 18 years. Once patients reach the age of 18, they may receive further treatment until they are 23. Alternatively, they can be transferred to mental healthcare services for adults.

The supervision covered the hospital trust’s outpatient activities.

The principal objective of the supervision was to assess whether the health trust ensures that the patient pathways provided by these services are characterised by:

• satisfactory progress and continuity,
• satisfactory quality in the work, including interaction with the patient, parents (or guardians) and first-line services (provided by the municipalities), as well as (if applicable) school/educational and psychological counselling services (known as PPT) and the child welfare services.

Patient pathways can be divided into the following four phases, all of which formed part of the supervision:

• receipt and evaluation of the referrals,
• assessment and diagnosis,
• treatment,
• conclusion and following-up of treatment.

Good treatment depends on a correct diagnosis, based on good referrals and sound assessments. This supervision therefore primarily addressed the early stage of patient pathways. There was less emphasis on appraising patient treatment and the concluding phases of the patients’ contact with the health service.

In order to determine whether patient pathways are medically sound, patient records for the following two patient groups were selected (for practical reasons):

• children aged between 7 and 15 with healthcare needs based on restlessness and acting out, and where ADHD was suspected,
• children aged more than 12 years with healthcare needs based on sadness and suspected depression.

These two patient groups represented the most common reasons for referral to psychiatric outpatient clinics for children and young persons; they are amply represented at all the country’s outpatient clinics, and they are also reliable  indicators for suicide risk and drug problems, which were topics included in the supervision.

5. Findings

Non-conformity 1

Møre og Romsdal Hospital Trust does not ensure that receipt and evaluation of referrals to BUP Molde is in compliance with the requirement to collect supplementary information or to document medical assessments.

The non-conformities are based on the following regulatory requirements:

• Section 2-2 of the Act relating to Patients' Rights, see the Regulations on Prioritisation   
• Section 39 of the Act relating to Health Personnel etc., see the Regulations on to Patient Records
• Section 3, subsection one, of the Act relating to Public Supervision of Health and Care Services, see the Regulations on Internal Control

The non-conformity is based on the following:

• It emerged during the supervision that according to the intake procedure the gathering of supplementary details for referrals that are incomplete or inadequate is divided between the office staff and the intake co-ordinator. The following contradictory information emerged regarding the practical handling of incomplete or inadequate referrals:
  • When further details are required, some of these are collected by the office staff and some by the intake co-ordinator.
  • Incomplete or inadequate referrals result in patients being rejected. The required information is requested in the form of a new referral.
• A review of patient records relating to ADHD referrals shows that all patients are assigned a commencement date after 13 weeks. According to the prioritisation guidelines, this is the maximum time limit. There is no sign of any individual assessments being performed for this patient group.
• There is no evidence in the patient records of medical assessments forming the background for prioritisation.
• The documentation form cites items from the referral, but not the professional assessments which are made at the intake meeting, and based on which an individual deadline is set by which treatment should commence. There is no description of the standard that is expected in documenting individual assessments. There has been no staff training programme to ensure a consistent approach to medical record-keeping. No controls are performed regarding the information that is entered in the patient records (the documentation obligation).
• The referrer and parents (or guardians) are informed of the deadline by which the patient should be offered treatment and when treatment will commence (an appointment is given). However, this is not the case for the Molde team. The Molde team sends out letters detailing the deadline by which the patient should be offered treatment, but without stating when treatment is due to start or who will treat the patient.
• A non-conformity processing procedure was presented. The presented non-conformity log indicated that few non-conformities are reported. There is no sign of a culture or that there is a practice of reporting non-conformities. When undesirable events related to receipt and assessment of referrals occur these are handled straight away, in talks at meetings, etc. The department management expects the non-conformity control system to be used, but does not monitor this in practice. The minutes of the meeting of 25 January 2013 indicate that training and introduction of non-conformity procedures is to be performed by or in the summer of 2013.
• The presented procedures are available in EQS. The management expects everybody to use EQS continuously. However, this is not done. No control function or monitoring activity has been implemented. Not everybody has been trained in EQS. 

Non-conformity 2

Møre og Romsdal Hospital Trust does not ensure that patients referred to BUP Molde are given the required healthcare within stipulated time limits for being offered treatment.

