The Role of Deinstitutionalization in Experience-Based Quality of Psychiatric Treatment: Results of a Mixed Methods Study

The Role of Deinstitutionalization in Experience-Based Quality of Psychiatric Treatment: Results of a Mixed Methods Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Role of Deinstitutionalization in Experience-Based Quality of Psychiatric Treatment: Results of a Mixed Methods Study Timo Beeker, Sebastian von Peter, Martin Heinze, Yuriy Ignatyev This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7294297/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Since the mid-twentieth century, many Western European countries have shifted the focus of mental health care from hospital-based to community-based settings. While the impact of deinstitutionalization on various quality indicators has been widely studied, its effects on patient-experienced quality of care remain underexplored. This study aims to identify deinstitutionalization-related conditions that are necessary and/or sufficient for achieving a high level of experience-based quality in psychiatric treatment. Methods We employed a mixed-methods design following a qual→quan→QUAL sequence. Our analysis drew on quantified interview data and routine data from a precursor study involving nine hospitals implementing flexible and integrative psychiatric treatment (FIT64b) and five control hospitals in Germany. We conducted a crisp-set Qualitative Comparative Analysis (QCA) to identify necessary and sufficient conditions associated with deinstitutionalization that could—individually or in combination—lead to higher or lower patient-reported quality of care. To further interpret the QCA results, we performed a Grounded Theory-inspired qualitative re-analysis of the original interview material. Results FIT64b with a reduced number of hospital beds was identified as a necessary condition for a higher experience-based quality of psychiatric treatment. Surprisingly, a longer average hospital length of stay was a sufficient condition for this outcome, while a shorter hospital length of stay was found to be a necessary one for a lower experience-based treatment quality. The interview re-analysis showed that inpatient treatment of adequate length can potentially be a deeply transformative experience that requires a suitable amount of time to make use of a multitude of occasions for processes of learning, reflection and behavioural changes. Conclusions Deinstitutionalization can play an important role in achieving higher experience-based quality in mental healthcare if certain conditions are fulfilled. Modern psychiatric services with a reduced number of hospital beds and well-developed outpatient care like FIT64b are necessary but have to be combined with an appropriate hospital length of stay. Trial registration: This study was part of the multi-center controlled PsychCare trial (German Clinical Trials Register No. DRKS00022535; Date of registration: 2020–10 − 02). Deinstitutionalization Configurational Comparative Methods Mental Healthcare Flexible and Integrative Treatment Patient-Reported Experience Measures 1 INTRODUCTION According to an influential definition by the Council of Europe, quality of care in healthcare is the degree to which the treatment dispensed increases the patient’s chances of achieving the desired results and diminishes the chances of undesirable results [ 1 ]. In the current discussion, there are different views on what constitutes the quality of (psychiatric) treatment. It is highlighted that quality is a latent construct [ 2 ] that requires a precise definition or normative specifications [ 3 ]. In this context, in addition to the collection of routine and social data to evaluate the results and quality of mental health care, the use of so-called patient-reported parameters is recommended. While "patient reported outcome measures" (PROMS) relate to the outcome of a treatment, e.g. the quality of life achieved or the state of users’ health, "patient reported experience measures" (PREMS) aim at systematically mapping the users' experiences with a treatment or care process [ 2 ]. In a UK study using participatory expert panels to evaluate common psychiatric outcome measures, the suitability of the measures was found to be consistently low [ 4 ]. This finding is highly problematic, as it becomes increasingly acknowledged that high-quality mental healthcare that ultimately enables recovery is only possible if evaluation instruments are grounded in the specific perspectives of users [ 5 ]. As a result of a controlled, prospective, multicenter cohort study in Germany, an exploratory construct of experience-related quality components that grasp the users’ experiences of psychiatric care was developed in participative-collaborative cooperation [ 6 ]. The construct contained twelve key quality components, which were presented in an operationalized form and in relation to each other based on multidimensional scaling. Furthermore, the construct made it possible to separate structural from interpersonal requirements of the quality components. It further indicated which experience-related quality components are more feasible for the home treatment setting, and which ones for an institutional setting. This bipolar dimension seems to be critical for the current state of mental health services in Germany, where different variations of flexible and integrative treatment models take place alongside the standard ones. One of the features of the standard German system of psychiatric care is that regular and relatively high reimbursement of inpatient care results in a large number of beds and high bed occupancy, following the infamous Roemer’s law for insured populations that a hospital bed built is a bed filled [ 7 ]. However, there is also a clear trend to deinstitutionalization. Since 2012, a new law (§ 64b, Book V of the Social Security Code [SGB V]) allows the implementation of flexible and integrative treatment (FIT64b) models for patients with mental illness in Germany. The specific components of FIT64b are continuity of care provided by multidisciplinary teams, providing therapeutic group sessions across all settings, involving informal caregivers, assuring accessibility of services, sovereign steering of services, and collaboration across sectors, and to expand professional expertise [ 8 ]. However, the central FIT64b components are the rapid movement of patients from inpatient to outpatient care being a core feature of any kind of deinstitutionalization, plus flexible care management across settings, and outreach [ 9 ]. The transition to providing new community-based mental health services is often described in terms of deinstitutionalization and is expected to achieve an overall reduction in the number of inpatient beds [ 10 ]. Community services, seen as part of deinstitutionalization, are evolving to meet the diverse and complex needs of both patients discharged from hospitals and, more importantly, all those patients who, through these services, either never enter hospitals or spend only a short time in them. Despite the positive aspects of deinstitutionalization on mental health care quality [ 11 ], it also arguably increases readmission rates [ 12 – 14 ]. Although patients are generally positive about FIT and outreach health care, in some cases home treatment may have been perceived as associated with "disrupting a person's or family's privacy" [ 8 ]. In most studies [ 15 – 17 ] the impact of deinstitutionalization on the quality of mental health care was examined through indicator analysis. Only a few studies [ 11 , 18 , 19 ] investigated the impact of deinstitutionalization on the experience-based quality of mental health care by predominantly using questionnaires, which were not developed by the health care users themselves. To our knowledge, there have been no comprehensive studies of indicators of deinstitutionalization and PREMS obtained in collaboration with mental health care users, especially not in the context of FIT64b and comparable attempts for reorganizing psychiatric care. This study aims (1) to identify which deinstitutionalization-related conditions are sufficient and/or necessary for experience-based quality of psychiatric treatment as defined by characteristics established in a participatory research process [ 6 ] and (2) to develop explanations why the identified conditions are of high, maybe even causal importance for the positive outcome. The identification will be carried out through a Qualitative Comparative Analysis (QCA), a method that is increasingly recognized for the analysis of causal relationships in rather small data sets. Explanations will be developed through a qualitative re-analysis of interview material inspired by grounded theory methodology. 2 METHODS 2.1 Project context and design Our study builds on some of the results of the prospective, controlled PsychCare cohort study for the evaluation of FIT64b hospitals that was conducted between 2017 and 2021. PsychCare itself was partly prepared by Eva-Mod64, a previous study in which 13 FIT hospital departments were evaluated between 2016 and 2017 [ 8 , 9 , 20 ]. For each FIT department included in PsychCare, a structurally comparable psychiatric control department was identified [ 21 ]. Nine of 17 eligible FIT64b hospitals and five control hospitals consented to take part also in the qualitative part of the study. Quantitative baseline and qualitative data collection lasted from March 2018 to September 2019, with the latter encompassing a total of 71 problem-centred interviews. The details on the collection and evaluation of interviews are published elsewhere [ 22 ]. The research design combined phases qual→quan→QUAL within a single integrated cycle. In J.M. Morse’s mixed-methods terminology [ 23 , 24 ], this design refers to a sequential research process that begins with an exploratory qualitative phase to develop insights or hypotheses, followed by a quantitative phase to test or measure those insights, and concludes with a final, in-depth qualitative phase to interpret or contextualize the findings. This integrated cycle ensures both breadth and depth, enhancing the validity and richness of the overall understanding. Routine data and quantified qualitative interview data were used to develop potentially necessary and sufficient conditions, as well as to define the outcome of interest, which was then examined using Qualitative Comparative Analysis (QCA) as the core method. Subsequently, the original interview data were re-analyzed to interpret the formal results of the QCA. 2.2 QCA using crisp sets QCA was developed by Ragin (1987), as a combination of the strengths of qualitative and quantitative research methods based on Boolean algebra [ 25 ]. There is now a growing body of published research in public health and related fields drawing on QCA methods [ 26 ]. QCA is known to be robust against small sample size [ 27 ] and can, therefore, be used for smaller data sets seen in firm-level studies. It focuses on two aspects—whether a given outcome is observed when a particular configuration is present and whether the outcome is not observed when the configuration is absent. Thus, it has the potential to cover for both necessary and sufficient conditions for outcomes. A condition is considered necessary for an outcome if it is always present when the outcome occurs. In other words, the outcome cannot occur in the absence of the condition, but its presence does not guarantee the outcome. A condition or combination of conditions is sufficient for an outcome if the outcome always occurs when the condition or combination is present. The presence of a sufficient condition or combination of sufficient conditions guarantees the outcome when the necessary conditions are present. QCA also generates statistics on “consistency” and “coverage” to ascertain if tested configurations are statistically rigorous enough. Consistency (Con) is seen as being similar to the significance score in conventional regression, and high consistency indicates that a specific configuration-outcome relationship is salient. Coverage (Cov) evaluates the degree to which a particular configuration accounts for instances of an outcome. To rule out that a necessary condition is trivial, a measure called relevance of necessity (RoN) was suggested [ 28 ]. Another statistic measure called proportional reduction in inconsistency (PRI) expresses how much it helps to know that a given condition X is a subset of outcome Y rather than a subset of either Y, its complement ~ Y, or the intersection between Y and ~ Y. Qualitative Comparative Analysis (QCA) can be conducted using dichotomous (crisp sets), numerical (fuzzy sets), or categorical (multi-value) data. In this study, we employed the crisp-set QCA (cs-QCA) method, which uses binary values to indicate full membership (1) or full non-membership (0), for several reasons: First, dichotomized scores help move beyond a gradualist perspective by highlighting qualitative differences in kind rather than merely differences in degree. This facilitates the development of models that are more accessible and actionable for practitioners. Second, cs-QCA conceptualizes cases as configurations of conditions, allowing different case types to be distinguished by relatively integrated sets of features [ 29 ]. Third, cs-QCA offers a balance between deep, case-specific understanding and the identification of cross-case patterns, thereby enabling new insights into both individual complexities and shared structures [ 30 ]. 2.3 Identifying, assessing and calibrating the outcome of interest The potential of QCA in analysing qualitative interview data was demonstrated by a number of studies [ 31 , 32 ]. The basis of the outcome of interest (experience-based quality of psychiatric treatment) were twelve experience-related characteristics ( Flexibility, Activity, (Preventing) Stigmatization, Compatibility with everyday life, Autonomy, Safety, Continuity, Intensity, Knowledge, Time, Solidarity, (Absence) of coercion ), which were developed through a re-analysis of data from the EvaMod64b precursor study EvaMod64b [ 8 , 9 ]. Detailed definitions of these characteristics are given elsewhere [ 33 ]. Based on them, qualitative interview guides were developed. To be able to systematically compare the data from the qualitative interviews, conversion of these data into quantified items was necessary. For this purpose, a data transformation was performed, which involved four steps orientated at previous and other publications [ 34 , 35 ]. Drawing on the open coding process ( step 1 ), codes were classified as positive (component fulfilled in this department) or negative (not fulfilled), and these weights added ( step 2 ). The cumulative mean of the classified and weighted codes of all statements that were queried was set in relation to the cumulative mean of codes for spontaneous statements ( step 3 ). The negative and positive, corrected partial scores were added, resulting in a total score for each department ( step 4 ). This step-by-step process is described in more detail elsewhere [ 6 , 22 ]. For the implementation of the QCA, the dichotomised total scores were assumed to be outcome (positive experiences in psychiatric treatment) and non-outcome (negative experiences in psychiatric treatment). The dichotomization was carried out on the basis of complete linkage clustering method by using QCA software [ 36 ]. 