Parent and Young Adult Satisfaction with Psychiatry Consultation Services in a Children's Hospital

Psychosomatics 2013:54:575–584

© 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Original Research Reports Parent and Young Adult Satisfaction with Psychiatry Consultation Services in a Children’s Hospital Robert L. Kitts, M.D., Katie Gallagher, M.A., Patricia Ibeziako, M.D., Simona Bujoreanu, Ph.D., Georgina Garcia, M.D., David R. DeMaso, M.D.

Background: Quality of health care services can be improved by promoting patient- and family-centered care informed by patient and family satisfaction with services delivered. Few studies have been conducted looking at satisfaction with psychiatric consultation services within an inpatient pediatric hospital setting. Objective: The objective of the quality improvement pilot project was to identify ways to enhance services delivered and to guide the development of more comprehensive quality improvement projects. Method: Fortyeight parents of forty-eight patients and 10 adult patients were administered the Pediatric Psychiatry Consultation Satisfaction Survey, which surveyed satisfaction with the psychiatric consultation services received during their stay in a freestanding tertiary pediatric academic hospital. Results: Sixty-nine percent of participants reported overall high satisfaction (i.e., reports of excellent or very good) with the psychiatric

consultation service along with 88% reporting that they would recommend this service to a friend. Overall high satisfaction with the service was associated with positive ratings with three core components of a consultation: provisions of impressions and recommendations (P ⫽ 0.018), consultant–participant communication and working relationship (P ⬍ 0.001), and the helpfulness of the consultation (P ⬍ 0.001). Conclusions: This quality improvement project underscores the importance of having psychiatry consultants convey their clinical impressions and recommendations, communicate effectively, and provide helpful interventions to parents and young adults in the pediatric hospital. It serves as an initial step responding to national consumers’ demand for higher levels of quality and service and will provide guidance in future design and implementation of more comprehensive quality improvement projects. (Psychosomatics 2013; 54:575–584)

A

to medically hospitalized youth for over 70 years.4 The past decade has seen a significant increase in demand for psychiatric consultations for children and their families hospitalized on general medical and surgical units.4 – 6 Despite this heightened service demand, there has been es-

patient’s and his or her family’s personal beliefs, values, and participation in decision-making are critical components to consider in providing patient- and family-centered pediatric care.1–3 Consumer satisfaction surveys are a means of providing a voice for patients and families and assessing whether their own desired outcomes are being reached. In this context, such surveys can help promote patient- and family-centered care and have the potential to enhance healthcare services.1–3 Hospitalbased psychiatry consultations to children and adolescents would benefit from such quality improvement investigation. Psychiatry consultation services have been provided Psychosomatics 54:6, November-December 2013

Received September 12, 2012; revised January 21, 2013; accepted January 21, 2013. From the Department of Psychiatry, Boston Children’s Hospital and Harvard Medical School, Boston, MA. Send correspondence and reprint requests to Robert Kitts, M.D., Department of Psychiatry, Boston Children’s Hospital and Harvard Medical School, Hunnewell 120, 300 Longwood Avenue, Boston, MA 02115; e-mail: [email protected] © 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

www.psychosomaticsjournal.org

575

Satisfaction with Psychiatry Consultation Services sentially no examination of consumer satisfaction of the services provided by psychiatry consultants in inpatient pediatric hospital settings.5 The few satisfaction studies regarding hospital-based psychiatry consultation services in the literature have focused on medical provider satisfaction with the child psychiatry consultation services or on adult patient satisfaction in general hospital settings.5–7 Other than one prospective case-controlled study of pediatric inpatient referrals that included a brief parental satisfaction component and one parent satisfaction study on ambulatory child psychiatry consultation services to primary care providers, there are no reports in the literature comprehensively assessing either parent or young adult patient satisfaction of psychiatry consultation services provided in an inpatient pediatric hospital setting.8,9 This project aimed to explore the satisfaction of parents and young adults regarding the provision of hospitalbased psychiatry consultation services in a children’s hospital. The relationship of overall consumer satisfaction was examined in regards to the consumer’s awareness/ understanding of the consultation, feedback on the conveyance of the consultant’s clinical impressions/recommendations, feedback on the communication and working relationship with the consultant, and feedback on the helpfulness of the consultant’s interventions. This pilot is part of a quality improvement initiative designed to enhance mental health services delivered in the inpatient pediatric hospital setting and to promote effective patient- and family-centered healthcare. METHOD Psychiatry Consultation Service Description Boston Children’s Hospital (BCH) is a 395-bed pediatric hospital where the Psychiatry Consultation Service (PCS) has provided over 800 inpatient psychiatry consultations annually to the Hospital’s general medical and surgical units. The PCS has 3.0 FTE child and adolescent psychiatrists, 1.5 FTE child psychologists, 1.0 FTE child and adolescent psychiatry residents, 1.5 FTE pre-doctoral psychology interns, and 2.0 FTE post-doctoral psychology fellows providing consultations to general medical and surgical units. In addition, the PCS provides additional specialty inpatient consultation services to the Hospital’s Solid Organ Transplant Program (2.0 FTE child psychologists), Oncology Service (0.5 FTE psychiatrist), and Critical Care Service (1.0 FTE child psychologist and 1.0 FTE post-doctoral psychology fellow). Consultations are gen576

