February 5, 1999

By John M. Oldham, M.D.
Chair
Task Force on Quality Indicators

There is a groundswell of interest in the development of performance measures, so that health care systems can be held accountable for the care they provide. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recently introduced an ambitious performance measurement program. Other organizations, such as the National Committee on Quality Assurance (NCQA) and the American Medical Accreditation Program (AMAP), are developing methods to evaluate health care, and the JCAHO, NCQA, and AMAP have announced a collaboration on an initiative to coordinate performance measurement activities across the entire health care system.

At the instigation and under the leadership of President Rodrigo Muņoz, M.D., the American Psychiatric Association established a Task Force on Quality Indicators to begin the development of clinically based, patient-focused quality indicators, utilizing existing and ongoing research and clinical consensus. Under the joint auspices of the Council on Research and the Council on Economic Affairs, the task force was asked to produce a framework for the development of clinical indicators, along with an initial set of sample indicators. The task force has reviewed similar efforts by other organizations and has sought input widely from APA councils and components and from other consultants.

A draft report has been circulated to the Assembly and presented to the Board of Trustees, and the report is now in the final stages of revision, to be broadly distributed in the near future, after Board approval. This initial report, the task force emphasizes, is a "work in progress." The specific examples of indicators are not intended to be comprehensive, and many additional indicators could be developed (and are expected to be) to address other important aspects of the broad recommendations about clinical care.

In developing a framework for quality indicators, the task force agreed upon a set of principles to guide in the selection of indicators. These include the following:

• The indicator addresses an important aspect of care.


• The indicator will be useful in identifying opportunities for improvement of care.


• The indicator will be practically quantifiable.


• Where possible, the indicator will be documented by an evidence-based practice guideline, for example, APA practice guidelines.


• The indicator will minimize the potential for unintended adverse consequences.

To emphasize areas of greatest importance, a list of priority areas was developed that included populations or diagnostic groups of high clinical concern. In turn, definitions were agreed upon, to facilitate the creation of a framework for the development of indicators:

Recommendation/Goal: an important clinical principle that reflects quality patient care.

Indicator: a component of quality patient care.

Measure: a mechanism or instrument to quantify the indicator.

Standard: levels of the measure that suggest that the component of care is of adequate quality.

The task force then set about to develop clinical recommendations and goals, followed by sample quality indicators with their corresponding measures and standards, in the following categories:

A. Access
1. To effective medication
2. To effective psychosocial treatment
3. To appropriate specialized services

B. Quality
1. Comprehensive evaluation
2. Appropriate use of medication
3. Appropriate provision of psychosocial treatment
4. Appropriate use of screening/prevention services

C. Perceptions of Care
1. Patient
2. Family
3. Clinician

D. Outcome
1. Improved level of functioning and quality of life, and minimization of social and economic costs. 2. Reduction and/or stabilization of symptoms.

The draft report of the task force presents a set of clinical recommendations and goals, along with one or more sample indicators in each of the above categories in each of the four dimensions of care. Our hope is that this will launch an ongoing process that will continue under the auspices of the new APA Office of Quality Improvement and Psychiatric Services, so that a growing, clinically based guide will become increasingly useful for determining the quality and effectiveness of organized systems of care.

We invite suggestions and recommendations from the membership, and we hope to post the report, once it is finalized, on the APA Web site to facilitate this potential for participatory input.