2.4 Identifying, assessing and calibrating the conditions of interest Deinstitutionalization is the process of shifting mental health care and support from long-stay psychiatric institutions to community mental health services. There are two crucial aspects of deinstitutionalization [ 37 ]: the first involves reforming the conditions and service delivery within psychiatric institutions and downsizing the number of long-stay beds. This is accompanied by the second aspect - strengthening of community-based mental health facilities. In QCA, it is suggested not to examine a large number of conditions, especially when the number of cases is limited, in order to avoid having too many condition combinations that are not present in any of the cases. In our analysis, three conditions were considered as potential explanations for the outcome. The condition relating to the first aspect of deinstitutionalization was the dichotomized number of psychiatric beds (BED) in examined nine FIT64b hospitals and five control hospitals. Conditions more related to the second aspect of deinstitutionalization were the dichotomized treatment type in psychiatric departments (flexible integrative treatment (FIT) vs. standard treatment) as well as the average hospital length of stay (HLS). Whereas BED is a widely used structural quality indicator to assess psychiatric deinstitutionalization [ 38 ], HLS could be considered as one of its outcome quality indicators, as discharge from inpatient-care usually signifies clinical improvement [ 39 ]. Community-based mental health services like FIT64b are designed to reduce HLS [ 40 ] and increase patient satisfaction [ 41 ]. Like the outcome, BED and HLS conditions were dichotomized on the basis of complete linkage clustering method [ 36 ]. 2.5 Data analysis The QCA started by defining potential necessary and sufficient conditions as a first step. For necessary conditions, a consistency threshold of at least 0.9 seems advisable [ 25 ]. For sufficient conditions, an outcome is present if the consistency is above 0.75 [ 28 ]. For coverage no lower threshold exists. The second step was to compile a combined (for outcome and non-outcome) truth table. Truth tables are an important tool in QCA as they contain the empirical evidence gathered by the researcher by sorting cases into one of the 2 k logically possible combinations, aka truth table rows, of k conditions. Each row linked to the outcome can be interpreted as a statement of sufficiency [ 28 ]. In the third step, different solution formulas of QCA were produced and compared. The solution formula presents the combination of conditions which lead to the outcome in a consistent way. If a solution has consistency of 1.0, this indicates that such a combination of conditions always leads to the outcome. If a solution has a coverage of 1.0, this indicates that this combination of conditions is able to explain all of the occurrences of the outcome. Following recommendations of good practice in QCA [ 29 ], several solution formulas of different complexity (conservative solution, parsimonious solution, enhanced parsimonious solution and enhanced intermediate solution) were produced and presented. According to Schneider and Wagemann [ 28 ], conservative solution rests on no assumption about logical remainders (rows for which not enough empirical evidence is at hand). It is based solely on truth table rows that are deemed sufficient for the outcome based on empirical evidence. It is the subset of all other possible solutions. The parsimonious solution is more simplified in comparison to the complex solution. It is obtained by employing a less conservative approach over the empirical evidence and includes remainders in the minimization process (summary of the information contained in a truth table, applying the rules of Boolean algebra). The enhanced parsimonious solution is the result of the minimization process excluding the untenable assumptions. For instance, it is contradictory to use the same remainders to simplify the necessary conditions of the outcome and of the negated outcome. The enhanced intermediate solution is based on directional expectations which filter out both the untenable remainders and the difficult counterfactuals. The QCA calculation for this dataset was performed with R, a software environment for statistical computing, and the QCA package for R, version 3.11 [ 36 ]. To present the results, the following formal logical connectives were used: for the conjunction of conditions (logical AND) ‘*,’ for disjunctions (logical OR) ‘ + ,’ and the negation ‘ ~ .’ 2.6 Qualitative interpretation of QCA-results QCA results, expressing relationships between variables and outcomes in the binary logic of Boolean algebra, are by definition highly formalized and abstract. As a downside of clear-cut causal statements such as “ A is a sufficient condition for B ”, they do not contain any information in themselves about why and how a certain condition leads to a certain outcome. However, as such knowledge is crucial for advancing the quality of psychiatric care, we introduced a second qualitative step by enriching the interpretation of QCA-results with material from the original 71 problem-centred interviews that we performed from March 2018 to September 2019 in FIT and control hospitals. As the same interviews were used to identify the conditions and outcomes of interest that were the basis of our QCA, our study follows a mixed methods design (qual→quan→QUAL) closed in a single loop. The precursory, initial analysis of the user-interviews comprised the inductive creation of categories by an open-coding process, leading to the aforementioned twelve main categories that were identified as central experiential components. For this study, we used an approach that was inspired by Grounded Theory Methodology [ 42 ] to obtain an empirically saturated explanation of the causal relationships established through QCA, especially of one finding that seemed to contradict our expectations. At the beginning, all twelve main-categories including their subcategories were screened for relevance for our QCA-results, leading to a selection of three components with the strongest intrinsic connection to the explanandum. Within these three categories, all codes and the associated interview fragments were re-analysed for thematic relevance. In an iterative process, the most typical and / or salient with regard to the explanandum were selected and used for an empirically saturated interpretation of the QCA-results of interest that could be considered a middle range theory in line with Grounded Theory. 3 RESULTS 3.1 Results of crisp-set qualitative comparative analysis Using open coding, experiences in psychiatric treatment were classified as positive or negative and weighted accordingly. Weighted codes from queried and spontaneous statements were compared, and corrected partial scores were summed to yield a total score per department. The results from this full step-by-step process are detailed elsewhere [ 6 , 22 ]. The median value of positive experiences in psychiatric treatment was 8.0 and for the negative ones it was 3.0. Dichotomizing the total experience scores showed that only four hospitals could be assigned a positive outcome. The median values of high and low number of beds were considered to be 0.83 and 0.51 beds per 1000 inhabitants, respectively. The median values for high HLS were 36.5 days and for low HLS, it was 23.3 days. There were nine FIT psychiatric departments and five departments with standard psychiatric care. The calibrated values of the outcome and conditions can be found in Table 1 . Table 1 Calibrated hospital characteristics and data derived from interviews Hospital characteristics Quantified data from interviews Hospital FIT HLS BED OUT FL AС PS CL AU SA CO IN KN TI SO AB H1 1 0 0 0 0 0 1 0 1 1 0 1 0 0 0 0 H2 1 0 0 0 0 0 1 1 1 1 0 0 0 1 0 0 H3 1 0 0 1 1 1 0 0 1 1 1 1 0 1 1 0 H4 1 1 0 1 1 1 1 0 1 1 1 1 1 1 1 0 H5 1 0 0 0 1 0 0 0 0 1 0 1 0 1 0 0 H6 1 1 0 1 1 1 1 0 1 1 0 1 0 1 0 1 H7 1 0 0 0 1 1 0 0 0 0 0 0 0 1 0 0 H8 1 1 0 1 1 1 1 0 1 1 1 1 1 1 0 0 H9 1 0 0 0 1 0 1 0 1 1 1 0 0 1 0 0 H10 0 0 1 0 0 0 0 0 1 0 0 0 0 1 0 0 H11 0 0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 H12 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 H13 0 0 1 0 0 1 0 0 0 1 1 0 0 1 0 0 H14 0 0 1 0 0 1 0 0 1 0 0 1 0 0 0 0 H = Hospital, FIT = Flexible and integrative treatment, HLS = Hospital length of stay, BED = Psychiatric hospital beds, OUT = Outcome (Total score of positive experiences in psychiatric treatment), FL = Flexibility, AC = Activity, PS = Preventing of stigmatization, CL = Compatibility with everyday life, AU = Autonomy, SA = Safety, CO = Continuity, IN = Intensity, KN = Knowledge, Time = TI, SO = Solidarity, AB = Absence of coercion. Dichotomized values: 0 = characteristic not present or low; 1 = characteristic present or high. The fit measures of necessary conditions for a certain outcome are represented in Table 2 . Surprisingly, there were two conditions (FIT and ~ BED) that could exceed the perfect threshold of 1.0 in consistency with the positive outcome (= positive treatment experience). However, these conditions were not complete duplicates. The ~ BED condition was necessary for FIT condition (consistency of 1, coverage = 0.89), but had slightly lower сoverage and relevance scores to explain the outcome. For the negative outcome (= negative treatment experience), only ~ HLS was identified to be necessary. Table 2 Analysis of potential necessary conditions for outcome (positive experiences in psychiatric treatment) and non-outcome (negative experiences in psychiatric treatment) Condition Fit measure Outcome Non-outcome Con CovN RoN Con CovN RoN FIT 1 0.44 0.50 0.50 0.56 0.56 HLS 0.75 1 1 0 0 0.79 BED 0 0 0.71 0.40 1 1 ~FIT 0 0.64 0 0.50 1 1 ~HLS 0.25 0.09 0.23 1 0.91 0.75 ~BED 1 0.40 0.40 0.60 0.60 0.50 Con = Consistency, CovN = Coverage of necessity, RoN = Relevance of necessity, FIT = Flexible and Integrative treatment, HLS = Hospital length of stay, BED = Psychiatric hospital beds. The truth table (Table 3 ) revealed four specific combinations of conditions for which there were no empirical cases. The sufficiency inclusion score (Incl.) shows how consistent the cases from a given causal configuration are, to display the same value in the outcome. The case H3 in the Table 1 showed the positive outcome. However, because the consistency score of the configuration involving H3 with the outcome was well below the 0.9 threshold, the negative outcome in the truth table was attributed to this case. In summary, the positive outcome entailed fewer cases (3) than the negative outcome (11). Table 3 Combined truth table for outcome and non-outcome No Condition Outcome Non-Outcome Case FIT HLS BED OUT Incl. PRI OUT Incl. PRI 1 0 0 0 0 0.00 0.00 1 1.00 1.00 H11 2 0 0 1 0 0.00 0.00 1 1.00 1.00 H10, H12, H13, H14 3 1 0 0 0 0.17 0.17 1 0.83 0.83 H1, H2, H3, H5, H7, H9, 4 1 1 0 1 1.00 1.00 0 0.00 0.00 H4, H6, H8 5 0 1 0 ? - - ? - - Logical remainder (no empirical case) 6 0 1 1 ? - - ? - - Logical remainder (no empirical case) 7 1 0 1 ? - - ? - - Logical remainder (no empirical case) 8 1 1 1 ? - - ? - - Logical remainder (no empirical case) H = Hospital, FIT = Flexible and Integrative treatment, HLS = Hospital length of stay, BED = Psychiatric hospital beds, OUT = Outcome (total score of positive experiences in psychiatric treatment), Incl: Sufficiency inclusion score PRI: Proportional reduction in inconsistency, All minimization algorithms revealed only one path with consistency of 1.00 and coverage of 0.75, but different solution terms for the positive outcome (Table 4 ). Both FIT and ~ BED conditions that were considered to be necessary, disappeared from the formula of the parsimonious solution (= hidden necessary conditions). The enhanced parsimonious solution provided more interpretable terms after the contradictory 5th and 6th rows of the truth table were excluded. However, ~BED condition still remained minimized out of the formula what was difficult to defend. Therefore, enhanced intermediate solution including directional expectations of the theory-guided condition ~ BED was also taken in account. The formula of this solution FIT* ~BED *HLS ->OUT was identical to that of the conservative solution (Table 4 ) and chosen for the further considerations. Table 4 Solution terms of the crisp-set QCA Solution Path Incl. PRI CovS Case Outcome Conservative solution FIT*HLS* ~BED 1.00 1.00 0.75 H4, H6, H8 Parsimonious solution HLS 1.00 1.00 0.75 H4, H6, H8 Enhanced parsimonious solution FIT*HLS 1.00 1.00 0.75 H4, H6, H8 Enhanced intermediate solution FIT*HLS* ~BED 1.00 1.00 0.75 H4, H6, H8 Non-Outcome Conservative solution ~FIT*~HLS 1.00 1.00 0.50 H10, H11, H12, H13, H14 Parsimonious solution ~FIT 1.00 1.00 0.50 H10, H11, H12, H13, H14 Enhanced parsimonious solution ~FIT*~HLS 1.00 1.00 0.50 H10, H11, H12, H13, H14 Enhanced intermediate solution ~FIT*~HLS 1.00 1.00 0.50 H10, H11, H12, H13, H14 FIT = Flexible and Integrative treatment, HLS = Hospital length of stay, BED = Psychiatric hospital beds, Incl: Sufficiency inclusion score PRI: Proportional reduction in inconsistency, CovS = Sufficiency coverage score, H = Hospital. One of the central results of QCA was the emphasis on the role of FIT as a necessary condition for achieving positive experiences of psychiatric treatment. The role of a lower bed number as another necessary condition for the development of the positive PREMS was more ambiguous, as this indicator may reflect either simply low bed capacity by default or represent a structural, intended component of FIT. In the latter case, both identified necessary conditions could be compressed into one (FIT64b with reduced number of hospital beds). Most surprising, however, was the finding of HLS as a sufficient condition for a higher experience-based quality of psychiatric treatment. According to that, a lower HLS was found to be necessary for the non-outcome. 3.2 Grounded Theory - inspired interpretation of QCA-results It is in line with the expectations of FIT-hospitals and proponents that FIT, if compared to standard treatment, is causally linked with more positive treatment experiences, especially when combined with a lower number of hospital beds as an indirect marker for well-developed outpatient services. However, it is highly remarkable and unexpected that HLS was found to be a sufficient condition for the positive outcome. With the provision of outpatient instead of inpatient treatment or at least the rapid shifting of patients into an outpatient setting being a cornerstone of the concept of FIT, this finding seems even somewhat contradictory to FIT’s intrinsic logic and requires an explanation. In order to better understand the meaning of this finding, in other words, why and by which mechanism a rather long hospital stay can be causal for positive treatment experience, we decided to interpret this result in the light of our initial analysis of user-interviews. In a process of increasing abstraction, the initial analysis had produced the twelve individual experience components of FIT (Flexibility, Activity, (Preventing) Stigmatization, Compatibility with everyday life, Autonomy, Safety, Continuity, Intensity, Knowledge, Time, Solidarity, (Absence) of coercion)) that were the main-categories of our inductive coding process and have been implemented into our QCA as constituent ingredients of our outcome of interest (Table 1 ). Going back to the categories and codes of the initial analysis is a means of winding back the level of abstraction with the purpose of finding potential explanations within the original material. As a first step of selecting material for our re-analysis, all twelve components used to characterize FIT were screened for their relevance to explain that FIT is most likely to generate positive outcomes when it is combined with an appropriate HLS. As hospital length itself is a highly abstract, descriptive term, and was very rarely found in the subjective reports of participants, we decided to focus on the direct and indirect mention of time when meant as important part of helpful processes or experiences as the most suitable subjective equivalent of HLS combined with positive treatment experience. As subcategories and codes of users describing what was helpful for them about inpatient-treatment in relation to time in the above sense were nearly exclusively found in the main categories Intensity , Solidarity and Time , we decided to focus on them for our qualitative re-analysis. 3.2.1 Intensity The subcategories used to detail Intensity’s possible effects already highlight that its core is learning and un-learning, with explicit mention of, among others, learning patience, learning new strategies, learning self-care, learning to accept one’s own condition, or learning a different sense of self. That a sufficient amount of time is necessary for this kind of deeply personal, potentially transformative learning was supported by participants typically describing that the lessons they learned or the skills that they acquired as part of a larger process: I was provided with strategies how to break out of my old patterns […] or maybe also how to develop my own strategies. This is, of course, a long process, and it doesn’t always work out that well, but [it does work out] significantly better now than one month ago, two months ago, and it’s this kind of success that is pushing me. The learning process described in the interview is complex and apparently took at least two months to produce a subjectively satisfying outcome. Starting with the cognitive element of understanding one’s own negative patterns, the user then is endowed with common coping strategies and finally encouraged to find their own strategies. Those personalized strategies are gradually transferred from theory into real life conditions, with an emphasis on the need for recurrent practise of the recently adopted strategies as a sub-process of learning itself. Also, when interviewees did not directly mention the procedural nature of their learning experiences, the described results of their overall treatment often imply complex and time-consuming changes that took place during FIT: I always used to put myself in the background. Always helped others, but now I can say: Okay, I can be egoistic sometimes, I can fend for myself. I can reward myself sometimes with something good, which in return is good for me. I learned a lot about myself. That I am capable of much more than I usually think I am. What I learnt after almost 60 years of being alive is to use the word ‘no’ as it is meant to be used. Just as ‘No!’ Transformations of this kind and scale, consisting of substantial shifts in the way a person thinks, feels, and acts, are not likely to happen within a few days. They may often start with intensive reflections of one’s current situation, of potentials to change it and of goals to be achieved: Everything collapsed over me. I am lying under this pile of debris and slowly start crawling out. Then, I turn around and look back: What should I just throw away? What should I discontinue? What would deserve to be rebuild? What would be worth a new start? To stimulate beneficial changes, recovery or even personal growth, interviewees regularly referred to the importance of exchange with or feedback and impulses from both professionals and peers. This was described as especially beneficial when combined and a multitude of views on an individual’s problems were provided: Most patients speak about their own experiences or own crises […] and sometimes it is helpful to just try it the way other people did who already had similar experiences, and sometimes it is helpful to know the [scientific] background. Also, the heterogeneity of professional perspectives from the different specialists (psychiatrists, psychologist, occupational therapists, social workers etc.) involved in a patient’s treatment was perceived as helpful: „Through the different approaches of the professionals and the whole team, one came to know many different aspects. [There were] psychological approaches, ranging from CBT to psychodynamic therapy. There was a lot to take home for me about my disorder, and also the way how I can relate to it improved enormously due to knowing its scientific backgrounds.” Intensity , thus, refers to processes of learning and un-learning in order to think, feel or act differently in ways that enable a person to improve or even to recover from a certain condition or crisis. According to the interview material, these processes seem to play a main role for any kind of treatment success and are necessarily requiring an appropriate amount of time. They involve intensive reflections and the gradual translation of newly acquired knowledge into changes of perception and interpretation of e.g., inner states and social interactions, ideally also resulting in beneficial behavioural changes. Since intensity as a property of treatment can occur in both inpatient and day care settings, it apparently should be attributed to the FIT component of the formula FIT* ~BED *HLS ->OUT. 3.2.2 Solidarity In the interview material, contact with other users was mostly categorized as belonging to the component of solidarity . In contrast to intensity , the concept of solidarity probably refers more to informal ways of interacting, such as shared meals and shared leisure time in the evening. Accordingly, this feature can be more clearly attributed to the HLS component in the formula outlined above. It was highly valued for various reasons, among which most consistently were open and straightforward feedback, the exchange of experiences and coping strategies, and contact as a source of self-validation, hope and confidence: There are also experiences from other patients that give you back your confidence when you are doubting if you are still going somewhere. Or if you will be able to get healthy again at all. Giving feedback between users was often described as bold, but well-meaning: “It’s about pointing out each other’s strengths as much as each other’s weaknesses, but without anyone taking offense”. Feedback was perceived as a particularly strong incentive to effectively change one’s behavior when articulated by a whole group, ideally comprising professionals and users: You know, everyone has some tics and quirks. […] When it is only one person telling you, you don’t know if you have to take it seriously. But when there are several people that tell you […], when you notice there is something about you the team and the others don’t really appreciate, well, then you try to change, change in a positive way. While it is obvious that direct feedback was a strong stimulus for behavioral change and ultimately improvement, the presence of other users was also linked to more subtle experiences, which helped interviewees to recover. Regularly, the realization of not being alone with a certain condition in the sense of sharing a similar fate or life-reality with other people was mentioned as beneficial. Sometimes, the observation that other users that the observer held in high regard were suffering from the same condition could even be an origin of indirect self-validation: It was a real light bulb moment when I noticed that all the others with depression were just ordinary and even great people somehow. And they got into the same mess anyways. […] And it doesn’t make you a bad person. It can happen to people you would never think of when you meet them out in the streets. Even more indirect, but frequently mentioned factors were group dynamics in the sense of the experience of being part of a community in which people cared for each other, or a strong feeling of togetherness. What helped me a lot were the other ‘inmates’. Obviously, we are all sitting in the same boat. We are all pulling together for getting better. The whole thing was like being part of a big family. It was relatively familial. It was just empathic without thinking too much about it. The familial atmosphere could also encourage practicing certain skills through interactions with other users in a casual, subjectively risk-free way, which sometimes started important bottom-up learning processes: In here, you are talking to 10, 15 different persons a day, with some you get along well, with some not so well. […] And you notice, also in your private life, that is exactly what you need to do about your social behaviour if you don’t want to be lonely. Solidarity, entailing a multitude of feedback, but also feelings of togetherness and experiences of belonging to a certain community, was described as a strong stimulus for beneficial changes in the way a person thinks, feels, and acts. Once again, these kinds of deep-running changes imply procedurality and thus, an appropriate amount of time. 3.2.3 Time Interestingly, statements categorized as explicitly belonging to the component time were often of a more general nature. Among other things, it was highlighted that any kind of therapy schedule should be neither too dense to avoid additional stress, nor contain too much unstructured time, which might demotivate users and make them feel like there is no real help provided. Also, it was regularly mentioned that professionals should offer enough time for regular and spontaneous conversations, that the therapy schedule should be transparent and reliable and that users should be able to decide for how long they want to stay in any kind of therapeutic setting. However, while those aspects are general in the sense that they can be equally applied to inpatient and outpatient-treatment, there were also single statements that corroborated the above considerations by explicitly linking time spent at an inpatient-setting with improvement: “[At the inpatient ward,] I had a relatively long waiting time until my therapy program started, but it was alright. I had a lot of time for myself, in which I could think about myself and about what had happened. The insight just came on its own. […] But it took quite a while until I somehow accepted the insight, just for myself. Well, it’s that being on your own. Being on your own and think, that worked somehow. Plus, the regular therapeutic sessions in which you can articulate what you just thought”. Time, in this example, is described as empty waiting time until the therapeutic schedule was initialized but seems to also serve as a period of reaching a state of inner readiness for therapy. While the former is of a structural nature and could be potentially shortened through organizational optimisation, the latter seems to be a highly individual matter in the sense that it takes as long as it takes . In this vein, a shortening of waiting time could even be detrimental to the process of readying yourself for therapy and ultimately for therapeutic success. 4 DISCUSSION The results of our crisp-set qualitative comparative analysis suggest that a combination of all three conditions FIT, ~BED, and HLS can contribute to the explanation of what constitutes and how to reach a high experience-based quality of psychiatric treatment. ~BED represented a necessary condition for FIT, which in turn was a necessary condition for the outcome of interest. A longer HLS was a sufficient condition for a higher experience-based quality of psychiatric treatment. According to that, a shorter HLS was found to be necessary for a lower experience-based treatment quality. The role of FIT as a necessary condition for positive treatment experience in psychiatry is in line with results from other qualitative studies examining comparable psychiatric services such as ACT in Great-Britain, where ACT clients were more satisfied and better engaged with services [ 43 ] or Norway, where ACT was experienced by clients as improved service that promotes recovery [ 44 ]. The importance of longer HLS for positive treatment experiences was also highlighted by some precursor studies that showed a positive correlation between HLS and patient satisfaction [ 45 ], while shortening the length of stay was found to be likely to decrease patient satisfaction [ 46 ]. Longer hospital stay was even identified as the strongest positive predictor of patients’ satisfaction with care [ 47 ]. The analysis of our interview material corroborates these findings and sheds a light on the unexpected result, that FIT most likely generates positive outcomes when it is combined with inpatient treatment of an appropriate length. The users do not only describe their hospital stay as an occasion for learning, understanding, practising and in the end getting better. They effectively portray it as a kind of immersive experience , in which encounters with peers, group dynamics and emotional aspects are main drivers for substantial change and improvement. It is obvious that such processes of learning, substantial change and improvement require a suitable amount of time, provided by a sufficiently long hospital stay. Time, in this case, is rather a precondition for certain processes to happen or experiences to be made than a causal factor for improvement in its own right. Also, it seems likely that opportunities for feedback, impulses, and exchange with a multitude of people with different backgrounds can much more easily be provided in inpatient than in outpatient-treatment-settings. Last but not least, an immersive experience is much more likely to emerge in settings that are separated from the outer world to a certain extent. There is a long and ongoing debate about how to define the quality of psychiatric services from different perspectives, sometimes even formulating conditions for an “ideal psychiatry” [ 48 ] or the “psychiatry of the future” [ 48 ]. In this debate, user perspectives usually stress the importance of preservation of human rights, being treated with dignity and respect by competent, empathic and friendly staff, beneficial therapeutic relationships, being well informed and able to decide about any kind of therapy and receiving the individually right type of care [ 49 – 51 ]. The re-analysis of our interview material may contribute to this debate by allowing to outline a kind of ideal inpatient-setting from a user perspective: This would be a place that provides a broad variety of different impulses in a relatively short time span, that enables reflection of one’s own situation, the activation of pre-existing knowledge and the acquisition of new, useful knowledge. Ideally, this place would be at the same time a highly professionalized environment, where different kinds of therapies are offered, and a space for solidarity, with a friendly or even familial atmosphere, that encourages trial and error, bold but well-meaning feedback, and engenders a feeling of togetherness However, it is highly questionable that standard inpatient treatment can reliably provide this kind of ideal setting, as it is quite regularly criticized for being a place of disrespect, coercion, and violation of human rights with very little treatment offered other than pharmaceuticals [ 52 , 53 ]. In this context, it is important to highlight that our analysis only found a positive effect of a longer hospital stay when FIT was present as well. This begs the question why hospital stays in facilities that are offering FIT may be closer to the outlined ideal inpatient-setting than at non-FIT psychiatric hospitals