Generating Performance Measures for CL Service Effectiveness

Psychosomatics 2013:54:567–574

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

Original Research Reports How Do You Know Your Consult Service is Doing a Good Job? Generating Performance Measures for C-L Service Effectiveness Mallika Lavakumar, M.D., Emily D. Gastelum, M.D., Filza Hussain, M.B.B.S., Jon Levenson, M.D., Ralph N. Wharton, M.D., Philip R. Muskin, M.D., Peter A. Shapiro, M.D.

Background: There is no consensus in the literature on measures for evaluating the performance of general hospital Consultation-Liaison psychiatry services. Objective: The purpose of this study was to investigate what indicators might be used to this end. Methods: We surveyed United States Psychosomatic Medicine fellowship directors (n ¼ 53) about the use of performance measures for their psychiatric consultation services. Results of this survey led to the construction of a second survey, which was distributed to the representatives of services calling for psychiatric consultations at our hospital (n ¼ 21); this survey sought to determine the importance of various performance parameters to overall consultee satisfaction. Results: Sixty-three percent of responding psychiatric consult services do not use any of the parameters identified

in the literature as performance measures. Consultee satisfaction was endorsed as a valuable performance indicator by 67.7% of them, but no satisfaction rating instrument was identified. The internal survey of consultees identified 11 of 16 candidate parameters as important or very important to consultee satisfaction, of which ‘‘consultant understands the core situation and the core question being asked’’ received the highest rating. Conclusions: Consultee satisfaction is perceived as a useful global measure of the effectiveness of a psychiatric consult service. We elicited parameters that can be used to create a measurement tool for consultee satisfaction with Consultation-Liaison services. The use of such a tool merits testing in a larger multicenter study. (Psychosomatics 2013; 54:567–574)

A

usefulness of the recommendations and patient care they provide. Quality assurance measures are generally accepted as important measures of the process of care. Their use fosters vigilance in providing the highest level of patient care, may help to identify specific shortcomings

t a recent faculty meeting, a senior member of the faculty of our psychiatric Consultation-Liaison (C-L) service asked, ‘‘Is our psychiatric consult service doing a good job?’’ We found it difficult to answer this inquiry. Here we report 3 stages of our subsequent investigation of the question.

LITERATURE REVIEW Psychiatric consultation services need to know whether they are doing a good job, or risk finding themselves irrelevant to their institutions’ mission. They have a vested interest in being able to assess the quality and Psychosomatics 54:6, November/December 2013

Received November 10, 2012; revised March 5, 2013; accepted March 6, 2013. From MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH (ML); Mayo Clinic, WS (FH); Columbia University, New York, NY (EDG, JL, RNW, PRM, PAS). Send correspondence and reprint requests to Mallika Lavakumar M.D., MetroHealth Medical Center, Case Western Reserve University School of Medicine 8th floor, Hamman Building, 2500 Metrohealth Drive Cleveland, OH 44109; e-mail: [email protected] & 2013 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

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Performance Measures for C-L Service Effectiveness in the delivery of clinical services, and can guide interventions to improve outcomes. Quality assessment and performance data may be used by hospitals to inform which services may be retained or eliminated. We sought to identify quality indicators for psychiatric consultation services by review of the literature. A number of metrics for C-L service quality have been considered in the literature, including the effect of psychiatric consultation services on length of stay, hospital costs, overall medical costs, readmission rates, patient health status, and detection of alcohol and substance abuse disorders.1–4 In the absence of a comparison condition (i.e., either no functioning consult service or some alternative model of psychiatric consultation), it is not possible to assess if a C-L service is having a beneficial effect on any of these outcomes. Moreover, although these studies suggest certain specific parameters for evaluation of a psychiatric C-L service, they do not help psychiatrists to answer the more global questions of: ‘‘Is my consultation service generally doing a good job?’’ and ‘‘Overall, do our consultants provide a useful service within the hospital?’’ Two studies offered a wider perspective on this issue. Karasu et al. created a survey for physicians and nursing staff to gain a better understanding of which aspects of the psychiatric consultation referring clinicians found most useful, and discovered that the elements most valued depended upon the level of training and specialty of the referring clinician.5 This study highlighted that knowledge of the perceptions of referring physicians (hereafter referred to as ‘‘consultees’’) was key to understanding the utility of a C-L psychiatry service. Most recently, Solomons et al. turned to consultees to help generate performance indicators and to identify aspects of consultation that were valuable. He and his colleagues conducted face-to-face interviews of 25 senior medical physicians and nursing staff in the United Kingdom (UK) and thereby identified several measures of performance that might be used in conducting more structured quality assessments, including response time, length of stay of patients, outpatient psychiatric follow-up, medical readmission rates, clarity of documentation, and satisfaction of those requesting the consultation (also hereafter referred to as ‘‘consultees’’).6 Both these studies suggest that consultee satisfaction is relevant to answering the question, ‘‘Is my consult service doing a good job?’’ Consultee satisfaction can be construed as an indicator of consultants’ success in meeting the needs of those who utilize their services and has been used as a quality assurance measure in other mental health treatment 568


