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Project Summary


Continuous Enhancement of Quality Measurement (CEQM) in Primary Mental Health Care: Closing the Implementation Loop
A Primary Health Care Transition Fund National Envelope Project

The goal of CEQM was to improve the quality of mental health care for all Canadians by fostering quality measurement in Primary Mental Health Care. It aimed to achieve this goal through building pan-Canadian consensus on a small set of quality measures. These measures can be used in quality improvement efforts at various levels of the health system including the practice level. The project reached the end of its Primary Health Care Transition Funded work on September 30th 2006.

Breaking New Ground

While other jurisdictions (e.g. the United Kingdom and United States) are examining how to improve the quality of primary mental health care, CEQM built on this work in a Canadian context. It also:

  • Covered a comprehensive set of topics
  • Incorporated new knowledge about best practices
  • Used rigorous consensus methods with national, regional and multi-stakeholders at all stages
  • Collaborated with a wide range of partners to determine the initial project focus

A Legacy for Primary Mental Health Care – green light for action

A three stage process lead to a final set of 30 consensus measures. This project identified measures that Canadians view as important - providing both practical means for implementing quality measurement, as well as strategic direction in policy development and research. However further work is required to continue the iterative process of implementation required for a complex undertaking such as CEQM.

Design

National Consensus subproject

  • Stage 1 – employed a two round process that built consensus around priority areas (domains) for measurement
  • Stage 2 – populated these domains with potential measures through literature reviews and an expert survey.
  • Stage 3 - A subset of these measures was incorporated into a two round postal Delphi survey, using ratings of relevance, actionability and overall importance to identify the final measures.

Data Infrastructure subproject

  • Identified data quality standards for primary mental health care quality measures through literature reviews and key informant interviews

Measurement Implementation subproject

  • Systematic literature review to create an implementation checklist on the facilitators and barriers to quality measurement in primary health care. Subsequent pilot testing of the checklist with an expert panel

Participants

Over 500 people from every province/territory in Canada representing –

  • Consumers/advocates
  • Clinicians
  • Academics
  • Government decision-makers from regional, provincial, and federal levels
  • A small group of people with expertise in First Nations and Rural Health issues also included

Results

National Consensus

All measures are available in our Quality Measures database – you can search for individual measures best suited to your interests.

  • Stage 1 – 91% response rate; identified 20 priority domains
  • Stage 2 – several hundred potential measures identified
  • Stage 3 – 160 measures rated by 212 final respondents (80% response rate) leading to a final set of 30 consensus measures

Examples of CEQM Quality Measures

Domain Measure Title
Patients With Mood Disorders Education about Depression
Patient and families should be educated on:
•  The causes, symptoms and natural history of major depression
•  Treatment options (trial and error approach)
•  What to expect during the course of treatment
•  How to monitor symptoms and side effects
•  Follow-up protocols (office visits and/or telephone contacts)
•  Early warning signs of relapse or recurrence
•  Length of treatment.
Patients With Acute Conditions Risk Assessment for Self Harm
Healthcare professionals attending a person who has self-harmed should conduct and record a comprehensive and respectful assessment of (in order of urgency):
1.  risk
2.  current emotional and mental state
3.  psychosocial needs
4. main clinical and demographic factors associated with risk of further self-harm and/or suicide.
Continuity Secondary Care Discharge Plans
Development of a discharge plan addressing monitoring and follow-up actions for adults with low prevalence psychiatric disorders (e.g., schizophrenia) who have received specialist mental care and have been transferred back to primary health care.

 

Data Infrastructure

This project identified needs for standard measurement approaches, and the value of electronic data capture as a tool for quality improvement, an approach that both meets the quality measurement needs of the mental health primary care sector as well as ensures standardized measurement practices across the country.

Measurement Implementation

Creation of a practical checklist for organizations to identify facilitators and barriers to implementing quality measurement.

Key Findings

National Consensus

  • Respondents placed special emphasis on measures associated with self harm and depression.
  • Most variation in ratings occurred around actionability.
  • Consumers and Quebec respondents showed the most distinct results.
  • The largest differences between stakeholders were for measures associated with the domains of personal resources, co-morbidity and rehabilitation.
  • The most significant consideration used by respondents to rate measures was “quality of life” for people in care.

Data Infrastructure

There are significant gaps in the information that is available to calculate measures in Primary Mental Health Care. Electronic Health Records, when available, and if standardized, will become a possible source of data for quality improvement efforts in PHC and other areas of health care in the future.

Measurement Implementation

The Readiness to Implement Quality Measurement Checklist is an internal management tool that allows an organization to assess its position regarding implementing quality measurement. The checklist is brief but comprehensive, based on a systematic literature review and pilot test ed with a heterogeneous group of stakeholders.

Summary of Implications – a roster of key messages

Uniqueness of initiative

  • Ground breaking from both a national and international perspective
  • One of the first pan-Canadian projects to look at quality improvement through quality measurement

Breadth and depth of initiative

  • Synthesizes published evidence developed over the last 10-15 years and expands on it by adding new expert knowledge
  • Extensive efforts to align results of the project with recent best practices and quality improvement work in Canada
  • Availability of a searchable web-based inventory that allows for priority measures to be examined from regional and stakeholder perspectives

Builds momentum for primary health care transition

  • CEQM deliverables will further the work of organizations such as the Health Council of Canada, regional health quality councils and the proposed Canadian Mental Health Commission
  • Crucial that this project’s next steps are translated into action now - given the recent release of the Kirby Report and its proposal for a Mental Health Transition Fund and a Canadian Mental Health Commission.
  • This project will help improve the quality of mental health care for all Canadians -more effectively and efficiently than if each region in the country tackled this issue on its own.
  • If implemented and augmented by other system changes, the project’s outcomes should produce maximum results by focusing on the intersection of mental health and primary health care – where most people with mental health problems seek help.
  • In terms of system change and quality improvement, the mental health sector of the health care system (primary level and other levels) has traditionally not received appropriate attention. This project offers a starting point to consider these important issues.
  • The project will help provide direction for current and new initiatives by addressing gaps in quality, as well as facilitating evaluation and maximized improvement .
  • The project creates a legacy whereby people designing new services can use measures as “yardsticks” for system change.

Project Lead

Paul S. Waraich, MD, MHSc, FRCP (C)
Adjunct Professor, CARMHA
Centre for Applied Research in Mental Health & Addiction
Faculty of Health Sciences, Simon Fraser University
Assistant Professor
Department of Psychiatry
Faculty of Medicine, University of British Columbia

Centre for Applied Research in Mental Health & Addiction (CARMHA)
Faculty of Health Sciences
Simon Fraser University

Department of Psychiatry
Faculty of Medicine
University of British Columbia

Project Sponsor

Primary Health Care Transition Fund
(National Envelope), Health Canada

 

 


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The views expressed herein do not necessarily represent the official policies of Health Canada