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Improving the Performance of the Public Mental Health System: Quality Assessment and Improvement


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Title: Improving the Performance of the Public Mental Health System: Quality Assessment and Improvement

Improving the Performance of the Public Mental
Health System Quality Assessment and
Berwicks Question
  • How can one tell whether or not a healthcare
    organization is really serious about improving
    its quality, instead of simply engaging in
    defensive measurement to protect itself against
    the demands of outsiders for information?
  • Don Berwick, The Basic Concepts of Quality
    Improvement, unpublished paper, 1987

Quality Assessment and Improvement
  • Definitions
  • The Quality Environment
  • The Quality Assessment Component
  • DMAIAn Ongoing Process
  • Fundamental Principles of Quality Management

  • Performance measurement is the regular
    collection and reporting of data to track work
    produced and results achieved
  • Performance measure is the specific quantitative
    representation of capacity, process, or outcome
    deemed relevant to the assessment of performance
  • Performance standard is a generally accepted,
    objective standard of measurement such as a rule
    or guideline against which an organizations
    level of performance can be compared

  • Performance management is the use of performance
    measurement information to help set agreed-upon
    performance goals, allocate and prioritize
    resources, inform managers to either confirm or
    change current policy or program directions to
    meet those goals, and report on the success in
    meeting those goals
  • Performance measurement is NOT punishment
  • Guidebook for Performance Measurement ,
  • Turning Point Project

  • Two of the primary uses for the results of
    performance measurement are for
  • Making comparisons of performance levels
  • Improving the quality of the processes and
    outcomes of the organization
  • The American College of Mental Health
    Administration (ACMHA) applied these distinctions
    between comparison and quality improvement in the
    proposed Consensus Set of Indicators for
    Behavioral Health

  • In the ACMHA project, five national accreditation
    entities reached consensus on a set of
    performance measures (CARF The Rehabilitation
    Commission, the Council on Accreditation, the
    Council on Quality and Leadership in Support of
    Persons with Disabilities, JCAHO and NCQA) but
    not on the specifications for measurement
  • They concluded that it was important to
    recognize that selecting appropriate measures
    depends on the purpose of assessing performance
  • They designated measures as either a comparison
    measure or a quality improvement measure to
    clarify the intended use of each measure and its
    data set

  • For comparison purposes, the standards and
    measures should provide sufficiently valid and
    reliable quantification such that comparison
    across the systems programs and departments can
    be made. By identifying the highest level of
    performance or outcome (the benchmark), an
    organization can duplicate those work processes
    to achieve higher performance overall.
  • For improving quality, some standards and
    measures lend themselves more to internal
    monitoring of performance and local
    accountability and are most suitable for
    supporting the improvement of the organization
    rather than for comparability among organizations.

  • Balanced Budget Act (BBA) of 1997 was a
    substantial rewrite of the Medicaid and Medicare
    program rules. Final rules were passed on
    6/14/02 protocols and checklists then rolled
    out. Details in the protocols and checklists are
    critical for an understanding of BBA impact.
  • External Quality Review Organization (EQRO) is an
    independent entity that meets competence criteria
    for conducting Medicaid EQR activities EQROs are
    being selected through state procurement
    processes to review the operations of risk
    bearing organizations contracting with state
    Medicaid agencies.

  • Managed Care Organization (MCO) is Medicaids
    term for a health plan that provides health care
    services to Medicaid enrollees
  • Examples include Group Health Cooperative,
    Community Health Plan of Washington and Molina
  • Prepaid Inpatient Health Plan (PIHP) is
    Medicaids term for a health plan that provides a
    more limited range of services than an MCO, for
    specialty services such as mental health
  • Examples include the Washington State Regional
    Support Networks (RSNs) and Oregons Mental
    Health Organizations (MHOs)

The Quality Environment
  • Crossing the Quality Chasm a New Health System
    for the 21st Century, Institute of Medicine (IOM)
  • Redesign of the health care system based on 10
    new rules
  • Build organizational supports for change,
    including the incorporation of care process and
    outcome measures into daily work and revising
    financial methods to support quality work
  • Priority Areas for National Action Transforming
    Health Care Quality, IOM 200320 priority areas
    selected including major depression (screening
    and treatment) and severe and persistent mental
    illness (focus on treatment in the public sector)