www.psychosomaticsjournal.org

erally assigned both to a trainee and a staff psychiatrist/ psychologist, with preferential assignment to a psychiatrist if a medication question is the primary consultation question. The PCS follows the principles outlined in the American Academy of Child and Adolescent Psychiatry’s (AACAP) Practice Parameter for the Psychiatric Assessment and Management of Physically Ill Children and Adolescents.10 Consultation requests typically involve at least one of the following inter-related requests: (1) diagnostic assessments (e.g., “Please determine if this is a mood, somatoform, and/or anxiety disorder”); (2) psychiatric management (e.g., “Please help with preparing for surgery, assisting with coping, or managing behavioral issues”); and (3) disposition (e.g., “Please determine the need for psychiatric hospitalization”). The consultant performs a standardized psychiatric diagnostic interview with the patient and separately with the parent(s) (as developmentally indicated). For patients aged 18 years or older, patients are the primary source of information, but parent(s) may be interviewed if they are actively involved in the patient’s care and the patient provides permission. Additional information is collected from the patient’s medical record and healthcare team. As indicated, collateral contact with community providers (e.g., school or outpatient providers) is sought. After the assessment, the consultant provides a biopsychosocial formulation and diagnosis to the patient, family, and healthcare team along with any treatment recommendations. The consultant generally remains involved subsequently during the hospitalization to provide time-limited interventions (e.g., medication management, supportive therapy, behavioral interventions, coping skills training) targeting the identified consultation concern(s). As part of its Psychiatry Quality Program, the Hospital’s Department of Psychiatry mandated quality improvement projects for all clinical service programs in the Department. The PCS identified the measurement of consumer satisfaction as an important outcome measure to assist in determining its ability to provide the highest quality patient- and family-centered care healthcare. Sample Characteristics Between June and August 2010, all parents and adult patients (18 years old or older) who were seen by the PCS on the general medical and surgical units were informed at the initiation of the consultation by the PCS consultant that they may be asked to participate in an optional confidential Psychosomatics 54:6, November-December 2013

Kitts et al. satisfaction survey regarding the psychiatry consultation at the conclusion of their hospital care. At discharge or the completion of the consultation, a quality improvement project assistant (non-clinician and not part of the PCS) invited the parents or adult patients to complete the satisfaction survey. The project assistant read the survey to the parents (private hospital conference room) or young adults (patient’s room or private hospital conference room if preferred). The project assistant interviewed those participants who could not be interviewed prior to discharge or who expressed the preference over the phone within 2 weeks of discharge. An interpreter was made available if necessary. As a pilot project, the decision was made to focus exclusively on consultations to the general medical and surgical services because of the inherent complexity of the specialty services combined with the ongoing outpatient psychiatric care that was often provided by the psychiatry consultant. Adult patients were included to account for the Hospital’s demographics whereby 20% of patients on the general hospital services are age 18 years or older. Participants were excluded: (1) if the consultation was not completed within the project time period; (2) children and adolescents without parental involvement (e.g., protective service custody); and (3) if deemed inappropriate by the consultant (e.g., concerns that the survey would potentially worsen the emotional or behavioral state of the patient and/or parent). After review by the Hospital’s Office of Clinical Investigation, this project was viewed as a quality improvement initiative. All participants were informed that the survey results might be published using combined, anonymous data. Measure—Pediatric Psychiatry Consultation Satisfaction Survey Although the Hospital uses the National Research Corporation (NRC) Picker Pediatric Inpatient Survey to assess consumer satisfaction, the survey does not measure the satisfaction of consultations separate from the overall inpatient care. Furthermore, the nature of a psychiatric consultation varies significantly from an inpatient medical admission. The lack of an accepted measure for consumer satisfaction regarding psychiatric consultations in the inpatient pediatric hospital setting led to the construction of a specific measure of consultation satisfaction for parents and young adults. The pediatric psychiatry consultation satisfaction survey (PPCSS) is based upon the principles outlined in the Psychosomatics 54:6, November-December 2013

