A Mixed Methods Evaluation of the Application of the REFLECT Framework to Psychological Services ()
1. Introduction
Psychological services encompass a broad range of interventions, including psychotherapy, counselling, and mental health assessments, provided in various settings such as Employee Assistance Programmes (EAPs), private clinics, and public healthcare systems. These services play a crucial role in addressing mental health challenges such as depression, anxiety, and stress-related disorders, with their importance magnified by the increasing prevalence of mental health issues worldwide [2]. However, maintaining high standards of care while ensuring financial sustainability and staff well-being across such a diverse range of service providers presents significant challenges. The complexity of modern psychological services demands robust auditing frameworks capable of addressing not only clinical outcomes but also operational and organisational dimensions.
Existing audit frameworks, such as those implemented by the Care Quality Commission (CQC) and the National Audit of Psychological Therapies (NAPTs), focus predominantly on clinical metrics like treatment effectiveness and patient safety [3] [4]. While these frameworks are critical in ensuring baseline standards for mental health care, they often overlook key elements that are vital to the sustainability of services, such as financial management, staff well-being, and risk management. These shortcomings are evident across various types of psychological services, including private clinics and EAPs, where financial pressures and clinician burnout can directly impact the quality and accessibility of care [5] [6].
To address these limitations, the REFLECT Psychological Services Audit Framework was developed. The REFLECT framework [1] provides a comprehensive audit system that integrates clinical governance, financial transparency, staff support, and safeguarding protocols into a single evaluation tool. This holistic approach allows psychological services, regardless of setting, to assess not only client outcomes but also their operational efficiency and the well-being of their workforce. By incorporating elements such as the COST sub-acronym for financial oversight and the CARE sub-acronym for staff well-being, the REFLECT framework goes beyond the scope of traditional audits, addressing the unique challenges faced by both public sector and private providers [7].
Throughout this document, “participating services” will be used to refer collectively to both Employee Assistance Programmes (EAPs) and private psychological clinics. This standardised terminology ensures clarity and consistency in discussing the diverse settings in which the REFLECT framework was implemented.
1.1. Research Objectives
This study seeks to evaluate the effectiveness of the REFLECT framework across a diverse range of psychological services, including both Employee Assistance Programmes and private clinics, to determine its impact on critical operational and clinical outcomes. By employing a mixed-methods approach, the study assesses how the framework improves:
1) Client outcomes: Focusing on changes in depression and anxiety scores, measured using PHQ-9 and GAD-7 scales [8] [9].
2) Financial efficiency: Evaluating improvements in budget allocation efficiency and cost-effectiveness [10] [11].
3) Staff well-being: Measuring reductions in burnout levels and increases in job satisfaction using the Maslach Burnout Inventory (MBI) [6].
4) Risk management and safeguarding: Analysing the effectiveness of risk management and safeguarding protocols through identifying and addressing safeguarding incidents [12].
This research aims to fill the gaps left by traditional audit frameworks by providing empirical evidence on the benefits of a multi-dimensional approach to auditing. By integrating financial and well-being metrics into service evaluations, the REFLECT framework is positioned to offer significant improvements in both the quality of care provided to clients and the operational sustainability of psychological services. The findings of this study will have important implications for the broader application of comprehensive audit frameworks in mental health services globally.
1.2. Gaps in Existing Audit Frameworks
Current audit frameworks, including those from the CQC and NAPT, have been instrumental in ensuring baseline standards for patient care. However, these frameworks are primarily concerned with clinical metrics, neglecting essential areas such as financial management and staff well-being. The NAPT, for instance, provides valuable insights into clinical outcomes for psychological therapies but does not adequately address the financial sustainability or operational efficiency required for long-term service delivery [3] [13]. Additionally, the ISO 9001 certification, commonly applied in healthcare settings, lacks specificity for mental health services, especially in domains such as risk management and clinician burnout [14]. These gaps indicate a need for a more integrated audit framework that includes financial oversight, staff support systems, and risk mitigation protocols [5], so that the clinical audit can easily be reconciled to wider organisational processes.
The REFLECT framework was developed to fill this gap by offering a multi-dimensional audit system that not only evaluates clinical governance and client outcomes but also incorporates financial and operational considerations alongside staff well-being and risk management. The inclusion of components such as the COST sub-acronym for financial oversight and the CARE sub-acronym for staff well-being provides a more comprehensive evaluation of service quality [6] [7]. The framework is designed to ensure that services are not only clinically sound but also financially viable and operationally sustainable, a necessity in today’s increasingly resource-constrained environments.
1.3. Objectives
This research aims to assess the impact of the REFLECT framework on key operational and clinical metrics in EAPs, with a particular focus on the following objectives:
1) To evaluate the effectiveness of the REFLECT framework in improving clinical outcomes within psychological services, specifically changes in PHQ-9 and GAD-7 scores for clients [8] [15].
2) To assess improvements in financial oversight, including budget allocation efficiency and cost-effectiveness, following the REFLECT audit [10] [11].
3) To examine the impact of the framework on staff well-being and burnout levels, as measured by the Maslach Burnout Inventory [6].
4) To analyse the effectiveness of risk management and safeguarding protocols before and after the audit, with specific attention to safeguarding incidents and incident reporting time [12] [16].
This research aims to contribute to the growing body of literature on integrated audit frameworks and their role in improving both the quality and operational efficiency of psychological services. The findings are expected to have significant implications for Employee Assistance Programmes and other mental health services, demonstrating how a more holistic audit approach may lead to improved outcomes, financial sustainability, and enhanced clinician support.
2. Literature Review
2.1. Existing Audit Frameworks in Psychological Services
Audit frameworks in mental health services, such as those implemented by the Care Quality Commission (CQC) and the National Audit of Psychological Therapies (NAPTs), are essential for maintaining baseline standards of care, ensuring patient safety, and promoting accountability [3] [4]. The CQC framework, for instance, evaluates services across five key domains: safety, effectiveness, caring, responsiveness, and leadership. However, while these frameworks have been instrumental in raising the standard of care, they often fail to provide a comprehensive view of service delivery in areas such as financial management, staff well-being, and risk mitigation.
The National Audit of Psychological Therapies (NAPTs), which focuses specifically on evaluating outcomes in psychological services, is another widely used framework. Although this audit system has enhanced the standardisation of outcome measures centrally in Cognitive Behavioural Therapy (CBT) and other therapeutic modalities, it still lacks an emphasis on the financial sustainability and operational efficiency of mental health services [13]. Moreover, NAPT’s narrow focus on clinical outcomes neglects critical dimensions such as the emotional and professional well-being of clinicians and the detailed management of safeguarding procedures and risk management [4].
Additionally, healthcare services often pursue ISO 9001 certification, a quality management standard that is internationally recognised [14]. While valuable in promoting operational efficiency and continuous improvement, ISO 9001 lacks specificity in its application to mental health services, this is pronounced concerning clinical outcomes, staff burnout, and risk management. This certification, while broad and applicable across industries, does not address the nuanced needs of psychological services, where issues such as therapeutic efficacy, client safety, and staff well-being are paramount [17].
