Implementation of care standards
When a multitude of guidelines were introduced in the field of mental health in the past decades, implementation proved to be a slow and difficult process. A multi-faceted approach is mostly promoted as the best strategy with actions targeted at the professional level (training programs, educational material, access to peer information about good practice experiences), the organizational level (introduction of care pathways, tools for cost estimation) and the patient level (information brochures or option grids). A multitude of resources and tools to help to implement guidelines has been developed but implementation is still work in progress. Continuous efforts and financial incentives are necessary to optimize the use of guidelines13. Whether improved adherence to guidelines, will improve quality of care and patients outcome is open to debate and a little researched question4.
Although the implementation of the number of standards seems to be an obstacle for some, it can also be an advantage. There might be some advantages with implementation of the standards compared to implementation of guidelines. The introduction of elements of clinical expertise in the standards might enthuse clinicians more than before to adapt to these standards as they represent the daily clinical practice better. At the same time, patients will recognize more elements of experiential knowledge in the standards and the associations of patients representatives might enforce the use of these standards much stronger than the guidelines before.
Where NKO previously supported the field in the development of standards, Akwa GGZ14 now supports mental health care on a national level with the implementation of these standards. For all standards of care a test was carried out among clinical practitioners to assess the practicability of the care standard and the conditions that are necessary to implement the care standard. With that information Akwa GGZ has developed implementation plans that includes strategies to inform professional organizations how to use the standards; there is an online database where all standards can be found and searched; all standards have been translated to version for users which are on-line, there is an toolkit with strategies to help the implementation and Akwa GGZ will monitor the process of implementation of the standards. This nationwide, encompassing and structured program for implementation might help the implementation process further. But the professional organizations are responsible for the actual implementation. Insurance parties probably will be an active promotor of implementation as the care standards do represent the best care as possible. The goal is that professionals, patients and their families know and use the practice guidelines in daily practice; that professionals and providers learn from each other by exchanging information and that the quality of care in Dutch mental health care as a whole will improve.
In conclusion, the process of the development of care standards and generic standards in the Netherlands is an important next phase in the ongoing challenge to improve the quality of care for mental health disorders with evidence based medicine. Some of the difficulties that arose in the guideline development in the early phase like the multitude of different and sometimes conflicting monodisciplinary guidelines, the limited scope of the monodisciplinary guidelines and the omission of clinical expertise and patients preferences in the guidelines are addressed by this nationwide, multidisciplinary, integrated new set of standards of care and generic standards, all developed by the same methodology with a strong influence of patients and families, and acceptance by the different health care insurance companies. Still, there are important challenges for the future because the consequences of implementation of the standards (for example the financial consequences) are not fully identified. Furthermore, the question how to update the standards of care is as relevant as it was for the clinical guidelines5. Finally, the efforts and expenses for the development and implementation of these standards can only be justified, if it really improves the care for those with mental disorders.