Quality Measures: Necessary but Not Sufficient

In this issue, a group of Canadian investigators describes a laudable effort to develop a set of measures for evaluating the quality of care for individuals with schizophrenia. Following the dictum “You can't improve what you don't measure,” the translation of empirical studies, systematic reviews, and clinical guidelines into measurable performance indicators is a key first step in improving the quality of care.

As documented in the Institute of Medicine's (IOM) Quality Chasm Series, the quality of U.S. health care—and especially mental health care—leaves much to be desired. Crossing the “chasm” between the quality of care currently received by individuals with mental illness and the quality of care that they should receive will require much more than measurement. Modern quality improvement strategies (often adapted from industrial engineering) need to be embedded in the day-to-day work of mental health clinics and providers. Although such approaches have been widely applied in hospitals, very few innovative mental health organizations have had experience in this area, much less woven these processes into the fabric of delivering care. Organizations similar to the Institute for Healthcare Improvement (www.ihi.org) and NIATx (www.niatx.net) need to be established to assist mental health programs in applying and disseminating these tools. Measurement and improvement are greatly assisted by incentives to adopt health information technology, but current law does not include behavioral health organizations. Policy levers such as public reporting of performance and value-based reimbursement incentives are already being accelerated by the Affordable Care Act and will be increasingly applied to mental health settings.

The mental health field is unprepared for this sea change. Although a virtual blueprint for creating a quality infrastructure was incorporated in the 2006 IOM report Improving the Quality of Health Care for Mental and Substance-Use Conditions, few of the recommendations have been implemented. Leadership is absolutely necessary and clearly insufficient. Training for mental health professionals of all disciplines must be fundamentally altered to place evidence-based practices and quality improvement at its core.

This is not to say that we should be satisfied with the quality of existing quality measures that have been developed. We need measures that are truly associated with better outcomes for patients, that are feasible to collect, and that reflect the values of patients and families. Many indicators measure relatively trivial elements of quality because they look “under the lamppost”—that is, where data are easily accessible. Other indicators that appear to assess important aspects of care are either wholly impractical to implement or lack testing for reliability and validity. Adequate resources for and effective stewardship of measure development are essential.