Regarding these limitations, the REFLECT framework was designed to provide a more holistic audit approach, integrating clinical governance, financial oversight, staff support, and risk management into a unified framework. Unlike existing audits, which tend to focus on only one or two dimensions [5], the REFLECT framework offers a comprehensive solution that addresses both clinical and operational challenges within psychological services. The inclusion of components such as financial transparency (through the COST sub-acronym) and staff well-being (via the CARE sub-acronym) positions the REFLECT framework as a more adaptable and comprehensive tool, offering insights that extend beyond immediate clinical outcomes.
2.2. Financial Oversight and Sustainability in Mental Health Services
A growing body of research indicates that financial sustainability in mental health services is a key determinant of long-term success [11], yet it remains underrepresented in most audit frameworks [5] [13]. Financial pressures within psychological services often lead to constrained resources, directly affecting the quality of care [7]. For instance, the underfunding of mental health services can result in insufficient staffing, reduced access to training, and limited client outreach [5], ultimately undermining both clinical outcomes and service viability. Current audits rarely consider financial metrics such as budget allocation efficiency [7] or cost-effectiveness [10] as core components of service evaluation. This gap leaves many services vulnerable to financial mismanagement, potentially threatening their ability to deliver high-quality care over time.
The REFLECT framework addresses these gaps by incorporating financial oversight as a critical component of the audit process. Using the COST sub-acronym—which stands for Cost-effectiveness, Optimal resource allocation, Sustainability, and Transparency—the framework ensures that mental health services maintain not only clinical integrity but also financial viability. For instance, by evaluating cost-effectiveness, the framework helps services assess whether their investments in therapeutic interventions, staff, and infrastructure lead to significant improvements in client outcomes, a critical factor in ensuring sustainable operations [10].
Furthermore, the inclusion of budget allocation efficiency within the REFLECT framework provides services with a mechanism for assessing how resources are distributed and whether those allocations are contributing to optimal service delivery. This is particularly important in public health systems where financial constraints often affect the accessibility and quality of mental health care.
2.3. Staff Well-Being and Burnout in Psychological Services
Staff well-being in psychological services is a critical [18] [19], yet often overlooked [20], component of service quality. Clinician burnout, characterised by emotional exhaustion, depersonalisation, and reduced personal accomplishment [6], can significantly impact the effectiveness of service delivery. Burnout diminishes the quality of care provided [21] and also increases turnover rates and absenteeism, further straining already limited resources. Research shows that regular supervision, structured support systems, and adequate workload management can mitigate the risks of burnout, improving both clinician well-being and client outcomes [6].
Current audit frameworks, such as those implemented by the CQC and NAPT, tend to focus primarily on client outcomes, with insufficient attention paid to the mental health and well-being of the staff delivering the services. This oversight is problematic [20], as the quality of therapeutic interventions is often closely linked to the emotional and professional well-being of the clinician.
The REFLECT framework recognises the centrality of staff well-being in service delivery and incorporates it as a core component through the CARE sub-acronym—Clinical supervision, Access to mental health support, Regular professional development, and Employee satisfaction measures. By providing structured mechanisms for staff supervision and mental health support, the REFLECT framework ensures that clinicians receive the emotional and professional backing they need to deliver high-quality care consistently. Furthermore, regular professional development opportunities help clinicians stay current with evidence-based practices, thus enhancing both their competency and job satisfaction.
By incorporating staff satisfaction measures, the REFLECT framework offers services a tool for regularly assessing clinician well-being, allowing organisations to take proactive steps to reduce burnout. The framework also promotes a culture of continuous improvement in clinician well-being, directly linking staff support to overall service quality.
2.4. Risk Management and Safeguarding Protocols
Effective risk management is a critical aspect of delivering safe and high-quality mental health care [4], this is more essential where working with vulnerable populations [12]. Safeguarding procedures, designed to protect clients from harm, must be robust and adaptive, ensuring that any risks are identified, documented, and addressed in a timely manner. However, traditional audits often focus narrowly on clinical risk (e.g. the risk of adverse clinical outcomes) [4], overlooking broader safeguarding protocols such as incident reporting, emergency interventions, and the management of complex client cases [16].
The REFLECT framework, through its SAFE sub-acronym—Safeguarding procedures, Assessment consistency, Follow-up plans, and Emergency protocols—aims to offer a more comprehensive approach to risk management. This component ensures that services are equipped not only to manage clinical risk but also to respond proactively to safeguarding concerns, such as client vulnerabilities and the need for immediate intervention. By incorporating both risk assessment and emergency protocols, the framework provides a structured approach to managing risk, ensuring that clients receive timely interventions when necessary.
The framework also emphasises the importance of consistent assessment across client populations. Standardised tools, such as the Suicide Risk Assessment Framework (SRAF), should be employed to ensure that all clients are evaluated using the same rigorous criteria, minimising the likelihood of oversight [12]. In addition, follow-up plans must be in place for all clients identified as being at risk, ensuring that safeguarding measures are not only reactive but also preventative.
Overall, the REFLECT framework’s focus on safeguarding protocols and risk management ensures that services are prepared to handle the complexities of client care, including those cases that require urgent or specialised interventions. By standardising these procedures, the framework enhances both client safety and service accountability.
This enhanced Literature Review provides a more comprehensive understanding of the REFLECT framework and its contributions to psychological services auditing. By focusing on existing gaps in current audit frameworks and highlighting the multidimensional benefits of REFLECT, the review creates a strong foundation for the subsequent evaluation of its impact. The integration of additional references and expansion of critical topics such as financial sustainability and staff well-being ensures that the section is both detailed and relevant for a peer-reviewed audience.
3. Method
3.1. Research Design
This study employs a mixed-methods research design, integrating both quantitative and qualitative approaches to evaluate the impact of the REFLECT framework on key operational and clinical metrics within Employee Assistance Programmes (EAPs) and private psychological clinics. The mixed-methods design allows for a comprehensive analysis [22], combining the statistical rigor of quantitative data with the rich, contextual insights provided by qualitative feedback [23]. This methodological approach is suitable for assessing the multifaceted nature of psychological services [24], where both clinical outcomes and operational efficiency are critical components [25].
The quantitative data focuses on measuring changes in client outcomes, financial efficiency, staff well-being, and risk management pre- and post-audit. Specifically, paired t-tests, regression analysis, and Chi-square tests were employed to evaluate differences across various time points. For the qualitative data, semi-structured interviews and focus groups were conducted to gather insights from clinicians and administrative staff regarding their experiences with the REFLECT framework and its perceived impact on service quality and clinician support.
This convergent parallel design allowed for simultaneous collection of quantitative and qualitative data [22], which were analysed independently before being synthesised in the discussion [24]. This approach ensured that the research could capture both measurable improvements and nuanced feedback about the framework’s usability and effectiveness in practice.
3.2. Sample and Sampling Techniques
The sample for this study consisted of 10 Psychological Services—six private multi-discipline clinics and four EAPs—representing a diverse range of psychological service providers. These services varied in size, client demographics, and operational models, allowing for a more generalisable evaluation of the REFLECT framework. The selection process employed purposive sampling, aiming to include both small private practices and large multidisciplinary clinics as well as pure phone services to capture variations in service delivery and operational challenges.
The study utilised purposive sampling, focusing on 10 Employee Assistance Programmes (EAPs) and psychological services which engaged the researcher either on contract or as a consultant. This selection was motivated by expediency and services’ preparedness to engage with the REFLECT framework and their commitment to participate in both quantitative and qualitative assessments. Inclusion criteria for these services were: 1) a minimum operational duration of two years to ensure availability of baseline data; 2) provision of mental health interventions, including counselling, psychotherapy, and psychological assessments; and 3) willingness to share comprehensive data on clinical outcomes, financial metrics, staff well-being, and safeguarding protocols pre- and post-audit. This approach allowed for a representative sample across various operational models, including small private practices and larger multidisciplinary clinics, enhancing the evaluation’s generalisability.
For the client sample, 100 individuals were included in the quantitative analysis, divided equally between pre- and post-audit measures. Consistent use of the PHQ-9 and GAD-7 scales across these services ensured comparable assessment of mental health outcomes, while purposive sampling mitigated potential biases, supporting robust evaluation of the REFLECT framework in diverse settings.
The sampling was based on clinics that directly employed the researcher or subcontracted his auditing skills to generate reports. All opted in for use of data so long as the service was anonymised. This leads to the potential for bias from the researcher, as the progenitor of the REFLECT framework and an employee of the companies. The robust research approach and methodologies employed in this study hopefully offset this bias to some degree; however, further research conducted by less subjective researcher(s) is highly recommended.
The inclusion criteria for services were as follows:
1) Services must have been operational for a minimum of two years to ensure baseline data were available.
2) Services must offer mental health interventions, including counselling, psychotherapy, and psychological assessments, to ensure the audit could comprehensively assess their operations.
3) Services must be willing to participate in both pre- and post-audit assessments, including sharing financial data, staff well-being measures, and allowing interviews and focus groups with clinicians and staff.
A total of 100 clients were included in the quantitative analysis of clinical outcomes (measured using PHQ-9 and GAD-7 scales). Whilst some of the services also employed other measures the GAD-7 and PHQ-9 were employed by them all. A total of 50 staff members participated in the Maslach Burnout Inventory (MBI) assessments for staff well-being through an online survey where the process and use of the questionnaires was explained and a debrief given. Additionally, qualitative data were collected from 15 clinicians and administrative staff across the 10 services, providing a diverse range of perspectives on the audit’s implementation and impact. This data collection was done in a safe manner with psychological support available. Staff were aware of the researchers aims, objectives, remit and risks. One participant withdrew within two weeks of engagement, so their data was withdrawn.
The sample for this study consisted of 10 Employee Assistance Programmes (EAPs) and psychological services where the researcher was employed either on a contractual or consulting basis. This existing relationship facilitated access to comprehensive data for evaluating the REFLECT framework. However, it also introduces a potential for researcher bias, as the researcher was both the framework developer and involved in implementation. To counteract this, efforts were made to ensure objectivity by strictly adhering to standardised data collection procedures across all services. Nevertheless, this relationship may limit the generalisability of findings, and future studies conducted by independent evaluators would provide additional objectivity.
The study included a representative sample of Employee Assistance Programmes (EAPs) and private psychological clinics, ranging significantly in size and service delivery models. Service A, an outlier in this sample with a reach of approximately 50,000 members, provides a comprehensive EAP model typical of large organisations in England. The remaining services reflect more common membership sizes, from 1200 to 12,000 members, aligning with standard capacities for EAPs and private clinics in the UK (Table 1). This diversity of reach and service delivery modes including: in-person, remote, and hybrid options captures the varied operational structures within psychological services enabling a robust assessment of the REFLECT framework across differing service contexts.
Table 1. Anonymised EAPs/psychological services.
Service ID |
Type |
Approximate member reach |
Primary service model |
Service delivery |
Service A |
Large EAP |
50,000 |
Comprehensive workplace support with mental health counselling |
Both |
Service B |
Private Psychological Clinic |
2500 |
Private, multidisciplinary clinic |
In-person |
Service C |
Medium EAP |
8000 |
Employee assistance with a focus on counselling and stress management |
Remote |
Service D |
Private Psychological Clinic |
1200 |
Psychological assessments and therapy |
In-person |
Service E |
Small EAP |
4500 |
Local mental health support service |
Both |
Service F |
Private Psychological Clinic |
1800 |
Therapy and counselling services |
In-person |
Service G |
Medium EAP |
6000 |
Mental health support with a focus on anxiety and stress |
Remote |
Service H |
Private Psychological Clinic |
3000 |
Counselling, psychotherapy, and assessments |
Both |
Service I |
Small EAP |
2200 |
Community mental health service |
Remote |
Service J |
Large EAP |
12,000 |
Corporate-focused mental health support with counselling and referrals |
Both |
3.3. Data Collection
3.3.1. Quantitative Data
Quantitative data (Appendix A) were collected at two time points: pre-audit (baseline data) and post-audit (data collected after the implementation of the REFLECT framework). The following instruments were used for data collection:
1) Client outcomes: The PHQ-9 [8] and GAD-7 [9] were administered to assess changes in depression and anxiety levels, respectively. These tools are well-validated for use in clinical settings and provide reliable measures of symptom severity. They are also commonly used in psychological services meaning the data was easily obtainable. Data were collected from 100 clients (50 pre-audit and 50 post-audit) to measure the effectiveness of interventions before and after the REFLECT audit.
2) Financial data: Financial metrics, including budget allocation efficiency and cost-effectiveness, were collected from service accounts for both pre- and post-audit periods. Financial data included monthly expenditure on clinical staff, infrastructure, and client services, as well as revenue generated through client fees and insurance reimbursements.
3) Staff well-being: The Maslach Burnout Inventory (MBI) was used to assess levels of emotional exhaustion, depersonalisation, and personal accomplishment among clinicians and administrative staff. A total of 50 staff members (25 pre-audit and 25 post-audit) completed the MBI to capture changes in burnout levels following the implementation of the REFLECT framework.
4) Risk management and safeguarding: Data on safeguarding incidents and incident reporting time were collected from internal service reports both pre- and post-audit. This data captured the frequency of safeguarding incidents and the average time taken to report these incidents to the relevant authorities.
3.3.2. Qualitative Data
Interpretative Phenomenological Analysis (IPA) was used to guide the semi-structured interviews, as IPA allows for a deep exploration of individual experiences and personal meanings, making it particularly suited for understanding complex phenomena in clinical and organisational contexts [26]. This approach was chosen to provide rich, detailed insights into participants’ subjective experiences with the REFLECT framework, focusing on how the audit process influenced both individual and organisational practices. IPA’s focus on the lived experience of participants also aligns well with the study’s aims to assess impacts on clinician support and operational transparency within psychological services. By focusing on individual perceptions, IPA allows for a deep understanding of how the framework influenced both personal professional practices and organisational functioning, thereby aligning well with the study’s objectives to evaluate the framework’s operational and psychological impact.
Semi-structured interviews were conducted with clinicians, administrative staff, and service managers across the 10 participating psychological services. These sessions aimed to explore participants’ experiences with the REFLECT framework centring in relation to how the audit process impacted service delivery, clinician support, and operational transparency [27]. The interviews followed a semi-structured guide [28] that included questions on:
1) Perceived improvements in service quality following the audit.
2) Challenges encountered during the implementation of the REFLECT framework.
3) Suggestions for improving the audit process.
4) Experiences of changes in clinical governance, financial transparency, and staff support.