and, ultimately, might produce better treatment results. While the interview material and the used methodology do not allow a definite answer, two hypotheses can be formulated: First, as a kind of soft factor, the necessary friendly, non-threatening and supportive atmosphere for an immersive experience may be easier to reach in institutions that embrace the principles of FIT, in short, providing services tailored to the individuals’ needs with a maximum of respect. In the terminology of the a German sociologist Max Weber [ 54 ], there might be a specific “spirit” of FIT at play, that permeates the structures of such institutions as well as it is reflected in the stance and behaviour of the staff towards users. Second, as a kind of hard factor, FIT-institutions may be structurally better equipped for a smooth and timely transfer of users from the somewhat artificial hospital reality back into the “real world”. Typical structural properties of FIT like flexibility and continuity permit a successive reduction of treatment intensity instead of the clear-cut binary of inpatient- versus outpatient-care that usually implies an abrupt change of therapeutic approach, the therapeutic personnel in charge and a loss of contact with the inpatient peer-group. This kind of smooth and gradual transfer may be key for any sustainable process of change and treatment success. A general limitation of the study is its cross-sectional design in which deinstitutionalization cannot be traced in dynamics and analysed as a process. To compare the results of the present study with the findings previously obtained with other analysis techniques, the same data set was analysed, which had already been calibrated for the multidimensional scaling. However, a highly formalized level of this calibration may limit its transparency. Furthermore, our sample included only fourteen hospitals, which may limit the generalizability of results to other mental health hospitals in the country. For data protection reasons, the examined hospitals could not be made identifiable. Therefore, even though the data were analysed at the macro-level (hospitals), it was possible to discuss the results only at the micro-level (patients). As a second limitation, it is noteworthy that while our analysis builds on experience-based quality of psychiatric treatment as defined in a participatory research process, both its first (QCA) as well at its second step (qualitative re-analysis of interview material) were performed by experts by profession only. While results of QCA seem to be robust against individual biases, it is possible that the second step of our study, involving essentially hermeneutic operations such as the selection and interpretation of relevant interview passages, might have come to different results if conducted by experts by experience. An additional source of bias may arise from the fact that, in FIT models, it is often the more severely ill patients who are admitted to the relatively limited number of inpatient beds, suggesting a potentially different pattern of inpatient selection. Against the background of the overall positive impression of a FIT64b-hospital stay derived from the interviews, another limitation seems to be relevant: The described “ideal” conditions may only be ideal for a certain part of users. To effectively immerge into a space for learning and encounter as ideally provided by FIT may only work for those who can socially afford to stay at a ward for an adequate period of time. This might not be the case, among others, for single-parents, parents of younger children, or for users that provide daily care for other people, e.g. partners or elderly relatives. Also, users with extensive negative experiences with inpatient treatment in the past, for instance through coercive measures, may only have limited benefits from another hospitalization. For users with these kinds of obstacles or experiences, inpatient-treatment might be a quite sub-optimal choice. However, it may be one of the greatest strengths of FIT64b-Institutions that they offer a comparatively wider range of flexible possibilities to receive the personally most important parts of treatment also for users who have compelling reasons to stay at home. Finally, our findings on deinstitutionalization are based solely on an analysis of flexible and integrated psychiatric treatment under Section 64b of the German Social Code Book V and can only be cautiously extended to other forms of deinstitutionalized mental health care. 5 CONCLUSION In our mixed-methods study with a qual→quan→QUAL design closed in a single loop, we identified three deinstitutionalization-related conditions that were necessary and/or sufficient for a high experience-based quality of psychiatric care. Based on a re-analysis of interview data, we suggested an interpretation of their importance for this positive outcome. Our qualitative-comparative analysis including data from 14 German psychiatric hospitals showed that a combination of the conditions FIT* ~BED *HLS could be a causal factor for a high experience-based quality of psychiatric care: Modern psychiatric services with a reduced number of hospital beds and well-developed outpatient care like FIT64b were necessary for a higher experience-based quality, but inpatient treatment should include an appropriate length of stay. Subsequent analysis of interview data clarified the importance of HLS. Inpatient treatment of adequate length, if provided in a FIT64b hospital, can potentially be an immersive and deeply transformative experience that requires an appropriate amount of time to make use of a multitude of occasions for processes of learning, reflection and behavioural changes, provided by encounters with peers, group dynamics and a highly professionalized therapeutic environment. Overall, the data presented can be used for planning mental health services and furthering the deinstitutionalization of psychiatry. Abbreviations BED Psychiatric hospital beds Con Consistency Cov Coverage CovN Coverage of necessity cs-QCA Crisp-set QCA FIT Flexible and Integrative psychiatric treatment FIT64B Flexible and integrated psychiatric treatment under Section 64b of the German Social Code Book V HLS Hospital length of stay OUT Outcome PROMS Patient Reported Outcome Measures PREMS Patient Reported Experience Measures PRI Proportional reduction in inconsistency QCA Qualitative Comparative Analysis RoN Relevance of necessity Declarations Ethics approval and consent to participate PsychCare trial was reviewed and approved by Institutional Review Board of the Medical Faculty of the Technical University Dresden and at each site where a separate approval was mandatory. All methods were performed in accordance with relevant guidelines and regulations, including the 1964 Declaration of Helsinki and its later amendments. The authors afrm that signed informed consent was obtained from all individual participants included in this study. Consent for publication Not applicable as there are no image or other confidentiality-related issues. Competing interests The authors declare no competing interests. Funding This study was part of the multi-center controlled PsychCare trial, which was funded by the Innovation Fund at the Federal Joint Committee Germany under reference number 01VSF16053. The funder had no role in the study design and is not involved in its execution, data analysis, and dissemination of results Author Contribution SvP, MH, and YI contributed in the conception and the design of the work. YI conducted the data acquisition and analysis. TB, YI, SvB, and MH contributed in the interpretation of the data. TB and YI drafted the work and SvP and MH revised it. All authors read and approved the final manuscript. Acknowledgement The multi-center controlled PsychCare trial was funded by the Innovation Fund at the Federal Joint Committee Germany. The authors would like to thank all participants in the PsychCare trial. Data Availability The datasets used and analysed during the current study are available from the corresponding author upon reasonable request. References The development and implementation of quality improvement. systems (QIS) in health care: recommendation no. R (97) 17, adopted by the Committee of Ministers of the Council of Europe on 30 September 1997, and explanatory memorandum. Strasbourg: Council of Europe Pub.; 1998. Coulter A. Measuring what matters to patients. BMJ. 2017;356:j816. Fernandes S et al. Measuring the patient experience of mental health care: a systematic and critical review of patient-reported experience measures. Patient Prefer Adherence. 2020:2147–61. 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In the current discussion, there are different views on what constitutes the quality of (psychiatric) treatment. It is highlighted that quality is a latent construct [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] that requires a precise definition or normative specifications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In this context, in addition to the collection of routine and social data to evaluate the results and quality of mental health care, the use of so-called patient-reported parameters is recommended. While \"patient reported outcome measures\" (PROMS) relate to the outcome of a treatment, e.g. the quality of life achieved or the state of users\u0026rsquo; health, \"patient reported experience measures\" (PREMS) aim at systematically mapping the users' experiences with a treatment or care process [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In a UK study using participatory expert panels to evaluate common psychiatric outcome measures, the suitability of the measures was found to be consistently low [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This finding is highly problematic, as it becomes increasingly acknowledged that high-quality mental healthcare that ultimately enables recovery is only possible if evaluation instruments are grounded in the specific perspectives of users [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAs a result of a controlled, prospective, multicenter cohort study in Germany, an exploratory construct of experience-related quality components that grasp the users\u0026rsquo; experiences of psychiatric care was developed in participative-collaborative cooperation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The construct contained twelve key quality components, which were presented in an operationalized form and in relation to each other based on multidimensional scaling. Furthermore, the construct made it possible to separate structural from interpersonal requirements of the quality components. It further indicated which experience-related quality components are more feasible for the home treatment setting, and which ones for an institutional setting. This bipolar dimension seems to be critical for the current state of mental health services in Germany, where different variations of flexible and integrative treatment models take place alongside the standard ones.\u003c/p\u003e\u003cp\u003eOne of the features of the standard German system of psychiatric care is that regular and relatively high reimbursement of inpatient care results in a large number of beds and high bed occupancy, following the infamous Roemer\u0026rsquo;s law for insured populations that a hospital bed built is a bed filled [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, there is also a clear trend to deinstitutionalization. Since 2012, a new law (\u0026sect;\u0026nbsp;64b, Book V of the Social Security Code [SGB V]) allows the implementation of flexible and integrative treatment (FIT64b) models for patients with mental illness in Germany. The specific components of FIT64b are continuity of care provided by multidisciplinary teams, providing therapeutic group sessions across all settings, involving informal caregivers, assuring accessibility of services, sovereign steering of services, and collaboration across sectors, and to expand professional expertise [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, the central FIT64b components are the rapid movement of patients from inpatient to outpatient care being a core feature of any kind of deinstitutionalization, plus flexible care management across settings, and outreach [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe transition to providing new community-based mental health services is often described in terms of deinstitutionalization and is expected to achieve an overall reduction in the number of inpatient beds [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Community services, seen as part of deinstitutionalization, are evolving to meet the diverse and complex needs of both patients discharged from hospitals and, more importantly, all those patients who, through these services, either never enter hospitals or spend only a short time in them. Despite the positive aspects of deinstitutionalization on mental health care quality [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], it also arguably increases readmission rates [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although patients are generally positive about FIT and outreach health care, in some cases home treatment may have been perceived as associated with \"disrupting a person's or family's privacy\" [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn most studies [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] the impact of deinstitutionalization on the quality of mental health care was examined through indicator analysis. Only a few studies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] investigated the impact of deinstitutionalization on the experience-based quality of mental health care by predominantly using questionnaires, which were not developed by the health care users themselves. To our knowledge, there have been no comprehensive studies of indicators of deinstitutionalization and PREMS obtained in collaboration with mental health care users, especially not in the context of FIT64b and comparable attempts for reorganizing psychiatric care.\u003c/p\u003e\u003cp\u003eThis study aims (1) to identify which deinstitutionalization-related conditions are sufficient and/or necessary for experience-based quality of psychiatric treatment as defined by characteristics established in a participatory research process [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and (2) to develop explanations why the identified conditions are of high, maybe even causal importance for the positive outcome. The identification will be carried out through a Qualitative Comparative Analysis (QCA), a method that is increasingly recognized for the analysis of causal relationships in rather small data sets. Explanations will be developed through a qualitative re-analysis of interview material inspired by grounded theory methodology.