Quality of mental health care indicators to improve care.

The relevance of measuring quality of mental health care is widely recognized and a number of authors have defined quality of health care by describing this concept according to a set of dimensions and using different indicators. Despite the growing interest around these issues, in mental health care there is still a lack of agreement on the dimensions and measures which should be used as indicators of quality of care (Hermann et al. 2006). This is due to the differences in organization of health care systems, in policy priorities and in data sources available among countries (Amaddeo & Tansella, 2011). According to the Health Care Quality Indicator Project of the Organization for Economic Cooperation and Development (OECD), quality of care can be defined as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’ (Lohr & Schroeder, 1990; OECD, 2004; Arah et al. 2006). Several countries have implemented projects and initiatives to define and evaluate quality of care in health and mental health systems. The aims of such projects on quality of care were to tackle growing cost containment pressure, concerns about patients’ treatment choice and rights, and demands of transparency. Interest in this field is rising also due to advances in information technology systems monitoring the performance and utilization of services. According to Danabedian’s framework (1988), quality of care could be described by using three main dimensions: (1) input, the structural characteristics of healthcare organization; (2) process of care, the consumer’s interaction with the healthcare system which includes technical and interpersonal components of care; and (3) outcome of care, which reflects the results of treatment. Quality should be assured in all these phases and a balance across input-process-outcome is indicated to improve quality of care (NMHWG Information Strategy Committee Performance Indicator Drafting Group, 2005). Thornicroft & Tansella (2009) declined the three dimensions of quality of care in the field of mental health. Inputs consist of visible (mainly staff, facilities and budget) and invisible (experience, qualification and skills of staff, working relationship, legal and policy framework) resources. As suggested by the World Health Organization (2005), an appropriate human resources policy for mental health should be developed; continuing education, training and supervision should be developed for the provision of the best quality care that meets users’ needs and a motivated workforce will be more cost-effective. Other important input issues are the balance of expenditure between hospital and community services and the dissemination of clinical guidelines and protocols and higher level policy inputs. Processes represent a range of actions which take place in the delivery of mental health care. The measurement of processes helps to identify areas of relative over and under provision or whether people receive care that is evidence-based or conform to consensus expectations about quality. Surprisingly, while the pathway from evidence generation to evidence synthesis and guideline development is highly developed and quite sophisticated, the pathway from evidence-based guidelines to an evidence-based practice is much less developed (Barbui & Tansella, 2012). Moreover, process measures at national/regional level, such as admission rates, allow international comparison. An important process issue is individuals’ pathways to and through mental health services (the term is connected to accessibility and continuity domains of quality of care). Outcomes are usually considered to be changes in functioning, in morbidity or in mortality and, in a narrowed definition, they refer to changes in health status. They can regard different aspects: employment status, physical morbidity, suicide and self-harm, homelessness, mortality, symptoms severity, impact on care givers, satisfaction with services, quality of life, disability, met and unmet needs for care (Ruggeri et al. 2001; Thornicroft & Tansella, 1999). Suicide rate is a commonly used outcome at national/regional level; all * Address for correspondence: Professor Francesco Amaddeo, Department of Public Health and Community Medicine, Section of Psychiatry, University of Verona, Ospedale Policlinico “G.B. Rossi”, Piazzale L.A. Scuro 10, 37134-Verona, Italy. (Email: [email protected]) Epidemiology and Psychiatric Sciences (2013), 22, 1–2. © Cambridge University Press 2012 doi:10.1017/S2045796012000698 EDITORIALS IN THIS ISSUE, MARCH 2013