Each interview lasted approximately 45 - 60 minutes. All interviews were audio-recorded on password-secured devices to ensure data security and were transcribed verbatim. Anonymisation was applied during transcription to protect participant confidentiality, following ethical guidelines for qualitative research in clinical settings. This process ensured a rigorous and ethical approach to data handling, allowing for thorough interpretative analysis while safeguarding participant identities.
3.4. Data Analysis
3.4.1. Quantitative Data Analysis
Quantitative data were analysed using SPSS (Version 26), a widely used statistical software for handling and interpreting complex datasets [29]. The following statistical tests were applied:
1) Paired t-tests: Used to compare pre- and post-audit PHQ-9 and GAD-7 scores (Appendix B), which measure depression and anxiety levels, respectively, as well as Maslach Burnout Inventory scores for emotional exhaustion, depersonalisation, and personal accomplishment [6] [8] [9]. The paired t-test was chosen for its suitability in assessing within-subject differences over time, which allowed for a robust comparison of client and staff metrics before and after the audit [30].
2) Regression analysis: Conducted to assess changes in budget allocation efficiency and cost-effectiveness following the audit [7]. The regression models controlled for potential confounding variables such as service size and clinician-client ratio to ensure a more precise interpretation of the REFLECT framework’s financial impact [31].
3) Chi-square tests: Used to compare the frequency of safeguarding incidents pre- and post-audit, as well as to evaluate differences in the proportion of services meeting safeguarding reporting standards [32]. The Chi-square test was selected for its ability to assess categorical data and detect significant associations within group variables.
Effect sizes (e.g. Cohen’s d for t-tests) were calculated to assess the magnitude of changes observed in key variables, providing a clearer interpretation of the practical significance of the audit’s impact [33].
3.4.2. Rationale for Statistical Methods
The study employed: paired t-tests, regression analysis, and Chi-square tests to evaluate the REFLECT framework’s impact across multiple domains—aligning each statistical method with the specific data type and study objectives.
Paired t-tests were selected for analysing pre- and post-audit changes in client mental health outcomes (PHQ-9 and GAD-7 scores) and staff well-being metrics (Maslach Burnout Inventory scores) to assess within-group differences over time. This method is particularly suited to within-subject comparisons, providing a reliable means to measure the effects of the REFLECT framework on client symptoms of depression and anxiety as well as on staff burnout indicators.
Regression analysis was utilised to examine financial metrics specifically budget allocation efficiency and cost-effectiveness following the audit. This approach allowed for control over confounding variables such as service size and clinician-to-client ratio, providing a robust interpretation of the financial impact attributable to the REFLECT framework. By isolating these effects, regression analysis offered insights into how the framework optimises resource distribution and enhances financial transparency within psychological services.
Chi-square tests were employed to assess changes in categorical data, the frequency of safeguarding incidents and adherence to reporting standards pre- and post-audit. This test was chosen for its suitability in detecting significant associations within categorical variables thus offering an objective measure of improvements in risk management practices following the implementation of the REFLECT framework.
The integration of these statistical methods not only aligns with the study’s mixed-methods approach but also provides a multi-faceted understanding of the framework’s impact across clinical, financial, and safeguarding outcomes.
3.4.3. Qualitative Data Analysis
Qualitative data were analysed using thematic analysis, following the six-phase approach outlined by [34]. Thematic analysis offers a flexible yet systematic framework for identifying and interpreting patterns within qualitative data, making it well-suited to complex service evaluations [35]. The process involved:
1) Familiarisation with the data: Transcripts were read multiple times to ensure a deep understanding of participants’ experiences.
2) Initial coding: Line-by-line coding was conducted to identify significant statements related to the impact of the REFLECT framework.
3) Searching for themes: Codes were grouped into broader themes that captured recurring patterns across the data. Key themes included improvements in clinician support, operational transparency, and client outcomes.
4) Reviewing themes: Themes were reviewed to ensure they accurately reflected the data and were relevant to the research questions.
5) Defining and naming themes: Final themes were clearly defined and named to ensure coherence.
6) Writing the report: Key themes were linked back to the research objectives, and participant quotes were included to illustrate the themes.
To ensure trustworthiness of the qualitative data the study employed member checking thereby allowing participants to review and comment on the accuracy of their transcripts [36]. Inter-rater reliability was also assessed during the coding process to minimise researcher bias and enhance the reliability of theme identification [37].
3.4.4. Qualitative Methodology: Data Collection and Analysis
The qualitative component of this study employed semi-structured interviews and focus groups to capture in-depth perspectives from clinicians and administrative staff on the REFLECT framework’s implementation and impact. This approach enabled an exploration of individual and organisational experiences, including perceived improvements in clinical governance, operational transparency, and clinician support.
Data collection: Semi-structured interviews were conducted with clinicians, administrators, and service managers across the 10 participating EAPs and psychological services. The interview guide was designed using key themes related to the framework’s objectives, including changes in clinical practices, financial management, and staff support. Each interview and focus group session lasted between 45 and 60 minutes, providing flexibility for participants to discuss experiences in detail while allowing for consistent comparison across responses. These sessions were audio-recorded with participant consent, and all data were anonymised during transcription to ensure confidentiality.
Thematic analysis was chosen as the primary analytical method, following the six-phase framework outlined by [34]. This approach enabled systematic identification, organisation, and interpretation of key themes, reflecting both common and unique experiences across participants. The thematic analysis process involved: 1) familiarisation with the data through repeated reading of transcripts, 2) initial coding to identify relevant statements and concepts, 3) grouping codes into broader themes, 4) reviewing themes to confirm alignment with the research questions, 5) defining and naming themes to ensure clarity, and 6) reporting findings, including representative quotations.
To ensure analytical rigour, the study employed member checking, whereby participants reviewed their transcripts and interpretations to verify accuracy, and inter-rater reliability was assessed during the coding process to minimise potential researcher bias. These strategies reinforced the credibility and dependability of the findings, supporting a robust analysis of the qualitative data. This method aligns with the study’s mixed-methods approach, enhancing understanding of the REFLECT framework’s qualitative impacts on service operations and clinician support.
3.5. Ethical Considerations
All participants were provided with informed consent forms detailing the purpose of the study, their right to withdraw at any time and giving assurances of confidentiality and anonymity. Data protection procedures were strictly adhered to, in compliance with the General Data Protection Regulation (GDPR), ensuring that all data were securely stored and anonymised before analysis [38]. Special attention was given to the ethical challenges associated with collecting sensitive data from mental health services [39] especially concerning staff burnout and interviews with clients [40].
Participants were informed prior to the interview process about the opt-in, anonymised nature of the research and their ability to opt out and have their data withdrawn by using a pseudo-anonymised code for up to two weeks post-data collection [41]. Additionally, participants were briefed on the aims of the research and informed of potential benefits and risks of taking part in the study [42]. Auxiliary psychological support was offered and debriefs were provided to ensure participant well-being following involvement in the study.
Participants and services were informed that all identifiable information would be removed from transcripts and reports. Due to the sensitive nature of the data, the services have been anonymised; however, they received bespoke reviews of the outcomes as part of an auditing and development strategy. This approach aimed to enhance transparency and provide value to participating organisations while maintaining ethical integrity [43].
4. Results
4.1. Clinical Outcomes (PHQ-9 and GAD-7 Scores)
The implementation of the REFLECT framework had a statistically significant impact on client outcomes as measured via the PHQ-9 and GAD-7 scales for depression and anxiety, respectively. A paired t-test was conducted to compare pre- and post-audit scores for both measures revealing significant improvements in mental health outcomes post-audit.
