Sunday, December 01, 2013

Quantifiable Goals


A local hospital was recently reviewed by one of those hospital accreditation agencies.  It did well-- passed with bells and whistles -- but for a few citations for psychiatry.

Individual Treatment Plans (ITP)s:
"Surveyors cited us for not having measurable goals in the ITPs. So, changes were made to [the electronic records system] to  clarify the requirement for objective and measurable patient goals as well as the patient’s progress toward those goals."


Okay, so help me with this.  Two decades of trying to come up with acceptable, measurable goals and I'm left with the idea that therapy has a limited number of goals and they aren't that measurable:
~Patient wants to feel better / Less psychic pain.
~To work and to love.
~No psychosis (and we measure that how?)
~To remain out of the hospital. (While measurable, I'm not sure that is acceptable to the bean counters).
~To remain out of jail/prison.
~Patient will resist urges to drink alcohol/shoot heroin/snort cocaine.
~Fewer self-injurious behaviors.
~Living up to potential.
~Acceptance of self as is, including the reality that patient may never be as beautiful/rich/smart or accomplished as he once believed he should  be.

What's measurable?  

Patient will have a Beck Depression Inventory score of less than 10 at every visit?
Patient will report spending less than 1 hour a day on compulsive checking?
Patient will lacerate himself fewer than 4 times per week and all lacerations will be less than 2 cm long and none will penetrate arteries?
Patient will report having suicidal thoughts less than 23% of waking hours?  

I remain clueless.  And of course, the treatment plan is about naming the goals, there are no citations for achieving them or not, or even for having them make sense in the context of the patient's life.

Paperwork chaos is not new.  I remember being an intern and being paged in the middle of the night to put a cause of death on a death certificate.  It was 3AM and I wrote down "pneumonia," because the patient had died of pneumonia.  I was paged again soon after.  "Pneumonia" is not an acceptable cause of death.  But that was what the patient died from.  I needed to know what organism caused the pneumonia, and that could only be known if a culture was done and that would take days to know.  The requirements said that a cause of death needed to be given now.  "Sepsis," I said (overwhelming infection).  Nope, I would still need to know the infectious agent, something I still didn't have access to at 3AM with a newly admitted patient.  I tried again: cardiopulmonary arrest.  That worked, sort of.  What was the cardiopulmonary arrest due to, I was asked?  Pneumonia, I said.  That's still not acceptable, unless I knew the organism.  I finally asked what is an acceptable cause of death.  I was given a few options, none of which pertained to the patient, but I picked one because there was nothing else to do.  

Okay, so what are acceptable, measurable goals in psychiatry?  And does measuring something make it more meaningful?