aforementioned AACAP practice parameter10 and is informed by standard satisfaction survey measures from other settings.11–13 The PPCSS is a 28-item survey (see Appendix) that includes two overall satisfaction measures along with four core consultation components that are necessary to consider in evaluating an effective psychiatric consultation in the pediatric setting: (1) the consumer’s awareness and understanding of the consultation, (2) the consumer’s feedback on the communication and working relationship with the consultant, (3) the consumer’s feedback on the consultant’s impressions/recommendations, and (4) the consumer’s feedback on the helpfulness of the consultant’s treatment interventions. Survey questions for each of the four core consultation components used a mixture of yes/no questions, ratings on a six-point Likerttype scale anchored from very poor (1) to excellent (6), and open-ended questions. Demographic data including age, gender, race, ethnicity, living situation, reason for the hospitalization, reason for the psychiatric consultation, and psychiatric diagnoses was collected via medical chart review. Statistical Analyses To accommodate for “not sure” responses, all survey questions were coded into binary responses to indicate satisfactory vs. unsatisfactory responses; [yes] vs. [no or not sure]; or for Likert-type questions, [excellent/very good] vs. [good/fair/poor/very poor/not sure]. If a question was skipped or missing because of an interrupted survey or because it was not applicable to the participant’s situation, the participant was excluded from the affected analyses. Therefore, some analyses have fewer than 58 participants. Overall satisfaction was defined as the combination of the binary ratings of (1) overall helpfulness and (2) whether the participant would recommend a psychiatric consultation to a friend. Four component subscale scores were computed based on the percentage of items within each component that were scored as either [Excellent/Very Good] or [Yes]. A series of statistical tests was used to explore which elements of the patient’s demographic characteristics, features of the consultation, and component scores were associated with overall satisfaction. Three participants did not respond to the overall satisfaction questions and, therefore, were excluded from these analyses. Given the small sample sizes and generally high overall satisfaction, the ␹2 test and Fisher’s exact 2-sided test were used for categorical measures. For continuous www.psychosomaticsjournal.org

577

Satisfaction with Psychiatry Consultation Services measures, Student’s t-test and Kruskal-Wallis one-way analysis of variance (by ranks) were used. RESULTS Participants’ Characteristics The Psychiatry Consultation Service (PCS) performed 122 consultations on the medical and surgical patients with 97 meeting inclusion criteria. Of these, eight (8%) declined participation, one (1%) participant’s child died during hospitalization, 27 (28%) did not complete the survey, and three (3%) parent/adult patients were missing updated contact information. The remaining 58 (60%) participants (see Table 1) were either parents of youth seen (48 parents, 83% of participants) or adult patients (10 patients, 17% of participants). Participating patients were on average younger than those who did not participate (14.5 vs. 17.0, t ⫽ 2.62, df ⫽ 95, P ⫽ 0.01). There were no significant differences between participants and nonparticipants on characteristics such as the patient’s gender, race/ethnicity, length of stay, or any of the psychiatric diagnostic categories. For the 58 survey participants, 86% of the consultations were conducted on the medical units compared with 14% on the surgical units. The largest percentage of consultations were requested by the Adolescent Medicine service (24%) with most of those admissions attributable to an eating disorder followed by the General Pediatrics service (17%), where the most common reason for admission was infection. Orthopedic Surgery was the most common surgical service to request consultation (10%) with the majority of those admissions attributable to fractures. Neurology (10%) and gastroenterology (9%) were two other common sources of consultations with reasons for admission including seizures, demyelinating disease, or gastrointestinal inflammation. Three patients (5%) were admitted because of intentional overdose of medication(s).

TABLE 1. Survey Patient Participant Characteristics (n ⴝ 58) Mean (ⴞ SD) Patient age, years Length of stay, days Patient gender Female Male Race/ethnicity White Black or African American Hispanic or Latino Asian American Indian or Alaska Native Living situation Two parents Single parent Other relative (grandmother) Independent Admitting service Medical Surgical Reason for consult (may be more than one) Diagnostic Management Disposition Psychiatric diagnostic categories (may be more than one) Anxiety disorders Mood disorders Eating disorders Adjustment disorders Conduct/behavior disorders Neurodevelopmental disorders (autism spectrum) Somatoform disorders Substance-related disorders Mental disorders due to a general medical condition Neurocognitive disorders (delirium/dementia) Psychotic disorders No diagnosis Person completing survey Mother Father Adult patient

14.5 (4.4) 7.3 (5.6) n

%

39 19

67 33

46 5 4 2 1

79 9 7 3 2

40 16 1 1

69 28 2 2

50 8

86 14

40 30 22

69 52 38

17 16 11 10 10 7

29 28 19 17 17 12

6 3 3

10 5 5

2

3

2 2

3 3

45 3 10

78 5 17

Satisfaction with Psychiatry Consultation The helpfulness of the psychiatric consultation was rated as excellent/very good by 69% of participants (82% if good was included) with 88% indicating that they would recommend psychiatric consultation to a friend in need of similar services (see Table 2 for PPCSS results). Almost all participants (97%) were aware of the consultation and indicated that the consultant clearly identified him or herself. About one-third of the participants (31%) stated that 578

www.psychosomaticsjournal.org

they had initiated the consultation themselves with the rest being initiated by a member of the healthcare team. Approximately 65% of the participants who did not initiate the consult knew who requested the consultation and 68% acknowledged that the reason for the consultation was explained to them. Approximately 80% of the participants reported that the consultant’s clinical impressions and recommendaPsychosomatics 54:6, November-December 2013

Kitts et al.

