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The quality of medical care that patients receive has been an issue discussed with increasing urgency and frequency in the last few years by almost all parties with a stake in the U.S. health care system.
Defining the components of quality care and developing indicators to assess those factors, however, are daunting tasks only undertaken in the last few years by regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee on Quality Assurance (NCQA). But the steps taken by those groups to devise systems for evaluating performance and outcomes in the mental health area are, in the view of some who have tried to use them, tentative, piecemeal, and incomplete.
Not content to wait for other organizations to develop suitable criteria for assessing the care provided to psychiatric patients, APA has decided that its members possess the unique expertise needed carry out such a project when the evaluations involve the quality of mental illness and substance abuse care and has appointed a task force to spearhead the complex effort.
The effort to develop such measures for psychiatric care "is long overdue," according to psychiatrist John Oldham, M.D., who chairs APA’s new Task Force on Quality Indictors. The task force is a joint component of the Council on Research and the Council on Economic Affairs.
The task force is charged with developing measurement tools that will provide valuable information on quality that can be used by public- and private-sector health care systems, insurance plans, physicians, patients and their advocates, regulatory bodies, and accrediting organizations.
"There is a serious need for a good, clinically based system of accountability that can be used as the professional standard," said Oldham, who is director of the New York State Psychiatric Institute and chief medical officer of the New York State Office of Mental Health.
"When such a system comes from a group of experts," as will be the case with APA’s mental health care quality indicators, "interested parties will be able to say that [the indicators] come from a well-informed position."
At its first meeting, held in December, the task force began its initiative by agreeing on the "dimensions" and "domains" that will form the framework of the development process. The dimensions that must be measured include, for example, the availability and accessibility of care; the technical quality and appropriateness of care; satisfaction of patients, families, individual physicians, and other care providers; and the outcomes and results of the care provided.
Domains are defined as specific focus areas, among them specific patient populations such as children, the elderly, and the those with chronic mental illnesses, and diagnostic categories such as major affective disorder, HIV/AIDS, schizophrenia, Alzheimer’s disease, trauma/PTSD, and substance use disorders.
In the current phase of the quality indicators project, the task force is reviewing a variety of indicators that might hold promise as successful measures of quality in relationship to the specific domains and dimensions of psychiatric care.
The task force members will then evaluate several existing indicators that could be used immediately to evaluate psychiatric and substance abuse treatment and recommend others that appear useful but will need more time for research, development, and implementation.
As part of the task force’s work, its members and staff will also analyze whether existing APA products, such as several in the practice guidelines series, for example, may be applicable to the process of developing quality indicators.
At its December meeting the task force members agreed that their goal is not to produce a comprehensive set of quality indicators for mental illness and substance abuse care, but to come up with several such measures that can be used to evaluate major concerns in these treatment areas. The indicators the task force develops should be applicable to three aspects of care - structure, process, and outcomes, with the primary focus being on assessing outcomes.
In addition to Oldham, the task force members are Sara Charles, Helen Egger, Anthony Lehmann, Denis Milke, Charles Riordan, and Lloyd Sederer (all M.D.’s). Lawrence Kline, M.D., and Samuel Guze, M.D., chairs, respectively, of the Council on Economic Affairs and Council on Research, are corresponding members, and Joseph Mawhinney, M.D., is the liaison from the American Academy of Child and Adolescent Psychiatry. Task force staff include Harold Alan Pincus, M.D., Deborah Zarin, M.D., Claudia Hart, and Beatrice Edner.