Improving Mental Health Care: A Guide to Measurement-Based Quality Improvement

Brace yourself. This is not a book for a casual reader who wants Cliffs Notes on performance measurement (PM) and quality improvement (QI). This is a master guide that is unparalled in its clarity, uniformity, and conciseness, despite being 697 pages long. We need it.

PM and QI are methods administrators, consumers, advocates, payers, accreditors, and clinicians—in the case of health care, including mental health care—use to identify and change the structure and process of just about anything in order to improve outcomes and safety and to reduce unwelcome and untoward events. QI can also reduce variability in service delivery and outcome and improve conformance with evidence-based practices. It is not research because its goal is to produce change—and improvement—not to demonstrate correlation between intervention and outcome.

Curiously, QI has not been consistently demonstrated to be effective. Instead, studies show "pockets of improvement." Should we be promoting its widespread use with a limited or variable evidence base? Yes, Richard Hermann, the book's author, argues—and I agree. QI has great face validity, and it works a lot better when organizations adopt it as a value, train their staff, structure it into standard operations, work in teams, are innovative, and know how to identify what key processes of care and outcomes are important to them. It works much better when external performance goals are set by payers and oversight groups, when there are financial incentives, and when results are compared with those of other providers. The problem, it seems to me, is not QI; the problem is creating a better environment for mental health care and letting QI rise with that tide.

This text is drawn from research that Dr. Hermann has done over the years at the Center for Quality Assessment and Improvement in Mental Health at Tufts and at previous positions that have made him one of the premier spokesperson's in this complex and necessary field. The book has two parts: five chapters on the conceptual basis for mental health PM and QI followed by a compendium of 275 process measures for mental health and substance abuse services. The five conceptual chapters are thick with information but carefully done so to avoid denseness and confusion. Chapter 4 is an excellent summary of how to compare and interpret results and the best summary I have seen about standards, means, norms, and benchmarks. Chapter 5 is a frank discussion about the effectiveness of QI itself. We are provided with information about how QI can serve our consumers and providers well if we create, and operate under, the right circumstances. Although QI is essential, the author warns us that it is no panacea for the many ailments that affect health care. I thought that Chapter 3 would have benefited from a more how-to approach for measurement selection, such as who and what you want to measure, for what purpose, for what audiences, with what materials and resources.

The second section is the best short handbook of measures we have: 275 of them each presented in one to two pages with a standard format that summarizes the measure, gives its specifications, depicts who developed it for what constituents, presents its evidence base—levels A, B, and C from the Agency for Healthcare Research and Quality—and provides a glimpse into its use. There are seven indices, organized into topics such as population, treatment, and quality domain. I tried an exercise in which I used the text to help me summarize the evidence base for public mental health alcohol and substance abuse interventions. I then discovered how useful the text could be in an effort to create a compelling case for what services my agency should advocate for and support.

Dr. Hermann comments that mental health PM and QI is a young and developing field. We have him and his able colleagues to thank for providing the field with a text that will hopefully produce a growth sport. I hope this book will be widely and properly used as a resource and guide as we all continue to make mental health care safer, more client and family responsive, and more effective.