The CBHSQ Report header
National Mental Health Services Study
Short Report
July 11, 2017
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In Brief
  • In 2010, quality assurance practices related to the behavioral health workforce were common standard operating procedures in mental health treatment facilities; however, use of certain practices differed by facility characteristics and by U.S. state.  
  • Most facilities (89.4 percent) monitored the continuing education requirements for professional staff. In general, percentages did not differ by facility characteristics.
  • Almost all facilities (91.5 percent) had regularly scheduled case review with a supervisor, and many facilities (70.3 percent) had regularly scheduled case review by an appointed quality review committee. These percentages tended to differ by facility characteristics.
  • Two-thirds of facilities (66.8 percent) used both types of case review practices (case review with a supervisor and case review by an appointed quality review committee); only 4.9 percent of facilities used neither type of case review practice.
Behavioral Health Workforce: Quality Assurance Practices in Mental Health Treatment Facilities
Authors

Laura J. Sherman, Ph.D., Sean E. Lynch, Ph.D., L.C.S.W., Catherine G. Greeno, Ph.D., and Elizabeth M. Hoeffel

Introduction

    
Nationwide, there is concern about shortages, retention, and training in the behavioral health workforce.1,2 Tremendous changes have occurred in recent years in the way mental health services are delivered, suggesting that mental health workers may need support and supervision to help them keep pace with changing practices.3 In the field of mental health, research is developing and supporting new and innovative treatment strategies, but practitioners may not be able to deliver these important evidence-based practices without training.4,5 The Annapolis Coalition, a prominent public-private partnership devoted to understanding and addressing the behavioral health workforce crisis, supported in part by the Substance Abuse and Mental Health Services Administration (SAMHSA), has made the improvement of training and staff education a primary goal.1

Members of the behavioral health workforce benefit from continued training and clinical supervision to maintain high-quality services. In addition, these practices may prevent staff from experiencing burnout2 and may assist in overcoming challenges in retention of qualified workers. For example, positive leadership (i.e., transformational leadership) has been shown to serve as a protective factor in community mental health providers' emotional exhaustion and turnover.6 Mental health treatment facilities can play a key role in supporting their workforce through training and supervision practices. 

This issue of The CBHSQ Report focuses on quality assurance practices related to the behavioral health workforce that are used in specialty mental health treatment facilities in the United States (a companion report on substance abuse treatment facilities is also available). These practices include monitoring continuing education requirements for professional staff, regularly scheduled case review with a supervisor, and regularly scheduled case review by an appointed quality review committee. This report uses data from the National Mental Health Services Survey (N-MHSS) to describe the number of mental health treatment facilities that use these quality assurance practices related to the behavioral health workforce as standard operating procedures. In addition, this report examines whether the use of these practices differs by facility characteristics and by state in the United States (including territories and the District of Columbia). 

Data and Methods

N-MHSS, conducted by SAMHSA, is an annual7 survey of all known public and private mental health treatment facilities in the United States. N-MHSS is the only source of national and state-level data on the mental health services reported by publicly and privately operated specialty mental health treatment facilities. N-MHSS is used to collect basic data on the number, location, and characteristics of specialty mental health treatment facilities and the people they serve throughout the 50 states, the District of Columbia, and other U.S. jurisdictions.8 N-MHSS is a point-prevalence survey that provides a picture of facilities' activities on a typical day but may not represent the full scope of practice in a given year.

The 2010 N-MHSS data are used for this report.9,10 There were 10,374 eligible mental health treatment facilities that responded to the survey. The response rate was 91.2 percent. Basic facility information, service characteristics, and client counts were reported for 9,139 of the 10,374 facilities. This report examines use of three types of quality assurance practices: (1) monitoring continuing education requirements for professional staff, (2) regularly scheduled case review with a supervisor, and (3) regularly scheduled case review by an appointed quality review committee. There was some missing data for each quality assurance practice; the numbers of facilities reporting data for each practice were 9,117, 9,116, and 9,101, respectively. There was also some missing data for facility characteristics (facility operation and service delivery setting). The percentages described in this report were calculated using available data for each analysis presented, and the totals used to calculate the percentages are listed in the tables.