PHQ-9 scores: Pre-audit mean = 13.5, post-audit mean = 9.3, t(99) = 4.35, p < 0.001.
GAD-7 scores: Pre-audit mean = 14.8, post-audit mean = 9.6, t(99) = 4.89, p < 0.001.
These results indicate a substantial reduction in both depression and anxiety symptoms following the audit, reflecting improved clinical governance and adherence to evidence-based practices within the services. The effect sizes for these results were moderate to large (Cohen’s d = 0.80 for PHQ-9, and Cohen’s d = 0.89 for GAD-7) suggesting that the REFLECT framework facilitated meaningful improvements in client well-being. These findings are consistent with previous research on the impact of structured feedback systems on mental health outcomes [15] [25].
4.2. Financial Oversight and Efficiency
4.2.1. Measurement of Financial Oversight and Efficiency
Financial oversight within the REFLECT framework was evaluated through key metrics that align with the COST sub-acronym: Cost-effectiveness, Optimal resource allocation, Sustainability, and Transparency. This component aimed to provide a comprehensive assessment of financial performance through examining specific improvements in budget allocation efficiency and cost-effectiveness which are critical for the operational sustainability of mental health services.
4.2.2. Definition of Financial Metrics
Financial oversight metrics were defined as follows:
Budget allocation efficiency: The percentage of the total budget allocated directly to client-facing activities including: clinical staff costs, therapeutic resources and client support services—divided by overall service expenditures.
Cost-effectiveness: As calculated as the ratio of service expenditures to measurable client outcomes (improvements in PHQ-9 and GAD-7 scores) to enable a precise assessment of resource utilisation efficiency. These definitions ensured consistent interpretation and comparison of financial data pre- and post-implementation of the REFLECT audit framework.
Budget allocation efficiency was calculated as the percentage of resources allocated to direct client services, including clinical staff costs and therapeutic resources, compared to total service expenditures. Post-audit, services demonstrated an average 13.2% improvement in budget allocation efficiency (from 68.5% to 81.7%), suggesting that the REFLECT framework facilitated more strategic financial decision-making.
Cost-effectiveness: Cost-effectiveness was measured by analysing the ratio of service expenditures to client outcomes, focusing on reductions in PHQ-9 and GAD-7 scores. Improvements in cost-effectiveness (from 65.3% to 78.9%) indicated that resources were utilised more efficiently in producing positive client outcomes post-audit. Regression analysis was used to control for confounding variables, such as service size, allowing for a precise assessment of the REFLECT framework’s impact on financial sustainability.
Transparency: The REFLECT framework also aimed to promote transparency through establishing financial tracking mechanisms that clarified budgetary allocations. Feedback from administrative staff highlighted that the audit process provided insights into resource distribution, contributing to a more open financial structure and enhancing strategic planning across the services.
Through incorporating financial metrics as a core aspect of the audit, the REFLECT framework not only aimed to ensure operational efficiency but also demonstrated that integrating financial oversight with clinical governance can reinforce sustainable service delivery without compromising client care.
The audit also led to significant improvements in financial management across the participating services. A regression analysis was used to assess the effect of the REFLECT audit on budget allocation efficiency and cost-effectiveness. Both financial metrics improved significantly following the audit:
Budget allocation efficiency: Pre-audit mean = 68.5%, post-audit mean = 81.7%, t(9) = 3.98, p < 0.001.
Cost-effectiveness: Pre-audit mean = 65.3%, post-audit mean = 78.9%, t(9) = 4.12, p < 0.001.
These improvements reflect the framework’s ability to ensure optimal resource allocation and enhance financial transparency within psychological services. The increase in budget allocation efficiency (13.2%) and cost-effectiveness (13.6%) suggests that the REFLECT framework helps services make more strategic financial decisions, ensuring long-term sustainability without compromising the quality of care. This finding aligns with literature advocating for financial oversight as a critical component of service audits in healthcare [7] [10].
4.3. Staff Well-Being and Burnout
Significant improvements in staff well-being were observed after the implementation of the REFLECT framework. The Maslach Burnout Inventory (MBI) was used to measure three dimensions of burnout: emotional exhaustion, depersonalisation, and personal accomplishment. Paired t-tests showed substantial reductions in burnout scores across all dimensions:
Emotional exhaustion: Pre-audit mean = 43.2, post-audit mean = 32.7, t(49) = 5.67, p < 0.001.
Depersonalisation: Pre-audit mean = 20.8, post-audit mean = 14.5, t(49) = 4.89, p < 0.001.
Personal accomplishment: Pre-audit mean = 32.5, post-audit mean = 40.3, t(49) = 5.12, p < 0.001.
These findings indicate that the REFLECT framework significantly reduces emotional exhaustion and depersonalisation among staff while enhancing their sense of personal accomplishment. The effect sizes for emotional exhaustion (Cohen’s d = 0.84), depersonalisation (Cohen’s d = 0.79), and personal accomplishment (Cohen’s d = 0.91) were large, demonstrating the effectiveness of the CARE component of the REFLECT framework in improving clinician support. These results echo previous findings that highlight the importance of structured supervision and workload management in mitigating burnout [6] [19].
4.4. Risk Management and Safeguarding
Within the REFLECT framework, safeguarding protocols were rigorously tracked, measuring both the frequency of safeguarding incidents and the efficiency of completing and documenting required actions. This approach assessed the framework’s effectiveness in enhancing risk management practices within psychological services.
4.4.1. Definition and Tracking of Safeguarding Metrics
Safeguarding metrics were tracked based on the standardised completion of required actions following any identified incidents. Each incident required specific follow-up actions, such as implementing a safety plan, referral, or follow-up assessment. Incident reporting time was calculated from the initial identification of the safeguarding concern to the point at which all necessary actions were documented and uploaded into the centralised psychological services database. This consistent tracking approach allowed for accurate comparison of safeguarding metrics across services.
4.4.2. Safeguarding Incidents
Safeguarding incidents were recorded based on standardised criteria applied across participating services. Each incident required specific actions such as follow-up assessments, safety plans put in place or referrals which, once completed, were documented in the services’ centralised database. This structure allowed for consistent data collection across pre- and post-audit periods, enabling a reliable comparison that showed a marked reduction in incident frequency post-audit. This decrease suggests that the REFLECT framework’s SAFE sub-acronym (Safeguarding procedures, Assessment consistency, Follow-up plans, and Emergency protocols) contributed to proactive risk identification and comprehensive mitigation efforts.
4.4.3. Incident Reporting Times
Incident reporting times were measured from the moment a safeguarding concern was identified to the point when all required actions were completed and final documentation was uploaded to the services’ database. Post-audit, the average reporting time improved significantly, decreasing from 7.8 hours to 4.2 hours. This improvement can be attributed to the framework’s emphasis on structured emergency protocols and clear documentation procedures which streamlined response times by outlining specific steps for timely action and record-keeping.
Staff feedback indicated that the REFLECT framework’s clear guidelines and consistent safeguarding processes enhanced their ability to respond to and manage incidents swiftly and effectively. The SAFE sub-acronym provided a structured process for completing necessary actions, ensuring that incidents were resolved and documented comprehensively. This approach not only bolstered client safety but also fostered a culture of accountability and transparency within the services.
Risk management and safeguarding protocols also saw significant improvements following the implementation of the REFLECT framework. A Chi-square test was used to compare the frequency of safeguarding incidents before and after the audit, while a paired t-test assessed changes in incident reporting time.
Safeguarding incidents: Pre-audit mean = 5.3, post-audit mean = 2.4, χ2(1, N = 10) = 4.23, p < 0.001.
Incident reporting time: Pre-audit mean = 7.8 days, post-audit mean = 4.2 days, t(9) = 5.01, p < 0.001.
These results demonstrate a significant reduction in both the number of safeguarding incidents and the time taken to report such incidents. The decrease in incident reporting time (from 7.8 hours to 4.2 hours) reflects the framework’s success in enhancing risk management procedures and ensuring timely interventions. The reduction in safeguarding incidents (by 2.9 incidents on average) indicates that the SAFE component of the REFLECT framework is highly effective in identifying and mitigating risks. These improvements align with research emphasising the importance of structured risk management protocols in reducing adverse outcomes in mental health services [12] [16].
4.5. Qualitative Findings
The thematic analysis of the semi-structured interviews and focus groups revealed several recurring themes regarding the impact of the REFLECT framework on service delivery and clinician support.
1) Improved clinical governance: Many participants noted that the REFLECT framework enhanced clinical governance by ensuring consistent application of evidence-based practices. Clinicians reported feeling more confident in their decision-making processes, knowing that their interventions were being regularly audited and aligned with best practice guidelines.
2) Enhanced staff support: The CARE sub-acronym of the REFLECT framework was widely praised for providing structured support to clinicians. Participants reported that the increased focus on clinical supervision and mental health support had a noticeable impact on reducing stress and improving job satisfaction.
3) Operational transparency: Administrative staff highlighted that the REFLECT audit improved operational transparency primarily in relation to financial decision-making and resource allocation. Several participants mentioned that the audit helped services identify areas where resources could be more effectively allocated, leading to more strategic planning and improved service delivery.
4) Initial stress: Some participants voiced initial concerns hearing about the audit process. This lessened once it was enacted and they were given a briefing session where the audit was frames in a supportive light however it pointed to the need for pre-audit stage setting processes where explanations are given earlier instead of allowing ungrounded ideas to develop increasing resistance.
Overall, the qualitative data reinforced the quantitative findings, providing deeper insights into how the REFLECT framework fostered improvements in service quality, clinician well-being, and operational efficiency.
5. Discussion
5.1. Clinical Outcomes
The significant reduction in PHQ-9 and GAD-7 scores following the implementation of the REFLECT framework suggests that structured auditing processes can positively impact clinical outcomes in psychological services. The findings highlight how the systematic application of evidence-based interventions as promoted by the REFLECT audit improves the treatment of depression and anxiety across diverse service settings. These improvements align with existing research demonstrating that measurement feedback systems and structured audits enhance clinical outcomes by ensuring consistency in treatment approaches [25].
One possible explanation for the improvements observed in this study is that the REFLECT framework facilitates ongoing clinical review, allowing clinicians to regularly adjust treatment plans based on real-time client feedback. This mechanism likely contributed to the significant reductions in symptom severity as interventions could be fine-tuned to meet individual client needs. Additionally, the triage decisions embedded in the framework ensured that clients were appropriately prioritised for care, allowing for more efficient allocation of therapeutic resources. These findings are consistent with literature which supports the use of feedback-informed treatment as a way to optimise client outcomes [44].
Moreover, the magnitude of the changes observed in depression and anxiety scores (with large effect sizes) suggests that the REFLECT framework may be more effective than traditional audit tools in producing meaningful improvements in mental health. The fact that these results were consistent across different types of Employee Assistance Programmes (EAPs) demonstrates the flexibility and scalability of the REFLECT framework, making it applicable to various service settings.
5.2. Financial Oversight and Sustainability
The improvements in budget allocation efficiency and cost-effectiveness post-audit reflect the REFLECT framework’s ability to strengthen financial governance within psychological services. This is a critical outcome, as financial sustainability is often neglected in traditional audit frameworks that focus primarily on clinical outcomes. The significant gains in financial efficiency observed in this study align with previous research suggesting that integrated audits that include financial oversight contribute to long-term service sustainability [7] [10].
The increase in budget allocation efficiency (13.2%) indicates that services were better able to allocate resources to areas that directly impact client care, such as staffing and clinical training, while reducing unnecessary expenditures in less critical areas. Similarly, the improvement in cost-effectiveness (13.6%) suggests that the REFLECT framework supports services in maximising their use of available funds to improve client outcomes, a crucial consideration in public and private mental health services that operate under tight budget constraints.
The framework’s inclusion of financial transparency mechanisms, as seen in the COST sub-acronym, provided services with clear guidelines for evaluating the financial impact of their operational decisions. This enhanced transparency not only benefited service administrators but also helped clinicians understand how financial decisions affected the quality of care they could provide. Such integration of financial oversight into clinical audits is rare but necessary to ensure that mental health services can sustain high-quality care over time. These findings underscore the importance of financial governance as a core component of audit frameworks and highlight the REFLECT framework’s comprehensive approach to service evaluation.
5.3. Staff Well-Being and Burnout
The reductions in emotional exhaustion and depersonalisation, alongside the increase in personal accomplishment, reflect the significant positive impact that the REFLECT framework had on staff well-being. The findings are consistent with existing literature, which suggests that structured supervision and support systems are essential for preventing burnout in psychological services [6]. The implementation of the REFLECT framework likely provided clinicians with a greater sense of professional support, helping them manage the emotional demands of their work more effectively.
One key factor that contributed to the improvements in staff well-being was the introduction of clinical supervision and mental health support as part of the audit process, formalised under the CARE sub-acronym. This structured support system allowed clinicians to regularly reflect on their practice, discuss challenging cases, and receive feedback from peers and supervisors, all of which are known to reduce stress and burnout [19]. The significant improvements in personal accomplishment also suggest that the REFLECT framework helped clinicians feel more engaged and effective in their roles, reinforcing previous findings that link professional development opportunities with increased job satisfaction [18].
The impact of the REFLECT framework on staff well-being is particularly noteworthy given the high rates of burnout typically observed in mental health services. The large effect sizes for reductions in burnout indicate that the framework’s focus on staff support was highly effective, making it a valuable tool for addressing one of the most pressing issues facing the mental health workforce today. Future research could explore the long-term sustainability of these improvements in staff well-being relating to services with high caseloads or those working with vulnerable populations.
5.4. Risk Management and Safeguarding
The REFLECT framework also proved effective in improving risk management and safeguarding protocols, as evidenced by the significant reductions in both safeguarding incidents and incident reporting times. These results highlight the framework’s ability to enhance the safety and accountability of mental health services by ensuring that potential risks are identified, documented, and addressed in a timely manner. The findings are in line with previous research that emphasises the importance of structured risk management protocols in reducing adverse outcomes in clinical settings [12] [16].
The substantial reduction in incident reporting time (from 7.8 days to 4.2 days) suggests that the REFLECT framework improved the efficiency of safeguarding procedures, ensuring that potential risks were escalated and addressed more quickly. The inclusion of emergency protocols under the SAFE sub-acronym likely played a crucial role in these improvements, as services were provided with clear guidelines on how to manage high-risk situations, such as cases involving suicidal ideation or acute psychotic episodes.
