Achieving consensus across diverse stakeholders on quality measures for mental healthcare

Prioritizing core components of successful transitions from child to adult mental health care: a national Delphi survey with youth, caregivers, and health professionals

Youth accessing mental health care often experience a disruption in care as they attempt to transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). Few studies have evaluated interventions seeking to improve the experience and outcomes of CAMHS-AMHS transitions, in part due to lack of consensus on what constitutes best practices in intervention success. As such, the aim of this study was to engage patients, caregivers, and clinicians to prioritize core components of successful CAMHS-AMHS transitions which can be used in the design or evaluation of transition interventions. As such, a Delphi study was conducted to determine core components of successful CAMHS-AMHS transitions. Guided by the principles of patient-oriented research, three balanced expert panels consisting of youth, caregivers, and clinicians ranked and provided feedback on the importance and feasibility of core components of CAMHS-AMHS transitions. Components endorsed as feasible or important with ≥ 70% agreement from any panel moved to the next round. As a result, a list of 26 core components of CAMHS-AMHS transitions has been refined which can be used in the design, implementation, or evaluation of interventions intended to improve transition experiences and outcomes for youth in mental health care. Youth and families were engaged in an expert advisory role throughout the research process, contributing their important perspectives to the design and implementation of this study, as well as interpretation of the findings.

Measuring the patient experience in community mental health services for older people: A study of the Net Promoter Score using the Friends and Family Test in England

OBJECTIVES

The research aimed to explore the value of the Net Promoter Score as a service improvement tool and an outcome measure. The study objectives were to (1) explore associations between the Net Promoter Score with patient and service-receipt characteristics; (2) evaluate the strength of association between the Net Promoter Score and a satisfaction score; and (3) evaluate its test-retest reliability.

METHODS

A postal survey was sent to service users on caseloads of community mental health teams for older people in four localities of England. The survey collected the Net Promoter Score, a single satisfaction question, and data on socio-demographics, clinical profile, and service receipt. Analysis used non-parametric tests of association and exploratory least squares regression. A second survey was administered for test-retest reliability analysis. Fieldwork concluded in April 2016.

RESULTS

For 352 respondents, the Net Promoter Score was negatively related to age and was lowest for those still within 6 months of their initial referral. Receiving support from a psychiatrist and/or support worker was linked to higher scores. A strong but imperfect correlation coefficient with the satisfaction score indicates they evaluate related but distinct constructs. It had a reasonable test-retest reliability, with a weighted kappa of 0.706.

CONCLUSIONS

Despite doubts over its validity in community mental health services, the Net Promoter Score may produce results of value to researchers, clinicians, service commissioners, and managers, if part of wider data collection. However, multi-item measures would provide greater breadth and improved reliability.

Quality indicators for care of depression in primary care settings: a systematic review

BACKGROUND

Despite the growing interest in assessing the quality of care for depression, there is little evidence to support measurement of the quality of primary care for depression. This study identified evidence-based quality indicators for monitoring, evaluating and improving the quality of care for depression in primary care settings.

METHODS

Ovid MEDLINE and Ovid PsycINFO databases, and grey literature, including relevant organizational websites, were searched from 2000 to 2015. Two reviewers independently selected studies if (1) the study methodology combined a systematic literature search with assessment of quality indicators by an expert panel and (2) quality indicators were applicable to assessment of care for adults with depression in primary care settings. Included studies were appraised using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument, which contains four domains and 20 items. A narrative synthesis was used to combine the indicators within themes. Quality indicators applicable to care for adults with depression in primary care settings were extracted using a structured form. The extracted quality indicators were categorized according to Donabedian's 'structure-process-outcome' framework.

RESULTS

The search revealed 3838 studies. Four additional publications were identified through grey literature searching. Thirty-nine articles were reviewed in detail and seven met the inclusion criteria. According to the AIRE domains, all studies were clear on purpose and stakeholder involvement, while formal endorsement and usage of indicators in practice were scarcely described. A total of 53 quality indicators were identified from the included studies, many of which overlap conceptually or in content: 15 structure, 33 process and four outcome indicators. This study identified quality indicators for evaluating primary care for depression among adult patients.

CONCLUSIONS

The identified set of indicators address multiple dimensions of depression care and provide an excellent starting point for further development and use in primary care settings.

The development of an outcome measures toolkit for spinal cord injury rehabilitation

BACKGROUND

Spinal cord injury (SCI) is a complex medical condition that can be difficult to monitor.

PURPOSE

This study aimed to establish a common set of validated outcome measures specifically for SCI clinical practice.

METHOD

In a three-round online Delphi process, experts in SCI care across Canada suggested and ranked outcome measures for clinical practice. The facilitators provided feedback between rounds and determined if consensus (at least 75% agreement) was reached on a single outcome measure per clinical area.

FINDINGS

One hundred and forty-eight outcome measures were initially considered for inclusion. After three rounds, consensus was reached for 23 out of 30 clinical areas. In the remaining seven, more than one outcome measure was recommended. The final toolkit comprises 33 outcome measures with sufficient measurement properties for use with a SCI population.

IMPLICATIONS

An outcome measures toolkit validated specifically for SCI should lead to improved identification of best practice and enable clinicians to monitor client progress effectively.

Evaluation dimensions for collaborative mental health services in primary care systems in latin america: results of a Delphi group

This article presents the results of a Delphi group to identify the dimensions of an evaluation framework for collaborative mental health care (CMHC) in Latin America. A three-round Delphi process was implemented with 26 experts from Latin America and Canada to identify main areas of consensus, as well as disagreements, about the importance and feasibility of potential evaluation dimensions previously identified in Mexico, Nicaragua and Chile. Participants validated 40 evaluation dimensions. They strongly endorsed a comprehensive evaluation framework for CMHC in Latin America. This study represents a solid foundation for developing an evaluation framework for CMHC.

Composing a core set of performance indicators for public mental health care: a modified Delphi procedure

Public mental health care (PMHC) systems are responsible for the wellbeing of vulnerable groups that cope with complex psychosocial problems. This article describes the development of a set of performance indicators that are feasible, meaningful, and useful to assess the quality of the PMHC system in Amsterdam, the Netherlands. Performance indicators were selected from an international inventory and presented to stakeholders of the PMHC system in a modified Delphi procedure. Characteristics of indicators were judged individually, before consensus on a core set was reached during a plenary discussion. Involving stakeholders at early stages of development increases support for quality assessment.

Measurement of Perceived and Technical Quality of Care for Depression in Racially and Ethnically Diverse Groups

Measurement of patient satisfaction is now considered essential for providing patient centered care and is an important tool for addressing health care disparities. However, little is known about how ethnically and racially diverse (ERD) groups differ in how they perceive quality, and widely used instruments for measuring perceived quality give little attention to cultural elements of care. This study examined the relationship between the culturally determined beliefs and expectations of four ERD groups (African Americans, Latinos, Portuguese-speakers, and Haitians, total N = 160) and the technical quality of treatment for depression provided in four "culturally-specific" primary care clinics. Using data from the Experiences of Care and Health Outcomes survey, chart reviews and focus groups, the study addressed a set of questions related to the psychometric properties of perceived care measures and the technical quality of care. The groups differed in preferred cultural elements except all preferred inclusion of religion. They did not differ in overall perceived quality. Technical quality was higher for Portuguese and Haitians than for African Americans and Latinos. Implications of group differences for measuring quality are discussed.

Development and testing of indicators to measure coordination of clinical information and management across levels of care

BACKGROUND

Coordination across levels of care is becoming increasingly important due to rapid advances in technology, high specialisation and changes in the organization of healthcare services; to date, however, the development of indicators to evaluate coordination has been limited. The aim of this study is to develop and test a set of indicators to comprehensively evaluate clinical coordination across levels of care.

METHODS

A systematic review of literature was conducted to identify indicators of clinical coordination across levels of care. These indicators were analysed to identify attributes of coordination and classified accordingly. They were then discussed within an expert team and adapted or newly developed, and their relevance, scientific soundness and feasibility were examined. The indicators were tested in three healthcare areas of the Catalan health system.

RESULTS

52 indicators were identified addressing 11 attributes of clinical coordination across levels of care. The final set consisted of 21 output indicators. Clinical information transfer is evaluated based on information flow (4) and the adequacy of shared information (3). Clinical management coordination indicators evaluate care coherence through diagnostic testing (2) and medication (1), provision of care at the most appropriate level (2), completion of diagnostic process (1), follow-up after hospital discharge (4) and accessibility across levels of care (4). The application of indicators showed differences in the degree of clinical coordination depending on the attribute and area.

CONCLUSION

A set of rigorous and scientifically sound measures of clinical coordination across levels of care were developed based on a literature review and discussion with experts. This set of indicators comprehensively address the different attributes of clinical coordination in main transitions across levels of care. It could be employed to identify areas in which health services can be improved, as well as to measure the effect of efforts to improve clinical coordination in healthcare organizations.

Organizational factors and change strategies associated with medical home transformation

There is limited information about how to transform primary care practices into medical homes. The research team surveyed leaders of the first 132 primary care practices in Minnesota to achieve medical home certification. These surveys measured priority for transformation, the presence of medical home practice systems, and the presence of various organizational factors and change strategies. Survey response rates were 98% for the Change Process Capability Questionnaire survey and 92% for the Physician Practice Connections survey. They showed that 80% to 100% of these certified clinics had 15 of the 18 organizational factors important for improving care processes and that 60% to 90% had successfully used 16 improvement strategies. Higher priority for this change (P = .001) and use of more strategies (P = .05) were predictive of greater change in systems. Clinics contemplating medical home transformation should consider the factors and strategies identified here and should be sure that such a change is indeed a high priority for them.

The DIAMOND initiative: implementing collaborative care for depression in 75 primary care clinics

Background

The many randomized trials of the collaborative care model for improving depression in primary care have not described the implementation and maintenance of this model. This paper reports how and the degree to which collaborative care process changes were implemented and maintained for the 75 primary care clinics participating in the DIAMOND Initiative (Depression Improvement Across Minnesota–Offering a New Direction).

Methods

Each clinic was trained to implement seven components of the model and participated in ongoing evaluation and facilitation activities. For this study, assessment of clinical process implementation was accomplished via completion of surveys by the physician leader and clinic manager of each clinic site at three points in time. The physician leader of each clinic completed a survey measure of the presence of various practice systems prior to and one and two years after implementation. Clinic managers also completed a survey of organizational readiness and the strategies used for implementation.

Results

Survey response rates were 96% to 100%. The systems survey confirmed a very high degree of implementation (with large variation) of DIAMOND depression practice systems (mean of 24.4 ± 14.6%) present at baseline, 57.0 ± 21.0% at one year (P = <0.0001), and 55.9 ± 21.3% at two years. There was a similarly large increase (and variation) in the use of various quality improvement strategies for depression (mean of 29.6 ± 28.1% at baseline, 75.1 ± 22.3% at one year (P = <0.0001), and 74.6 ± 23.0% at two years.

Conclusions

This study demonstrates that under the right circumstances, primary care clinics that are prepared to implement evidence-based care can do so if financial barriers are reduced, effective training and facilitation are provided, and the new design introduces the specific mental models, new care processes, and workers and expertise that are needed. Implementation was associated with a marked increase in the number of improvement strategies used, but actual care and outcomes data are needed to associate these changes with patient outcomes and patient-reported care.

Development of mental health quality indicators (MHQIs) for inpatient psychiatry based on the interRAI mental health assessment

Background

Outcome quality indicators are rarely used to evaluate mental health services because most jurisdictions lack clinical data systems to construct indicators in a meaningful way across mental health providers. As a result, important information about the effectiveness of health services remains unknown. This study examined the feasibility of developing mental health quality indicators (MHQIs) using the Resident Assessment Instrument - Mental Health (RAI-MH), a clinical assessment system mandated for use in Ontario, Canada as well as many other jurisdictions internationally.

Methods

Retrospective analyses were performed on two datasets containing RAI-MH assessments for 1,056 patients from 7 facilities and 34,788 patients from 70 facilities in Ontario, Canada. The RAI-MH was completed by clinical staff of each facility at admission and follow-up, typically at discharge. The RAI-MH includes a breadth of information on symptoms, functioning, socio-demographics, and service utilization. Potential MHQIs were derived by examining the empirical patterns of improvement and incidence in depressive symptoms and cognitive performance across facilities in both sets of data. A prevalence indicator was also constructed to compare restraint use. Logistic regression was used to evaluate risk adjustment of MHQIs using patient case-mix index scores derived from the RAI-MH System for Classification of Inpatient Psychiatry.

Results

Subscales from the RAI-MH, the Depression Severity Index (DSI) and Cognitive Performance Scale (CPS), were found to have good reliability and strong convergent validity. Unadjusted rates of five MHQIs based on the DSI, CPS, and restraints showed substantial variation among facilities in both sets of data. For instance, there was a 29.3% difference between the first and third quartile facility rates of improvement in cognitive performance. The case-mix index score was significantly related to MHQIs for cognitive performance and restraints but had a relatively small impact on adjusted rates/prevalence.

Conclusions

The RAI-MH is a feasible assessment system for deriving MHQIs. Given the breadth of clinical content on the RAI-MH there is an opportunity to expand the number of MHQIs beyond indicators of depression, cognitive performance, and restraints. Further research is needed to improve risk adjustment of the MHQIs for their use in mental health services report card and benchmarking activities.

Performance indicators for public mental healthcare: a systematic international inventory

Background

The development and use of performance indicators (PI) in the field of public mental health care (PMHC) has increased rapidly in the last decade. To gain insight in the current state of PI for PMHC in nations and regions around the world, we conducted a structured review of publications in scientific peer-reviewed journals supplemented by a systematic inventory of PI published in policy documents by (non-) governmental organizations.

Methods

Publications on PI for PMHC were identified through database- and internet searches. Final selection was based on review of the full content of the publications. Publications were ordered by nation or region and chronologically. Individual PI were classified by development method, assessment level, care domain, performance dimension, diagnostic focus, and data source. Finally, the evidence on feasibility, data reliability, and content-, criterion-, and construct validity of the PI was evaluated.

Results

A total of 106 publications were included in the sample. The majority of the publications (n = 65) were peer-reviewed journal articles and 66 publications specifically dealt with performance of PMHC in the United States. The objectives of performance measurement vary widely from internal quality improvement to increasing transparency and accountability. The characteristics of 1480 unique PI were assessed. The majority of PI is based on stakeholder opinion, assesses care processes, is not specific to any diagnostic group, and utilizes administrative data sources. The targeted quality dimensions varied widely across and within nations depending on local professional or political definitions and interests. For all PI some evidence for the content validity and feasibility has been established. Data reliability, criterion- and construct validity have rarely been assessed. Only 18 publications on criterion validity were included. These show significant associations in the expected direction on the majority of PI, but mixed results on a noteworthy number of others.

Conclusions

PI have been developed for a broad range of care levels, domains, and quality dimensions of PMHC. To ensure their usefulness for the measurement of PMHC performance and advancement of transparency, accountability and quality improvement in PMHC, future research should focus on assessment of the psychometric properties of PI.

Recovery in the USA: from politics to peer support

Efforts to transform the mental health service delivery system to a more consumer-driven and recovery-orientated approach has its roots in a somewhat radical anti-psychiatry and civil-rights movement dating back to the 1970s. This grass-roots effort gained momentum and credibility with Harding's landmark study published in 1988 followed by the work of Anthony et al. from Boston University in beginning to define the term 'recovery'. In 1998 the Office of the US Surgeon General issued its first report on mental health, and this critical view of the shortcomings of the existing service system set the stage for the 2003 President's New Freedom Commission and its recommendations for recovery-orientated systems transformation. The recovery movement has evolved from a more radical view in the early days, to participatory involvement in systems, to returning to alternative models of care that are more independent. Now as more peer specialists work in systems, there is an increased emphasis on non-medical alternatives and the cycle continues. Regardless, recovery, self-determination, choice, etc. are always at the centre. This paper notes the interesting cycles of recovery-orientation and how they spin around the values/tenets of the movement's early roots.

Performance measurement in mental health care: present situation and future possibilities

SUMMARY

This paper describes performance measurement and its indicators for mental health care services. Performance measurement can serve several goals such as accountability, quality improvement and performance management. For all three purposes structure, process and outcome indicators should be measured. Literature was retrieved from Medline and PsychInfo in order to see which performance indicators were used for the three purposes of performance measurement in mental health care. The indicators were classified in structure, process and outcome indicators. The results show no big differences in the indicators used among studies. Performance management is the performance measurement purpose most referred to, followed by accountability, and quality improvement. Outcome and process indicators are used most, structure indicators are in the minority. Several levels of measurement, that is national or service level, came forward in the literature review. To overcome misinterpretation of data and to be able to improve quality and manage performances, performance indicator sets should refer to structure, process and outcome. Indicators should be chosen carefully with the aim of the measurement taken into mind. Based on this review, a conceptual framework is presented to support managers in their decisions about which indictors can best be used for performance measurement. Additionally, a model that provides an understanding of the use of information gained by performance measurement is given.

Challenges and opportunities in measuring the quality of mental health care

The purpose of our paper is to delineate the barriers to mental health quality measurement, and to identify strategies to enhance the development and use of quality measures by mental health providers, programs, payers, and other stakeholders in the service of improving outcomes for people with mental health and substance use disorders. Key reasons for the lag in mental health performance measurement include lack of sufficient evidence regarding appropriate mental health care, poorly defined quality measures, limited descriptions of mental health services from existing clinical data, and lack of linked electronic health information. We discuss strategies for overcoming these barriers that are being implemented in several countries, including the need to have quality improvement as part of standard clinical training curricula, refinement of technologies to promote adequate data capture of mental health services, use of incentives to promote provider accountability for improving care, and the need for mental health researchers to improve the evidence base for mental health treatment.

Development of a set of schizophrenia quality indicators for integrated care

AIM

We aimed at developing a prioritized set of quality indicators for schizophrenia care to be used for continuous quality monitoring. They should be evidence-based and rely on routine data.

METHODS

A systematic literature search was performed to identify papers on validated quality indicators published between 1990 to April 2008 in MEDLINE, the Cochrane databases, EMBASE and PsycINFO. Databases of relevant national and international organizations were searched. Indicators were described with respect to meaningfulness, feasibility and actionability. A workshop with relevant stakeholders evaluated the measures through a structured consensus process.

RESULTS

We identified 78 indicators through literature search and selected 22 quality indicators. Furthermore, 12 structural and case-mix indicators were choosen. Only five quality indicators were rated "essential indicators" (priority 1), 14 were rated "additional first choice" (priority 2), and three were rated as "additional second choice" (priority 3). Only four indicators assessed outcome quality. In the majority of indicators the evidence base supporting the indicator recommendation was weak. None of the selected indicators was validated in experimental studies.

CONCLUSIONS

Evidence and validation base played only a subordinate role for indicator prioritisation by stakeholders indicating that there are discrepancies between clinical questions and requirements in schizophrenia care and scientific research.

Performance measurement and improvement frameworks in health, education and social services systems: a systematic review

PURPOSE

To perform a systematic review, supplemented by a targeted grey literature scan, for performance measurement and improvement frameworks within and across the health, education and social service systems. The intended outcome was the creation of a foundation of evidence to inform the development of cross-sectoral quality improvement frameworks.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, ERIC, EMBASE, Social Services Abstracts, Social Work Abstracts and Education Index Full Text were searched up to April/May 2007. In addition, 26 governmental and 27 organizational websites were searched.

