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Quality Indicators in ConsultationLiaison

Psychiatry

Article in Psychosomatics September 2009

DOI: 10.1176/appi.psy.50.5.550 Source: PubMed

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Psychosomatics 2013:54:567574 & 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 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 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 identied
A 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 difcult 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 nding 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
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 identied. The internal survey of consultees
identied 11 of 16 candidate parameters as important or
very important to consultee satisfaction, of which con-
sultant 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; 54:567574)
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 specic shortcomings
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 oor, Hamman Building, 2500 Metrohealth
Drive Cleveland, OH 44109; e-mail: Mxl555@case.edu
& 2013 The Academy of Psychosomatic Medicine. Published by
Elsevier Inc. All rights reserved.
www.psychosomaticsjournal.org 567
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.14 In the absence of a com-
parison condition (i.e., either no functioning consult
service or some alternative model of psychiatric con-
sultation), it is not possible to assess if a C-L service is
having a benecial effect on any of these outcomes.
Moreover, although these studies suggest certain specic
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 identied 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 here-
after 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 indi-
cator 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 www.psychosomaticsjournal.org
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 out-
patient 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 collec-
tively 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 identied only
one other study. A radiology department sought to
develop a questionnaire for measuring consultee satis-
faction.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 identied 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 qual-
ity and effectiveness. The survey concluded with a
request to forward any existing tools used to measure
the effectiveness of the respondents 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 respond-
ents 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
States who were included in the fellowship directory of
the Academy of Psychosomatic Medicine (n 53).
Fellowship directors were selected as the study popula-
tion 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 anon-
ymous, we cannot characterize respondents vs. non-
respondents.
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

TABLE 1. 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 services 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 ml3328@columbia.edu.

C-L Consultation-Liaison.
n
Indicates questions to which the answers are free-text responses.

Psychosomatics 54:6, November/December 2013 www.psychosomaticsjournal.org 569

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 reect 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 www.psychosomaticsjournal.org
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 instru-
ment to measure consultee satisfaction was identied
either by literature search or by the survey.
SURVEY NO. 2: A PILOT STUDY OF CONSULTEE
SATISFACTION PARAMETERS
The results of the rst survey highlighted the important
role of consultee satisfaction in evaluating the effective-
ness 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 param-
eters were derived from the results of the literature search
described previously and by consensus of the authors.
Responses were recorded and quantied 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 Consult occurs within four hours of request

J Consult occurs within 24 hours of request
J Consultant understands the situation and the core question being asked
J Consultant quickly manages patients behavioral problem
J Consultant helps manage substance intoxication and/or withdrawal
J Consultant provides diagnostic clarication (e.g. dementia vs. depression) leading to appropriate management and disposition planning
J Consultant has practical and helpful suggestions for medical staff
J Consultant has practical and helpful management suggestions for nursing staff
J Consultant communicates verbally with the team in addition to placing notes in the chart
J After the initial consult, Consultant follows up for the duration of admission
J Consultant is involved in educational activities with medical staff
J Consultant is involved in educational activities with nursing staff
J Consultant reduces length of stay
J Consultant does not increase length of stay
J Consultant arranges disposition that removes problem patient from my service
J 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 satisfac-
tion 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 respond-
ents from their service (i.e., people actively involved in
clinical care). The survey respondents included attend-
ings on teaching services, hospitalists, and chief resi-
dents. The identied service representatives (n 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.
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
rst question of the survey. The parameters are tabulated
in order of decreasing value with the most important
parameter being listed rst 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 under-
stands 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, Con-
sultation occurs within 24 hours of request, Consultant
quickly manages patients behavioral problems, Pro-
viding diagnostic clarication that aided in manage-
ment, Communicating verbally with the primary

Psychosomatics 54:6, November/December 2013 www.psychosomaticsjournal.org 571

Performance Measures for C-L Service Effectiveness

TABLE 3. Breakdown of Recipients of Survey at New York- 24 hours of request as being either important or very
Presbyterian Hospital, Columbia Campus important and 70% of respondents rated Consultation
Number of people occurs within 4 hours of request as being either
contacted important or very important, highlighting the role
Service (N 21)
of timeliness in consultee satisfaction.
Internal medicine teaching service 4 Free-text responses demonstrated the importance to
Internal medicine hospitalist service 1 the consulting teams of having psychiatric consultants
Neurology 2
present and accessible. One respondent requested twice
Physical medicine and rehabilitation medicine 1
HIV 1 daily C-L rounds on patients in restraints or on constant
Gynecological oncology 1 observation and for routine psychiatric evaluations to be
General surgery 1 provided on weekends and holidays. A few others
Obstetrics and gynecology 3
Transplant (lung, liver, and heart) 3 requested easy availability for questions by phone and
Minimally invasive surgery 1 expressed appreciation for the presence of a psychiatrist at
Surgical ICU and cardiothoracic ICU 2 family meetings. The presence of a psychiatric consultant
Orthopedic surgery 1
on the primary teams rounds and identication or
ICU intensive care unit.
availability of an attending psychiatrist were all suggested
as additional points to include in a satisfaction measure.

team in addition to placing notes in the chart, Con- DISCUSSION

sultant does not increase the length of stay, Consultant
facilitates transfer to inpatient psychiatry service, Con-
sultant 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
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 pneumo-
nia, and spending per patient, as mandated by the Joint
Commission. Performance measures have been in place