TABLE 2.

Pediatric Psychiatry Consultation Satisfaction Survey Results

Awareness and Understanding of the Consultation

% Yes

1. Aware that the psychiatric consultation service was involved 2. Who initiated the psychiatric consultation? Patient/parent Medical/surgical team a. if medical/surgical team, patient/parent knows who initiated the consultation b. if medical/surgical team, reason for the consultation explained to patient/parent 3. Psychiatry consultant(s) clearly identified themselves at time of consult Mean Subscale score (% yes of items 1, 2a, 2b, 3) ⴝ 87.1% (SD ⴝ 20.5%) Clinical impressions and recommendations 4. Participant was provided with clinical impressions* a. clinical impressions delivered in a timely fashion b. understood the clinical impressions c. agreed with the clinical impressions 5. Participant was provided with treatment recommendations a. treatment recommendations delivered in a timely fashion b. understood the recommendations c. agreed with the recommendations Mean Subscale score (% yes of items 4, 4a, 4b, 4c, 5, 5a, 5b, 5c) ⴝ 79.1% (SDⴝ27.7%) Consultant/participant communication and working relationship 6. Consultant was able to listen to parent’s concerns 7. Consultant was able to answer parent’s questions adequately 8. Consultant spent an adequate amount of time with parent 9. Consultant was able to listen to patient’s concerns** 10. Consultant was able to answer patient’s questions adequately** 11. Consultant spent an adequate amount of time with patient** 12. Consultant tailored the explanations at participant’s level of understanding

97% (56/58) 31% (18/58) 69% (40/58) 65% (26/40) 68% (27/40) 97% (56/58) % Yes 81% (47/58) 94% (44/47) 96% (45/47) 89% (42/47) 79% (46/58) 98% (45/46) 100% (46/46) 89% (41/46)

13. Consultant’s efforts to include participant in making decisions 14. Participant’s working relationship with the psychiatry consultant Mean Subscale score (% yes/excellent/very good of relevant items of 6-14) ⴝ 84.6% (SDⴝ20.2%) Helpfulness of the consultation 15. Helpfulness with understanding patient’s medical or physical illness** 16. Helpfulness with understanding patient’s emotional/behavioral reactions to their medical illness** 17. Helpfulness with understanding patient’s emotional/behavioral reactions to the hospitalization** 18. Helpfulness with understanding how patient can cope with medical illness** 19. Helpfulness with understanding how patient can better manage illness and treatment** 20. Helpfulness with patient’s recovery** 21. Helpfulness with providing support and/or coping skills to patient** 22. Helpfulness with providing support and/or coping skills to parent/family 23. Helpfulness with improving communication with medical or surgical team 24. Helpfulness of the team meeting 25. Helpfulness of discharge planning 26. Helpfulness of behavioral interventions Mean Subscale score (% excellent/very good of relevant items of 15-28) ⴝ 61.1% (SDⴝ38.7%) Overall satisfaction with psychiatry consultation services 27. Overall helpfulness of the psychiatric consultation 28. Would participant recommend a psychiatric consultation to a friend Mean Subscale score (1 point if item 27 is excellent/very good; 1 point if item 28 is yes) ⴝ 1.6 (SD ⴝ0.7)

% Yes 92% (44/48) 92% (43/47) 94% (45/48) 75% (41/55) 67% (34/51) 87% (48/55) 98% (56/57) % Excellent/Very good 79% (44/56) 79% (45/57) % Yes 71% (24/34) 62% (28/45) 60% (25/42) 63% (29/46) 68% (32/47) 73% (30/41) 58% (27/47) 58% (23/40) 51% (18/35) 92% (23/25) 77% (24/31) 71% (5/7) % Yes 69% (38/55) 88% (49/56)

* Participant refers to parent or adult patient. ** For adult patients, question answered regarding self. For child and adolescent patients, parent answered question with their perspective of child/adolescent’s experience.

tions had been communicated to them. They indicated that both the impressions and recommendations of the consultation were understandable (96% - impressions/100% recommendations) and were delivered in a timely fashion Psychosomatics 54:6, November-December 2013

(94% - impressions/98% - recommendations). Agreement with impressions and the recommendations were equally high (89% for both). Consultants were rated highly on spending time with parents (94%), listening to their conwww.psychosomaticsjournal.org

579

Satisfaction with Psychiatry Consultation Services

FIGURE 1.

