Pierre-André Michaud.1
1Multidisciplinary Unit for Adolescent Health, CHUV/University Hospital, Lausanne, Switzerland.
Executive summary
The Unité Multidisciplinaire de Santé des Adolescents (UMSA) of the University Hospital in Lausanne was created in 1998. Its mission is to:
provide comprehensive health care for adolescents aged 12 to 20 years
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foster epidemiological and clinical research
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provide training sessions at undergraduate and postgraduate levels
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serve as a reference centre in the field of adolescent health.
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Around 12 people work in the unit, seeing 700−800 adolescents a year and complying as much as possible with the criteria for youth-friendly health services.
In 2005, the staff of the unit decided to embark on a voluntary certification process. The unit is required under the certification process to describe the main procedures developed to assure an ongoing assessment of the quality of its activities. This is reviewed by an expert who decides whether the documents provided by the institution meet specific standards in terms of the feasibility, validity and reliability of performance indicators.
After a nine-month process, the unit gained certified status via an independent specialist agency. Procedures have now been developed, refined and monitored and have proved very effective in improving the quality of health care and in strengthening human resources management and budgetary control. All staff are involved in the process and take the view that there is added value in implementing the quality management tool in the unit.
Introduction
In 1996, the Department of Paediatrics and the head of the University Hospital of Lausanne, Switzerland decided that something should be done to improve the health of adolescents in the region. Hospitals of the canton (county/administrative region) were faced with an increasing number of admissions for conditions such as obesity and eating disorders, unstable chronic conditions, unplanned pregnancies,
sexually transmitted infections (STIs), alcohol-induced coma, injuries and suicidal behaviours. Practitioners increasingly felt ill-prepared to cope with these new morbidities, leading to a sense that adolescent health and medicine should be put on the undergraduate and continuing professional education agendas of health care professionals.
Consequently, the Unité Multidisciplinaire de Santé des Adolescents (UMSA) was opened in January 1998.
Its mission is to:
offer an adolescent-friendly unit for adolescent care;
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foster clinical and epidemiological research (in collaboration with an affiliated research group
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focusing on adolescent health);
provide teaching courses at every level of the training curriculum of doctors, nurses and other
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professionals; and
become a centre of reference in the field of adolescent health, both at individual and public health
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levels.
more than 4000 consultations in 2008. Most patients present with complex situations requiring a
multidisciplinary approach, including eating disorders (25% of the case-load), chronic conditions, concerns about growth and puberty, functional disorders and substance misuse. Around 35% of patients consult for gynaecological problems, including menstrual disorders and planned or unplanned pregnancy.
Currently, the research group publishes six or seven papers yearly in peer-reviewed journals. UMSA staff deliver 300−400 teaching sessions each year for students, doctors, nurses and other professionals and coordinate a training programme called EuTEACH (which stands for “European training in effective adolescent care and health”). EuTEACH has a freely available web site (http://www.euteach.com), offers a one-week international training course annually and provides advice, services and evaluations in the fields of school health, public health and policy development. A special consultation dedicated to the care of male adolescents facing pubertal and sexual issues was launched in 2005.
All these activities require a collaborative approach within a wide network of institutions, including the Department of Child and Adolescent Psychiatry, schools, foster homes and social services.
The certification process
Quality management is a major concern within the University Hospital. More and more departments and units are being encouraged, on a voluntary basis, to embark on programmes designed to improve quality, including, in a limited number of cases, a formal certification process.
UMSA’s staff decided to initiate a certification process in 2005, along with International Organization for Standardization (ISO) standards (http://www.iso.org/iso/home.htm). The decision was taken following a staff vote, as it was felt that the process would involve all members of the unit and that everyone should understand that it would require special effort.
The certification process requires institutions to describe the main procedures for ongoing assessment of the quality of its activities. This is reviewed by an expert who decides whether the documents provided by the institution meet specific standards in terms of the feasibility, validity and reliability of performance indicators. It is important that the whole process is conducted voluntarily.
A researcher who had already worked in the certification process of a health institution was appointed to monitor the process and assist the members of the unit in discussing the content of the documents describing quality management. The ISO 9001−2000 norm was proposed by the agency which certifies health care institutions in Switzerland as the reference for this course of action.
Staff had numerous meetings to check the progress of the work over a period of around nine months. In June 2006, the unit was certified by the Swiss Association for Quality and Management Systems (http://www.
sqs.ch/en/index.htm), an independent agency specializing in the certification of health services. All the main activities of the unit were included in the certification − health care, research and public health activities, as well as managerial aspects.
Currently, a senior member of the secretariat is in charge of the maintenance of the quality management process, which she does with the support of three other members of staff (including the chief physician director of the unit), meeting once a month for a review. While the opinion of young people is often elicited when new activities are planned (through focus group discussions, for instance), it was felt that their input in such administrative work would not be useful.
Management of health care quality
The two main activities reviewed were health procedures in specific situations and institutional collaboration.
There is consensus currently on how young people should be received and treated within youth-friendly health services (YFHS). UMSA staff have developed a chart that is displayed at the entrance to the unit,
along with the YFHS guidelines. This chart stresses issues such as confidentiality and the importance of involving parents as much as possible in the care of their adolescent children. It also insists on reinforcing the autonomy of consultants and improving their decision-making capacity in this field.
The chart is discussed and re-evaluated during the biannual staff retreat, during which all the processes of the unit are reviewed. It is therefore not a static document, but provides a foundation for ongoing
improvement. The unit has now asked the research group to survey the satisfaction of adolescents and their parents coming to the clinic.
Apart from establishing the unit’s basic principles and ethos, staff have also focused on the content of the consultation and how to respond to specific situations. Several documents emphasize a holistic or global approach to adolescent patients, combining a focus on the reason for the visit with a broader exploration of the adolescent’s health and lifestyle. While this basic approach to adolescent health care has achieved consensus, there is currently little evidence on how to address many of the clinical situations which may present.
For instance, it could be argued that there are currently few evidence-based sources identifying the most effective way to treat anorexia nervosa or functional disorders, or how to provide advice to modify risk-taking behaviours. It was therefore difficult to develop evidence-based guidelines to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. It was nevertheless decided to review the available literature and to compose health care protocols on the key areas dealt with in the unit to guide young resident doctors in their everyday work. The unit therefore has an agreed description of how to treat adolescents with conditions such as substance misuse, eating disorders, suicidal behaviours, functional disorders and dysmenorrhoea; these contribute to efforts to increase quality and develop
consistency of care within the unit.
The unit receives many adolescents referred by professionals working in shelters or foster homes, in the school health system or in social services. The treatment of such young patients often requires a network approach involving cooperation with various stakeholders. While the network approach is especially important in the care of high-risk drop-out adolescents or youngsters who are already enrolled in social programmes, it is often a challenge to successfully manage this kind of collaboration. For instance, one has to balance the need for confidentiality against recognition of the need for professionals to know about the different issues in a given situation. The issue of how and when to transmit information, and to whom, is also highly sensitive.
To address these potential problems and improve the partnership approach, the unit has worked with the staff of all main collaborating institutions to establish a protocol outlining precisely what each institution expects from the other and detailing the commitments of each partner. These protocols are reviewed annually.
The added value of these discussions has become more and more obvious over time. They have led to decreases in misunderstandings and improvements in the satisfaction of colleagues using the unit’s services.
In a recent meeting with the staff of a foster home, for instance, the head of the home mentioned that the discussions around, and use of, the protocol had not only improved compliance levels of adolescent girls visiting the UMSA, but had also increased their satisfaction levels with the service.
Improving the quality of the management of the unit
Management of human resources is part of the function of any unit of the University Hospital. Achieving certification has contributed to clarifying the management process, with each employee now having a document detailing the specifications of his or her position. This document is reviewed every year with discussion on whether the objectives set for the preceding year have been met. If they have not been met, the reasons for this are explored and objectives for the following year are agreed. These discussions result in improved satisfaction for employees, better utilization of the specialist skills of all members of staff and a better overall view of the running of the unit for its director. Informal checks are also carried out throughout
the year, according to employees’ needs. These regular assessments contribute to the incorporation of new ideas and strategies into the work and progress of the unit.
Following-up on proposals made or decisions taken is often a neglected area in a unit’s processes. Problems that need an appropriate response in terms of administrative organization or health care approach quite often arise during individual discussions and staff meetings. The quality management procedures now in place guarantee that each of these problems and its planned solutions are noted and reviewed regularly to determine if the proposed changes have been implemented or not.
Another central aspect of any unit is management of finance. UMSA has recently moved from a system where a fixed amount of money is received at the beginning of the year to a “fee-for-service” system in which the budget is dependent upon the performance of the unit. As a consequence, financial indicators which allow for fine-tuning of all elements of the budget are needed.
The framework provided by certification has been essential in the development of this new financial framework. Indicators have been developed in areas such as:
the time lapse between the consultation and its registration on the hospital’s central computer;
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yearly and monthly invoices billed to insurance against the cost of salaries; and
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the distribution of gains over the years.
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Conclusion
UMSA staff have established a set of procedures for all the unit’s main activities and have ensured that these procedures are regularly reviewed and, where necessary, revised. It is recognized that certification is an ongoing process that focuses less on the provision of services than on how the unit improves the quality of its performance on a regular, ongoing basis. Certification provides a means through which staff can adopt a critical stance to their service provision and set high aspirations for the nature and quality of services provided.
Four years on, staff feel the certification process, which has been endorsed democratically by all members of the unit, has provided added value to their service. Implementing a certification process is a time-consuming task which should not be underestimated, but the consequent middle- and long-term benefits are important.
The participation and “mobilization” of every member of the unit is an important condition for the success of such a process, especially in a relatively small unit such as UMSA.
The management system developed in UMSA has improved the quality of health care procedures and brought more satisfaction to employees. Moreover, it has certainly increased the visibility of the unit within the hospital and within the direction of the hospital.
Acknowledgement
The author is grateful to J-C Suris MD, PhD, and Gabrielle Cisse for their useful comments on an earlier version of the case study. He also wishes to acknowledge the invaluable assistance of F Peny, chief secretary of UMSA, who is in charge of the maintenance of quality procedures within the unit.
Further reading
American Academy of Pediatrics. The pediatrician and the “new morbidity”. Pediatrics, 1993, 92:731−733.
Elster AB, Kuznets N. AMA guidelines for adolescent preventive services (GAPS). Recommendations and rationale. Baltimore, Williams & Wilkins, 1994.
Epner JE, Levenberg PB, Schoeny ME. Primary care providers’ responsiveness to health-risk behaviors reported by adolescent patients. Arch Pediatr Adolesc Med, 1998, 152:774−780.
Field M, Lohr K. Clinical practice guidelines: directions for a new program. Washington, DC, National Academy Press, 1990.
Goldenring J, Rosen D. Getting into adolescent heads: an essential update. Pediatrics, 2004, 21:64−90.
McIntyre P. Adolescent friendly health services (draft report). Geneva, World Health Organization, 2001.
Michaud PA et al. The development and pilot-testing of a training curriculum in adolescent medicine and health. J Adolesc Health, 2004, 35:51−57.
Viner R, Keane M. Youth matters: evidence-based best practice for the care of young people in hospital. London, Caring for Children in Health Services, 1998.