settings. Outpatient mental health centers in the UK used consultee satisfaction along with patient satisfaction to evaluate the quality of the services they were providing.7 An Australian outpatient telepsychiatry consultation service sought to evaluate consultee satisfaction in addition to patient satisfaction with the goal that the information would help further develop the service.8 In this study, surveys were distributed to both primary care physicians and nurses to collect information. An outpatient psychiatry consultation service specializing in mood and anxiety disorders, also located in Australia, used consultee satisfaction, patient satisfaction, and patient impressions of clinical improvement to collectively evaluate the work of their service.9 Our search for published literature from other medical specialties addressing how they evaluate the performance of their consultation services identified only one other study. A radiology department sought to develop a questionnaire for measuring consultee satisfaction.10 The investigators conducted a pilot study in which a questionnaire was distributed to all physicians referring patients to their department. Respondents were asked to rate 29 separate parameters of their satisfaction with radiology services. The investigators concluded that widespread deployment of such a questionnaire could serve to establish best practice benchmarks. Aside from this study, we found no other published studies of how medical consult services based in a general hospital setting evaluate the performance of their service. In the absence of clear guidance from the literature, we determined to ask our Psychosomatic Medicine colleagues if they had a clear sense of the parameters relevant to evaluating their services, and whether they used standardized measures to assess the quality and effectiveness of the work of their consultation services. SURVEY NO. 1: PSYCHOSOMATIC MEDICINE TRAINING DIRECTORS We surveyed Psychosomatic Medicine fellowship training directors in the United States to determine the parameters they considered important in evaluating the effectiveness and quality of their psychiatry consultation services. Methods, Survey No. 1 Based on individual domains identified in the literature review described previously, a survey was developed by Psychosomatics 54:6, November/December 2013

Lavakumar et al. consensus of the authors. The purpose of the survey was to understand: 1. if other C-L services had means of assessing their effectiveness; 2. whether there was a consensus in the C-L community about which measures are valuable indicators of C-L service performance; and, 3. how C-L psychiatrists perceived consultee satisfaction as a measure of C-L service performance. The survey contained 6 questions in multiple-choice and open-ended (free-text) formats, including free-text responses for suggestions about measuring service quality and effectiveness. The survey concluded with a request to forward any existing tools used to measure the effectiveness of the respondent’s C-L service. Table 1 includes the questions in this survey. An online survey tool (SurveyMonkey) was used to create and distribute the survey and to collect results. Anonymity of respondents was preserved. In March 2012, an explanatory e-mail with a link to the web-based survey was delivered to all Psychosomatic Medicine fellowship training directors across the United TABLE 1.

States who were included in the fellowship directory of the Academy of Psychosomatic Medicine (n ¼ 53). Fellowship directors were selected as the study population both for convenience and because we believed they would have knowledge of the service evaluation practices of the largest and most evaluation-minded psychiatric consultation services in the United States, so that their replies would be likely to represent state-of-the-art practices. No incentives for reply were offered. Two follow-up e-mails were sent at intervals of 1 week to all programs to improve the response rate. The survey was closed on April 6, 2012. Results, Survey No. 1 Thirty (a 56.6% response rate) of 53 survey recipients submitted responses. Because the responses were anonymous, we cannot characterize respondents vs. nonrespondents. The most commonly cited domains for which C-L services collect data included consultee satisfaction (26.7%), length of stay (16.7%), and patient satisfaction (13.3%). The effect of psychiatric consultations on clinical costs and detection of psychiatric or substance