Satisfaction With Core Components of the Consultation by Overall Satisfaction Level (n ⴝ 55).

*Error bars represent 95% confidence intervals.

cerns (92%), and answering their questions (92%). Adult patients were highly satisfied with the consultant spending time with them (100%), listening to their concerns (100%), and answering their questions (88%). Responses were less positive from parents regarding the consultant spending enough time with their child (78%), listening to their child’s concerns (65%), and answering their child’s questions (52%). Participants rated their inclusion in decision-making and working relationship with the consultant as excellent/very good about 80% of the time. Items related to helpfulness of the consultation interventions such as providing support, improved understanding, and improved coping varied in being rated as excellent/very good with a range between 51% and 71% of participants. The satisfaction ratings for helpfulness were generally lower than the other PPCSS components. Team meetings, when held (n ⫽ 25), were highly rated, with 92% of respondents reporting their helpfulness was excellent or very good. Satisfaction Component Relationships Participants were split into three Overall Satisfaction levels: high (rated the consultation excellent/very good and would recommend it to a friend, n ⫽ 38), moderate (rated the consultation as good/fair/poor/not sure, but would recommend it to a friend, n ⫽ 11), and low (rated the consultation as good/fair/poor/not sure, and would not recommend it to a friend, n ⫽ 6). 580

www.psychosomaticsjournal.org

No demographic characteristics or features of the consultation were associated with high vs. moderate/low overall satisfaction level, including the consultant’s discipline (psychiatry or psychology) or the level of training, psychiatric diagnosis given, the person answering the survey (adult patient vs. parent), the survey format (phone vs. in person), the person initiating the consult (patient/parent vs. medical/surgical team), the patient’s medical diagnoses, or the patient’s demographic factors (age, gender, race/ethnicity, or living situation). The mean subscale score for each core consultation components was compared across high, moderate, and low levels of overall satisfaction (see Figure 1). While awareness and understanding of the consultation is not associated with differing levels of overall satisfaction (P ⫽ 0.993), overall satisfaction was significantly associated with consultant-participant communication and working relationship (P ⬍ 0.001), provision of impressions and recommendations (P ⫽ 0.018), and helpfulness of the consultation intervention (P ⬍ 0.001). DISCUSSION The majority of the parents and young adult patients were found to be very satisfied with the psychiatry consultation services provided in an inpatient pediatric hospital setting as evidenced by nearly 70% rating the overall helpfulness of the psychiatric consultation as excellent/very good with Psychosomatics 54:6, November-December 2013

Kitts et al. an additional 12% rating the overall helpfulness as good. Nearly 90% of the participants would recommend a psychiatry consultation to a friend in need of similar services. Consistent with national guidelines, the overall level of consumer satisfaction was significantly correlated with satisfaction with the consultant’s conveyance of clinical impressions and recommendations, the communication and working relationship with the consultant, and the helpfulness of the consultant’s interventions.10 These rates are comparable to the only other study that includes a measure on parent satisfaction with inpatient psychiatry consultation8 as well as consumer satisfaction studies completed in other child mental health settings.9,13,14 The overall high level of satisfaction was not correlated with the consultant’s discipline or the level of training, psychiatric diagnoses given, the person answering the survey, the survey format, the person initiating the consult, the patient’s medical diagnoses, or the patient’s demographic factors. These were not entirely expected results, particularly regarding diagnoses and demographics and may be a function of a limited number of respondents. For example, there were only six diagnoses of a somatoform disorder and two diagnoses of a psychotic disorder. Similarly, representation of participants whose race was not White was low. However, these findings are consistent with a parent satisfaction study in an ambulatory child psychiatry consultation service to primary care providers, which showed no significant difference in satisfaction based on race/ethnicity (White non-Hispanic vs. minority) and diagnosis (single vs. multiple).9 On the other hand, the lack of correlations may underscore that parent or young adult satisfaction lies less in characteristics such as demographics or diagnoses, but rather in consultant’s overall approach to the individual patient and family. The importance of overall approach is also reinforced by the lack of association between awareness and understanding of the consultation with overall satisfaction. The majority of participants reported high overall satisfaction despite among 70% of consultations not being initiated by the respondents and over 30% not knowing who requested the consultation and why. This is unlike the traditional outpatient mental health setting where the patients or parents generally initiate the referral themselves with a specific reason for wanting mental health involvement. Although communication and working relationship is one of the four core consultation components assessed, communication, including its influence on transparency of what actually occurs between patients, parents, and conPsychosomatics 54:6, November-December 2013

