Using six sigma principles: using principles developed to eliminate defects in the manufacturing process, the behavioral healthcare industry can measure, benchmark, and improve the quality of its services and demonstrate its effects to clients and payers alike.

At almost no other time in history have behavioral healthcare services been more necessary than they are today. A Rand Corporation survey found that depression alone accounts for $12 billion in lost workdays each year, (1) and several recent studies have documented the growing need for mental health services:

* One-third of Americans have needed mental health treatment within the past two years, but 37 percent of those who needed such treatment did not receive it. (2)

* Of those receiving treatment, 30 percent did not need the treatment they received. (3)

* Mental health disorders are the fourth leading cause of disability in the United States. (4)

According to the Disease Management Association of America, 70 percent of healthcare visits are driven by a behavioral factor. In fact, depression co-occurs with chronic conditions at alarming rates, as in people with the following disorders:

* 30 percent of cancer patients;

* 27 percent of patients with diabetes;

* 70 percent of patients with diabetic complications;

* 18-20 percent of patients suffering from cardiovascular disease:

* 40-65 percent of patients suffering from heart attacks;

* 10-27 percent of patients suffering from stroke; and

* 45-70 percent of patients with multiple sclerosis, rheumatoid arthritis, cystic fibrosis, sickle cell anemia, Parkinson's disease, and hemophilia.

With demand for mental health services growing, why isn't our industry experiencing a growth boom? I believe the answer is that the industry has not demonstrated the ability to measurably affect payers' needs in a meaningfully communicated manner.

It is time for behavioral health to enter the information age--the age of measurably demonstrating and reporting the impact of our services on issues that payers and clients care about and are willing to pay to resolve. The best place to start is by applying what other industries have learned in demonstrating the value of their services on issues their customers care about.

DEMONSTRATING VALUE: THE OLD METHOD

Historically, the effectiveness (or value) of behavioral healthcare treatment has been demonstrated by reporting compliance with practice guidelines, provider credentialing, utilization rates, length of care, and/or type of care. These measures are process-related rather than outcomes-related. The assumption behind process-based measurement is that a client will improve if certain processes are in place.

However, none of these metrics directly demonstrate whether a client is benefiting from treatment, since they focus on process rather than the actual outcome that is achieved. The practice of behavioral healthcare has been static for generations, based on a top-down, counselor-driven model. This model provides a type of care (i.e., evidence-based practice) that is predetermined and remains relatively unchanged over the course of the counselor-patient relationship.

The challenge facing the behavioral healthcare industry is to find a method for measuring its effectiveness that also can accomplish what has previously been impossible-documenting, tracking, and reporting outcomes measures that are meaningful to a non-clinical payer. An unexpected solution may be found in a concept rooted in mathematics and best known for its application in the manufacturing industry.

Six Sigma is a data-driven approach to measuring, improving, and reporting business process improvements. It focuses on what is most critical to customers, thereby resulting in increased performance and profitability. Motorola developed the Six Sigma approach in the 1980s in response to growing complaints about warranty claims for defective products. The concept was popularized by General Electric is the 1990s and has been employed successfully by other industry leaders.

DEMONSTRATING VALUE: THE NEW METHOD

Six Sigma requires organizations to focus on consumers--to base their activities on consumers' perceptions of services and measure and report success for each consumer. Marrying SIX Sigma to behavioral healthcare results in a dynamic counseling model that continually refines itself and adjusts the mode of treatment to best suit individual clients and maximize outcomes. Using Six Sigma principles, behavioral healthcare providers can statistically identify clients at risk, continually refine and improve the plan of care, and document the resulting positive outcomes.

The critical component of this approach--and what is missing from the traditional counselor-driven model--is a reliance on individual client input to determine the course of treatment. A methodology, such as a self-assessment of global functioning to measure a client's sense of overall functioning, can provide counselors with vital information to establish a benchmark of clinical distress and plan an initial course of treatment. This is especially helpful when the scores are plotted and demonstrated over time, as shown in the accompanying sidebar.

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Six Sigma was born when Motorola began to measure defects per million products, but the behavioral healthcare industry will struggle to achieve similar ratios of defects per million sessions. Therefore, program-specific algorithms have been created to enable the provider to statistically predict when a client is at risk for a negative or no outcome from behavioral healthcare services.

Six Sigma principles are best advanced using an online "treatment relationship management" system that facilitates ongoing assessments of the appropriateness and effectiveness of the counseling services delivered. With this system, each counseling session is systematically recorded in a database where client responses are captured and progress is represented in detailed, easy-to-read charts. This enables counselor and client alike to track and document progress while continually refining treatments to maximize positive outcomes.

Such a system can also use customer feedback to continually improve the effectiveness and efficiency of, and consumer satisfaction with, the counseling model. This is in keeping with Six Sigma's emphasis on statistical analysis to minimize variation, enabling process improvements that are predictable, repeatable, and based on actual data.

A WORKING MODEL

To understand how to apply Six Sigma principles to behavioral health, assume that a client contacts a counselor seeking specific behavioral wellness services. The counselor asks the client to provide a score from 1 to 10 in response to core questions addressing global functioning. Utilizing the total score of the client responses, the system provides a graphical representation of the average expected trajectory of change, along with the lower 25th percentile control limits to allow the clinician to statistically identify when a client is at risk for a negative or no outcome from the services provided.

In each session, the clinician asks the same four questions. The client's progress is tracked across his or her individual counseling history--from initial contact through the term of treatment--to determine the following:

Appropriateness of care. The system demonstrates severity, including when a client does not need treatment, to enable resources to be directed effectively and efficiently.

Efficiency and effectiveness of care. The system accomplishes this on three levels. First, it identifies when services are working for the individual client, resulting in improved outcomes more quickly Second, it quickly identifies clients who are at risk for a negative or no outcome from services, allowing the provider to establish what works for the client. Third, it demonstrates when a client has achieved maximum outcomes.

Because all data originate from the client, the system fosters collaboration between the coach/counselor and the client to gauge the success of the intervention. When clients are given the opportunity to choose services, they will maximize change in the most effective and efficient way.

REAPING THE BENEFITS

Traditional behavioral healthcare models are simply not equipped to statistically identify clients at risk and change a client's plan of care as necessary: They also are not able to track or document results to demonstrate effectiveness or value to the payer.

A Six Sigma-based approach, enabled by technology; can equip EA professionals with the tools to continually refine and improve the plan of care and document positive outcomes. Combining Six Sigma with a counseling model that emphasizes outcomes-informed treatment delivers significant, tangible benefits to the individual being treated as well as to the organizational payer. The result is accelerated improvement, reduced claims costs, improved productivity, reduced absenteeism, and a healthier workforce.

References

(1) Rand Corporation. Therapy in America: Mental Health Treatment Goes Mainstream. 2004. Harris Interactive.

(2) Therapy in 2004, Study Conducted by Harris Interactive on Behalf of PacifiCare Behavioral Health and Psychology Today

(3) Therapy in 2004, Study Conducted by Harris Interactive on Behalf of Pacificare Behavioral Health and Psychology Today

(4) National Mental Institute of Health, 2001 January, revised 2003, May. The numbers count: Mental disorders in America (NIMH Publication No. 01-4584).

Mary Beth Chalk is chief operating officer of Resources For Living, which provides integrated employee assistance and work/life services, depression disease management, obesity disease management, performance-based leadership coaching, and health and wellness behavioral modification programs. The company can be found on the Web at www.rfl.com.