The Quality Environment
  • Currently an IOM Committee is studying how to
    adapt the Quality Chasm recommendations to Mental
    Health and Addictive Disorders
  • In December 2004, a meeting was co-hosted by the
    National Council for Community Behavioral
    Healthcare (NCCBH), RWJ Center for Health Care
    Strategies and SAMHSA to frame a National
    Initiative for Behavioral Health Care Quality
    Improvement (CMS participated in this effort, an
    opportunity to generate their support as well as
    to foster relationships)

The Quality Environment
  • The Institute for Healthcare Improvement (IHI)
    and Don Berwick, MD, have led the healthcare
    dialogue from its early beginnings
  • IHI is a healthcare industry focal point through
    National Forums, trainings, and Breakthrough
    Series that target reducing adverse drug events,
    medical errors or reducing delays and waiting
    times throughout the system
  • IHI partnered with Health Resources and Services
    Administration (HRSA) in developing and staffing
    the Health Disparities Collaboratives for
    Federally Qualified Health Centers (asthma,
    diabetes, depression)

The Quality Environment
  • National Committee for Quality Assurance (NCQA),
    created jointly by healthcare purchasers and HMOs
    to assess, measure and report on the quality of
    care provided by managed care organizations
  • Measures performance through HEDIS, a
    standardized measurement system for MCOs
  • Accredits MCOs using standards grounded in
    QIaccreditation is based on a combination of
    accreditation survey scores and scores on HEDIS
    measures (33 of 100 points)
  • MAA incorporates most of the NCQA quality
    standards in MCO contracts, collects selected
    HEDIS performance measures, and uses NCQA
    accreditation for a major part of the EQRO review

The Quality Environment
  • Joint Commission on Accreditation of Healthcare
    Organizations (JCAHO) accreditation process has
    shifted from survey preparation and scores to
    continuous operational improvement in support of
    safe, high-quality care
  • ORYX core measure data are used to continually
    assess key performance areas, and eventually will
    be incorporated into the organizations
    performance report as core measures are adopted
    for programs
  • JCAHO prepared the CMS protocols for BBA EQROs to
    use in review of Medicaid MCOs and PIHPs

The Quality Environment
  • BBA requires EQROs to operate within specific
  • Determine Compliance with Federal Medicaid
    Managed Care Regulations
  • Validate performance measures and methods of
    calculating measures of performance
  • Validate Performance Improvement Projects (PIPs)
    and methods of conducting a PIP
  • Conduct an Information Systems Capabilities
    Assessment (ISCA)

The Quality Environment
  • BBA rules require that the MHD and PIHPs have a
    Quality Assessment and Performance Improvement
    Program (QAPI) that includes mechanisms to detect
    both under-utilization and over-utilization
  • MHD is expected to continuously and consistently
    monitor the appropriateness and quality of the
    consumer care delivery system in PIHPs
  • MHD infrastructure is charged with reviewing
    statewide mental health data, recommending system
    improvements, and designing and implementing
    quality improvement projects and processes

The Quality Environment
  • Sample questions from the EQRO protocol include
  • Have any recent QAPI activities been implemented
    to monitor compliance with established standards
    for timeliness of access to care and member
  • What types of information does the program
    provide to support recredentialing of providers?
  • How does your PIHP detect over- and
    under-utilization? Provide examples.
  • How are enrollee and provider data from all
    components of your network used in your QAPI?

The Quality Environment
  • So we have a QAPI and PIPsits all about the
    bureaucracy, right?wrong, the work must have
    relevance to the organizational vision, mission
    and goalsits about achieving your purpose and
    serving your consumers
  • Requires leadership commitment and a deep
    understanding of the vision and mission of the
    system and/or organization
  • If you cannot tell 1) how a project specifically
    relates to your agencys vision and mission, or
    2) (worse) if you cannot tell how your agencys
    mission and vision relate to quality, the project
    should be sidelined until you can…
  • Hayes and Nelson, A Handbook Of Quality Change
    Implementation For Behavioral Health

The Quality Assessment Component
  • Are your system decisions made in a data-free
  • How do you know if your agency is achieving its
  • How do you know when you should initiate a PIP?
  • How will you decide on implementing practice
  • How will you know if (and why or why not) the PIP
    or practice guideline is successful?

