A: It is essential that mental health services research occupies a place at the state and federal level where policy decisions are made. There is no doubt that the mental health system must change. How and in what direction depends on the allocation of resources by policymakers. Resources are most likely to be allocated to mental health service improvement if empirical data is available. It is my opinion that little change will happen in mental health delivery systems without a concentrated effort to document effectiveness of systems and organizations. The focus of my research focus is to provide empirical evidence to improve health care for people with mental illness and improve working conditions of clinicians and administrators.

The consumers of services as well as the clinicians and the administrators find mental health systems to be almost impossibly complex and truncated from general health care. The stress on consumer and provider is extreme. I focus on operational mechanisms of hospital organizations delivering inpatient psychiatric services. I use large public data sources and primary survey data of nurses. One of my first research questions was, "Are there general hospitals providing quality psychiatric inpatient care and positive work environments; if so, how do they differ from those that have poor quality?" My early research shows that some hospital systems work better than others. We often hear only about the negative inpatient psychiatric care and adverse events. If we are to transform the system, we must find the hospitals that have excelled despite difficult circumstances.

A: I look at organizational factors that are found to be associated with positive working conditions in hospitals, such as 1) there is an adequate quantity and quality of nurse staffing, 2) a treatment model is defined and shared by staff, 3) professional nursing staff are valued by hospital administrators, i.e., decisions and policies about patient care involve nurses, 4) managers at the unit level are skilled leaders, and 5) nurses and physician have collaborative relationships. Additionally, these organizational factors are associated with patient outcomes. Mental health services lags behind health services research performed in medical surgical settings. Mental health and substance abuse research is at the patient or clinician level and few have addressed the system level. I use large data sets of patient hospital discharge records, provider data, and survey data from nearly 100,000 nurses. Nurses are an excellent, and often untapped, resource about the quality of care. The nurse survey includes questions about the quality of the patient care, organizational factors that facilitated or undermined the work environment, adverse events, and the presence of staff burnout and turnover.

In a recent study, we examined the extent to which organizational factors in 67 general hospitals with psychiatric inpatient services influenced the occurrence of adverse events. Approximately a third of these hospitals were rated highly by the nurses that worked in them and a third were rated poorly. Better hospitals had fewer adverse events, lower levels of medication errors, lower levels of patient falls, fewer worker-related injuries, and less verbal abuse of nurses. Additionally, better hospitals had significantly lower psychiatric nurse burnout, better staffing levels, and better management and leadership at the unit level.