sultants, likely plays a significant role in the satisfaction of all four components and overall satisfaction. “Sharing complete, honest, and unbiased information with patients and their families on an ongoing basis and in ways they find useful and affirming, so that they may effectively participate in care and decision-making to the level they choose,” is one of the core principles of patient- and family-centered care for pediatricians, but certainly this premise is not limited to pediatricians.2 However, persistent and comprehensive communication with patients and their families may be more challenging for child psychiatry consultants due to the added level of confidentiality issues in working with young patients and their families and the tendency to assess and work with patients separately from their families as well as the simple lack of geographical proximity of the consultant’s office to the patient’s hospital bed. The most effective approach for inpatient psychiatry consultants working with families facing the loss of control and uncertainty of an ill child would be that of an empathic and active listening stance combined with both a clear communication of a biopsychosocial formulation and diagnoses and a well delineated treatment plan that is integrated into a patient’s overall care.10 Yet, approximately 20% of the participants indicated that they were not provided with clinical impressions and treatment recommendations by the psychiatry consultant. Considerations include the possibility that the consultant may have communicated only with the healthcare team or the participants in the midst of the stress of the hospitalization may not have heard the consultant’s impressions or recommendations. Nevertheless, this is an area needing further exploration and represents an area for improvement. Analogously, there appears to be a significant opportunity for improvement regarding the education of parents and young adults regarding “what the consultant is doing to help.” For example, only 51% of the participants highly rated the consultation’s helpfulness with improving communication with their medical or surgical team, while 26% of the participants responded “not sure.” It raises the question as to whether this actually did not take place or if it took place without the participant knowing. The lowest rating in the PPCSS communication component was “whether the consultant was able to answer the patient’s questions adequately” (67%). The importance of ongoing communication beyond the initial formulation and treatment plan is readily apparent in these finding around helpfulness of the consultation. Further study is needed as these same findings, particularly in context of the large www.psychosomaticsjournal.org

581

Satisfaction with Psychiatry Consultation Services standard deviation (38.7%), may also reflect significant variances in individual consultant’s use of evidence-based interventions. Team meetings were used in a limited number of situations despite the finding that 92% of the respondents found their helpfulness either very good or excellent. Team meetings can serve multiple purposes, including improving transparency of action to parents and enhancing communication when multiple disciplines are involved.15 An increasing number of studies are showing the importance of multidisciplinary team meetings, particularly within the field of oncology treatment.16,17 Such meetings including the patient and family can serve to foster a sense of teamwork, inclusion, and investment in the patient’s wellbeing and care. Consultants should be aware that team meetings, which promote patient- and family-centered care, can be used as part of regular care rather than just as an intervention when care becomes acute or more complicated. Limitations The project was limited by the sample size and variety of participants (e.g., patients predominately White and female) as well as being a cross-sectional analysis. By limiting itself to parents and adult patients, the project did not capture the perspectives of other consumers, including the medical/surgical providers who requested the consultations, the parents (if involved) of the adult patients, parents of patients seen by subspecialty consultants, and the pediatric patients themselves. The project did not include the specialty services with their more integrated care model of psychiatry consultants, which is important to understand. Different perspectives over different points in time may have had different satisfaction ratings and clinical implications.18 Psychiatry consultation services vary in structure and function from hospital to hospital. Funded by a combination of hospital, department, and billing revenue streams, the PCS is one of the larger services in the country, which may influence how the consultations are carried out based on time, resources, available trainees, established reputation, and collaborations with medical/surgical teams. This may limit generalization of the findings to other consultation services. This project has potential sources of bias from both the consultant and participant perspective. The consultants may be more inclined to improve the quality of care knowing that they were being studied (i.e., Haw582

www.psychosomaticsjournal.org

thorne effect). The responses of the parents and young adults may have been positively biased because of social desirability. Although attempts were made to decrease this (e.g., interviews by a project assistant unfamiliar with the patient’s care), a respondent still may have felt pressure to rate more positively because the interviewer was not a completely objective rater. Also, because there were potential participants excluded from recruitment based on input from individual clinicians, it is possible that the survey results might have been influenced by the exclusion of less favorable responses. A final limitation is the PPCSS itself, as it was developed specifically for this project and, therefore, has no established psychometric properties. Clinical Implications This quality improvement project is unique in demonstrating the critical importance for pediatric psychiatry consultants to convey their clinical impressions and recommendations clearly, to communicate effectively, and to provide helpful psychiatric interventions in an inpatient pediatric hospital setting. It shows that even in the face of parents and young adults having no awareness or understanding of the consultation as well as not requesting assistance, the psychiatry consultant can still provide care that is valued by parents and young adults. This project underscores the relevance of the national guidelines on the assessment and management of children and adolescents with physical illnesses.10 It also introduces the potential benefits of the Pediatric Psychiatry Consultation Satisfaction Survey. While in need of further validation, this survey does appear to be a useful tool in assessing parental satisfaction in the psychiatry consultation setting. There are many trends today that are impacting national healthcare, including consumers demanding higher levels of quality and service. This project services as a timely prototype for pediatric psychiatry consultation services to begin to respond to the need to demonstrate patient safety and outcome. Future quality improvement projects are needed in the inpatient pediatric hospital setting to serve as a bridge to the development and implementation of standard care guidelines designed to provide the highest quality of patient- and family-centered care. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article. Psychosomatics 54:6, November-December 2013

