2000 - Ensuring And Improving Quality In Community Mental Health Care

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Ensuring

and improvilg

quality

W

in comrnulity

nental

health care

STEFA}i PRIEBE Unit Jor Sociat and Conn

niry Prichiary-, St. Banholoneu\

dnd the RaJat Laftdan Schoot oJMedi.;he and

aJ The delini.;.n al Eoad quairy al matal health eft i canPl*. It daends a7 the pqspenee, the unde4tins bol,4 and the ind, Md fie peaon drestinc q'alirJ. Far Beafth ahd cinnal putpds d /edraionitdc aPProuh { ilcxtabte A?Prouh6 fu tuuits 9A00 €uiti.!in*' and ratul qualiry ,totuse' qraLia' al catun nb mdet heahh cdft, tuch as ou@ne nanaceftnr,ISO 'i inp,@nry tumr are .nnca ! ftrieted. Quat1g nanosendt aPpnacha in flentul h.ahh ceft hd'oe bd b rhe .an.lusian rnd Proenhtu* delored far othel tt"e! ai setute! cM be elfectirely dpPlied b cadmunni hen4t heal .aft, b8 tha' the n.n ann hr ehaaseoad the inaalvdent oJ aI le@k aJ &e odani.aian are tuarc inpottdnt ian echnial a:Pecs. Far ta.ba re^ons, nanasins qrctiry on ,ad throush uetnal Pr.slte alane ;s likeLt to Jail. It s ag*d thar canfdd.e al Yai dld rh. quzli4' &. bdis oJ eatemal iadat^ oa three kvk t ProPoed aJ tha/ rcldionthipt uth oaddB nsed b be @B;dded, aad a tuoltel Jot d,siaEushns in@rtu;aa

Reforms ofmenBl healrh cee have led to Lheclosure o r d o w n s r z i n go i ; a ! g e m e n r a l h o s p r l a . sa n d t o t h < ?rr establish$€.t of so called communir-vmenral health care (CMHC) in most westeln iDdusllialized courtries oler the last 50years.Th€te is no uri\trsally - a g r e e d d e i n i t i o n o f w h a r p r e c l s e L , vc o n s t r t u r e s CMHC.Ye!, there seems to be some consensusthat CMHC is delivered b]' services based in ihe colrreiry and rhat mulr;professional reams are a ' e n u a l c o m p o r e n r o f i r .T h c s e l e a - " m a y b e s e n e r ' c with carchmenr area responsibiliq', or have specific remiG for targeting defined sub-gxoups of patienls, e.g. rchabilitarion reams or assertiveoriireach reams (Hanilyr 1995; Mccreq & Bond r995j Slade et al, I 9 9 5 : P u g s l e ye ra / . . t o 9 0 , H a d l c y a ra l . l 9 0 7 ; H a r p e r & Minshelia, 1997). Regardless of how CMHC is opeEring exacdy, ensuing its quality and implovirg ir as much as possible are essential rasks for initiatives on a poliocal, adminisEauve, sanagenal, ano clmicr, level. wlrat

is good qualit)

?

Any aftesp, Lo lmprove qualiry u1 CMHC requ;es an irplicir or explicir deinidon of whar good and poor qualiry is. There seem ro be some obvious fearues descdbing good qualiry !.\a! mosr people would easily agrce on: e.g. seffices shodd respoDd quickly to problems arisrng n rhe carchmen! area; tbey shouid xpply eiidence-basedu:ea1mentmerhods; they should be efecuve as well as cosFeifecuve. A

mo.e thoroush and precise considemdon of whar chalacierizes good quaLiB',howeve!, r€veals lhar rhe issueis m facl a complex one. For iliusuariDs rhis, an exarnple shall be given that specificauv applies to hospiial ca!e, bur flags up ploblens lhst are reler@t to all meDml heallh se ices. In r994, LheFederalMilrstr-a of Heslth i! Gem1sy was concerned about the qualii,\' of psychiatdc hospiral care, and conmissioned a sror.rpto develoP a procedure for assessirgrt (Kunze & Piebe. 1998). The group had 34 meDbels from differenr backglourds, ilcludrDg psychiatists, pslchoiogisrs, n u s e . . m a n a g e r 5 p. a . r e n r (a n d m e r r r e l a r i \ e sT. h e y worked for 2 yea.s and came up with a lesull. Firsd,v, rhe group divided the pracrice of hospiral care lnro 28 areas.The areas covered mos. procedures od acriols takeDin apsychiaEic hospilal, such as adnne sion and discharge, dng treatment and other forms of ueamreDr, manageDe of sr3tr, anci public relations. Secondll; the group oudbed 23 quahtv alms1[ foul cat€gories:llealment goals (e.g. improvemefi of psychopar,\ology)i primary ntentlons (e.s. prorecuon o parieris human digriD : mean
CorFspoDdedce ro: SrefaD P:iebe, U.ir fo. Sociaj and Cor]d@q od '-\e Roj-al LondoD PsJchiary, Sr Bsrlholodesi Sciool of \4editue rnd Denr$r) qu.en M34 and V esdeld C ollege), Easr Ham lvlerorjrl i loslnal, Et BQR, London, u < . f l : - 4 i 2 0 o - S bi _ . . . E r . - 1 4 0 : 0 8 - b o ; , : - i E . 1 " . . S f - ' - - - 4 q a \ . , .ii I S S N0 9 5 1 0 2 6 1 p i n r l s s N t l i j E - 1 6 2 t o J r l : e r o o l o j o 2 : 6 L J ta l n s o L u Lo.f L r . h i i t r f

Connun;ry nental hedlth carc ihe whole institution. Thus, a thrcc-dimensional model with 2576 ceils was created. Each cell representsthe application of a qualiry aim ro an area of praciice on one of the lbur levels.Thc model is inlended to be used for developing questions. The user of the model is free to find quesrions fbr each cell. Depending on the circumslances, there may be cclls for which reasonable questions cannot bc de\€loped, whilst for others there are mam' different questions thatmake senseand addressrelcvant qualitv This systematic model for asscssingqualiry hetps to generate questions, but does not pmvide a single answer.Ifone r,mnted to go dmugh the nhole nodel step by step and to address each cell which is nor intended by the aurhors assessinsqualil-v \rould be an entremely complicated, time consuming and in practicai terms Dot a feasible exercise.Yer,whar the model demonstrates very well, is that a someshar comprehensive and tnorough approach ro qualiry assessmenrleadsIo a very long lisr of reievant ditrcrent tacets.What the model does nor address f'er, is the problem of who sives the answers.Various research studics have shown rhar clinicians'and patients' assessment of the same treatment may be very different. For instance, independenr rarings blr clini. i a n . d n d b ! p a r i e n r \o l r n e p a r ( n r \ n c c d , i n a s t r e n reamlent situation revealed,at best,$€ak ro modeDre colrelation coefiicienm, sometimes faiting to reach 'rari.ri(al .isnilrcan.e (e.s. Hotrmann & ln(b(, l9S6).Thus, cliDicians' and patienrs' assessmentsof qualitv app$r distinct, and bolh matter. Paticnts' global assessmentoftreatment in CMHC has repeai edly been shown to predict relevant ouicome c iena and, therefore! to have some validity Gricbe & Gruyters, 1995; Priebe & Brdkcr, 1999). Orher rarers such as patients' carers, managcls or independenr observers,mat' er?rcss vicws thar are differenr hom both, the clinicians' and the patients' assessmenrs. Thus, whcn it comes to statemenls on quality and not jusr questions, the above model with more rhan 2500 cells would hale to be multiplied b,vihe number Othcr aufiors proposing a systematic approach to the assessmenlof quality of psvchiatric scrvrcesalso identilied a widc rangc of relevanr indicarors thar may bc rated in ditrereni lvays depending on thc pcrspective.For rhel(/orld Health Organization, Sara ceno et da (1993) described 10 sets of indicarors: policy indicarors, context-framesork indicarors! lesource indicatorsj programme indicators, average activity indicaturs, costs indicatorq process indicato!s, paiient oulcome indicators, saiisfadn)n indica tors, and impact indicaton. For rcscarch and for clinical purposes, a reductionistic approachis inevitable.Uys ,, d/. ( t 99 7) developed questiomaires for assessingthe qualiq of pubxc sccror p ' ) c h i a r r i , , e r v i c e .b d . e d o n c o n . u m e r e r p ( c r a r i , , n . . T h e c o n . u m e r q u e . n o n n a I e c o \ < r sa " c e r . , f i n d n L e . ,

22i

Iechnical qualir]', communication, staff attitudes, consumers' attitudc towards carc, and incidcnts. P r u \ i n c i a ld u < c r u r .u f n r ( n r r l h ( a l f i a r e r u s i v
outcome

maoagement

A simplified and straightforward approach for ensuring quality lppcars in the regnlar assessmentof oulcome crite a- Rcscarch has developed a number ofwidely accepted outcome critcria and more or less lcliable methods for assessingthem. These include o b . ( r \ e r r a r e da n d . e l f r a r e d * r l r . f o r a . , e * r n g indicators of psychopatholog,v,qualiry of life, social networks, and treatment costs jusr to name a fe\l: It

22A

S/"Jdtl Priebc

has been repcatedly proposcd to assess outcomc criteria notjust inresearch studics and u]rusuBlmodel ,ervice., bur a. par of ruurne .are. aon.i\r(nl fccdback of the resr ts to commisstuncrs, managers, clinicians, and uscls in C-N{HC is a tust step lolr'ards outcome managemcnt. lnformalion about outcome .hould rnable e\erv,'n( In\olted In rhc (ummi'sioning and running of ser\ices 1o reflect on their os,n practice, to identify strengths and weaknesses, and to think about specific inrclvcntions :]nd amend menrs for improving performance. Although the idca of ourcome managemcnl sounds straishdos'ard and simple, irs implcmentation in plactice has posed various hurdles and difiiculries. Because of these problems, s,vstcmadcoutcome management has not been widel,v cstablished yel, ncither on the level of lervices and progmmmes nor $'irnin indlvidual care pro.(src.. Ne\eflhel(.'. th( c.rll i"r implmenring a n d r e . r r n g w r \ \ l o r o u l c . m e m a n a g < m e n ri . $ 1 d ( . p r e d d r n L h c r e c e n t l i l e r r r u r L .a n d . u g g e . t j . n ' have been madc for addressins thc vaious pmblems (Srebnik 'r dl, lg97; Clard)' tr d7. 1998; Huder', 1998j Marks, 1998; Harrison & Eaton, 19991 Sahador-Carulla, 1999). lt seemsfair to assumethat se will see the implemenlation of various forms of outcome managcment in CMHC in drc near future. Hopetully, rhere \rill also bc systemaic empincal srudies, c.g. in L\e form of randomized controlled trials,rcsling its effectiven€ssfor improving outcomcs on a patient and on thc se ice level, and idcntirying the mediating proccssesinvolved.

Quality

mmagement

Concerns as to whelheroutcomc managementwill in fact be etrectile ma]' be relatcd to expeiences in the manufaciuring and servicc industr,v since thc mid lo;0.. Du'rng rhi' rm(. s(t(ral comDanirt pmducing goods that werc not compedti!'e lookcd for !va]'s to improve their producis. The result itas thal just assessinsthc quality of the 6nal product, e.s. the qualilv of a complete car, does not necessarily lcad to an-vimprovement. If the quality of the product is demonstratcd to be poor, thar mav make managers and workers alike feel bad and possibly I n c o m p e r e n .Y. ( r . r r d o < . n " r a u r u m a r i c a l l tj m p r n ! e rhe structurcs and processcsdetermining the qualir]-'' of the car and does not \,er]' much help to produce a better one.That expcrience led to the delclopment of s,\,sremsfor qualitv management that wcrc fust applied in the manufacturing industr,\, and later became popular in rhe service sector as *ell. An example is the prosramme described in the guidelinesISO 9000 o n 0 4 , $ h i c h a r e . L d n d a r . h z e d" . r o . . E u r o r e u . 8 . Ellis, 1996; Moore, 1999). Cenification according to thc ISO 9000 group suidelines is often tegarded as a p r f r L q u i i r e l o r d o i n g J o n r d . l ' $ i t h o t h e rc | m p a n i c . in the indusrrl'. The suidelines define a set of formal rules on hor{ to mmage qualiq independcni ofwhal

the product is or what the seNice delivcrs; e g rhe rulcs demand that the company orscrvicehas a handbook on quality management! a dcsignated person responsible for it and accountable direcdy Io the top level of management, rcgxl:r meetinss on quatiry issues, etc. Some health sen'iccs have sought and r e . e r v e d. e r n f i c a n o n r n l i n c w t t h t } l e I S o r r . r u i r e mcnts. In a bealth care st'stem adopting some sort of f r e c m r r I c r , . u ( h c c r r i 6 c a t r o nc J n b c a n a d t a n r a g ei n competition \,ith other ploviders.\vhether, and if so, to what e{cnt that qualit-v management programme is acrually etrectivein improving lhe quality ofmental hcrlth care seniccs, remams an open quesnon. It m.y be concludcd that outcomc :rssessment and feedback alone cannot improve qualir,\' if there are no mechanisms in placc for ensuring that appropriate inicrvcntions are designed and raken tor mudrltrng he \rrucrLre of and pru.e'.e. in CMHC. As the exampic of the ISO suidciines highlights, quality manasemcnt has developed into a f i f U u l ( x p e r u . ea n d a b r a n L h . l h u . r n e . .I n r r . own right. Expcrts in quaht,v managemenl mar or m a v n o ' b ( r a m r l i a r$ i L hw h a r m e n t a h e a l * r r e r t i . e . do, but fecl competent to apply their knowledge and skills to any scnice. Various attempls havc been made to implement totaL quality manasemcnt (TQM) in menral health se ices, most of them in the US. McFariand tt d!, (r996) report positive enpeiences wilh an approach r o r T Q M I n d c o r m u n i n m e n r a l h e a l r hc L n r r ( u . i n g rhe Baldridge c rerja as a framework.The Baldridge health carc categoriesfocus on leadership, information and anaiysis,srmtegic pianning, human resourcc development ancl management, process manage menr, organizalionalpcnbrmance results,and satlsfaction of patients and other stakeholdels.The authors state ihat lhe criieria enabled them to idcntii areas for improvemenl, to formulate a strategic plan on the basis of a self-assessment,as lvell as to evaluale and 'rhe to lcan ftom lheit plan. They concludc that a {'remrri. c r i r e r i ah d e h e l p e d u ' . n approach thar rs . . condu.itc ru rhe \qeepins c h a n g e .r e q , r r r e di n r . ' d r ) . h e a l r h c a r e e n \ i ' o n ment'. On thc basis of expericnces in Australra, Birleson (1998) advocatesthe learning oryanzatron model formental hcaldr care servicesfocusing on *le organizationai elemcnts leadership, organizational d..isn. work de.isn. pe'cepllon. iniutmation processing,communicarion, and motivational slstcms 'offers a . . . comprehensjve He feels rhat thc model frame$'ork for desisning adaptive mcntal health services and supportina quality management practices'. Thc fe{, examples may show already that diHerenr quali{_ management prograrnmes overlap substantially and ma,v just use ditrerent wods for namins similar mechanisms. The reader of the literature on quality managemcnt in mental health care miglt somctimes be puzzled about what rhe concepts,often described in vague and general terms,

CoDtnunt4- mental hedhh.drc actually mean in daily cljnical and managedal practice, and {'hat t\e relevant diffcrcnccs arc bctsccn them. Thcrc is hard\' any doubt that quality management programmes can be applied to CMHC just as $ e l l d 5t o o L h e rh e a l r ha n d n o n h c a l $ r e l a r e d. e r \ i . e . . The expeiences, however, ha!€ not been uniformly emhusiasric. ft seems rhar rhe mere rechniques of quality management programmes have to be supported b_va willingness of rhe whole organizalion ro chanseand ro iDprove (Chos anee,1996). lihcthe! rhe philosophy and techniques of qualilv managemenr work in menral health care appears more a 'question . . . ofmorivation than offit' (Slu]-ter, 1996). SuccesstuIqualiry manasement requires unequivocal d n d o n g o i n g l e a d e r . h r p. u p p o r r a n d a c L o m p a n v i n s .hanse. rn fie Cllrurc of fic ,crvi. c dd $c .crvi. e provider organization. Othe vise qualir_\' ivill be manased mainly on $e basis of erlernal stardalds alone. Such an approach has been found to have se\€ral distinct limitations as describedby Slulter (1998)l (a) Reliance on extemal srandards to define qualitv alloss thc organization to shift responsibilit!' for qualir-vissuesto external authorities. (b) Chasing erleinal slandards creates a 'compli a n c em e n r d l i r y f i r o u g h o u t r h e o r g a n i a r i o n . (c) Quality is defined more by professionalstandards r h a n i r i , b v L h e. u . r o m e F o f r h e o r s a n i l a r i n no r (d) Dcficiency rcports are oftcn uscd as a kind of 'club' with which to beat people over ihe head, thereby reinforcing punitive organizalronal (e) Such rcports may also become ends in dlemselvcs rather than a useftl means fbr imprcving proce q s < .i n \ ) \ r c m \ a n d p ' u \ i d i n g b e r r c r. e r \ i c c . For someonc presently working in CMHC in thc UK, the above rema*s may appear a fair rcflecrion of rhe effects that current initiatives for imprcving quality such as the National Service Framework or Clinical Govcrnance have on serlices and on thc people working in them.

Beyond mere techniques Thc cxpcriencestlat havc bccn madc in industry for almostthree decadesandin attempts to lpply quality management to mental heald se ices in the US, i n d i c a r er h a t m e r e c o n ' r . l a n d t r e \ . u r e o n . e r v r e . L . meet extcrDal standards does not significantly hcip to improve qualiiy. In fact, the-v might even be detdmental. Some potential negative effects q'ere summa zed by Slu]'ter (1998, see list above). Orhers related ones are the development of different languages and the undermining of confidence of staff If quality maDaacment adopts a strong and < x r l u \ i \ { r o p J o $ n a p p r o a c h$ i $ I n < m d u m u r i \ a tion coming ftom outside the scrviccs themselves,

229

those appruaches may over time develop a separatc l d n s ! a g e$ h i c h i . n " r . r n k e n b v \ r a f l i n I } l < - e r \ ( c ' . There is an oficial rhetorlc sith politically highly c o r r e c r b u z z $ ' o r d sl i k e ' p a r r n c r s h i p ' , ' m o d e r n i z a tion','evidence-based','user involvement','intcragenc,vworkins', and'nccds lcd seNice' (examples takcn iiom the UK). This son of ofiicial langlase can be put on by everyone familiar s'ith it, if and $hen needed a phenomenon well knos'n from the former communis! regimes in eastern Europc. Nevertheless,the terms lose their real meaning, and dle lack ofcornmunication rvith people on the ground prevents an adiustment of L\c official language.Thus, initiatives for quatiq improvement adopting that rheroric do notha'c any clcdibility and are perceived as unrealistic and'nothing to do with us'A morc tundamcntal problem is the ellect extemal contiol may have on the confidence ofstaff- Mental healrh c:re requires borh, rechniques in rhe form of skills, on thc onc hand, and personalities with competence and confrdence, on rhe other hand. Curently, the former aspcct may bc seen as dominating the Anglo American literarurc, lvhilst the latter is more reflected in the traditional French and Gcrman teaching of psychiarr-v(Jaspers,I 9 6 5) . The two aspects may be seen as equall,v important and dimcult to balance. One can aryue rhat CMHC is administered in and dcfincd by ihe relation. h p o f J a ) e n r d \ e a l r h p r n i e . ' i " n a lJ n d r p a r i L n r . This relationship ls cenrral for cngaging in treatmenr and for deliverins it. Fisure I shoss a simplilied model ofpmcesses in communii_v mental healrh Characteristics of the service (c.s. acccssibilitn fundins), of the clinician (e.g. professional backsrould, mood on the da_v),the patient (e.C. symptoms, social characteristics),the teatment (e.g. requiring regulai contacts, side-cffccts), and tnc srtuatn)n (e.s. fcatures of the meeting room, rime of fie day) al1 influence and determine a process at the ccntrc of which there is a dyadic relationship between the clinician and rhe patient. The proccss leads at worst to non-adherence and otheNise ro an outcomc that one way or another consistenlly ;nfluencesany of thc lactors described befbre.The therapeutic relation ship is a son ofblack box in the middle, undcrstudicd in research (N{ccabe e, dl., 1999) and almost neglected in current qualiq management approaches. For establishing a positive and helpful relationship sith mutual respect and trust, stafl have to ttel confident to utilize their personal potentials. E r r e r n a l l ) i n i r i a t e d q u d l i n m d n a g e m e n ri n i r i a r i r ( . ma!' carry the inierent messagethat slaffneed to be controlled and thar they are so pooliy motivatcd or lazy that they would do worse if they were not aware of being conrrolled. A good example of this may be the Confidential Enquiries into Homicides and Suicides by People with a Mcntal Illness in the UK. Recendy praised in

230

SteldnPricbc Service Clinician

Outcome

Patient R€htionship

Figurc 1. r''o., .

a I on a.

a revicw by Thompson (1999), the enquiries can tacilitate openness and identili' failures and weak nessesin a menralhealrh care seNice.Thcyalso make anyone $'ho has been activel_v involved in thc gilcn case a defendanr and potenrial culprit. The)' proact i v e l yp r o m o r e a b l a m l n g . u l u r e a n d m a k < i , m ' , r c difiicult for staff to cope widl very difEcult experi ences such as the suicide ofone's own patient.

Levels of intervention Tn rhe above erample, one inrervenrron,r.<. an enquilv. is likel,v to have ditrerent etrects on diferent l e v e l .r f $ < h e r l f i . a r e ' ! . r { m : i r m i g h r h e l p r o g d i n relevant informarion for improving serviccs, and ir miaht al the same time make staffirritated, angry a n d f r u . t r a r { d . Q u a l i r y m J n a s e m e n .p r o s r a m m e \ I n mental health care need to involvc all pa.ticipanis on v d r i o u . l e r e l r ' f i o m $ e b o a r dr o . m r u r h e L o m m u n i r y room' (Communit)' Health Improvement Paftnersj 1998). The interventiors for improvins qualit! in CMHC can be described on at least three distinguishable levels:the general lcvcl of healrh care a n d t h e g r v ( n m e n r a l h e a l f i c a r <' r . t r m . r h e r e r r i , e . in CMHC, and the clinical practice (Bulns & Priebe, I o o o ) . I n l i g h r o f f i e L o m p l e x i r yo f r h < q u r l r r ] F s u e as outlined above, only a few examples can be siven for each inren'ention level. The supportive backsround for good quality in ( - M H C i s r ( r ) w i d ( . A s o r d e d u c a r o n a l. 1 . r e m r . likely ro produce better educated and not just beEer trained statr with many obvious positive implications. A more systematic and specilic training and not just more difiicult to pass exams for all pmfessionals in CMHC would also be helptul. The basic tnining and education acquired at a young age and determinine a prcfessional identity and comperence can hadly be matched by training counes on identi fied saps in knoii'ledge or skills ar a later sragein thc calccr. Better tundins for health care can lead to h i s h e r . d l a r i e . , w h r c h w . u l d f a . j l i r a r e" r a f l r ( . r J I ment andretention and improve rhe socialprestige of the profession. Funding is also required for sufiicient