Survey Sent to Psychosomatic Medicine Fellowship Directors

Question 1) What measures are in place at your institution to assess whether the inpatient C-L service is doing a good job?* Question 2) Does your service use any of the following measures to assess the effectiveness of the C-L service? J Consultee satisfaction J Patient satisfaction J Decrease in clinical cost J Increase in referral to outpatient psychiatric services J Decrease in length of stay J Improvement in detection of psychiatric disorders and/or substance use disorders J None Question 3) Do you think consultee satisfaction would be a valuable indicator of the C-L service’s performance? J Yes J No Question 4) Why do you think this?* Question 5) Do you have a system in place to assess consultee/colleague satisfaction?* J Yes J No Question 6) What stimulated establishment of a system to measure consultee/colleague satisfaction?* Question 7) Please share any other ideas that you may have about measuring the quality and effectiveness of C-L services With your permission, please forward us a copy of your assessment tool to Mallika Lavakumar at [email protected]. C-L ¼ Consultation-Liaison. n

Indicates questions to which the answers are free-text responses.

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Performance Measures for C-L Service Effectiveness FIGURE 1.

Responses to Question, ‘‘Does Your Service Use Any of the Following Measures to Assess the Effectiveness of the CL Service: Decrease in Length of Stay, Referral to Outpatient Psychiatric Services, Improvement in Detection of Psychiatric and/or Alcohol Use Disorders, Patient Satisfaction, Consultee Satisfaction, Decrease in Clinical Cost, and/or None?’’

disorders were less frequently assessed (3.3%). None of the programs surveyed reported rates of referral of patients to outpatient psychiatric care as an outcome measure of consultation effectiveness. A majority (63%) of respondents reported not using any of these parameters as quality indicators (Figure 1). In response, to question 3 in the survey, ‘‘Do you think consultee satisfaction is a useful measure of C-L service performance?,’’ 66.7% responded with ‘‘yes’’ and 33.3% responded with ‘‘no.’’ Free-text comments about this question were revealing. Many respondents endorsed the value of consultee satisfaction as an indicator because C-L psychiatrists are providing a service not only to patients but also to colleagues, and requests for consults might increase by assessing and responding to consultee satisfaction. Some respondents, however, were concerned because poor consultee satisfaction might reflect factors not fully within the psychiatric consultants’ control (e.g., rapidity with which patients respond to psychiatric medications and time to transfer off the medical or surgical service) or circumstances in which what is best for the patient is inconvenient for the primary service; in these instances, consultee satisfaction might not be a good measure of the consultants’ effectiveness. Despite our request, no respondent provided an existing instrument to measure consultee satisfaction, suggesting that no such instrument exists. 570


In summary, a majority of respondents (66.7%) felt that consultee satisfaction is a valuable measure of C-L service effectiveness, only 26.7% of respondents are currently collecting information, and no existing instrument to measure consultee satisfaction was identified either by literature search or by the survey. SURVEY NO. 2: A PILOT STUDY OF CONSULTEE SATISFACTION PARAMETERS The results of the first survey highlighted the important role of consultee satisfaction in evaluating the effectiveness of a C-L service, and the absence of a suitable assessment tool. We therefore undertook a second survey inside our own institution to understand how consultees rate various parameters as contributing to their overall satisfaction with our C-L service. Methods, Survey No. 2 This survey contained 3 questions, which are listed in Table 2. Respondents were asked to assess 16 parameters in determining satisfaction with the effectiveness and quality of psychiatric consultation services. These parameters were derived from the results of the literature search described previously and by consensus of the authors. Responses were recorded and quantified using a 5-point Psychosomatics 54:6, November/December 2013

Lavakumar et al. TABLE 2.

Survey Sent to Representatives of Medical and Surgical Services at New York-Presbyterian Hospital, Columbia Campus

Question 1) For each of the following parameters, please rate how important the parameter is in determining satisfaction with the effectiveness and quality of psychiatric consultation services using one of the following options: Very important – Important – Neutral – Not important – not at all Important – N/A J J J J J J J J J J J J J J J J