Kitts et al.

References 1. Institute of Medicine: Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press 2001 2. American Academy of Pediatrics: patient- and family-centered care and the pediatrician’s role. Pediatrics 2012; 129:394 – 404 3. National Strategy for Quality Improvement in Health Care. Washington, DC: US Department of Health and Human Services 2011 4. Shaw RJ, DeMaso DR: Textbook of Pediatric Psychosomatic Medicine. VA: American Psychiatric Publishing 2010 5. Rodrigue JR, Hoffmann RG, Rayfield A, Lescano C, Kubar W, Streisand R, et al: Evaluating pediatric psychology consultation services in a medical setting: an example. J Clin Psych Med Settings 1995; 2:89 –107 6. Olson RA, Holden EW, Friedman A, Faust J, Kenning M, Mason PJ: Psychological consultation in a children’s hospital: an evaluation of services. J Pediatr Psych 1988; 13:479 – 492 7. De Albuquerque Citero V, de Araújo Andreoli PB, NoqueiraMartins LA, Andreoli SB: New potential clinical indicators of consultation-liaison psychiatry’s effectiveness in Brazilian general hospitals. Psychosomatics 2008; 49:29 –38 8. Carter BD, Kronenberger WG, Baker J, Grimes LM, Crabtree VM, Smith C, et al: Inpatient pediatric consultation-liaison: a case-controlled study. J Pediatr Psych 2003; 28:423– 432 9. Dvir Y, Wenz-Gross M, Jeffers-Terry M, Metz WP: An assessment of satisfaction with ambulatory child psychiatry consultation services to primary care providers by parents of children with emotional and behavioral needs: the Massachusetts Child Psychiatry Access Project University of Massachusetts Parent Satisfaction Study. Front Psychiatry 2012; 3:1–2 10. DeMaso DR, Martini DR, Cahen LA, Bukstein O, Walter HJ, Benson S, et al, Work Group on Quality Issues: American Academy of Child and Adolescent Psychiatry practice parameter for the psychiatric assessment and management of physically ill children and adolescents. J Am Acad Child Adolesc Psychiatry 2009; 48:213–233 11. Bjørngaard JH, Andersson HW, Ose SO, Hanssen-Bauer K: User satisfaction with child and adolescent mental health services. Soc Psychiatry Psychiatr Epidemiol 2008; 43:635– 641 12. Hunter J, Higginson I, Garralda E: Systematic literature review: outcome measures for child and adolescent mental health services. J Public Health Med 1996; 18:197–206 13. Rey JM, Plapp JM, Simpson PL: Parental satisfaction and outcome: a 4-year study in a child and adolescent mental health service. Aust NZ J Psychiatry 1999; 33:22–28 14. Garland AF, Haine RA, Boxmeyer CL: Determinates of youth and parent satisfaction in usual care psychotherapy. Eval Program Plan 2007; 30:45–54 15. Williams J, DeMaso D: Pediatric team meetings: the mental health consultant’s role. Clin Child Psych Psychiatry 2000; 5:105–113 16. Field KM, Rosenthal MA, Dimou J, Fleet M, Gibbs P, Drummond K: Communication in and clinician satisfaction with multidisciplinary team meetings in neuro-oncology. J Clin Neurosci 2010; 17:1130 –1135 17. Ruhstaller T, Roe H, Thürlimann B, Nicoll JJ: The multidisciplinary meeting: an indispensable aid to communication between different specialties. Eur J Cancer 2006; 42:2459 –2462

Psychosomatics 54:6, November-December 2013

18. Hawley KM, Weisz JR: Youth vs. parent working alliance in usual clinical care: distinctive associations with retention, satisfaction, and treatment outcome. J Clin Child Adolesc Psych 2005; 34:117–128