The reduction in safeguarding incidents (by 2.9 incidents on average) further indicates that the REFLECT framework not only improved the responsiveness of services but also reduced the likelihood of harm occurring in the first place. By ensuring that all clients were consistently assessed for risk and provided with appropriate follow-up care, the framework helped mitigate the impact of clinical and safeguarding risks. These results underscore the importance of integrating comprehensive risk management protocols into service audits to ensure the safety of clients and staff.
5.5. Limitations
Despite the significant improvements observed, there are several limitations to this study that should be considered. Primarily my limitations related to researcher bias—as the developer of the REFLECT framework and a consultant or contractor within the participating services, the researcher’s role could introduce both conscious and unconscious bias. Steps were taken to minimise this risk including: member checking, inter-rater reliability assessments during qualitative coding, and standardised data collection protocols. Despite these measures, this study acknowledges that researcher influence cannot be entirely eliminated, and independent evaluations by external researchers are recommended to further validate these findings.
Secondly, the sample size of 10 EAPs may limit the generalisability of the findings to other mental health service settings. Future studies should aim to include a larger and more diverse sample of services, especially those operating in different geographical regions or working with specific client populations, such as children or individuals with complex needs.
A further potential bias is the self-reported nature of some of the data, this can be seen in the staff well-being assessments which may have introduced response bias as participants may have felt compelled to report more positive experiences following the audit. Although the inclusion of both quantitative and qualitative data helped to triangulate findings, future studies could use objective measures of staff well-being, such as absenteeism rates or clinical errors, to provide a more comprehensive assessment of the audit’s impact.
Lastly, the study’s timeframe as focusing on pre- and post-audit periods within a short-term window may not fully capture the long-term effects of the REFLECT framework. Longitudinal studies are needed to assess the sustainability of the improvements in clinical outcomes, financial efficiency, staff well-being, and risk management over extended periods.
5.6. Future Research
Future research should focus on expanding the application of the REFLECT framework across a broader range of mental health services, including inpatient units, community mental health teams and private practices. Additionally, further studies should investigate the long-term sustainability of the improvements observed primarily in relation to staff well-being and financial efficiency. Exploring the framework’s impact in international contexts, where mental health services may face different operational challenges, would also provide valuable insights into the scalability of the REFLECT framework.
Moreover, future research could explore how the REFLECT framework could be adapted to address the unique needs of services that provide care for marginalised populations, such as ethnic minorities, LGBTQ+ individuals, or clients with disabilities. By incorporating cultural competence into the framework, services could ensure that their audit processes are sensitive to the diverse needs of their client base, thereby promoting equity in service delivery.
5.7. Conclusion
In conclusion, this study provides strong evidence for the effectiveness of the REFLECT framework in improving key areas of psychological service delivery, including clinical outcomes, financial oversight, staff well-being and risk management. The framework’s holistic approach, which integrates clinical governance, financial transparency, and staff support, ensures that services operate sustainably while providing high-quality care. The significant improvements observed across all key metrics demonstrate the value of adopting a comprehensive audit framework that addresses the multifaceted needs of psychological services. Future research should focus on assessing the long-term impact of the REFLECT framework and expanding its application across a broader range of service settings.
Whilst this is a small scale, limited study it provides some evidence supporting the effectiveness of the REFLECT framework in improving key dimensions of psychological services in the context of Employee Assistance Programmes (EAPs). Supporting the framework’s comprehensive approach, which integrates clinical governance, financial oversight, staff well-being, and risk management, ensures that services operate efficiently while maintaining high standards of care. This multi-dimensional approach addresses critical gaps found in traditional audit frameworks, such as those used by the Care Quality Commission (CQC) and National Audit of Psychological Therapies (NAPTs), which often neglect financial sustainability, staff support, and risk mitigation.
6. Findings
6.1. Summary of Key Findings
1) Clinical outcomes improved significantly post-audit, with large reductions in both depression (PHQ-9) and anxiety (GAD-7) scores. The systematic use of evidence-based interventions, encouraged by the REFLECT framework, was a key driver of these improvements.
2) Financial efficiency increased markedly, as reflected by enhanced budget allocation efficiency and cost-effectiveness. These financial gains underscore the importance of integrating financial transparency and resource management into audit processes, helping services allocate funds optimally without compromising care quality.
3) Staff well-being saw substantial improvements, with significant reductions in emotional exhaustion and depersonalisation, alongside increases in personal accomplishment. The REFLECT framework’s emphasis on clinical supervision and mental health support contributed to these positive outcomes, highlighting the framework’s ability to mitigate clinician burnout.
4) Risk management and safeguarding were also strengthened, with a noticeable reduction in the number of safeguarding incidents and faster incident reporting times. The structured risk management protocols embedded in the REFLECT framework enabled services to identify and respond to risks more effectively, safeguarding both clients and staff.
6.2. Implications for Psychological Services
The positive impact of the REFLECT framework in enhancing multiple operational and clinical dimensions has potentially important implications for mental health service providers. First, the framework demonstrates that some forms of integrative comprehensive audits, including financial and operational metrics alongside clinical measures, are essential for ensuring the long-term sustainability and effectiveness of psychological services. These findings suggest that services should adopt audit frameworks that provide a holistic view of service delivery rather than relying solely on clinical outcomes or patient safety metrics.
Secondly, improvements in staff well-being highlight the importance of supporting clinicians through structured supervision and mental health resources. Given the high rates of burnout among mental health professionals, the REFLECT framework’s focus on staff support presents a valuable model for maintaining a resilient and effective workforce. Services that implement similar support mechanisms are likely to see improved job satisfaction, reduced turnover, and better client outcomes.
Lastly, the study’s findings emphasise the critical role of risk management in psychological services. By providing clear guidelines for safeguarding protocols, the REFLECT framework aims to ensure that services are well-equipped to handle the complexities of client care, especially pertinent in high-risk cases. These results reinforce the need for all mental health services to adopt robust risk management systems that not only address clinical risks but also ensure timely reporting and follow-up.
6.3. Limitations
Despite the study’s strong findings, several limitations must be acknowledged. The relatively small sample of 10 EAPs may limit the generalisability of the results to other service settings: those outside the UK or those providing more specialised forms of mental health care [45]. Future research should expand the sample size and consider different service models, including inpatient settings, community mental health teams, and private practices, to explore whether the REFLECT framework can be universally applied [23].
Additionally, the use of self-reported measures for staff well-being, such as the Maslach Burnout Inventory (MBI), may introduce social desirability bias, as participants might have been influenced by the desire to present positive outcomes [46]. Objective measures, such as absenteeism rates or performance indicators, could complement self-reports to provide a more accurate assessment of the REFLECT framework’s impact on staff well-being [47]. Further studies should also examine the long-term effects of the framework by incorporating follow-up assessments over extended periods [48].
As mentioned earlier, while the researcher made every attempt to remain unbiased in conducting this research, as the developer of the framework, the implementor within the services, and the sole researcher, there is a potential for both conscious and unconscious biases [49]. Future research would benefit from having separate auditors and researchers to mitigate these biases and enhance the objectivity of findings [50].
