Continuous Enhancement of Quality Measurement in Primary Mental Health Care: Closing the Implementation Loop

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Continuous Enhancement of Quality Measurement
in Primary Mental Health Care Closing the
Implementation Loop

• PHCTF National Envelope Project

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Partners from
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Total N 615
CEQM (Continuous Enhancement of Quality
Measurement in Primary Care Mental Health -
Closing the Implementation Loop. A PCHTF National
Envelope Project/Mheccu Source CEQM Database
Date of generation 2005-04-23
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Objectives

1. To review the need for the project
2. To review issues/controversies related to quality
   measurement
3. To give an overview of the purpose and desired
   outcomes of project
4. To provide an update on progress
5. To initiate dialogue

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• Why a national project on measuring the quality
  of primary mental health care and why now?

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Why bother?

• 25 of people visiting primary care have a
  significant mental health condition
• Over 80 of people who access mental health care
  in a given year do so exclusively in primary care
• Growing gaps between what we know works and what
  is funded/practiced
• Orphaned sector not owned by MH or PC
• Other levels of MH system of course still
  important
• Currently no consensus about how to measure
  quality in this sector
• Hard to improve what one cant measure

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What is a quality measure?

• Quality measures describe specific features or
  outcomes of health care practices that may be
  amenable to improvement.
• Patients are able to make an appointment to see a
  family physician within two days
• Clinicians use an appropriate dosage of
  medication for treatment of depression
• Treated clients have improved functioning in the
  community

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Challenges with QM

• Tension between maximizing the quality of
  measures and broadly representing diverse
  features of the health care system
• Competing priorities among interest groups about
  what should be measured
• Kisely flashlight analogy
• Need to decide what parts of the room and which
  flashlight

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How can measures be used?

• Measurement for judgement (PM)
• Measurement for improvement (QM)

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Clinicians
Decision-makers
Consumers
Academics
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Focus practice-level improvement over
system-wide accountability

• Practice level stable, actionable and can be
  rolled up to higher levels of the system
• Strong evidence for practice-level QM alone
  working
• Lack of shared quality culture and QI
  capacity/skills
• Lack of hard measures in mental health (not
  unique)
• High risk of gaming

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Project purpose

• Improve the quality of mental health care in
  Canada through fostering the use of measurement
• Develop a set of quality measures (in primary
  mental health care ) based on the input of
  diverse interest groups across the country
• Create the conditions for future implementation

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Why this project is unique

• Consultation and consensus integral from start
• Synthesizes new MHPC evidence and expands on it
• Will be an important factor in facilitating a
  shift to a shared quality culture
• However, many other factors needed as well e.g.
  quality improvement training through Institute
  for healthcare improvement
• Will build relationships and networks that last
  beyond March 2006

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Project Overview
Stage 1
Stage 2
Stage 3
Health Measures
Priority Areas
Evidence
KT
KT
KT
End Mar. 05
End Sep. 05
End Mar. 06
Data project
End Dec. 05
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Final product

• Set of up to 40 health measures that all or most
  interest groups nationally agree are important to
  measure quality of PCMH
• Format to allow for easy implementation into
  existing data systems or as survey tools
• Quality for improvement not judgement, evidence,
  actionability and feasibility considered in
  selection.
• Results March 2006

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Attributes of Measures

• Meaningful
• face validity, clinically important, problem
  area, predictive validity
• Feasible
• Data precisely specified, available, affordable,
  accurate, reliable, case-mix adjusted,
  confidential
• Actionable
• Comprehensible, under users control,
  interpretable, norms, benchmarks, standards

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Project update Survey 1 overview

• Purpose narrow down the universe of health care
  variables and determine what priority areas
  (domains) to focus on
• Process
• survey followed by focus groups
• consensus sought both between regions and
  interest groups
• 145 participants, 91 per cent response rate

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Survey 1 results

• Consensus on 22 out of 81 domains 9 system wide
  and 13 special areas of focus
• System-wide general aspects of the health system
  that can be broadly applied regardless of
  specific mental health conditions, clinical
  settings and age groups
• Special area domains areas not captured that
  participants felt required additional focus
  (youth, psychosis, shared care)

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System-wide priority domains








Process
Continuity
Appropriateness
Accessibility
Competence
Effectiveness
Patient-Centeredness
Outcome
Health Conditions
Non-Medical Determinants of Health
Personal Resources
Equity

• No input/structural

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Special area priority domains









Specific Conditions
Mood Disorders
Comorbid Conditions
Acute Conditions
Child Mental Health Disorders
Psychosis
Age Groups
Youth
Interventions
Psychotherapy
Early Detection
Rehabilitation
Clinical Setting
Shared Care
Emergency Services
Outreach Services
Community Health Care Centre
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Survey 1 regional diversity

• Some regional diversity regarding domains
• Focus on regional priorities outside project
  scope (i.e., self-management support AB, BC,
  ON substance misuse for SK)
• Some coverage through overlap with system-wide
  domains (i.e., access is an important issue in
  substance misuse)
• However, provinces need to be aware of the
  priorities in their regions and determine what to
  do with these

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Priority domains by Stakeholder Group

• Mental Health User Representatives rated the
  highest number of domains as very important
• Decision-makers rated the lowest number of
  domains as very important

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What next?

• 3rd survey final set of measures
• Validate measures to form a survey/chart
  abstraction/Electronic health record tool
• Pilot sites/projects?
• Collect data
• Build QI skills
• What do you think?

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Also building joint quality culture

• Improved collaborative relationships
• Promotion of common approaches to health measure
  and quality improvement activities
• Joint national advocacy for further quality
  improvement work
• Linkage of health measures to quality improvement
  work and/or budgets
• Allow for future authentic accountability efforts

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Related projects

• Canadian Collaborative Mental Health Initiative
• CHSPR Logic model for primary care
• National evaluation strategy/CIHI PC indicator
  project
• Regional projects
• MHAIP BC mental health indicators

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Thank-you !

• Radha Puri
• Program Manager
• MHECCU
• University of British Columbia
• 2250 Westbrook Mall
• Vancouver, British Columbia V6T 1W6
• Tel [phone] ext. 63552 Fax (604)
  806-8854
• rmpuri_at_interchange.ubc.ca

• Paul S. Waraich, MD, MHSc, FRCP(C)
• Principal Investigator,
• Assistant Professor, MHECCU,
• Department of Psychiatry
• University of British Columbia

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CEQM linkages to Health Canada objectives

• High level
• Ensuring high-quality health services that are
  efficient and accessible
• Providing health information to help Canadians
  make informed decisions.

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CEQM linkages to Health Canada objectives

• Health Care System Renewal
• Partnerships among federal, provincial and
  territorial governments, key stakeholders,
  Canadians and international organizations
  (Source Health Canada Performance Report, for
  period ending March 31,2003))
• PHCTF
• Provide fora for information sharing
• Improve the availability and quality of
  information on primary health care
• Practical tools to address the challenges in
  renewal
• Facilitate collaboration among professions
  involved in primary health care

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QM a Building block for PM

• Any measure is more accountability than no
  measure at all
• Add case-mix adjustment, benchmarks, aggregate
  up, compare across institutions, link to
  financial inputs, public reporting
• QM becomes PM measure

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What is primary health care?

• The first contact and/or the most common
  experience with a health system
• Examples
• regular checkup with a family physician,
• phone call to a health information line,
• visit from a public health nurse,
• advice given by a pharmacist.