Consult occurs within four hours of request Consult occurs within 24 hours of request Consultant understands the situation and the core question being asked Consultant quickly manages patient’s behavioral problem Consultant helps manage substance intoxication and/or withdrawal Consultant provides diagnostic clarification (e.g. dementia vs. depression) leading to appropriate management and disposition planning Consultant has practical and helpful suggestions for medical staff Consultant has practical and helpful management suggestions for nursing staff Consultant communicates verbally with the team in addition to placing notes in the chart After the initial consult, Consultant follows up for the duration of admission Consultant is involved in educational activities with medical staff Consultant is involved in educational activities with nursing staff Consultant reduces length of stay Consultant does not increase length of stay Consultant arranges disposition that removes problem patient from my service Consultant facilitates transfer to inpatient psychiatry service

Question 2) What additional parameters determine your satisfaction with the effectiveness and quality of psychiatric consultation services provided to your service?n Question 3) We welcome any other comments you would like to share with us.n n

Indicates questions to which the answers are free-text responses.

Likert scale, with scores ranging from ‘‘very important’’ (5) to ‘‘not at all important’’ (1). The degree to which each parameter was valued as important to consultee satisfaction was expressed as a mean value of the responses for that parameter. The 2 other questions were free-text responses for suggestions about other parameters that consultees thought were important for measuring satisfaction. Chiefs of Service of Medicine, Surgery, and other specialties across New York-Presbyterian Hospital, Columbia Campus, known to be high-volume utilizers of the psychiatric consultation service were contacted via e-mail to aid in identifying optimal survey respondents from their service (i.e., people actively involved in clinical care). The survey respondents included attendings on teaching services, hospitalists, and chief residents. The identified service representatives (n ¼ 21) received an e-mail message explaining our purpose, requesting their participation, and providing a link to the web-based survey. Table 3 describes the target group of respondents. Reminders were sent via e-mail and phone calls at intervals of 1 week to all prospective respondents so as to improve response rate. The results were collected anonymously between May 31, 2012 and July 11, 2012. Psychosomatics 54:6, November/December 2013

Results, Survey No. 2 Seventeen of 21 recipients of the survey request provided responses, resulting in a response rate of 81%. Generally, respondents did not consider any of the 16 parameters ‘‘not important’’ or ‘‘not at all important.’’ Table 4 captures the value that the respondent group collectively assigned to each of the 16 parameters in the first question of the survey. The parameters are tabulated in order of decreasing value with the most important parameter being listed first and the least important parameter being listed last. Mean scores of 4 or higher indicate that the respondent group rated the parameter as either important or very important, so these scores warrant special attention. Items rated as important to very important were the following: ‘‘Consultant understands the situation and the core question being asked,’’ which received the highest rating, ‘‘Consultant has practical and helpful management suggestions for the medical staff,’’ ‘‘Consultant has practical and helpful management suggestions for the nursing staff,’’ ‘‘Consultation occurs within 24 hours of request,’’ ‘‘Consultant quickly manages patient’s behavioral problems,’’ ‘‘Providing diagnostic clarification that aided in management,’’ ‘‘Communicating verbally with the primary www.psychosomaticsjournal.org

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Performance Measures for C-L Service Effectiveness TABLE 3.

Breakdown of Recipients of Survey at New YorkPresbyterian Hospital, Columbia Campus Number of people contacted (N ¼ 21)

Service Internal medicine teaching service Internal medicine hospitalist service Neurology Physical medicine and rehabilitation medicine HIV Gynecological oncology General surgery Obstetrics and gynecology Transplant (lung, liver, and heart) Minimally invasive surgery Surgical ICU and cardiothoracic ICU Orthopedic surgery

4 1 2 1 1 1 1 3 3 1 2 1

ICU ¼ intensive care unit.

team in addition to placing notes in the chart,’’ ‘‘Consultant does not increase the length of stay,’’ ‘‘Consultant facilitates transfer to inpatient psychiatry service,’’ ‘‘Consultant reduces the length of stay,’’ and ‘‘Consultant follows up during the duration of the admission after providing initial consultation.’’ The 2 least important parameters were consultants’ involvement in educational activities of medical or nursing staff and in management of substance intoxication or withdrawal. Ninety-four percent of respondents rated ‘‘Consultation occurs within TABLE 4.

24 hours of request’’ as being either ‘‘important’’ or ‘‘very important’’ and 70% of respondents rated ‘‘Consultation occurs within 4 hours of request’’ as being either ‘‘important’’ or ‘‘very important,’’ highlighting the role of timeliness in consultee satisfaction. Free-text responses demonstrated the importance to the consulting teams of having psychiatric consultants present and accessible. One respondent requested twice daily C-L rounds on patients in restraints or on constant observation and for routine psychiatric evaluations to be provided on weekends and holidays. A few others requested easy availability for questions by phone and expressed appreciation for the presence of a psychiatrist at family meetings. The presence of a psychiatric consultant on the primary team’s rounds and identification or availability of an attending psychiatrist were all suggested as additional points to include in a satisfaction measure. DISCUSSION Performance measures of the quality of service being provided are in place for a variety of medical presentations and surgical procedures. For example, hospitals monitor the percentage of patients with myocardial infarction who are given aspirin at arrival to the emergency room, death rate, readmission rate, rates of hospital-acquired pneumonia, and spending per patient, as mandated by the Joint Commission. Performance measures have been in place

Responses of Service Representatives to the Question, ‘‘For Each of the Following Parameters, Please Rate How Important the Parameter is in Determining Satisfaction with the Effectiveness and Quality of Psychiatric Consultation Services Using One of the Following Options: Very Important (5), Important (4), Neutral (3), Not Important (2) or Not at All Important (1).’’ The Survey had 17 Respondents. Numerical Responses to Each Question Were Added and Divided by 17 to Yield the Mean

Survey questions

Mean

Std dev

Consultant understands the situation and the core question being asked Consultant has practical and helpful management suggestions for medical staff Consultant has practical and helpful management suggestions for nursing staff Consultation occurs within 24 hours of request Consultant quickly manages patient’s behavioral problems Consultant provides diagnostic clarification leading to management and disposition planning Consultant communicates verbally with the medical team in addition to placing notes in the chart Consultant does not increase length of stay Consultant facilitates transfer to inpatient psychiatry service Consultant reduces length of stay After the initial consult, consultant follows up for the duration of the admission Consultant arranges disposition that removes problem patient from my service Consultation occurs within 4 hours of request Consultant is involved in educational activities with the medical staff Consultant helps manage substance intoxication and/or withdrawal Consultant is involved in educations activities with the nursing staff

4.94 4.76 4.71 4.65 4.53 4.53 4.53 4.35 4.35 4.24 4.00 3.94 3.88 3.82 3.76 3.53

0.24 0.42 0.46 0.76 0.78 0.78 0.61 0.90 0.68 0.73 0.69 0.87 0.83 0.71 1.11 0.61

Std dev ¼ standard deviation.

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Lavakumar et al. for inpatient psychiatric units since 2008.11 General hospital psychiatric C-L services are not guided by any performance measures even though they operate in a climate of great accountability. Directors of C-L services of 2 hospitals in Rhode Island have acknowledged the need for such measures and have grappled with determining what quality measures are the most relevant to measuring the effectiveness of a service.12 Several barriers hinder the development of a comprehensive quality assessment tool for hospital-based psychiatric consultations. The spectrum of clinical scenarios addressed by psychiatric consultants is vast. There is significant clinical heterogeneity in the problems that entail our involvement, and consequently, the specific outcomes that would define an effective consultation vary from one consultation to another. Psychiatric consultants are often called upon to assist with challenging ethical and systems-level problems, solutions to which are not easily quantified. Many people are involved in psychiatric consultations, including patients, their families, primary treating physicians, nurses, and social workers, and the agendas and needs of the many parties to the consultation may differ. It is unlikely that a single measurement tool can capture input from each of these parties and reconcile conflicting viewpoints. Thus it is challenging to create a universally applicable tool that measures consult service effectiveness in all situations. There has been no systematic exploration of perceptions within the C-L community regarding the use of consultee satisfaction as a performance measure. Our survey of 53 fellowship directors from the United States is the first organized attempt to understand how C-L psychiatrists view consultee satisfaction as a performance measure. A majority (66.7%) were of the opinion that consultee satisfaction was a valuable measure of C-L service performance. Of the total respondents, 26.7% appear to already be employing consultee satisfaction in formal or informal ways as a measure of C-L service effectiveness. Consultee satisfaction has face validity as a relevant performance measure of C-L service effectiveness. A review of the literature and our survey indicates that there are no operational definitions of satisfaction. Our internal survey of consultees is novel in that it is the first attempt to define consultee satisfaction in quantitative terms. We elicited parameters that are valuable to general hospital medical and surgical services, and that can be used in a measurement tool for consultee satisfaction and thereby, as one measure of C-L service effectiveness. Psychosomatics 54:6, November/December 2013