\u003c/p\u003e"},{"header":"2 METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Project context and design\u003c/h2\u003e\u003cp\u003eOur study builds on some of the results of the prospective, controlled PsychCare cohort study for the evaluation of FIT64b hospitals that was conducted between 2017 and 2021. PsychCare itself was partly prepared by Eva-Mod64, a previous study in which 13 FIT hospital departments were evaluated between 2016 and 2017 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. For each FIT department included in PsychCare, a structurally comparable psychiatric control department was identified [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Nine of 17 eligible FIT64b hospitals and five control hospitals consented to take part also in the qualitative part of the study. Quantitative baseline and qualitative data collection lasted from March 2018 to September 2019, with the latter encompassing a total of 71 problem-centred interviews. The details on the collection and evaluation of interviews are published elsewhere [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe research design combined phases qual\u0026rarr;quan\u0026rarr;QUAL within a single integrated cycle. In J.M. Morse\u0026rsquo;s mixed-methods terminology [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], this design refers to a sequential research process that begins with an exploratory qualitative phase to develop insights or hypotheses, followed by a quantitative phase to test or measure those insights, and concludes with a final, in-depth qualitative phase to interpret or contextualize the findings. This integrated cycle ensures both breadth and depth, enhancing the validity and richness of the overall understanding. Routine data and quantified qualitative interview data were used to develop potentially necessary and sufficient conditions, as well as to define the outcome of interest, which was then examined using Qualitative Comparative Analysis (QCA) as the core method. Subsequently, the original interview data were re-analyzed to interpret the formal results of the QCA.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 QCA using crisp sets\u003c/h2\u003e\u003cp\u003eQCA was developed by Ragin (1987), as a combination of the strengths of qualitative and quantitative research methods based on Boolean algebra [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. There is now a growing body of published research in public health and related fields drawing on QCA methods [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. QCA is known to be robust against small sample size [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and can, therefore, be used for smaller data sets seen in firm-level studies. It focuses on two aspects\u0026mdash;whether a given outcome is observed when a particular configuration is present and whether the outcome is not observed when the configuration is absent. Thus, it has the potential to cover for both \u003cem\u003enecessary\u003c/em\u003e and \u003cem\u003esufficient\u003c/em\u003e conditions for outcomes.\u003c/p\u003e\u003cp\u003eA condition is considered \u003cem\u003enecessary\u003c/em\u003e for an outcome if it is always present when the outcome occurs. In other words, the outcome cannot occur in the absence of the condition, but its presence does not guarantee the outcome. A condition or combination of conditions is \u003cem\u003esufficient\u003c/em\u003e for an outcome if the outcome always occurs when the condition or combination is present. The presence of a sufficient condition or combination of sufficient conditions guarantees the outcome when the necessary conditions are present.\u003c/p\u003e\u003cp\u003eQCA also generates statistics on \u0026ldquo;consistency\u0026rdquo; and \u0026ldquo;coverage\u0026rdquo; to ascertain if tested configurations are statistically rigorous enough. Consistency (Con) is seen as being similar to the significance score in conventional regression, and high consistency indicates that a specific configuration-outcome relationship is salient. Coverage (Cov) evaluates the degree to which a particular configuration accounts for instances of an outcome. To rule out that a necessary condition is trivial, a measure called relevance of necessity (RoN) was suggested [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Another statistic measure called proportional reduction in inconsistency (PRI) expresses how much it helps to know that a given condition X is a subset of outcome Y rather than a subset of either Y, its complement\u0026thinsp;~\u0026thinsp;Y, or the intersection between Y and ~\u0026thinsp;Y.\u003c/p\u003e\u003cp\u003eQualitative Comparative Analysis (QCA) can be conducted using dichotomous (crisp sets), numerical (fuzzy sets), or categorical (multi-value) data. In this study, we employed the crisp-set QCA (cs-QCA) method, which uses binary values to indicate full membership (1) or full non-membership (0), for several reasons:\u003c/p\u003e\u003cp\u003eFirst, dichotomized scores help move beyond a gradualist perspective by highlighting qualitative differences in kind rather than merely differences in degree. This facilitates the development of models that are more accessible and actionable for practitioners.\u003c/p\u003e\u003cp\u003eSecond, cs-QCA conceptualizes cases as configurations of conditions, allowing different case types to be distinguished by relatively integrated sets of features [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThird, cs-QCA offers a balance between deep, case-specific understanding and the identification of cross-case patterns, thereby enabling new insights into both individual complexities and shared structures [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Identifying, assessing and calibrating the outcome of interest\u003c/h2\u003e\u003cp\u003eThe potential of QCA in analysing qualitative interview data was demonstrated by a number of studies [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The basis of the outcome of interest (experience-based quality of psychiatric treatment) were twelve experience-related characteristics (\u003cem\u003eFlexibility, Activity, (Preventing) Stigmatization, Compatibility with everyday life, Autonomy, Safety, Continuity, Intensity, Knowledge, Time, Solidarity, (Absence) of coercion\u003c/em\u003e), which were developed through a re-analysis of data from the EvaMod64b precursor study EvaMod64b [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Detailed definitions of these characteristics are given elsewhere [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Based on them, qualitative interview guides were developed. To be able to systematically compare the data from the qualitative interviews, conversion of these data into quantified items was necessary. For this purpose, a data transformation was performed, which involved \u003cem\u003efour steps\u003c/em\u003e orientated at previous and other publications [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDrawing on the open coding process (\u003cem\u003estep 1\u003c/em\u003e), codes were classified as positive (component fulfilled in this department) or negative (not fulfilled), and these weights added (\u003cem\u003estep 2\u003c/em\u003e). The cumulative mean of the classified and weighted codes of all statements that were queried was set in relation to the cumulative mean of codes for spontaneous statements (\u003cem\u003estep 3\u003c/em\u003e). The negative and positive, corrected partial scores were added, resulting in a total score for each department (\u003cem\u003estep 4\u003c/em\u003e). This step-by-step process is described in more detail elsewhere [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. For the implementation of the QCA, the dichotomised total scores were assumed to be outcome (positive experiences in psychiatric treatment) and non-outcome (negative experiences in psychiatric treatment). The dichotomization was carried out on the basis of complete linkage clustering method by using QCA software [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Identifying, assessing and calibrating the conditions of interest\u003c/h2\u003e\u003cp\u003eDeinstitutionalization is the process of shifting mental health care and support from long-stay psychiatric institutions to community mental health services. There are two crucial aspects of deinstitutionalization [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]: the first involves reforming the conditions and service delivery within psychiatric institutions and downsizing the number of long-stay beds. This is accompanied by the second aspect - strengthening of community-based mental health facilities.\u003c/p\u003e\u003cp\u003eIn QCA, it is suggested not to examine a large number of conditions, especially when the number of cases is limited, in order to avoid having too many condition combinations that are not present in any of the cases. In our analysis, three conditions were considered as potential explanations for the outcome. The condition relating to the first aspect of deinstitutionalization was the dichotomized number of psychiatric beds (BED) in examined nine FIT64b hospitals and five control hospitals. Conditions more related to the second aspect of deinstitutionalization were the dichotomized treatment type in psychiatric departments (flexible integrative treatment (FIT) vs. standard treatment) as well as the average hospital length of stay (HLS). Whereas BED is a widely used structural quality indicator to assess psychiatric deinstitutionalization [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], HLS could be considered as one of its outcome quality indicators, as discharge from inpatient-care usually signifies clinical improvement [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Community-based mental health services like FIT64b are designed to reduce HLS [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and increase patient satisfaction [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Like the outcome, BED and HLS conditions were dichotomized on the basis of complete linkage clustering method [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Data analysis\u003c/h2\u003e\u003cp\u003eThe QCA started by defining potential necessary and sufficient conditions as a first step. For necessary conditions, a consistency threshold of at least 0.9 seems advisable [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. For sufficient conditions, an outcome is present if the consistency is above 0.75 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. For coverage no lower threshold exists. The second step was to compile a combined (for outcome and non-outcome) truth table. Truth tables are an important tool in QCA as they contain the empirical evidence gathered by the researcher by sorting cases into one of the 2\u003csup\u003ek\u003c/sup\u003e logically possible combinations, aka truth table rows, of k conditions. Each row linked to the outcome can be interpreted as a statement of sufficiency [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the third step, different solution formulas of QCA were produced and compared. The solution formula presents the combination of conditions which lead to the outcome in a consistent way. If a solution has consistency of 1.0, this indicates that such a combination of conditions always leads to the outcome. If a solution has a coverage of 1.0, this indicates that this combination of conditions is able to explain all of the occurrences of the outcome.\u003c/p\u003e\u003cp\u003eFollowing recommendations of good practice in QCA [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], several solution formulas of different complexity (conservative solution, parsimonious solution, enhanced parsimonious solution and enhanced intermediate solution) were produced and presented. According to Schneider and Wagemann [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], conservative solution rests on no assumption about logical remainders (rows for which not enough empirical evidence is at hand). It is based solely on truth table rows that are deemed sufficient for the outcome based on empirical evidence. It is the subset of all other possible solutions. The parsimonious solution is more simplified in comparison to the complex solution. It is obtained by employing a less conservative approach over the empirical evidence and includes remainders in the minimization process (summary of the information contained in a truth table, applying the rules of Boolean algebra). The enhanced parsimonious solution is the result of the minimization process excluding the untenable assumptions. For instance, it is contradictory to use the same remainders to simplify the necessary conditions of the outcome and of the negated outcome. The enhanced intermediate solution is based on directional expectations which filter out both the untenable remainders and the difficult counterfactuals.\u003c/p\u003e\u003cp\u003eThe QCA calculation for this dataset was performed with R, a software environment for statistical computing, and the QCA package for R, version 3.11 [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. To present the results, the following formal logical connectives were used: for the conjunction of conditions (logical AND) \u0026lsquo;*,\u0026rsquo; for disjunctions (logical OR) \u0026lsquo; + ,\u0026rsquo; and the negation \u0026lsquo; ~ .\u0026rsquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Qualitative interpretation of QCA-results\u003c/h2\u003e\u003cp\u003eQCA results, expressing relationships between variables and outcomes in the binary logic of Boolean algebra, are by definition highly formalized and abstract. As a downside of clear-cut causal statements such as \u0026ldquo;\u003cem\u003eA is a sufficient condition for B\u003c/em\u003e\u0026rdquo;, they do not contain any information in themselves about \u003cem\u003ewhy\u003c/em\u003e and \u003cem\u003ehow\u003c/em\u003e a certain condition leads to a certain outcome. However, as such knowledge is crucial for advancing the quality of psychiatric care, we introduced a second qualitative step by enriching the interpretation of QCA-results with material from the original 71 problem-centred interviews that we performed from March 2018 to September 2019 in FIT and control hospitals. As the same interviews were used to identify the conditions and outcomes of interest that were the basis of our QCA, our study follows a mixed methods design (qual\u0026rarr;quan\u0026rarr;QUAL) closed in a single loop.\u003c/p\u003e\u003cp\u003eThe precursory, initial analysis of the user-interviews comprised the inductive creation of categories by an open-coding process, leading to the aforementioned twelve main categories that were identified as central experiential components. For this study, we used an approach that was inspired by Grounded Theory Methodology [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] to obtain an empirically saturated explanation of the causal relationships established through QCA, especially of one finding that seemed to contradict our expectations. At the beginning, all twelve main-categories including their subcategories were screened for relevance for our QCA-results, leading to a selection of three components with the strongest intrinsic connection to the explanandum. Within these three categories, all codes and the associated interview fragments were re-analysed for thematic relevance. In an iterative process, the most typical and / or salient with regard to the explanandum were selected and used for an empirically saturated interpretation of the QCA-results of interest that could be considered a middle range theory in line with Grounded Theory.