The non-conformities are based on the following regulatory requirements:

• Section 2-1b of the Act relating to Patients' Rights
• Section 3, subsection one, of the Act relating to Public Supervision of Health and Care Services, see the Regulations on Internal Control

The non-conformity is based on the following:

• Upon reviewing the patient records, it emerged that Molde team had cases in which patients had not been given treatment within the stipulated time limit. The waiting lists presented on 14 May show that there were 18 cases in which treatment deadlines had not been adhered to at BUP Molde. 17 of these were part of Molde team's case load. Examples include:
  • A patient assessed 20 February had been given 20 March as the treatment deadline, but had not yet (as per 14 May) been given an appointment.
  • The patient at the top of the list had been given 5 March as treatment deadline, but had not yet (as per 14 May) been given an appointment.
• From 5 September 2012 to 10 May 2013 a total of 32 failures to comply with treatment deadlines were recorded. Approximately 20 of these were from the Molde team. Failures to comply with treatment deadlines are reported to the director (via the clinic director) every month.
• The report form for non-compliance with the treatment deadline requires indication of why treatment is not offered within the stipulated time limit. Similarly, efforts to correct the matter and measures shall be stated.  In the 11 forms relating to failures to comply with the treatment deadline, no comments/evaluation had been made by the department head.
• BUP Molde’s has particular problems with adhering to the treatment deadline. These issues centre on the Molde team. According to the minutes of the meeting from the A-council, where the clinic management is present, one has been aware of this since the autumn of 2012.
• Molde team has not had a team co-ordinator since February 2013. As a result, the employees have had to distribute the duties of the team co-ordinator among themselves. No control measures have been implemented to see whether this actually works.
• An account is provided of the following measures regarding the Molde team:
  • Following the intake meeting’s evaluation, there is a failure to give appointments for commencing treatment in line with procedures. Patients belonging to Molde team receive a letter regarding the treatment deadline. This is followed by a letter that the clinic will be unable to meet the deadline.
  • A variety of messages are sent regarding whether and on which grounds cases on the waiting list are prioritised:
    • the section leader and specialist have reviewed the waiting list in order to prioritise patients due to commence treatment - based on greatest need,
    • those who have been on the list the longest, with everyone waiting their turn,
    • depending on which mental health speciality has capacity and resources to handle the case,
    • in response to external inquiries.
  • Attempts to re-distribute cases to other teams.
  • Additional resources will be brought in from the autumn of 2013.
  • Telephone calls from referrer, parents (or guardians) etc. are transferred to the section leader.
• The outlined measures have not yet had any effect.
• Prioritisation of persons waiting for treatment by the Molde team is not done with any evaluation of the overall waiting list for BUP Molde.  The department head expects this to be done; however, no measures have been implemented to monitor this.

Non-conformity 3

Møre og Romsdal Hospital Trust does not ensure that assessment and diagnosis at BUP Molde are sufficiently multidisciplinary, or that a diagnosis is made as soon as assessment is concluded. The health trust has not set any targets for how much time may elapse before a diagnosis is made.

The non-conformity is based on the following regulatory requirements:

• Section 2-1 b of the Act relating to Patients' Rights
• Section 2-2 of the Act relating to the Specialist Health Services
• Section 39 et seq. of the Act relating to Health Personnel
• Section 3, subsection 1, of the Act relating to Public Supervision of Health and Care Services, see the Regulations on Internal Control

The non-conformity is based on the following:

• Patient pathway procedures at BUP Molde (outpatients) have been presented, describing the process for patient assessment and treatment, as well as for case closure. Not everybody is familiar with this procedure. Practice is not in line with the adopted procedure.
   o Assessment plans are not used.
   o The degree to which templates for treatment plans are used varies. They should be drawn up after the first treatment session, but this is rarely done. They are used sometimes as an aid for the assessment and treatment pathway, partly as subsequent documentation for what has been done, and when it has been done. In some cases, patient pathways contain no treatment plan at all.
   o According to the job description the team co-ordinator is responsible for following up treatment plans. There is no indication that this is in fact done, or that non-conformities are reported if there is no treatment plan.
   o The Action Plan for 2012 and 2013, and the minutes from the A-council show that the department management has on several occasions pointed out that treatment plans are to be used.  No measures to verify that this is done have been implemented.
   o Failure to tell patients what the expected/standardised timeframe is for the assessment pathway. Interviews indicate that practice varies among the teams and among the practitioners in the team regarding how long the assessment process takes, and how it is structured.
   o The situation that has been outlined for Molde team results in long waiting times in those cases where there is a need for other professional expertise. No non-conformities are reported regarding this.
   o The procedure for the person in charge of the case outlines the points at which the case is taken to the multidisciplinary team for a review. In practice it is up to the person in charge of the case when and how often a case is discussed by the multidisciplinary team.
   o The A-council meeting of 20 February 2012 has stated that axial diagnoses are to be used. In practice diagnoses are not set according to the axial system in assessment pathways.
   o Axial diagnoses are only occasionally indicated in the BUP-data system at the time of case closure.
   o The diagnostic conclusion is stated at the very top of the case summary.
   o There is little consistency regarding what is documented.  Staff are not trained in carrying out documentation in the patient records. There is no information as to what the duties of the person in charge of the patient records are. There is no system or established practice for checking of patient records, including a lack of verification to see that there are treatment plans, and that diagnostic assessments have been performed.
• Any suicide risk is to be identified in the first treatment session, see Procedure for first treatment session/control point.  This is well known and it is clear from the patient records that staff give importance to the matter. However,
   o not all staff have been trained, nor has a plan to ensure that all staff have these skills been adopted. There is no evidence of this in the competency plan presented.
   o No general agreement on screening versus assessing suicide risk, see guidelines for suicide prevention in mental healthcare.
• No screening for drug problems.
• There is no description of routine/procedure to identify and follow up patients who do not show up. There is no evidence of risk assessments being made regarding the need for special follow-up of particular children. As a rule,
   o the patient and/or parents (or guardians) are contacted,
   o the referrer is contacted,
   o letters regarding a new appointment are sent,
   o upon the third no-show the case is closed. 
• There is no evidence of a joint understanding or practice as to when or whether a report of serious concern regarding the child/young person’s care situation shall be sent to the child welfare services.

The County Governors also noted the following:

The supervision among other things reviewed treatment and closure of patient cases, concentrating on the following areas:

Are patients and parents (or guardians) involved in treatment planning? Are arrangements made to provide for the necessary collaboration between BUP and first-line services (offered by the municipality) when this is necessary to ensure sound treatment? Is the patient discharged in co-operation with the patient/parents (or guardian) and the first-line services provided by the municipality (or mental healthcare for adults, if applicable)?

In the areas addressed in this supervision the supervisory body found the organisation’s activities to be in line with regulatory requirements and the organisation’s own system of management.

6. Assessment of the organisation’s management system

All health service providers are obliged to establish internal control/management systems in order to ensure professionally sound services. It is the duty of the owner and the management to create a framework and organisational solutions resulting in services of satisfactory quality, and that reduce the likelihood of human failure while also limiting any harmful effects. The requirements to internal control shall ensure that day-to-day duties are planned, organised, performed and improved in accordance with the requirements defined in or in pursuance of health legislation.

The electronic quality system EQS does not appear to be in much active use, nor have monitoring or verification operations been established to ensure that it is used actively. The adopted procedures are not always complied with. The organisation appears to lack oversight and control.

Patient details are recorded in the documentation systems BUP-data and DocuLive. The supervision has uncovered that not all information that is necessary and relevant is entered in the patient records, and that practice varies with regard to what is recorded in the patient records, and where it is recorded.

The outpatient clinic lacks an effective non-conformity system.

Children and young persons with mental health illness are a vulnerable patient group. Early intervention has great potential in terms of preventing subsequent mental illness. It is therefore very unfortunate that BUP Molde is not of the size or managed in a manner that ensures that patients are treated within the stipulated time limit. Furthermore, it is unfortunate that BUP Molde has failed to establish a system of standardised practice that results in the quickest possible making of diagnoses/conclusions in all six assessment areas with a view to commencing treatment as soon as possible, and based on an assessment that is satisfactory with regard to multidisciplinary and broadness of approach.

The management of BUP Molde has implemented a number of procedures that are not followed and the control procedures required to monitor these are inadequate. Practice varies, both among teams and within certain teams. As a result there is a risk of inequalities occurring in the quality of service delivered in patient treatment at BUP Molde.

7. Regulations

The Act relating to the Specialist Health Services
The Act relating to the Establishment and Provision of Mental Healthcare
The Act relating to Patients' Rights
The Regulations on Prioritisation in Health Services etc.
The Act relating to Health Personnel etc.
The Regulations on Patient Records
The Act relating to Public Supervision of Health and Care Services etc.
The Regulations on Internal Control Systems in Social Services and Healthcare 

8. Case documents

The organisation’s own documentation related to day-to-day operations and other matters of significance that were sent to the auditors during preparation for the audit:

• Organisational chart for the Clinic for Children and Young Persons
• Organisational plan for the Outpatients’ Clinic Molde BUP 1 March 2013
• List of positions at the Outpatients’ Clinic Molde BUP 1 January 2013
• List of qualifications and expertise within mental healthcare, Outpatients’ Clinic Molde 2012
• Plan for upskilling Outpatients’ Clinic Molde BUP, adopted by the A-council on 19 March 2012
• User satisfaction survey 2011
• Action plan for 2012 including evaluation, 5 February 2013
• Action plan for 2013
• Meeting and teaching schedules for BUP Molde, autumn 2012
• EQS procedures
  Job description for case responsible person/patient responsible person
  Job description for the team co-ordinator
  Unit advisors, medical and psychological
  Intake procedures
  Assessment of hyperkinetic (ADHD/ADD) disorder, BUP Molde
  Patient history
  First treatment session/control point
  Patient pathways at BUP outpatient clinic Molde
  Treatment plan
  Psychological tests/questionnaires BUP Molde
  Case closure in the documentation systems BUP-data and DocuLive BUP Molde
  Registration of reports in EQS
• Meeting regarding EQS on 25 January 2013
• Key figures report
• Statistics for the years 2010, 2011, 2012 for BUP Molde
• Collaboration agreement between Møre og Romsdal Hospital Trust and the municipalities of Møre og Romsdal

Documentation reviewed during the audit visit:

• Documentation form for referral evaluations
• Minutes from the A-council
• Minutes from the department council
• Non-conformity log
• Failure to comply with treatment deadlines 2012-2013
• Waiting list as per 14 May 2013

The following selection of patient records was made:

 

Selection og patients records

Themes  patient groups	Scope
Children aged between 7 and 15 with healthcare needs based on restlessness and acting out, and where ADHD was suspected	Ten patient records which arrived a fortnight before notification of the supervision was given A minimum of 15 patient records: selected at random: Admitted at least six months ago Latest discharged patients Some of the referrals must be from the child welfare authorities
Children aged more than 12 years with healthcare needs based on sadness and suspected depression.	Ten patient records which arrived a fortnight before notification of the supervision was given A minimum of 15 patient records: selected at random Admitted at least six months ago Latest discharged patients Some of the referrals must be from the child welfare authorities
Rejected referrals	The 10-15 last ones

The patient record review was carried out electronically using the documentation systems BUP-data and DocuLive, with assistance from the office team co-ordinator office Laila Åramnes.

Correspondence between the organisation and the Office of the County Governor of Sør-Trøndelag:

• Provisional notification and information regarding the supervision, 28 January 2013
• Notification regarding supervision and further details, 4 March 2013
• Documentation received, 20 March 2013
• Miscellaneous e-mails during preparation of the supervision

9. Persons participating in the supervision

The table below lists the persons attending the opening and closing meetings, and the persons who were interviewed.

Not published here

The following individuals from the County Governors participated:
Auditor, Advisor/Psychiatric Nurse Åse Hansen, Office of the County Governor in Møre og Romsdal
Auditor, Assistant County Medical Officer Tor-Finn Granlund, Office of the County Governor of Nord-Trøndelag
Audit Leader, Senior Advisor/Lawyer Mona B Parow, Office of the County Governor of Sør-Trøndelag
Observer, Senior Advisor Aud Frøysa Åsprang, Norwegian Board of Health Supervision (Statens helsetilsyn)