The Quality Assessment Component
  • JCAHO ORYX Core Measurement Sets
  • Data Quality Principles (Handout 1)
  • May vary by setting or by key issue
  • Relate to the basic principles of care, process
  • Performance measure categories considered useful
    in the accreditation process
  • Clinical
  • Health status
  • Perception of care/service
  • Categories not considered useful include
  • Financial measures
  • Utilization measures, unless related to a
    standard of quality

The Quality Assessment Component
  • For JACHO Behavioral Health, requirements differ
    by type of organization
  • Organizations providing 24 hour care
  • Select a minimum of six clinical, health status
    or perception of care measures from the set of
    JCAHO approved measures
  • Measures must focus on the clients that receive
    24 hour services
  • Organizations providing non-24 hour care and/or
    24 hour care for an ADC of less than 10
  • Select at least six measures from any relevant
  • Share data, analytic conclusions and actions
    taken with surveyor
  • In future will be expected to select and enroll
    in a listed performance measurement system when
    core measures relevant to their services are

The Quality Assessment Component
  • NCQA HEDIS BH Measurement Sets (Handout 2)
  • Follow up after hospitalization for mental
  • Antidepressant medication management
  • Mental health utilizationinpatient discharges
    and average length of stay
  • Mental health utilizationpercentage of members
    receiving services
  • Chemical dependency utilizationinpatient
    discharges and average length of stay
  • Initiation and engagement of AOD dependence
  • Identification of AOD services

The Quality Assessment Component
  • PIHP Measurement Sets
  • Verity examples (Handout 3)
  • ACMHA Indicators (Handout 4)
  • PIHP Master Calendar (Handout 5)
  • Pilot Measurement of Initiation and Engagement
    (Handout 6)

The Quality Assessment Component
(No Transcript)
The Quality Assessment Component
  • The quality assessment component requires that a
    group of selected indicators are regularly
    tracked and reported
  • The data should be regularly analyzed through the
    use of control charts and comparison charts (Stay
    tuned for details!)
  • These indicators should tell you if you are
    achieving your agency goals and objectives
  • These indicators can provide the basis for
    deciding when a PIP might be indicated and the
    baseline information for measuring the future
    impact of PIPs

The Quality Assessment Component
  • The quality organization does not wait to be told
    (via regulations or requirements) what processes,
    procedures, or programs to implement. Instead the
    quality organization proactively implements a
    program that it recognizes it may have to alter
    as standards or regulations are developed…
  • Consider the ACMHA list of indicators as a
    starting placeit includes measures of what
    quality service means to consumers

From Hayes and Nelson, A Handbook Of Quality
Change Implementation For Behavioral Health
The Quality Assessment Component
  • Quality assessment is an absolutely necessary,
    but not sufficient, step to change from a
    data-free environment to a culture of

DMAIAn Ongoing Process
  • Living in a the plan-do, plan-do world?
  • Too busy fighting fires to close the loop?
  • Quality assessment indicators must have relevance
    to the organizational vision, mission, goals and
  • PIPs based on goals and objectives must use a
  • Improve cycle

DMAIAn Ongoing Process
  • MHD Implementation and Design Group has
    designated a standard methodology for the
    infrastructure to use in assessing, choosing,
    developing, monitoring and evaluating QI
    opportunities and outcomes
  • The Design, Measure, Analyze and Improve (DMAI)
    model is
  • Congruent with and supported by JCAHO
  • Data drivenintegrates trending, tracking,
    analysis and action into day-to-day processes
  • Already used by numerous providers and at least
    one RSN

DMAIAn Ongoing Process
From Hayes and Nelson, A Handbook Of Quality
Change Implementation For Behavioral Health
DMAIan Ongoing Process
  • Designtwo steps at the beginning
  • Establish objectives of the project
  • Establish the processes used to meet the
  • Measure
  • Establish the specific outcome and process
    measures the project will use for baseline and
    post implementation measurement

DMAI-An Ongoing Process
  • Analyzetwo types of analysis
  • Use statistical and numerical methods
  • Use comparative methods
  • Improve
  • Implement revised processes until analysis of
    measures indicates that the objectives have been