Because N-MHSS is considered a census of facilities and provides actual counts rather than estimates, statistical significance and confidence intervals are not applicable. The differences between percentages mentioned in this report were assessed using Cohen's h. The results described here have a Cohen's h effect size ≥0.20, which indicates that there were meaningful differences between the groups.11

Quality Assurance Practices in Mental Health Treatment Facilities

Figure 1. Percentage of mental health treatment facilities using workforce quality assurance practices as standard operating procedures: 2010

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In 2010, quality assurance practices related to the behavioral health workforce were common standard operating procedures in mental health treatment facilities. Specifically, 89.4 percent of mental health treatment facilities monitored continuing education requirements for professional staff as a standard operating procedure; 91.5 percent of mental health treatment facilities used regularly scheduled case review with a supervisor as a standard operating procedure; and 70.3 percent of mental health facilities used regularly scheduled case review by an appointed quality review committee as a standard operating procedure (Figure 1).  

Quality assurance practices across facility operation

The percentage of mental health treatment facilities that monitored the continuing education requirements for professional staff did not vary by type of facility operation with one exception (Table 1). Specifically, facilities operated by the U.S. Department of Veterans Affairs (VA) had a higher percentage of facilities monitoring continuing education requirements for professional staff as a standard operating procedure than the U.S. percentage overall (98.2 vs. 89.4 percent).  

The percent of mental health treatment facilities that used regularly scheduled case review with a supervisor as a standard operating procedure varied. Compared with the U.S. percentage overall, a smaller percentage of facilities operated by a regional or district authority and by the VA used this practice (79.9 and 78.3 vs. 91.5 percent, respectively; Table 1). 

The percent of mental health treatment facilities that used regularly scheduled case review by an appointed quality review committee as a standard operating procedure varied. Compared with the U.S. percentage overall, a lower percentage of facilities operated by a regional or district authority used this practice (55.9 vs. 70.3 percent), whereas a higher percentage of facilities operated by the VA used this practice (79.6 percent).

   

Table 1. Mental health treatment facilities using workforce quality assurance practices as standard operating procedures, by facility operation: 2010

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Quality assurance practices across service settings

A higher percentage of facilities offering inpatient services monitored continuing education for professional staff compared with the U.S. percentage overall (95.4 vs. 89.4 percent), whereas facilities that offered outpatient or residential settings were not different from the U.S. percentage (89.3 and 87.7 percent, respectively) (Table 2). It should be noted that these service delivery settings were not mutually exclusive; thus, some facilities offered services in two or more settings.

A lower percentage of facilities offering inpatient services used case review with a supervisor as a standard operating procedure compared with the U.S. percentage (79.5 vs. 91.5 percent), whereas facilities offering services in outpatient and residential settings were not different from the U.S. percentage (93.1 and 94.6 percent, respectively; Table 2). 

The percentage of facilities using case review by an appointed quality review committee as a standard operating procedure did not vary by service delivery setting (Table 2).

Table 2. Mental health treatment facilities using workforce quality assurance practices as standard operating procedures, by service setting: 2010

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Case review patterns

The majority of facilities (66.8 percent) used both types of case review practices as standard operating procedures (regularly scheduled case review with a supervisor and regularly scheduled case review by an appointed quality review committee; Figure 2). The next most common pattern (24.8 percent) was for facilities to use regularly scheduled case review with a supervisor as a standard operating procedure but not case review by an appointed quality review committee. The least common pattern (3.6 percent) was for facilities to use case review by an appointed quality review committee but not case review with a supervisor. The remaining 4.9 percent of facilities used neither case review practice as a standard operating procedure.

Figure 2. Mental health treatment facilities using regularly scheduled case review practices: percentages, 2010

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State Results

States varied in their use of the three quality assurance practices examined in this report (Table 3). Delaware was the only state with a higher percentage of facilities using all three practices compared with the percentage for the United States overall. 

Table 3. Quality assurance practices in mental health treatment facilities, by state: 2010

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State Results (continued)

Four states had higher percentages compared with the percentage for the United States overall for two of the three practices and were not different from the U.S. percentage for the other practice. The percentage of facilities that used regularly scheduled case review with a supervisor and regularly scheduled case review by an appointed quality review committee as standard operating procedures was higher in the District of Columbia and Maine than in the United States overall. The percentage of facilities that monitored continuing education requirements for professional staff and used case review by an appointed quality review committee as standard operating procedures was higher in Arkansas and Wyoming than in the United States overall.

Twelve states had a higher percentage of facilities compared with the percentage for the United States overall for one of the three practices, typically monitoring continuing education, and were not different from the U.S. percentages for the other two practices. Arizona, Georgia, Idaho, Missouri, Nebraska, New Mexico, North Carolina, Oklahoma, and Tennessee all reported this pattern. Compared with the United States overall, Connecticut had a higher percentage of facilities using regularly scheduled case review with a supervisor as a standard operating procedure, and South Carolina and Utah had higher percentages of facilities using regularly scheduled case review by an appointed quality review committee as a standard operating procedure.  

Five states had lower percentages of facilities using two of the three practices than the percentage for the United States overall and were not different from the U.S. percentage for the other practice. The percentages of facilities using regularly scheduled case review with a supervisor and regularly scheduled case review by an appointed quality review committee as standard operating procedures were lower in Louisiana and North Dakota compared with the percentages in the United States overall. The percentages of facilities that monitored continuing education requirements for professional staff and used case review by an appointed quality review committee as standard operating procedures were lower in Alabama and New Hampshire than in the United States overall. The percentages of facilities that monitored continuing education requirements for professional staff and used case review with a supervisor as standard operating procedures were lower in Colorado than in the United States overall.

Six states had a lower percentage of facilities using one of the three practices as a standard operating procedure than the percentage for the United States overall, most commonly regularly scheduled case review by an appointed quality review committee, and were not different from the U.S. percentages for the other two practices. Montana, Rhode Island, Virginia, and Wisconsin all showed this pattern. The percentage of facilities that monitored continuing education requirements for professional staff as a standard operating procedure was lower in Hawaii than in the United States overall, whereas the percentage of facilities using regularly scheduled case review with a supervisor as a standard operating procedure was lower in Iowa than in the United States overall.

Kansas, Vermont, Maryland showed mixed results. In Kansas, the percentage of facilities that monitored continuing education requirements for professional staff was higher than the U.S. percentage overall, but the percentage of facilities using regularly scheduled case review with a supervisor was lower that the U.S. percentage overall. In Vermont, the percentage of facilities using regularly scheduled case review with a supervisor as a standard operating procedure was higher than the U.S. percentage overall, yet the percentage of facilities using regularly scheduled case review by an appointed quality review committee was lower than in the United States overall. In Maryland, the percentage of facilities that monitored continuing education requirements for professional staff as a standard operating procedure was higher than the U.S. percentage overall, but the percentage of facilities using regularly scheduled case review with a supervisor and the percentage of facilities using regularly scheduled case review by an appointed quality review committee were lower than the U.S. percentage overall. 

Discussion

The 2010 N-MHSS data used in this report indicate that quality assurance practices related to the behavioral health workforce are common in mental health treatment facilities. Regularly scheduled case review with a supervisor was the most commonly used practice, followed closely by monitoring continuing education requirements for professional staff. Although regularly scheduled case review by an appointed quality review committee was a less commonly used standard operating procedure than review with a supervisor or monitoring continuing education requirements, it was still common in facilities. About two thirds of facilities used both types of case review in their standard operating procedures. Facilities operated by a regional or district authority had lower percentages of both types of case review when compared with the U.S. total. Although compared with the other settings, facilities offering inpatient services had higher percentages of monitoring continuing education requirements for professional staff and lower percentages of regularly scheduled case review with a supervisor as standard operating procedures.

Facilities can play a role in supporting the behavioral health workforce by including the practices outlined in this report in their standard operating procedures.1,2 The best quality outcomes are likely to be produced when they go beyond the provision of basic continuing education and clinical supervision.12,13 For example, continuing education that is interactive or tailored to individuals' practices and clinical supervisor expertise, especially in the areas of competencies and procedural knowledge, tends to yield better outcomes.12,13,14 Furthermore, studies indicate that formal documentation and evaluation are important when supervision is conducted in groups,15 which has implications for case review by a quality review committee. Some practices may be more easily integrated into existing facility procedures, such as monitoring the continuing education requirements for professional staff, compared with other practices that require greater time, resources, coordination, and funds (e.g., case review by a quality review committee). Online tools, video conferencing, and electronic health records might facilitate case review for facilities in understaffed or under-resourced areas.16,17 Additional resources to support the behavioral health workforce can be found at http://www.samhsa.gov/workforce and http://www.integration.samhsa.gov/workforce/education-training.