TABLE 4. 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 4.94 0.24
Consultant has practical and helpful management suggestions for medical staff 4.76 0.42
Consultant has practical and helpful management suggestions for nursing staff 4.71 0.46
Consultation occurs within 24 hours of request 4.65 0.76
Consultant quickly manages patients behavioral problems 4.53 0.78
Consultant provides diagnostic clarication leading to management and disposition planning 4.53 0.78
Consultant communicates verbally with the medical team in addition to placing notes in the chart 4.53 0.61
Consultant does not increase length of stay 4.35 0.90
Consultant facilitates transfer to inpatient psychiatry service 4.35 0.68
Consultant reduces length of stay 4.24 0.73
After the initial consult, consultant follows up for the duration of the admission 4.00 0.69
Consultant arranges disposition that removes problem patient from my service 3.94 0.87
Consultation occurs within 4 hours of request 3.88 0.83
Consultant is involved in educational activities with the medical staff 3.82 0.71
Consultant helps manage substance intoxication and/or withdrawal 3.76 1.11
Consultant is involved in educations activities with the nursing staff 3.53 0.61

Std dev standard deviation.

572 www.psychosomaticsjournal.org Psychosomatics 54:6, November/December 2013


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 determin-
ing what quality measures are the most relevant to
measuring the effectiveness of a service.12
Several barriers hinder the development of a com-
prehensive quality assessment tool for hospital-based
psychiatric consultations. The spectrum of clinical sce-
narios addressed by psychiatric consultants is vast. There
is signicant clinical heterogeneity in the problems that
entail our involvement, and consequently, the specic
outcomes that would dene 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
quantied. 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
conicting 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 percep-
tions 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 rst 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 effective-
ness. A review of the literature and our survey indicates
that there are no operational denitions of satisfaction.
Our internal survey of consultees is novel in that it is
the rst attempt to dene 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
Lavakumar et al.
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 documenta-
tion, 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 dene it in quantitative terms.
Karasu et al., in the 1970s, addressed the question of what
aspects of psychiatric consultation are valued by physi-
cians.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 conicts 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 ndings 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 dimen-
sions 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 573
Performance Measures for C-L Service Effectiveness
medically stable enough to be transferred to a psychiatric
unit, and consultees insist on this intervention under-
standably but prematurely. Sometimes referring services
are unyielding in their belief that an inpatient psychiatric
hospitalization is clinically necessary, when in the con-
sultants 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 dissatises the consultee but is beyond the
control of the consultant.
Our study has several limitations. We rst surveyed
fellowship training directors, and their programs may not
reect service evaluation practices in institutions without
Psychosomatic Medicine fellowships. We suspect, how-
ever, that this limitation, if anything, introduces a
conservative bias to our nding that the practice of
C-L service performance evaluation is underdeveloped,
as training programs tend to occur in larger and better-
established 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 ndings to
References
1. Levitan SJ, Kornfeld DS: A study of liaison psychiatry
effectiveness: clinical and cost benets. Am J Psychiatry
1981; 136:790793
2. Levenson JL, Hamer RM, Rossiter LF: A randomized controlled
study of psychiatric consultation guided by screening in general
medical inpatients. Am J Psychiatry 1992; 149:631637
3. Desan PH, Zimbrean PC, Weinstein AJ, Bozzo JE, Sledge WH:
Proactive psychiatric consultation services reduce length of
stay for admissions to an inpatient medical team. Psychoso-
matics 2011; 52:513520
4. Diehl A, Nakovics HB, Reinhard I, Kiefer F, Mann K:
Consultation-liaison psychiatry in general hospitals: improve-
ment in physicians detection rates of alcohol use disorders.
Psychosomatics 2009; 50:599604
5. Karasu TB, Plutchik R, Conte H, Siegel B, Steinmuller R,
Rosenbaum M: What do physicians want from a psychiatric
consultation service? Compr Psychiatry 1977; 18:7381
6. Solomons LC, Thachil A, Burgess C, et al: Quality of
psychiatric care in the general hospital: referrer perceptions
of an inpatient liaison psychiatry service. Gen Hosp Psychiatry
2011; 33:260266
574 www.psychosomaticsjournal.org
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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 inuenced 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
identied a discrete and manageably sized list of param-
eters 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 con-
junction 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.
7. Milne D, Gibson L: Quality assurance in the voluntary sector.
Int J Health Care Qual Assur 1994; 7:1619
8. Clarke PH: A referrer and patient evaluation of a telepsychiatry
consultation-liaison service in South Australia. J Telemed
Telecare 1997; 3:1214
9. Lewis R, Musella E, Berk M, Dodd S, McKenzie H, Hyland M:
An audit of clinical outcomes and client and referrer satisfaction
with a Mood and Anxiety Disorders Unit. J Eval Clin Pract
2004; 10:549552
10. Kubik-Huch RA, Rexroth M, Porst R, Durselen L, Otto R,
Szucs T: Referrer satisfaction as a quality criterion: devel-
oping an questionnaire for measuring the quality of services
provided by a radiology department. Rofo 2005; 177:
429434
11. Available from: http://www.jointcommission.org/core_measure_
sets.aspx. 2012.
12. Goldberg RJ, Burock J, Harrington CJ: Quality indicators in
consultation-liaison psychiatry. Psychosomatics 2009; 50:550
13. Kornfeld DS, Muskin PR, Tahil FA: Psychiatric evaluation of
mental capacity in the general hospital: a signicant teaching
opportunity. Psychosomatics 2009; 50:468473
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