Reports From the Field

Applying Robust Process Improvement Techniques to the Voluntary Inpatient Psychiatry Admission Process



From the Wake Forest School of Medicine (Ms. Newman), and Wake Forest Baptist Health, Department of Psychiatry and Behavioral Medicine (Dr. Kramer), Winston-Salem, NC.


  • Background: Adults voluntarily admitted to inpatient behavioral health units can ask to sign a Request to Discharge (RTD) form if they would like to be discharged before the treatment team agrees that discharge is appropriate. This gives the team 72 hours to determine whether the patient is safe to discharge or to involuntarily commit the patient to the unit. At 1 medical center, patients who were offered voluntary admission often lacked complete understanding of the “72-hour rule” and the early discharge procedure.
  • Methods: Robust Process Improvement® techniques were implemented to improve the admission process. Flow charts, standardized scripts, and pocket cards were distributed to relevant staff. The Request for Voluntary Admission form was revised to emphasize the “72-hour rule” and the process for requesting a RTD form.
  • Results: The unit’s average overall Press Ganey score improved from 77.1 to 81.6 (P = 0.003), while the average discharge score improved from 83.0 to 87.5 (P = 0.023) following implementation of the new process.
  • Conclusion: Incorporating strategies such as an opportunity to “teach back” important information about the voluntary admission process (ie, what the 72-hour rule is, what the request to discharge form is, and the possibility of involuntary commitment) allows clinicians to assess capacity while simultaneously giving patients realistic expectations of the admission. These changes can lead to improvement in patient satisfaction.

Keywords: behavioral health; communication; patient satisfaction.

Communication is paramount within medical teams to improve outcomes and strengthen rapport with patients, particularly with psychiatric patients in acute crisis. Studies have indicated that information sharing is inadequate at the interface between medical contexts, including high-acuity settings, such as the emergency department,1 patient handoffs at shift changes,2 and across professional boundaries, including between doctors and nurses. The barriers to effective communication in health care teams include educational, psychological, and organizational barriers. These obstacles can be overcome by teaching effective communication strategies, training teams as a unit, training teams with simulation exercises, defining inclusive and democratic teams, supporting teamwork with protocols and procedures, and developing an organizational culture supporting teamwork.3

While some forms of communication are required to protect the safety of patients and others around them, other forms are required to build strong relationships with patients. However, these 2 goals do not have to be mutually exclusive in the psychiatric hospital environment. Hospitals aim to improve patient satisfaction while simultaneously providing effective communication about treatment. Studies have indicated that communication during graduate medical training may decline due to “emotional and physical brutality” associated with residency training programs.4 To ameliorate this and emphasize communication education, accredited psychiatry residency programs require residents to use structured communication tools to achieve a level 2 in the Accreditation Council for Graduate Medical Education milestone project for the category of patient safety and health care team.5 These standardized processes allow all patients to receive the same important information related to their care while minimizing human error. Such communication skills aim to improve health care outcomes and satisfaction for patients while also training better physicians.

For legal and ethical reasons, the adult inpatient behavioral health units at major hospitals are highly regulated. In most states, a patient who is admitted to an adult inpatient behavioral health unit on a voluntary basis can ask to sign a request to discharge (RTD) form if he or she would like to be discharged from the hospital before the treatment team sees fit.6 In most jurisdictions, this action gives the treatment team 72 hours to determine whether the patient is safe to discharge. Within that time frame, the physician must either discharge the patient, or, if it is not safe to do so, involuntarily commit him or her to the unit. In most jurisdictions, this process is commonly referred to as the “72-hour rule.”

In North Carolina, state legislation Chapter 122C, Article 5, Part 2(b) specifies: “In 24-hour facilities the application shall acknowledge that the applicant may be held by the facility for a period of 72 hours after any written request for release that the applicant may make, and shall acknowledge that the 24-hour facility may have the legal right to petition for involuntary commitment of the applicant during that period. At the time of application, the facility shall tell the applicant about procedures for discharge.”7 This requirement can be somewhat confusing for both medical team members and patients alike.


Next Article: