Challenge

GGz Breburg is an integrated specialist mental health organization in the Midden- and West-Brabant region of the Netherlands. The organization provides mental health care to all target groups, young and old, with an emphasis on the more complex target groups. The acute care chain, including the crisis service, is also part of GGz Breburg. For sending out questionnaires, the organization has worked for years with iQoutcome (formerly QuestManager), linked to its EHR and eHealth application.

The link with the EHR is at the heart of this challenge. Questionnaires in QuestManager are linked to the client in the EHR by default, including the associated security: only staff with a treatment relationship can access the data. That is appropriate for questionnaires within treatment as part of Routine Outcome Monitoring, but GGz Breburg increasingly wants to use questionnaires more broadly. Then you want clients to be able to respond anonymously, colleagues without EHR access to be able to help clients complete them, and a low-threshold way to achieve a wide reach through alternative channels, for example QR codes and links that you can put on a poster or flyer or share online.

The first concrete occasion was the client satisfaction survey among the organization's most complex target group: clients in long-term mental health care who receive outpatient or inpatient support. A group that is not used to completing questionnaires and for whom reading and online applications are not self-evident, but who of course do have an opinion and can give very valuable feedback on their care. Part of this group also prefers to respond on paper, or needs help doing so.

In addition, a scientific study was running to gather information on the possible relationship between the menstrual cycle and mental health complaints in girls and young women aged 11 to 23. Little is known yet about the role of the menstrual cycle in mental health complaints within youth mental health care, while the outcomes may be relevant for tailoring treatments and preventing relapse. For both studies, anonymity had to be guaranteed, and the aim was to reach as broad and representative a group as possible in a low-threshold way, including people who would otherwise not be reached.

Experiences and impact

Using QuestManager, GGz Breburg set up anonymous questionnaires via links and QR codes. The data is stored in a separate location, apart from the EHR, so that anonymity is guaranteed. For the client satisfaction survey, each team received its own QR code, created from a specific link to the questionnaire for that team. “By using anonymous administration via a QR code that a client, or a client's support worker, can scan to complete the questionnaire, the answers remain anonymous, yet they can still be linked to a team. This is essential, because you want to know the feedback on care per team so that the team can learn from it,” says Margot Metz, Senior Researcher at GGz Breburg.

The approach was deliberately kept low-threshold. The questionnaire is short: five questions about experiences with care, with room for comments. Each client was personally handed a flyer with an explanation and the QR code, and was encouraged to take part. Clients completed the questionnaire themselves, whether or not together with a support worker. For clients who are not digitally skilled, a substantial group within this target group, the flyer could also be completed on paper. These paper responses could easily be entered digitally in QuestManager afterwards via the QR code, including by colleagues who have no access to the EHR.

The result is impressive: many completed questionnaires from a target group that is hardly used to this kind of participation. The data was imported per team into GGz Breburg's reporting portal and analyzed per team together with the analyzed text answers, then presented. Each team sees its own results as well as those of its colleague teams. From this, each team identified two points for improvement, which have been included in the annual plans. Examples include better alignment with the client on the balance between self-management and support, or more concrete reporting on recovery goals. Posters were used to report back per team on what is being done with the feedback, so that clients see that their input has an effect and hopefully take part again next year.

The scientific study by GGz Breburg on the menstrual cycle and mental health complaints mentioned above had its own setup, in line with the standards of scientific research: participants give formal consent, and anonymity is guaranteed in further data processing. Alongside the QR code to the research questionnaire (shown on posters and cards), a parallel email version was set up, in which a stable link to the questionnaire was emailed to the young people. And that email, surprisingly, turned out to work even better. The explanation: unlike the client satisfaction survey described above, this study is more closely connected to treatment in terms of content, so the administration itself does not necessarily have to be anonymous (only the later processing of the data does). In addition, not every practitioner remembers to hand out the QR code, and completing a questionnaire via a QR code that was handed out or shown on a poster in the waiting room is still a hurdle. An email, on the other hand, stays in the inbox until someone acts on it. On top of that, the system automatically sends reminders when a questionnaire is completed via email.

The researchers suspect there is added value in promoting participation in the study through multiple channels. Clients were asked to take part by their practitioners, received an email, were given a card with a QR code and saw posters promoting the study in the building. Senior researcher Mirjam Kouijzer had not expected beforehand that the largest response would come via the link in the email: "Young people don't email that much anymore, and the phone they can use to scan the QR code is within reach for most of the day." Yet most of the responses came via the email that was sent, and not via the QR codes on posters in the waiting rooms and treatment rooms.

The lesson GGz Breburg draws from this: the success of a form of administration depends on the purpose, the target group and the moment. There is a gradation in questionnaires within treatment: outcome measurements (ROM), client satisfaction surveys and scientific research. Each application requires a different approach. For ROM, embedding in treatment is essential. For client satisfaction surveys, low-threshold and anonymous administration is important. For the scientific study described, the motivating role of the care professional is crucial: young people want a personal explanation, and the system and the personal approach reinforce each other.

This approach also fits a broader movement towards client-centered care and self-management. Clients of GGz Breburg already have access to their own outcome information (ROM), for example for questionnaires they completed themselves. The client satisfaction survey adds another dimension: not feedback within treatment, but feedback about treatment and the care process, from which the teams then demonstrably learn. For a target group that is less used to influencing the quality of care in this way, that is a significant step.

From an administration perspective there is also insight into the process: for anonymous questionnaires, the numbers and the completed data can be viewed and compared with the aggregated data in the reporting portal.

Future vision and recommendations for other organizations

GGz Breburg will use QR codes more widely. In the follow-up to the client satisfaction survey, the client's network will also be involved, so that relatives can give independent feedback as well, without the hurdle that can arise when you give feedback on care that your loved one depends on.

The organization is also looking at informant versions of questionnaires. “In youth mental health care, working with questionnaires for informants is already quite normal; that approach is being extended to, for example, older adults and the complex long-term target group, where there is also a need for it. The fact that client and relative sometimes answer differently is not a problem, but actually valuable: you want to be able to discuss those perspectives side by side,” says Margot.

GGz Breburg also formulated concrete wishes for QuestManager. They want to be able to generate QR codes directly at team or location level in QuestManager, preferably for several questionnaires at once. From an administration perspective, there is a need for a status overview of anonymous questionnaires.

The most important recommendation to other organizations: determine the purpose of your questionnaire in advance, analyze your target group and choose the most low-threshold and suitable form of administration. Relevant questions here are: Do you want responses within or outside treatment? How important is anonymity? Don't just send out a questionnaire without thinking, but consider what will get you the highest response and who needs to support it.

Practical tips from their own experience: keep questionnaires as short and efficient as possible to lower the threshold for completing them, and choose the right moment to offer them, for example before the consultation, so that any questions can be discussed during the conversation. And don't underestimate the role of the care professional. Also pay attention to the independence of completing the questionnaire, so that socially desirable answers are kept to a minimum. Anonymous QR codes are a powerful addition for reaching groups you would otherwise miss, especially target groups that are not used to having a say, and for making it easier to respond, including anonymously outside the EHR.