DMAIAn Ongoing Process
  • DMAI adds clarity about objectives into the
    cycle this is implied, but not specified in the
    PDCA or PDSA, and two types of analyses are

Fundamental Principles of Quality Management
  • Know your customers and what they need
  • Focus on processes
  • Use data for making decisions
  • Understand variation in processes
  • Use teamwork to improve work
  • Make quality improvement continuous
  • Demonstrate leadership commitment

Know Your Customers
  • Identify customers and their needsin
    healthcare there are usually two sets of
  • The people who use your services are the primary
  • The purchasers of your services also have
  • Set goals based on their needs and DMAI
    objectives based on the goals
  • Monitor performance and satisfaction to target
    performance improvement opportunities
  • Improve or redesign how work is done

Focus on Processes
  • 85 of poor quality is a result of poor work
    processes, not of staff doing a bad job
  • When things go wrong, it is often at the point of
    the handoff in the process
  • Attend to improving the overall design, not just
    one partsome of the most complex and poor
    quality processes are the result of improving
    and creating work arounds at some steps instead
    of redesigning the entire process

Focus on Processes
  • Advice from NCQA, JCAHO and othersmeasure
    processes that are
  • High-risk
  • High-volume
  • Problem prone And
  • Can be tracked and reported as summary or
    aggregate statistics
  • Are being selected by other organizations to
    allow statistically valid comparisons to be made
    (for purposes of benchmarking)

Use Data to Make Decisions
  • Use performance assessment data to target
  • Use data analysis tools to develop information
  • Analyze data to identify root cause
  • Use data to monitor performance outcomes

Use Data to Make Decisions
  • Collection of data on clinical outcome alone does
    not provide useful information about what led to
    the outcome, or how it can be replicated or
  • Pairing collection of outcome data with data on
    key process performance measures associated with
    the outcome will provide information on the
    consistency of the process of care
  • Statistical analysis of these sets of data tells
    an organization whether it is improving
    performance on outcomes while improving

Use Data to Make Decisions
Use Data to Make Decisions
  • Symptom is the indication of a problem, but not
    a statement of cause
  • Theory is the preliminary diagnosis about the
  • Analysis includes data that confirms or rules
    out theories
  • Solutionis the change that will best address
    the cause
  • Information is data that confirms whether the
    solution is having the expected impact

Use Data to Make Decisions
From Hayes and Nelson, A Handbook Of Quality
Change Implementation For Behavioral Health
Use Data to Make Decisions
Numerical Tools
Conceptual Tools
  • Check Sheet
  • Bar Chart
  • Histogram
  • Pareto Chart
  • Control Chart
  • Run Chart
  • Affinity Diagram
  • Brainstorming
  • Process Flow Chart
  • Interrelational Diagraph
  • Matrix Diagram
  • Tree Diagram
  • Cause and Effect Diagram

Use Data to Make Decisions
  • Conceptual tools support theory generation
    regarding root causes, a key step in the PIP
  • Root causes
  • In the logical chain of causes
  • Directly and economically controllable
  • Can be considered a constant part of (or
    deficiency in) the process under study
  • If eliminated, the problem disappears or is
    drastically reduced (the Pareto Principle or
    80-20 rule)
  • Initiating a PIP that defines a desired solution,
    rather than a process to be studied can be
    hazardous to your QAPI s health!

Use Data to Make Decisions
  • Brainstorming for root causestheory generation
    thrives on divergent thinking, so no idea is a
    bad one…
  • What can go wrong in the process we are studying?
  • Problems in hand-offs between steps
  • Problems in execution within steps
  • Look at machines, materials, methods,
    measurements, and people
  • Cause-effect or Fishbone diagram (Handout 7)
  • Organizes and displays theories
  • Encourages divergent thinking
  • Demonstrates the complexity of the problem
  • Encourages scientific analysis (rule-out)
  • Failure to use a Cause-effect diagram or use of
    an incomplete one, can be hazardous to a PIPs

Use Data to Make Decisions
  • Numerical tools support analysis of PIP theories,
    measurement of PIP implementation and ongoing
  • Specific theories are needed to drive data
    collection and analysis
  • Data collection and analysis leads to the vital
    few root causes by narrowing the competing
    theories of cause
  • Look for clusters of causes that can be tested
  • Use stratifying variables to localize the problem
    and identify likely causes
  • Do Pareto analysis of symptoms and theories