Endnotes

1.   Hoge, M. A., Morris, J. A., Stuart, G. W., Huey, L. Y., Bergeson, S., Flaherty, M. T., et al. (2009). A national action plan for workforce development in behavioral health. Psychiatric Services, 60(7), 883–887.

2.   Paris, M., Jr., & Hoge, M. A. (2010). Burnout in the mental health workforce: A review. Journal of Behavioral Health Services & Research, 37(4), 519–528.

3.   Hoge, M. A., Huey, L. Y., & O'Connell, M. J. (2004). Best practices in behavioral health workforce education and training. Administration and Policy in Mental Health, 32(2), 91–106.

4.   Lyon, A. R., Stirman, S. W., Kerns, S. E., & Bruns, E. J. (2011). Developing the mental health workforce: Review and application of training approaches from multiple disciplines. Administration and Policy in Mental Health, 38(4), 238–253.

5.   Gotham, H. J. (2006). Advancing the implementation of evidence-based practices into clinical practice: How do we get there from here? Professional Psychology Research and Practice, 37(6), 606–613.

6.   Green, A. E., Miller, E. A., & Aarons, G. A. (2013). Transformational leadership moderates the relationship between emotional exhaustion and turnover intention among community mental health providers. Community Mental Health Journal, 49(4), 373–379.

7.   Previously, N-MHSS was a biennial survey. Beginning in 2014, N-MHSS is conducted annually, alternating between a full-scale questionnaire and an abbreviated locator questionnaire. In 2012, the abbreviated locator questionnaire was administered. In 2014, the full-scale version of N-MHSS was conducted, and the abbreviated N-MHSS-Locator Survey was conducted in 2015. The abbreviated N-MHSS-Locator Survey includes only basic facility information needed to update SAMHSA's online Behavioral Health Treatment Services Locator (http://findtreatment.samhsa.gov/).

8.   The other U.S. jurisdictions include Guam, Puerto Rico, and the U.S. Virgin Islands. 

9.   Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2014, July 29). The N-MHSS Report: Introduction to the National Mental Health Services Survey, 2010. Retrieved from http://samhsa.gov/data/  

10. Substance Abuse and Mental Health Services Administration. (2010). National Mental Health Services Survey (N-MHSS): 2010: Data on mental health treatment facilities (HHS Publication No. SMA 14-4837, BHSIS Series S-69). Retrieved from http://samhsa.gov/data/

11. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, N.J.: Lawrence Erlbaum Associates.

12. Bloom, B. S. (2005). Effects of continuing medical education on improving physician clinical care and patient health: A review of systematic reviews. International Journal of Technology Assessment in Health Care, 21(3), 380–385.

13. Borders, L. D. (2014). Best practices in clinical supervision: Another step in delineating effective supervision practice. American Journal of Psychotherapy, 68(2), 151–162.

14. Cantillon, P., & Jones, R. (1999). Does continuing medical education in general practice make a difference? British Medical Journal (Clinical Research Edition), 318(7193), 1276–1279.

15. Kuipers, P., Pager, S., Bell, K., Hall, F., & Kendall, M. (2013). Do structured arrangements for multidisciplinary peer group supervision make a difference for allied health professional outcomes? Journal of Multidisciplinary Healthcare, 6, 391–397.

16. Abbass, A., Arthey, S., Elliott, J., Fedak, T., Nowoweiski, D., Markovski, J., & Nowoweiski, S. (2011). Web-conference supervision for advanced psychotherapy training: A practical guide. Psychotherapy, 48(2), 109–118.

17. Wegner, D. E., Macinnes, D., Enser, J., Francis, S. J., & Jones, F. W. (2013). Implementing video conferencing in mental health practice. Journal of Psychiatric and Mental Health Nursing, 20(5), 448–454.

suggested citation

Sherman, L. J., Lynch, S. E., Greeno, C. G. and Hoeffel, E. M. Behavioral health workforce: Quality assurance practices in mental health treatment facilities. The CBHSQ Report: July 11, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD.