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
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.
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
Over 500 people from every province/territory in Canada representing –
- 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
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
|Patients With Mood Disorders
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
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
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.
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.
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
Creation of a practical checklist for organizations to identify facilitators
and barriers to implementing quality measurement.
- Respondents placed special emphasis on measures associated with self harm
- 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.
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.
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
- The project creates a legacy whereby people designing new services can
use measures as “yardsticks” for system change.
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
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
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