In some respects, our survey study was similar to that by Solomons et al. (in the UK) who attempted to understand what consultees valued.6 They interviewed 25 referrers, including nursing staff and medical consultants. Response times, follow-ups and readmissions, quality of documentation, satisfaction of patients and clinicians, and educational activities were found to be important in these interviews. Most of these parameters were highly valued in our survey. The UK study described consultee satisfaction in qualitative terms, whereas we sought to define it in quantitative terms. Karasu et al., in the 1970s, addressed the question of what aspects of psychiatric consultation are valued by physicians.5 That study focused more on understanding how physicians differ in their expectations of consult services based on their level of experience and their medical or surgical specialty, rather than on developing a tool which might have broad applicability in general hospitals. It did, however, employ some of the same parameters in its questionnaire that we used in our survey of clinical services at New York-Presbyterian Hospital. It comes as no surprise that understanding the situation and the core question being asked was ranked the highest in our survey of consultees. This parameter is not always clear when a psychiatric consultation is requested. The interplay of abstract ideas, transference, and psychic conflicts make formulation of accurate questions challenging. Often the consultant has to help the consultee formulate his or her question after a brief conversation about the case. For example, consults for ‘‘Help us manage a patient with a personality disorder who is sabotaging treatment’’ might be cloaked as ‘‘does the patient have the capacity to leave AMA?’’13 In such a situation if the consultant simply answers the question asked and declares that the patient has the capacity to leave against advice, it does the patient a disservice and may leave the primary team feeling that the goals of care were not accomplished. The survey highlights that successful psychiatric consultants are those who are able to understand both the explicit and implicit questions posed by the team. Similarly, the other findings of the survey on consultee opinion systematically document and validate what might appear to be intuitively known to clinicians, and provide a means to measure these dimensions of consultation quality. There are limitations to using consultee satisfaction as a measurement of consult service effectiveness. In some situations doing what is in the best interests of the patient may result in disappointment or frustration for the consultee. Occasionally, a troublesome patient is not www.psychosomaticsjournal.org

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Performance Measures for C-L Service Effectiveness medically stable enough to be transferred to a psychiatric unit, and consultees insist on this intervention understandably but prematurely. Sometimes referring services are unyielding in their belief that an inpatient psychiatric hospitalization is clinically necessary, when in the consultant’s judgment it might be futile. Patients may demonstrate problems with behavior or judgment as a result of chronic conditions, such as mental retardation or dementia, that an inpatient psychiatric hospitalization is unlikely to resolve. Even when the patient is medically stable for transfer and the referral to a psychiatric unit is appropriate, a shortage of available beds might delay transfer, which dissatisfies the consultee but is beyond the control of the consultant. Our study has several limitations. We first surveyed fellowship training directors, and their programs may not reflect service evaluation practices in institutions without Psychosomatic Medicine fellowships. We suspect, however, that this limitation, if anything, introduces a conservative bias to our finding that the practice of C-L service performance evaluation is underdeveloped, as training programs tend to occur in larger and betterestablished C-L services. If even these services lack performance measures, it is likely that less established services also lack them. Our survey of consultees to establish important parameters of consultee satisfaction was limited to a small sample at a single teaching hospital in New York City. The generalizability of its findings to

other settings cannot be known without additional studies using more sites and larger samples. Another potential limitation is the possibility of a social desirability response bias, despite the anonymity of responses, arising because we surveyed colleagues who are personally known to us and who may have been influenced by previous discussions with us. This limitation can also be addressed through a larger, multicenter study. We think consultee satisfaction is a useful global measure of consult service effectiveness, and we have identified a discrete and manageably sized list of parameters that can be included in a consultee satisfaction measure. We do not believe that consultee satisfaction alone is a perfect index of consult service effectiveness. We envision consultee satisfaction being used in conjunction with others measures of service performance, such as nursing satisfaction, patient satisfaction, and additional process and outcomes measures. We also note that this work has potential for generalizability to hospital consultation services of other medical specialties striving to develop performance measures. If the results of this survey hold true in a multicenter study, they can be used by psychiatric C-L services as a self-assessment tool and by hospital regulatory bodies as benchmarks. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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