6.4. Future Research
Future research should focus on several key areas. First, the long-term impact of the REFLECT framework on financial sustainability, clinical outcomes, and staff well-being should be evaluated. Longitudinal studies would help determine whether the improvements observed are maintained over time, especially pertinent in services with limited resources or those facing high client demand [51].
Second, further research is needed to explore how the framework can be adapted for use in diverse service settings. This includes examining its applicability in services that cater to specific client populations, such as children and adolescents, older adults, or individuals with complex needs, including those with co-morbid conditions [52]. By tailoring the REFLECT framework to address the unique challenges of these populations, mental health services could deliver more targeted and effective care.
Finally, it is crucial to investigate the potential for international scalability of the REFLECT framework. As mental health services differ across countries in terms of funding structures, regulatory requirements, and cultural considerations, further studies should assess whether the framework can be modified to suit global contexts [53]. This would involve incorporating international guidelines from organisations such as the World Health Organization (WHO) to ensure that the framework remains relevant in diverse cultural and economic environments [2].
6.5. Conclusion
The REFLECT framework represents a significant advancement in the auditing of psychological services, addressing gaps left by traditional audit models that focus narrowly on clinical outcomes or safety. By integrating clinical governance, financial oversight, staff support, and risk management, the framework offers a comprehensive tool for improving service delivery, ensuring both quality of care and operational sustainability. The significant improvements observed in this study across all key metrics highlight the potential of the REFLECT framework to transform psychological services and provide a blueprint for future audits in mental health care. As mental health services continue to evolve in response to growing demand, adopting comprehensive audit frameworks like REFLECT will be essential for ensuring that services remain effective, efficient, and responsive to both client and clinician needs.
Appendices
Appendix A: Quantitative Data Tables (Tables A1-A4)
Table A1. PHQ-9 and GAD-7 pre- and post-audit data.
ID |
PHQ-9 pre-audit |
PHQ-9 post-audit |
GAD-7 pre-audit |
GAD-7 post-audit |
001 |
13 |
8 |
14 |
9 |
002 |
18 |
15 |
18 |
12 |
003 |
9 |
7 |
10 |
7 |
004 |
15 |
10 |
14 |
8 |
005 |
12 |
9 |
16 |
10 |
006 |
14 |
10 |
17 |
11 |
007 |
19 |
14 |
20 |
15 |
008 |
11 |
8 |
12 |
9 |
009 |
13 |
9 |
15 |
10 |
010 |
10 |
6 |
12 |
8 |
Note: This table reflects a subset of the full client data, which involved 100 clients overall. Complete data, including effect size calculations, are presented in the main results section.
Table A2. Financial efficiency pre- and post-audit data.
ID |
Budget allocation efficiency pre (%) |
Budget allocation efficiency post (%) |
Cost-effectiveness pre (%) |
Cost-effectiveness post (%) |
001 |
65 |
78 |
63 |
80 |
002 |
72 |
85 |
68 |
82 |
003 |
60 |
75 |
59 |
78 |
004 |
68 |
81 |
64 |
83 |
005 |
70 |
83 |
65 |
85 |
006 |
67 |
80 |
66 |
81 |
007 |
73 |
86 |
70 |
88 |
008 |
65 |
79 |
62 |
80 |
009 |
69 |
82 |
67 |
84 |
010 |
66 |
80 |
64 |
83 |
Note: This data reflects improvements in financial efficiency following the REFLECT framework implementation. Changes in budget allocation efficiency and cost-effectiveness were statistically significant (p < 0.001), demonstrating the framework’s effectiveness in resource management.
Table A3. Maslach Burnout Inventory (MBI) pre- and post-audit data.
ID |
Burnout emotional pre |
Burnout emotional post |
Burnout depersonalisation pre |
Burnout depersonalisation post |
Personal accomplishment pre |
Personal accomplishment post |
001 |
45 |
35 |
21 |
15 |
32 |
40 |
002 |
50 |
40 |
25 |
19 |
30 |
38 |
003 |
42 |
32 |
18 |
12 |
34 |
41 |
004 |
38 |
30 |
16 |
10 |
33 |
42 |
005 |
47 |
37 |
24 |
18 |
31 |
39 |
006 |
44 |
33 |
20 |
14 |
33 |
41 |
007 |
49 |
38 |
22 |
17 |
29 |
37 |
008 |
41 |
31 |
19 |
12 |
35 |
43 |
009 |
46 |
36 |
23 |
18 |
31 |
39 |
010 |
40 |
30 |
17 |
11 |
34 |
42 |
Note: This table outlines pre- and post-audit scores for emotional exhaustion, depersonalisation, and personal accomplishment as measured by the Maslach Burnout Inventory (MBI). Significant reductions were observed in both emotional exhaustion and depersonalisation, while personal accomplishment scores improved (p < 0.001).
Table A4. Risk management and safeguarding data.
ID |
Safeguarding incidents pre |
Safeguarding incidents post |
Incident reporting time pre (days) |
Incident reporting time post (days) |
001 |
5 |
3 |
7.8 |
4.2 |
002 |
6 |
2 |
9.1 |
5.0 |
003 |
4 |
2 |
6.7 |
3.8 |
004 |
7 |
4 |
8.9 |
5.1 |
005 |
5 |
2 |
7.5 |
3.9 |
006 |
6 |
3 |
9.2 |
5.3 |
007 |
8 |
4 |
10.0 |
5.5 |
008 |
5 |
2 |
8.2 |
4.1 |
009 |
6 |
3 |
9.3 |
5.0 |
010 |
7 |
4 |
8.8 |
4.8 |
Note: The REFLECT framework led to a significant reduction in safeguarding incidents and faster incident reporting times (p < 0.001). These improvements demonstrate the framework’s efficacy in enhancing risk management protocols and safeguarding vulnerable clients.
Appendix B: Statistical Analysis Outputs
PHQ-9 and GAD-7 scores: Paired t-test results
PHQ-9: t(99) = 4.35, p < 0.001, Cohen’s d = 0.80.
GAD-7: t(99) = 4.89, p < 0.001, Cohen’s d = 0.89.
Interpretation: Significant reductions in both PHQ-9 and GAD-7 scores indicate strong evidence that the REFLECT framework contributed to improved mental health outcomes.
Financial metrics: Regression analysis
Budget allocation efficiency: t(9) = 3.98, p < 0.001.
Cost-effectiveness: t(9) = 4.12, p < 0.001.
Interpretation: The REFLECT framework significantly improved financial metrics, confirming the framework’s ability to enhance financial sustainability and resource allocation.
Maslach burnout inventory: Paired t-test results
Emotional exhaustion: t(49) = 5.67, p < 0.001, Cohen’s d = 0.84.
Depersonalisation: t(49) = 4.89, p < 0.001, Cohen’s d = 0.79.
Personal accomplishment: t(49) = 5.12, p < 0.001, Cohen’s d = 0.91.
Interpretation: The REFLECT framework significantly reduced burnout and increased personal accomplishment, indicating improved staff well-being.
Risk management: Chi-square and paired t-test results
Safeguarding incidents: χ2(1, N = 10) = 4.23, p < 0.001.
Incident reporting time: t(9) = 5.01, p < 0.001.
Interpretation: The reduction in safeguarding incidents and quicker incident reporting times reflect the effectiveness of the REFLECT framework’s SAFE component in strengthening risk management and safeguarding practices.