Use Data to Make Decisions
  • From Methods and Tools of Quality Improvement
  • Institute for Healthcare Improvement

Use Data to Make Decisions
  • The Four Dimensions of Variability

Center average, median or mode
Spread range or standard deviation
Sequence trend
From Methods and Tools of Quality Improvement
Institute for Healthcare Improvement
Use Data to Make Decisions
  • The average by itself is not a good summary of
    data, use a variety of numerical summaries
    (Handout 8)
  • Measures of center include
  • Average/Mean the total data values divided by
    the total number of observations
  • Median the middle value in the data set, half of
    the data value lie above, half lie below the
  • Mode the most frequently occurring values in the
    set of data
  • Use histograms to look at overall variation
  • Use line graphs to look at patterns over time

Use Data to Make Decisions
  • Pareto Principle
  • In any group of things that contribute to a
    common effect, a relative few contributors will
    account for the majority of the effect
  • These few contributors are call the vital few
    while the many other contributors are called the
    useful many
  • The vital few hold the greatest potential gain
    from quality improvement efforts
  • Pareto DiagramA fact based tool for priority
    setting in quality improvement efforts (Handout 9)

Use Data to Make Decisions
  • Control charts (Handout 9)
  • Variation in performance data is the result of a
    complex system of causes
  • Variation in this system of causes has
    characteristics of random variation
  • Used for ongoing quality assessment, control
    charts can help decide when to take action on the
    process based on the data
  • Statistics provide standard distributions and
    mathematical methods for testing common and
    special cause variation

Understand Variation
  • Sources of variation include machines,
    materials, methods, measurements, people,
  • Control charts are pictures of trend data with an
    extra featurethe range of variation built into
    the system
  • Common cause variation occurs if the process is
    stable variation in data points will be random
    and obey a mathematical lawit is said to be in
    statistical control, with a large number of small
    sources of variation
  • If an organization reacts to random variation in
    a process that is stable/in statistical control,
    it is called tampering and leads to further
    complexity, increasing variation and mistakes

Understand Variation
  • Special cause variation arises because of
    specific circumstances which are not part of the
    process all the time and may or may not ever
    recurif the recurrence is periodic, clues to the
    root cause may emerge
  • Not in statistical control is
  • One data point above or below the upper/lower
    control limits (three standard deviations)
  • Two out of three consecutive data points beyond
    two standard deviations
  • Of five consecutive data point, four are on the
    same side of the mean and beyond one standard
  • Eight consecutive data points are on the same
    side of mean
  • Need to investigate special cause variation
    before making any conclusions about performance

Understand Variation
  • Dont redesign an entire process (a PIP) when
    there is special cause variation, because there
    is not a consistent process to improve or stable
    baseline data to measure the impact of PIP
  • A sentinel event is a special cause variation
    requiring root cause analysis
  • Examine specific incident(s) of special cause
    variation and make changes to a single element
    only after very careful analysis
  • Failure to distinguish between common and special
    cause variation can be hazardous to
    organizational performance!

Understand Variation
  • Control chart analysis is done before comparison
    analysis to ensure a given process is stable
    before evaluation of relative performance level
  • Comparison charts are based on multiple
    organizations performance data (or on
    standards/benchmarks that have been adopted) and
    are used to evaluate relative performance level
  • If the process is stable, the only way to make
    improvements is to fundamentally change some
    aspect of the processthrough a redesign of the
    process or PIP
  • Use benchmark data to create a new control chart
    that raises the bar on consistency of expected
    average performance and control limits

Use Teamwork
  • PIPs need buy-in from all stakeholders
  • Process being studied is stable, but complex
  • Creative ideas are needed
  • Division of labor is needed
  • Process often crosses functions
  • Solution generally affects many

Use Teamwork
  • Those who do the work
  • Have theories about the cause
  • Have the detailed knowledge needed for conceptual
    analysis tools such as fishbone diagrams
  • Have the clinical and intuitive judgment needed
    for design work
  • Have ideas about improving the processes
  • Improving processes means changeinvolvement in
    planning change and having staff that are seen as
    leaders for the change will be critical to
    successful implementation
  • Open, safe communication is critical for
    improving processes (Handout 10)