APPENDIX: PPCSS Skip any items that are not relevant Awareness and understanding of the consultation 1. Prior to this survey, were you aware that the psychiatric consultation service was involved in the care of your child during this hospitalization? (Yes/ No/Not Sure) 1b. Our record indicates that a psychiatrist, psychologist or trainee from our consultation service met with you and your child, do you remember this? (Yes/No) 2. Did you request the psychiatric consultation yourself? (Yes/No) Why did you do so? ______ 2a. If you did not request the consultation, do you know who requested it? (Yes/No) Who requested it? __________ 2b. Was the reason for the psychiatric consultation explained to you? (Yes/No) Who explained the reason for the consultation to you? __________ 3. Did the psychiatry consultant(s) clearly identify themselves to you and your child? (Yes/No/Not Sure) Clinical impressions and recommendations 4. Did the psychiatry consultant(s) share their impression with you regarding your child? (Yes/No/Not Sure) 4a. Were their impressions shared in a timely fashion? (Yes/No/Not Sure) 4b. Did you understand the impressions? (Yes/No/Not Sure) 4c. Did you agree with the impressions? (Yes/No/Not Sure) 4d. [If they did not agree with the recommendations] Please explain why you did not agree with the clinical impressions: _________ 5. Did the psychiatry consultant(s) provide treatment recommendations regarding your child to you? (Yes/No/Not Sure) 5a. if yes, what were they: __________ www.psychosomaticsjournal.org

583

Satisfaction with Psychiatry Consultation Services 5b. Were the recommendations shared with you in a timely fashion? (Yes/No/Not Sure) 5c. Did you understand the recommendations? (Yes/ No/Not Sure) 5d. Did you agree with the recommendations? (Yes/ No/Not Sure) 5e. [If they did not agree with the recommendations] Please explain why you did not agree with the clinical recommendations: __________ Consultant/participant communication and working relationship Regarding the psychiatry consultant: 6. Was he/she able to listen to your concerns? (Yes/ No/Not Sure) 7. Was he/she able to answer your questions adequately? (Yes/No/Not Sure) 8. Did he/she spend an adequate amount of time with you? (Yes/No/Not Sure) 9. Was he/she able to listen to your child’s concerns? (Yes/No/Not Sure) 10. Was he/she able to answer your child’s questions adequately? (Yes/No/Not Sure) 11. Did he/she spend an adequate amount of time with your child? (Yes/No/Not Sure) 12. Did he/she explain at a level where you could understand? (Yes/No/Not Sure) 13. How would you rate the psychiatry consultant’s efforts to include you in making decisions about your child’s care? (Excellent/Very Good/Good/ Fair/Poor/Very Poor/Not Sure) 14. How would you rate the quality of the working relationship with the psychiatry consultant? (Excellent/ Very Good/Good/Fair/Poor/Very Poor/Not Sure) Helpfulness of the consultation: For the next few questions I am going to go through a list of services that our psychiatric consultants may provide. Please indicate whether each has occurred [if not, rate as NA] and if it did occur, please rate its helpfulness based on the following scale [please provide visual scale: (Excellent/Very Good/Good/Fair/Poor/Very Poor/NA/Not Sure)] 15. Better understanding your child’s medical or physical illness

584

www.psychosomaticsjournal.org

16. Better understanding your child’s emotional or behavioral reactions to their medical illness 17. Better understanding your child’s emotional or behavioral reactions to the medical hospitalization 18. Better understanding how you can help your child cope with his/her medical illness 19. Better understanding how you can help your child better manage his/her illness and treatment 20. Helping with your child’s recovery 21. Providing support &/or coping skills to your child 22. Providing support &/or coping skills to you and your family 23. Improving communication with your medical or surgical team. Anything else that may have been helpful: __________ Did you participate in the following: 24a. Team meeting where you met with more than one clinical provider involved in your child’s care at the same time? (Yes/No/Not Sure) 24b. Please rate its helpfulness (Excellent/Very Good/ Good/Fair/Poor/Very Poor/NA/Not Sure) 25a. Behavioral interventions regarding your child (for example, reward chart, schedule, procedural support)? (Yes/No/Not Sure) 25b. Please rate its helpfulness (Excellent/Very Good/ Good/Fair/Poor/Very Poor/NA/Not Sure) 26a. Discharge treatment planning regarding your child? (Yes/No/Not Sure) 26b. Please rate its helpfulness (Excellent/Very Good/ Good/Fair/Poor/Very Poor/NA/Not Sure) Overall satisfaction with psychiatry consultation services 27. How would you rate the overall helpfulness of the psychiatric consultation? (Excellent/Very Good/ Good/Fair/Poor/Very Poor/NA/Not Sure) 28. If a friend’s child were in need of similar help while in the hospital, would you recommend that a psychiatric consultation be called? (Yes/No/Not Sure) Do you have any additional comments or recommendations regarding you or your child’s experience with the psychiatric consultation service? __________

Psychosomatics 54:6, November-December 2013