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Results of crisp-set qualitative comparative analysis\u003c/h2\u003e\u003cp\u003eUsing open coding, experiences in psychiatric treatment were classified as positive or negative and weighted accordingly. Weighted codes from queried and spontaneous statements were compared, and corrected partial scores were summed to yield a total score per department. The results from this full step-by-step process are detailed elsewhere [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The median value of positive experiences in psychiatric treatment was 8.0 and for the negative ones it was 3.0. Dichotomizing the total experience scores showed that only four hospitals could be assigned a positive outcome. The median values of high and low number of beds were considered to be 0.83 and 0.51 beds per 1000 inhabitants, respectively. The median values for high HLS were 36.5 days and for low HLS, it was 23.3 days. There were nine FIT psychiatric departments and five departments with standard psychiatric care. The calibrated values of the outcome and conditions can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCalibrated hospital characteristics and data derived from interviews\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"17\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eHospital characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"13\" nameend=\"c17\" namest=\"c5\"\u003e\u003cp\u003eQuantified data from interviews\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFIT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHLS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBED\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOUT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAС\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eCL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eAU\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eSA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003eCO\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c13\"\u003e\u003cp\u003eIN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c14\"\u003e\u003cp\u003eKN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c15\"\u003e\u003cp\u003eTI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c16\"\u003e\u003cp\u003eSO\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c17\"\u003e\u003cp\u003eAB\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eH14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c14\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c15\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c16\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c17\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"17\"\u003eH\u0026thinsp;=\u0026thinsp;Hospital, FIT\u0026thinsp;=\u0026thinsp;Flexible and integrative treatment, HLS\u0026thinsp;=\u0026thinsp;Hospital length of stay, BED\u0026thinsp;=\u0026thinsp;Psychiatric hospital beds, OUT\u0026thinsp;=\u0026thinsp;Outcome (Total score of positive experiences in psychiatric treatment), FL\u0026thinsp;=\u0026thinsp;Flexibility, AC\u0026thinsp;=\u0026thinsp;Activity, PS\u0026thinsp;=\u0026thinsp;Preventing of stigmatization, CL\u0026thinsp;=\u0026thinsp;Compatibility with everyday life, AU\u0026thinsp;=\u0026thinsp;Autonomy, SA\u0026thinsp;=\u0026thinsp;Safety, CO\u0026thinsp;=\u0026thinsp;Continuity, IN\u0026thinsp;=\u0026thinsp;Intensity, KN\u0026thinsp;=\u0026thinsp;Knowledge, Time\u0026thinsp;=\u0026thinsp;TI, SO\u0026thinsp;=\u0026thinsp;Solidarity, AB\u0026thinsp;=\u0026thinsp;Absence of coercion. Dichotomized values: 0\u0026thinsp;=\u0026thinsp;characteristic not present or low; 1\u0026thinsp;=\u0026thinsp;characteristic present or high.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe fit measures of necessary conditions for a certain outcome are represented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Surprisingly, there were two conditions (FIT and ~\u0026thinsp;BED) that could exceed the perfect threshold of 1.0 in consistency with the positive outcome (=\u0026thinsp;positive treatment experience). However, these conditions were not complete duplicates. The ~\u0026thinsp;BED condition was necessary for FIT condition (consistency of 1, coverage\u0026thinsp;=\u0026thinsp;0.89), but had slightly lower сoverage and relevance scores to explain the outcome. For the negative outcome (=\u0026thinsp;negative treatment experience), only\u0026thinsp;~\u0026thinsp;HLS was identified to be necessary.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAnalysis of potential necessary conditions for outcome (positive experiences in psychiatric treatment) and non-outcome (negative experiences in psychiatric treatment)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCondition\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eFit measure\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eNon-outcome\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCon\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCovN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRoN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCon\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCovN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eRoN\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFIT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHLS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e~FIT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e~HLS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e~BED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eCon\u0026thinsp;=\u0026thinsp;Consistency, CovN\u0026thinsp;=\u0026thinsp;Coverage of necessity, RoN\u0026thinsp;=\u0026thinsp;Relevance of necessity, FIT\u0026thinsp;=\u0026thinsp;Flexible and Integrative treatment, HLS\u0026thinsp;=\u0026thinsp;Hospital length of stay, BED\u0026thinsp;=\u0026thinsp;Psychiatric hospital beds.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe truth table (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) revealed four specific combinations of conditions for which there were no empirical cases. The sufficiency inclusion score (Incl.) shows how consistent the cases from a given causal configuration are, to display the same value in the outcome. The case H3 in the Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e showed the positive outcome. However, because the consistency score of the configuration involving H3 with the outcome was well below the 0.9 threshold, the negative outcome in the truth table was attributed to this case. In summary, the positive outcome entailed fewer cases (3) than the negative outcome (11).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCombined truth table for outcome and non-outcome\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eCondition\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003eNon-Outcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFIT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHLS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBED\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOUT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIncl.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePRI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eOUT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eIncl.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003ePRI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eH11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eH10, H12, H13, H14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eH1, H2, H3, H5, H7, H9,\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eH4, H6, H8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eLogical remainder (no empirical case)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eLogical remainder (no empirical case)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eLogical remainder (no empirical case)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eLogical remainder (no empirical case)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"11\"\u003eH\u0026thinsp;=\u0026thinsp;Hospital, FIT\u0026thinsp;=\u0026thinsp;Flexible and Integrative treatment, HLS\u0026thinsp;=\u0026thinsp;Hospital length of stay, BED\u0026thinsp;=\u0026thinsp;Psychiatric hospital beds, OUT\u0026thinsp;=\u0026thinsp;Outcome (total score of positive experiences in psychiatric treatment), Incl: Sufficiency inclusion score PRI: Proportional reduction in inconsistency,\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAll minimization algorithms revealed only one path with consistency of 1.00 and coverage of 0.75, but different solution terms for the positive outcome (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Both FIT and ~\u0026thinsp;BED conditions that were considered to be necessary, disappeared from the formula of the parsimonious solution (=\u0026thinsp;hidden necessary conditions). The enhanced parsimonious solution provided more interpretable terms after the contradictory 5th and 6th rows of the truth table were excluded. However, ~BED condition still remained minimized out of the formula what was difficult to defend. Therefore, enhanced intermediate solution including directional expectations of the theory-guided condition\u0026thinsp;~\u0026thinsp;BED was also taken in account. The formula of this solution FIT* ~BED *HLS -\u0026gt;OUT was identical to that of the conservative solution (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) and chosen for the further considerations.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSolution terms of the crisp-set QCA\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSolution\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePath\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIncl.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePRI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eCovS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConservative solution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFIT*HLS* ~BED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eH4, H6, H8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParsimonious solution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHLS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eH4, H6, H8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnhanced parsimonious solution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFIT*HLS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eH4, H6, H8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnhanced intermediate solution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFIT*HLS* ~BED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eH4, H6, H8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNon-Outcome\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConservative solution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e~FIT*~HLS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eH10, H11, H12, H13, H14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParsimonious solution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e~FIT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eH10, H11, H12, H13, H14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnhanced parsimonious solution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e~FIT*~HLS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eH10, H11, H12, H13, H14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnhanced intermediate solution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e~FIT*~HLS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eH10, H11, H12, H13, H14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eFIT\u0026thinsp;=\u0026thinsp;Flexible and Integrative treatment, HLS\u0026thinsp;=\u0026thinsp;Hospital length of stay, BED\u0026thinsp;=\u0026thinsp;Psychiatric hospital beds, Incl: Sufficiency inclusion score PRI: Proportional reduction in inconsistency, CovS\u0026thinsp;=\u0026thinsp;Sufficiency coverage score, H\u0026thinsp;=\u0026thinsp;Hospital.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOne of the central results of QCA was the emphasis on the role of FIT as a necessary condition for achieving positive experiences of psychiatric treatment. The role of a lower bed number as another necessary condition for the development of the positive PREMS was more ambiguous, as this indicator may reflect either simply low bed capacity by default or represent a structural, intended component of FIT. In the latter case, both identified necessary conditions could be compressed into one (FIT64b with reduced number of hospital beds). Most surprising, however, was the finding of HLS as a sufficient condition for a higher experience-based quality of psychiatric treatment. According to that, a lower HLS was found to be necessary for the non-outcome.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Grounded Theory - inspired interpretation of QCA-results\u003c/h2\u003e\u003cp\u003eIt is in line with the expectations of FIT-hospitals and proponents that FIT, if compared to standard treatment, is causally linked with more positive treatment experiences, especially when combined with a lower number of hospital beds as an indirect marker for well-developed outpatient services. However, it is highly remarkable and unexpected that HLS was found to be a \u003cem\u003esufficient\u003c/em\u003e condition for the positive outcome. With the provision of outpatient instead of inpatient treatment or at least the rapid shifting of patients into an outpatient setting being a cornerstone of the concept of FIT, this finding seems even somewhat contradictory to FIT\u0026rsquo;s intrinsic logic and requires an explanation.\u003c/p\u003e\u003cp\u003eIn order to better understand the meaning of this finding, in other words, \u003cem\u003ewhy\u003c/em\u003e and \u003cem\u003eby which mechanism\u003c/em\u003e a rather long hospital stay can be causal for positive treatment experience, we decided to interpret this result in the light of our initial analysis of user-interviews. In a process of increasing abstraction, the initial analysis had produced the twelve individual experience components of FIT (Flexibility, Activity, (Preventing) Stigmatization, Compatibility with everyday life, Autonomy, Safety, Continuity, Intensity, Knowledge, Time, Solidarity, (Absence) of coercion)) that were the main-categories of our inductive coding process and have been implemented into our QCA as constituent ingredients of our outcome of interest (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Going back to the categories and codes of the initial analysis is a means of winding back the level of abstraction with the purpose of finding potential explanations within the original material.\u003c/p\u003e\u003cp\u003eAs a first step of selecting material for our re-analysis, all twelve components used to characterize FIT were screened for their relevance to explain that FIT is most likely to generate positive outcomes when it is combined with an appropriate HLS. As hospital length itself is a highly abstract, descriptive term, and was very rarely found in the subjective reports of participants, we decided to focus on the direct and indirect mention of \u003cem\u003etime\u003c/em\u003e when meant as \u003cem\u003eimportant part of helpful processes or experiences\u003c/em\u003e as the most suitable subjective equivalent of HLS combined with positive treatment experience. As subcategories and codes of users describing what was helpful for them about inpatient-treatment in relation to \u003cem\u003etime\u003c/em\u003e in the above sense were nearly exclusively found in the main categories \u003cem\u003eIntensity\u003c/em\u003e, \u003cem\u003eSolidarity\u003c/em\u003e and \u003cem\u003eTime\u003c/em\u003e, we decided to focus on them for our qualitative re-analysis.