Use Teamwork
  • Provide every team with a clear charge and
    support resources
  • Teams should adopt working agreements (everything
    from cell phone rules to decision procedures)
  • Teams should have assigned roles of facilitators
    and recorders
  • The team process has some predictable stages that
    it is useful to keep in mind
  • Forming
  • Storming
  • Norming
  • Performing

Make QI Continuous
From Hayes and Nelson, A Handbook Of Quality
Change Implementation For Behavioral Health
Make QI Continuous
  • QI is a system-wide approach to assessing and
    continuously improving quality of the processes
    and services over time
  • See inter-relationships, not parts
  • Understand the flow of work, not the one-time
  • Detail the work processes
  • Determine cause and effect relationships
  • Identify points of highest leverage
  • Improve and innovate, not just change for
    changes sake
  • A way of doing business, not the exclusive
    responsibility of one individual or a committee

Make QI Continuous
  • Use quality assessment to identify areas for
  • Charge PIP team and provide support
  • Provide DMAI training
  • Use tools to understand root causes
  • Use data for baseline and analysis
  • Design process improvement to address root causes
  • Train ... train ... train …staff on the newly
    designed process improvement
  • Evaluate the impact of process improvements
  • If you dont get the results you expected…….use
    assessment to understand why, revise accordingly
    and try again

Make QI Continuous
  • Measure improvement over time and compared to
  • Health of the people served
  • Customer satisfaction
  • Cycle time
  • Accuracy/consistent features
  • Financial performance
  • Quality assessment is critical to measure the
    impact of PIPs and practice guidelines
  • Measurement of baseline rates
  • Initial and second remeasurement after
  • Plan to ensure demonstrated improvement can be
    maintained over time
  • EQROs are looking for performance measurement
    over time

Demonstrate Leadership Commitment
  • Build a QAPI culture
  • Connect the organizations strategic plan to
    performance improvement
  • Know and use quality principles
  • Encourage all staff to use quality improvement in
    daily work
  • Reward improvements
  • Assure adequate QAPI infrastructure for quality
    assessment and improvement activities

Demonstrate Leadership Commitment QAPI Culture
  • Clearly stated and enacted constancy of purposea
    deep understanding of the vision and mission
  • Regular review of key indicator data
  • Decisions made on data rather than hunches or
  • Long range view supports search for root causes
    and permanent solutions rather than quick fixes
  • Focus on systems rather than individuals
  • Continued identification of improvement
  • Publicize successes (Handout 11)
  • Clear communication agency-wide regarding the
    commitment to quality and the change processes
    necessary to implement improvement

Demonstrate Leadership Commitment QAPI
  • Governance
  • Oversight and accountability
  • Program structure
  • Who will do what when, with what processes for
    recommending or deciding
  • Staff
  • Support for ongoing monitoring and analysis, for
    training and facilitating improvement activities
  • Data system
  • Collect data and report in a user friendly way

Demonstrate Leadership Commitment QAPI
  • Goals
  • Organizational structures, responsibilities, and
    flow of information
  • Quality council/committee
  • Method for selecting PIP projects, charging PIP
    work teams
  • Scope
  • Programs/services/staff included
  • Processes included
  • Process for using quality assessment results to
    plan changes

Demonstrate Leadership Commitment QAPI Work Plan
  • Goals
  • Important aspects of care/services
  • Activities that involve a high volumes, high
    degree of risk and/or tend to produce problems
    for patients or staff
  • Monitoring activities associated with important
    aspects of care/services
  • Methods of measurement, frequency, timelines for
  • Consumer satisfaction monitoring

Demonstrate Leadership Commitment QAPI Work Plan
  • Planned PIPs (in process, new) and timelines
  • Evaluation of PIPs now implemented and timelines
  • Annual evaluation of QAPI workplan and program
    description, with proposed revisions

Berwicks Answer
  • Quality improvement is grounded in values,
  • It begins with a commitment at the top of the
  • It takes money,
  • It has mechanisms for horizontal integration of
    quality measurement and control up and down the
    line of management and is relevant to front line
  • It requires statistical sophistication,
  • The focus is on design, not simply on
  • Management is responsive and looks for ways to
    remove obstacles to improvement, and
  • There is a strategy to drive out fear