Organizational Change to Transfer Knowledge and Improve Quality and Outcomes of Care for Patients with Severe Mental Illness: A Systematic Overview of Reviews

Article excerpt

Objective: To provide a comprehensive overview of the research on organizational changes aimed at improving health care for patients with severe mental illness and to learn lessons for mental health practice from the results.

Method: We searched for systematic literature reviews published in English during 2000 to 2007 in PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane Central Register of Systematic Reviews. Three reviewers independently selected and assessed the studies' quality. Studies involving changes of who delivers health care, how care is organized, or where care is delivered were included. We categorized the studies using an existing taxonomy of 6 broad categories of strategies for organizational change.

Results: A total of 21 reviews were included. Among these, 17 had reasonably good methodological quality. Almost all reviews included or intended to include randomized controlled trials (RCTs), 6 reviews did not identify studies that met eligibility criteria. Multidisciplinary teams and integrated care models had been reviewed most frequently (a total of 15 reviews). In most studies, these types of changes showed better outcomes in terms of symptom severity, functioning, employment, and housing, compared with conventional services. Different results were found on cost savings. Other types of organizational changes, such as changing professional roles or introducing quality management or knowledge management, were much less frequently reviewed. Very few reviews looked at effects of organizational changes on professional performance.

Conclusions: There is a fairly large body of evidence of the positive impact of multidisciplinary teams and integrated care changes on symptom severity, functioning, employment, and housing of people with severe mental illness, compared with conventional services. Other strategies, such as changes in professional roles, quality or knowledge management, have either not been the subject of systematic reviews or have not been evaluated in RCTs. There is still a lack of insight in the so-called black box of change processes and the impact of change on professional performance.

Can J Psychiatry 2008;53(5):294-305

Clinical Implications

* Multidisciplinary teams and integrated care services can improve the quality of care and should be promoted in the severe mental health care setting.

* The lack of insight into processes of change and effects of implementation projects on professional and organizational performance can hinder practitioners and managers who want to improve care for people with chronic mental illness.

* Popular and costly organizational changes used in daily practice, such as quality management or routine outcome measurement and the introduction of computer systems, have not been studied by systematic reviews.

Limitations

* Our review assessed only recent systematic reviews.

* Single studies were excluded, although many exist.

* Reviews mainly focused on RCTs, although implementation studies of less rigorous quality exist.

Key Words: organizational change, implementation, severe mental illness

Abbreviations used in this article

ACT Assertive Community Treatment

CI confidence interval

CMHT community mental health team

FEP first episode psychosis

NNT number needed to treat

OR odds ratio

PSI percentage of studies with improvements

RCT randomized contolled trial

RR relative risk

WMD weighted mean difference

The challenges posed by chronic illnesses are especially pertinent to mental health care, as the prevalence and costs of chronic mental illness are growing and a clear perspective on their management is lacking.1 Chronic mental illness includes schizophrenia and related disorders, bipolar disorder, and depression with psychotic features. Schizophrenia is the most frequently diagnosed disorder among patients with severe mental illness, affecting 1% of the Canadian population. …