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1 Intensity\u003c/h2\u003e\u003cp\u003eThe subcategories used to detail \u003cem\u003eIntensity\u0026rsquo;s\u003c/em\u003e possible effects already highlight that its core is learning and un-learning, with explicit mention of, among others, learning patience, learning new strategies, learning self-care, learning to accept one\u0026rsquo;s own condition, or learning a different sense of self. That a sufficient amount of time is necessary for this kind of deeply personal, potentially transformative learning was supported by participants typically describing that the lessons they learned or the skills that they acquired as part of a larger process:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI was provided with strategies how to break out of my old patterns [\u0026hellip;] or maybe also how to develop my own strategies. This is, of course, a long process, and it doesn\u0026rsquo;t always work out that well, but [it does work out] significantly better now than one month ago, two months ago, and it\u0026rsquo;s this kind of success that is pushing me.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe learning process described in the interview is complex and apparently took at least two months to produce a subjectively satisfying outcome. Starting with the cognitive element of understanding one\u0026rsquo;s own negative patterns, the user then is endowed with common coping strategies and finally encouraged to find their own strategies. Those personalized strategies are gradually transferred from theory into real life conditions, with an emphasis on the need for recurrent practise of the recently adopted strategies as a sub-process of learning itself.\u003c/p\u003e\u003cp\u003eAlso, when interviewees did not directly mention the procedural nature of their learning experiences, the described results of their overall treatment often imply complex and time-consuming changes that took place during FIT:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI always used to put myself in the background. Always helped others, but now I can say: Okay, I can be egoistic sometimes, I can fend for myself. I can reward myself sometimes with something good, which in return is good for me.\u003c/p\u003e\u003cp\u003eI learned a lot about myself. That I am capable of much more than I usually think I am.\u003c/p\u003e\u003cp\u003eWhat I learnt after almost 60 years of being alive is to use the word \u0026lsquo;no\u0026rsquo; as it is meant to be used. Just as \u0026lsquo;No!\u0026rsquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTransformations of this kind and scale, consisting of substantial shifts in the way a person thinks, feels, and acts, are not likely to happen within a few days. They may often start with intensive reflections of one\u0026rsquo;s current situation, of potentials to change it and of goals to be achieved:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEverything collapsed over me. I am lying under this pile of debris and slowly start crawling out. Then, I turn around and look back: What should I just throw away? What should I discontinue? What would deserve to be rebuild? What would be worth a new start?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo stimulate beneficial changes, recovery or even personal growth, interviewees regularly referred to the importance of exchange with or feedback and impulses from both professionals and peers. This was described as especially beneficial when combined and a multitude of views on an individual\u0026rsquo;s problems were provided:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMost patients speak about their own experiences or own crises [\u0026hellip;] and sometimes it is helpful to just try it the way other people did who already had similar experiences, and sometimes it is helpful to know the [scientific] background.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAlso, the heterogeneity of professional perspectives from the different specialists (psychiatrists, psychologist, occupational therapists, social workers etc.) involved in a patient\u0026rsquo;s treatment was perceived as helpful:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026bdquo;Through the different approaches of the professionals and the whole team, one came to know many different aspects. [There were] psychological approaches, ranging from CBT to psychodynamic therapy. There was a lot to take home for me about my disorder, and also the way how I can relate to it improved enormously due to knowing its scientific backgrounds.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eIntensity\u003c/em\u003e, thus, refers to processes of learning and un-learning in order to think, feel or act differently in ways that enable a person to improve or even to recover from a certain condition or crisis. According to the interview material, these processes seem to play a main role for any kind of treatment success and are necessarily requiring an appropriate amount of time. They involve intensive reflections and the gradual translation of newly acquired knowledge into changes of perception and interpretation of e.g., inner states and social interactions, ideally also resulting in beneficial behavioural changes. Since \u003cem\u003eintensity\u003c/em\u003e as a property of treatment can occur in both inpatient and day care settings, it apparently should be attributed to the FIT component of the formula FIT* ~BED *HLS -\u0026gt;OUT.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2 Solidarity\u003c/h2\u003e\u003cp\u003eIn the interview material, contact with other users was mostly categorized as belonging to the component of \u003cem\u003esolidarity\u003c/em\u003e. In contrast to \u003cem\u003eintensity\u003c/em\u003e, the concept of \u003cem\u003esolidarity\u003c/em\u003e probably refers more to informal ways of interacting, such as shared meals and shared leisure time in the evening. Accordingly, this feature can be more clearly attributed to the HLS component in the formula outlined above. It was highly valued for various reasons, among which most consistently were open and straightforward feedback, the exchange of experiences and coping strategies, and contact as a source of self-validation, hope and confidence:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThere are also experiences from other patients that give you back your confidence when you are doubting if you are still going somewhere. Or if you will be able to get healthy again at all.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eGiving feedback between users was often described as bold, but well-meaning:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s about pointing out each other\u0026rsquo;s strengths as much as each other\u0026rsquo;s weaknesses, but without anyone taking offense\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFeedback was perceived as a particularly strong incentive to effectively change one\u0026rsquo;s behavior when articulated by a whole group, ideally comprising professionals and users:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eYou know, everyone has some tics and quirks. [\u0026hellip;] When it is only one person telling you, you don\u0026rsquo;t know if you have to take it seriously. But when there are several people that tell you [\u0026hellip;], when you notice there is something about you the team and the others don\u0026rsquo;t really appreciate, well, then you try to change, change in a positive way.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhile it is obvious that direct feedback was a strong stimulus for behavioral change and ultimately improvement, the presence of other users was also linked to more subtle experiences, which helped interviewees to recover. Regularly, the realization of not being alone with a certain condition in the sense of sharing a similar fate or life-reality with other people was mentioned as beneficial. Sometimes, the observation that other users that the observer held in high regard were suffering from the same condition could even be an origin of indirect self-validation:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt was a real light bulb moment when I noticed that all the others with depression were just ordinary and even great people somehow. And they got into the same mess anyways. [\u0026hellip;] And it doesn\u0026rsquo;t make you a bad person. It can happen to people you would never think of when you meet them out in the streets.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEven more indirect, but frequently mentioned factors were group dynamics in the sense of the experience of being part of a community in which people cared for each other, or a strong feeling of togetherness.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhat helped me a lot were the other \u0026lsquo;inmates\u0026rsquo;. Obviously, we are all sitting in the same boat. We are all pulling together for getting better.\u003c/p\u003e\u003cp\u003eThe whole thing was like being part of a big family. It was relatively familial. It was just empathic without thinking too much about it.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe familial atmosphere could also encourage practicing certain skills through interactions with other users in a casual, subjectively risk-free way, which sometimes started important bottom-up learning processes:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIn here, you are talking to 10, 15 different persons a day, with some you get along well, with some not so well. [\u0026hellip;] And you notice, also in your private life, that is exactly what you need to do about your social behaviour if you don\u0026rsquo;t want to be lonely.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSolidarity, entailing a multitude of feedback, but also feelings of togetherness and experiences of belonging to a certain community, was described as a strong stimulus for beneficial changes in the way a person thinks, feels, and acts. Once again, these kinds of deep-running changes imply procedurality and thus, an appropriate amount of time.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e3.2.3 Time\u003c/h2\u003e\u003cp\u003eInterestingly, statements categorized as explicitly belonging to the component \u003cem\u003etime\u003c/em\u003e were often of a more general nature. Among other things, it was highlighted that any kind of therapy schedule should be neither too dense to avoid additional stress, nor contain too much unstructured time, which might demotivate users and make them feel like there is no real help provided. Also, it was regularly mentioned that professionals should offer enough time for regular and spontaneous conversations, that the therapy schedule should be transparent and reliable and that users should be able to decide for how long they want to stay in any kind of therapeutic setting. However, while those aspects are general in the sense that they can be equally applied to inpatient and outpatient-treatment, there were also single statements that corroborated the above considerations by explicitly linking \u003cem\u003etime\u003c/em\u003e spent at an inpatient-setting with improvement:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[At the inpatient ward,] I had a relatively long waiting time until my therapy program started, but it was alright. I had a lot of time for myself, in which I could think about myself and about what had happened. The insight just came on its own. [\u0026hellip;] But it took quite a while until I somehow accepted the insight, just for myself. Well, it\u0026rsquo;s that being on your own. Being on your own and think, that worked somehow. Plus, the regular therapeutic sessions in which you can articulate what you just thought\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTime, in this example, is described as empty waiting time until the therapeutic schedule was initialized but seems to also serve as a period of reaching a state of inner readiness for therapy. While the former is of a structural nature and could be potentially shortened through organizational optimisation, the latter seems to be a highly individual matter in the sense that \u003cem\u003eit takes as long as it takes\u003c/em\u003e. In this vein, a shortening of waiting time could even be detrimental to the process of readying yourself for therapy and ultimately for therapeutic success.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"4 DISCUSSION","content":"\u003cp\u003eThe results of our crisp-set qualitative comparative analysis suggest that a combination of all three conditions FIT, ~BED, and HLS can contribute to the explanation of what constitutes and how to reach a high experience-based quality of psychiatric treatment. ~BED represented a necessary condition for FIT, which in turn was a necessary condition for the outcome of interest. A longer HLS was a sufficient condition for a higher experience-based quality of psychiatric treatment. According to that, a shorter HLS was found to be necessary for a lower experience-based treatment quality.\u003c/p\u003e\u003cp\u003eThe role of FIT as a necessary condition for positive treatment experience in psychiatry is in line with results from other qualitative studies examining comparable psychiatric services such as ACT in Great-Britain, where ACT clients were more satisfied and better engaged with services [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] or Norway, where ACT was experienced by clients as improved service that promotes recovery [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. The importance of longer HLS for positive treatment experiences was also highlighted by some precursor studies that showed a positive correlation between HLS and patient satisfaction [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], while shortening the length of stay was found to be likely to decrease patient satisfaction [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Longer hospital stay was even identified as the strongest positive predictor of patients\u0026rsquo; satisfaction with care [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe analysis of our interview material corroborates these findings and sheds a light on the unexpected result, that FIT most likely generates positive outcomes when it is combined with inpatient treatment of an appropriate length. The users do not only describe their hospital stay as an occasion for learning, understanding, practising and in the end getting better. They effectively portray it as a kind of \u003cem\u003eimmersive experience\u003c/em\u003e, in which encounters with peers, group dynamics and emotional aspects are main drivers for substantial change and improvement. It is obvious that such processes of learning, substantial change and improvement require a suitable amount of time, provided by a sufficiently long hospital stay. Time, in this case, is rather a precondition for certain processes to happen or experiences to be made than a causal factor for improvement in its own right. Also, it seems likely that opportunities for feedback, impulses, and exchange with a multitude of people with different backgrounds can much more easily be provided in inpatient than in outpatient-treatment-settings. Last but not least, an immersive experience is much more likely to emerge in settings that are separated from the outer world to a certain extent.