r\ -\lea rt H"r't. t n

supporting servicesin CMHC so that keyrvorkers m their coordinating role ha\.e sometling to cooidinate and can draw on other resources. Whether more money is spent on CMHC, has ro be declded by politicians and-indircctly by the public. Polirical will is also needed for establishing a snucrure lvithin fie given mental health care systcm that facilirares effective work ofservices. Politicians and meo,a seem particularly influential for this level, bur are nor in control of it. The sider le!€l has to be addrcssed if major chanses in ihe quality ofCMHC are aimed at, and il should be acknowledsed that CMHC does not work in isolation,but as pan of a complex socie+ Irs qualitv can only be as good or as bad as the rest of society wants and allows ii to be. The sftucture of serlices are the fust taiget of interveniions in mosr qualiry management programmcs.Thc composition of a ream, rhe skills of the team membels, the clarity of thc hieralchical snucture and the decision-making proccsses, the tre3r ment philosophy of dle servicc, the case load and many other f-eaturescan be analysed and chansed if the mechanisms for qualit_vimprovement arc in place and ifthe necessaryresourcesare available. II4hat appears sometimes overlookcd in rhe literature, is the level of clinical pracrice. Whethcr a service formally follows one structuml model o! another, may be jmporranl Equally relevant,howrvrr, is what clinicians actually do wirh theirpatients. \Vhat sort of care is delivered, q'hat are the clinical and non-clinical activiries of staff, and whar sorr of therapeutic relationships are established?In a wa,v. clinical praclice may be more difiiculr ro chanee rhan structural elements! yet, it is s'har counis for rhe patients whcn it comes ro qualiw. Researchproviding evidence for qualitv improvemenr, often tries ro link Ih( \rruLrure of ser\ic(. $irh individual patient outcome.The result is that many studics fail to yield empirical evidence rhat one organizational slauctnre leads ro a better oulcome than another, unless the diFfr'rcncc\ are .o marked e.g omce bd.ed pri.rce versus assertive outreach teams in the US that the f i n d i n s . a r e a l m o . r . r n i d l .I m p o n a n r i n l o r m a ' i o n o n the mcdiatina cffects of clinical practice may be lost

Community mentnl health carc

in tiosc studies.A theory-driven and hlpotheses led approach for studying how to influence clinical practice through changes of structure may be dislinsrished from studies relaring different clinical prr. ricesro indnidual oulcome.. Such a iep-$r.e approach ro rcsearch mayprcduce more reievant bits of information than altemprs for overall cvaluation of a semce m one go.

Conclusions D i f f e r e n rp e o p l ea r e l , k ( l y r o h a r e d r t T , r c n rr i e u . o n what good qualir_vin CMHC is. A iray out of the dilemma of finding a universally valid definition of quality may be provided by radical constructrvNm. According to that philosophy, quatity can be seen as a construct. Consmucls are maintained, modificd or given up not because they are true or farsr, ou! becauserhey are more or lessusetul to the oncholdins them. The usefulnessof a construct dcpends on the perspective and the intelcsts of the individual. Interests of different parties involved in CMHC such as politiciansj patients! mental heahh professionals, and insurance companies, vary. Al1 Se interests arc lcaitimate, but are likely ro be associatedwi*r diffcrcnt priorities for quality assuranceand qualit' improvcment.This perspeclive of radical consrucdvism does not lead ro new ways fo! iackling quality, but it might help to understand why tlere is no ovcrall accepred and cternal definition of qualit] and no singie 'right approach' for cnsurins and improving ir. Over the next years, we arc likel,v ro wirness &e wide implementation of quality managemeni programmes and tecbniques, with outcome managemenr being one element. Further developmenr oi CMHC would benelit if exisring experienccs of quality management programmes in health care and in other serviceswould be considered in this process. The most important message appears to be that ensuring and improving quality in CMHC should be seen as a philosophy of change and a comprehenslve cxcrcise involving all levels of rhe healrh clle systcm, and not just as a mere techlique ro be applied rhrough

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