\u003c/p\u003e\u003cp\u003eThere is a long and ongoing debate about how to define the quality of psychiatric services from different perspectives, sometimes even formulating conditions for an \u0026ldquo;ideal psychiatry\u0026rdquo; [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] or the \u0026ldquo;psychiatry of the future\u0026rdquo; [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. In this debate, user perspectives usually stress the importance of preservation of human rights, being treated with dignity and respect by competent, empathic and friendly staff, beneficial therapeutic relationships, being well informed and able to decide about any kind of therapy and receiving the individually right type of care [\u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. The re-analysis of our interview material may contribute to this debate by allowing to outline a kind of ideal inpatient-setting from a user perspective: This would be a place that provides a broad variety of different impulses in a relatively short time span, that enables reflection of one\u0026rsquo;s own situation, the activation of pre-existing knowledge and the acquisition of new, useful knowledge. Ideally, this place would be at the same time a highly professionalized environment, where different kinds of therapies are offered, and a space for solidarity, with a friendly or even familial atmosphere, that encourages trial and error, bold but well-meaning feedback, and engenders a feeling of togetherness\u003c/p\u003e\u003cp\u003eHowever, it is highly questionable that standard inpatient treatment can reliably provide this kind of ideal setting, as it is quite regularly criticized for being a place of disrespect, coercion, and violation of human rights with very little treatment offered other than pharmaceuticals [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. In this context, it is important to highlight that our analysis \u003cem\u003eonly\u003c/em\u003e found a positive effect of a longer hospital stay when FIT was present as well. This begs the question why hospital stays in facilities that are offering FIT may be closer to the outlined ideal inpatient-setting than at non-FIT psychiatric hospitals and, ultimately, might produce better treatment results. While the interview material and the used methodology do not allow a definite answer, two hypotheses can be formulated: First, as a kind of soft factor, the necessary friendly, non-threatening and supportive atmosphere for an immersive experience may be easier to reach in institutions that embrace the principles of FIT, in short, providing services tailored to the individuals\u0026rsquo; needs with a maximum of respect. In the terminology of the a German sociologist Max Weber [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], there might be a specific \u0026ldquo;spirit\u0026rdquo; of FIT at play, that permeates the structures of such institutions as well as it is reflected in the stance and behaviour of the staff towards users. Second, as a kind of hard factor, FIT-institutions may be structurally better equipped for a smooth and timely transfer of users from the somewhat artificial hospital reality back into the \u0026ldquo;real world\u0026rdquo;. Typical structural properties of FIT like flexibility and continuity permit a successive reduction of treatment intensity instead of the clear-cut binary of inpatient- versus outpatient-care that usually implies an abrupt change of therapeutic approach, the therapeutic personnel in charge and a loss of contact with the inpatient peer-group. This kind of smooth and gradual transfer may be key for any sustainable process of change and treatment success.\u003c/p\u003e\u003cp\u003eA general limitation of the study is its cross-sectional design in which deinstitutionalization cannot be traced in dynamics and analysed as a process. To compare the results of the present study with the findings previously obtained with other analysis techniques, the same data set was analysed, which had already been calibrated for the multidimensional scaling. However, a highly formalized level of this calibration may limit its transparency. Furthermore, our sample included only fourteen hospitals, which may limit the generalizability of results to other mental health hospitals in the country. For data protection reasons, the examined hospitals could not be made identifiable. Therefore, even though the data were analysed at the macro-level (hospitals), it was possible to discuss the results only at the micro-level (patients).\u003c/p\u003e\u003cp\u003eAs a second limitation, it is noteworthy that while our analysis builds on experience-based quality of psychiatric treatment as defined in a participatory research process, both its first (QCA) as well at its second step (qualitative re-analysis of interview material) were performed by experts by profession only. While results of QCA seem to be robust against individual biases, it is possible that the second step of our study, involving essentially hermeneutic operations such as the selection and interpretation of relevant interview passages, might have come to different results if conducted by experts by experience.\u003c/p\u003e\u003cp\u003eAn additional source of bias may arise from the fact that, in FIT models, it is often the more severely ill patients who are admitted to the relatively limited number of inpatient beds, suggesting a potentially different pattern of inpatient selection. Against the background of the overall positive impression of a FIT64b-hospital stay derived from the interviews, another limitation seems to be relevant: The described \u0026ldquo;ideal\u0026rdquo; conditions may only be ideal for a certain part of users. To effectively immerge into a space for learning and encounter as ideally provided by FIT may only work for those who can socially afford to stay at a ward for an adequate period of time. This might not be the case, among others, for single-parents, parents of younger children, or for users that provide daily care for other people, e.g. partners or elderly relatives. Also, users with extensive negative experiences with inpatient treatment in the past, for instance through coercive measures, may only have limited benefits from another hospitalization. For users with these kinds of obstacles or experiences, inpatient-treatment might be a quite sub-optimal choice. However, it may be one of the greatest strengths of FIT64b-Institutions that they offer a comparatively wider range of flexible possibilities to receive the personally most important parts of treatment also for users who have compelling reasons to stay at home. Finally, our findings on deinstitutionalization are based solely on an analysis of flexible and integrated psychiatric treatment under Section 64b of the German Social Code Book V and can only be cautiously extended to other forms of deinstitutionalized mental health care.\u003c/p\u003e"},{"header":"5 CONCLUSION","content":"\u003cp\u003eIn our mixed-methods study with a qual\u0026rarr;quan\u0026rarr;QUAL design closed in a single loop, we identified three deinstitutionalization-related conditions that were necessary and/or sufficient for a high experience-based quality of psychiatric care. Based on a re-analysis of interview data, we suggested an interpretation of their importance for this positive outcome.\u003c/p\u003e\u003cp\u003eOur qualitative-comparative analysis including data from 14 German psychiatric hospitals showed that a combination of the conditions FIT* ~BED *HLS could be a causal factor for a high experience-based quality of psychiatric care: Modern psychiatric services with a reduced number of hospital beds and well-developed outpatient care like FIT64b were necessary for a higher experience-based quality, but inpatient treatment should include an appropriate length of stay. Subsequent analysis of interview data clarified the importance of HLS. Inpatient treatment of adequate length, if provided in a FIT64b hospital, can potentially be an immersive and deeply transformative experience that requires an appropriate amount of time to make use of a multitude of occasions for processes of learning, reflection and behavioural changes, provided by encounters with peers, group dynamics and a highly professionalized therapeutic environment. Overall, the data presented can be used for planning mental health services and furthering the deinstitutionalization of psychiatry.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBED Psychiatric hospital beds\u003c/p\u003e\u003cp\u003eCon Consistency\u003c/p\u003e\u003cp\u003eCov Coverage\u003c/p\u003e\u003cp\u003eCovN Coverage of necessity\u003c/p\u003e\u003cp\u003ecs-QCA Crisp-set QCA\u003c/p\u003e\u003cp\u003eFIT Flexible and Integrative psychiatric treatment\u003c/p\u003e\u003cp\u003eFIT64B Flexible and integrated psychiatric treatment under Section 64b of the German Social Code Book V\u003c/p\u003e\u003cp\u003eHLS Hospital length of stay\u003c/p\u003e\u003cp\u003eOUT Outcome\u003c/p\u003e\u003cp\u003ePROMS Patient Reported Outcome Measures\u003c/p\u003e\u003cp\u003ePREMS Patient Reported Experience Measures\u003c/p\u003e\u003cp\u003ePRI Proportional reduction in inconsistency\u003c/p\u003e\u003cp\u003eQCA Qualitative Comparative Analysis\u003c/p\u003e\u003cp\u003eRoN Relevance of necessity\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e PsychCare trial was reviewed and approved by Institutional Review Board of the Medical Faculty of the Technical University Dresden and at each site where a separate approval was mandatory. All methods were performed in accordance with relevant guidelines and regulations, including the 1964 Declaration of Helsinki and its later amendments. The authors afrm that signed informed consent was obtained from all individual participants included in this study.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable as there are no image or other confidentiality-related issues.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003e This study was part of the multi-center controlled PsychCare trial, which was funded by the Innovation Fund at the Federal Joint Committee Germany under reference number 01VSF16053. The funder had no role in the study design and is not involved in its execution, data analysis, and dissemination of results\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSvP, MH, and YI contributed in the conception and the design of the work. YI conducted the data acquisition and analysis. TB, YI, SvB, and MH contributed in the interpretation of the data. TB and YI drafted the work and SvP and MH revised it. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e The multi-center controlled PsychCare trial was funded by the Innovation Fund at the Federal Joint Committee Germany. The authors would like to thank all participants in the PsychCare trial.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThe development and implementation of quality improvement. systems (QIS) in health care: recommendation no. R (97) 17, adopted by the Committee of Ministers of the Council of Europe on 30 September 1997, and explanatory memorandum. Strasbourg: Council of Europe Pub.; 1998.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCoulter A. Measuring what matters to patients. BMJ. 2017;356:j816.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFernandes S et al. Measuring the patient experience of mental health care: a systematic and critical review of patient-reported experience measures. 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Int J Qual Health Care. 2003;15(3):213\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePowell PA, Rowen D. What matters for evaluating the quality of mental healthcare? Identifying important aspects in qualitative focus groups with service users and frontline mental health professionals. Patient. 2022;15(6):669\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMion ABZ, Ventura CAA. The WHO QualityRights Initiative and its use worldwide: A literature review. Int J Soc Psychiatry. 2024;70(3):424\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMellow A, Tickle A, Rennoldson M. Qualitative systematic literature review: the experience of being in seclusion for adults with mental health difficulties. Ment Health Rev J. 2017;22(1):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeber M. The Protestant ethic and the spirit of capitalism. New York: Routledge; 2013.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Deinstitutionalization, Configurational Comparative Methods, Mental Healthcare, Flexible and Integrative Treatment, Patient-Reported Experience Measures","lastPublishedDoi":"10.21203/rs.3.rs-7294297/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7294297/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSince the mid-twentieth century, many Western European countries have shifted the focus of mental health care from hospital-based to community-based settings. While the impact of deinstitutionalization on various quality indicators has been widely studied, its effects on patient-experienced quality of care remain underexplored. This study aims to identify deinstitutionalization-related conditions that are necessary and/or sufficient for achieving a high level of experience-based quality in psychiatric treatment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe employed a mixed-methods design following a qual\u0026rarr;quan\u0026rarr;QUAL sequence. Our analysis drew on quantified interview data and routine data from a precursor study involving nine hospitals implementing flexible and integrative psychiatric treatment (FIT64b) and five control hospitals in Germany. We conducted a crisp-set Qualitative Comparative Analysis (QCA) to identify necessary and sufficient conditions associated with deinstitutionalization that could\u0026mdash;individually or in combination\u0026mdash;lead to higher or lower patient-reported quality of care. To further interpret the QCA results, we performed a Grounded Theory-inspired qualitative re-analysis of the original interview material.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFIT64b with a reduced number of hospital beds was identified as a necessary condition for a higher experience-based quality of psychiatric treatment. Surprisingly, a longer average hospital length of stay was a sufficient condition for this outcome, while a shorter hospital length of stay was found to be a necessary one for a lower experience-based treatment quality. The interview re-analysis showed that inpatient treatment of adequate length can potentially be a deeply transformative experience that requires a suitable amount of time to make use of a multitude of occasions for processes of learning, reflection and behavioural changes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eDeinstitutionalization can play an important role in achieving higher experience-based quality in mental healthcare if certain conditions are fulfilled. Modern psychiatric services with a reduced number of hospital beds and well-developed outpatient care like FIT64b are necessary but have to be combined with an appropriate hospital length of stay.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eThis study was part of the multi-center controlled PsychCare trial (German Clinical Trials Register No. DRKS00022535; Date of registration: 2020\u0026ndash;10\u0026thinsp;\u0026minus;\u0026thinsp;02).\u003c/p\u003e","manuscriptTitle":"The Role of Deinstitutionalization in Experience-Based Quality of Psychiatric Treatment: Results of a Mixed Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-29 17:51:05","doi":"10.21203/rs.3.rs-7294297/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4152ffbb-f217-4443-9ca9-a2eb1ce61c2a","owner":[],"postedDate":"August 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-14T18:53:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-29 17:51:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7294297","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7294297","identity":"rs-7294297","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}