STUDY SELECTION

English language material with a publication date of 1986 or more recent that described a health, education or social services multidimensional framework for performance measurement and improvement. Data extraction The framework name; administrative sector; level of application; setting; population of interest; categories of quality described within the framework; country of application; and citations to other performance measurement and improvement frameworks were extracted from each article.

RESULTS

In total, 111 frameworks were identified. Most frameworks (n = 97) were developed in or for the health sector. A concept sorting exercise identified 16 quality concepts applicable across many settings, sectors and levels of application.

CONCLUSION

This systematic review of quality domains will be relevant and useful to those who are developing and using performance measurement and improvement frameworks for adult and child populations within or across the health, social service or education sectors.

[The COMPAQH project: researches on quality indicators in hospitals]

After three years, the coordination de la mesure de la performance pour l'amélioration de la qualité hospitalière (COMPAQH) project can deliver its first findings and consider new perspectives of development. Which indicators are diffused? Under which criteria are they assessed? Which interhospital variability is observed? How to consider their application into hospitals? Which balance can we define between internal and external use? And finally, which consideration can we give to this program of quality measurement? This article addresses these different questions, giving a state of the development of this program.

Organization-based performance measures of cancer care quality: core measure development for breast cancer in Taiwan

The purpose of the study was to develop organization-based core performance measures (CPMs) for breast cancer patients treated in hospitals that participated in cancer quality improvement programmes in Taiwan. CPMs were developed in three stages that included a preparation, a consensus building stage, and two stages of stakeholder feedback. Three criteria and seven subcriteria were applied in the development process. Indicators listed in a Delphi questionnaire were based on a literature search, indicators developed by relevant institutions and discussion by authors. Each indicator needed to meet inclusion criteria as a final indicator. Evidence-based guidelines, expert opinions from panel group, 27 hospitals and empirical data were all applied to develop and revise the core measures. Fifteen out of 28 indicators were selected and modified after the three stages. There were two pre-treatment indicators for screening and diagnosis, nine treatment-related indicators, and four monitoring-related indicators. Six indicators were supported by evidence level I, and four indicators by level II evidence. The CPMs for breast cancer can be developed systematically and be applied for internal quality improvement and external surveillance. Our experience can be extended to other cancer sites and adapted to link with pay for performance or certification program in cancer care.

Aligning measurement-based quality improvement with implementation of evidence-based practices

Two models for improving quality of care have been adopted by segments of the US mental healthcare system. Measurement-based quality improvement (MBQI) is routinely conducted by many provider organizations (including practices, hospitals and health plans), either at their own initiative or at the behest of payers and oversight organizations. Systematic implementation of evidence-based practices (EBPs) is being undertaken by several state mental health authorities and by other systems of care, working in collaboration with services researchers and stakeholders. Although they are distinct approaches, MBQI and EBP implementation (EBPI) overlap in their objectives and means. This article explores the degree to which these two approaches are aligned and whether further coordination between them could yield greater effectiveness or efficiency.

Impact of patient-reported outcome measures on routine practice: a structured review

RATIONALE, AIMS AND OBJECTIVES

Regular use of patient-reported outcome measures (PROMs) by health care providers in their routine practice may help to improve the quality of care, but more evidence is needed before routine use of PROMs can be recommended. A structured review was undertaken to examine whether and how regular use of PROMs might improve routine practice.

METHODS

A systematic search of Medline accessed through Webspirs Silverplatter was undertaken for the years 1976-2004. Controlled trials in English evaluating the impact of clinical use of PROMs on routine practice were included. Data regarding study design, characteristics of PROMs feedback, patient populations and study results were extracted by three reviewers.

RESULTS

Feedback of PROMs results to health care providers appears to have a substantial impact on some processes of care, particularly on diagnosis of mental health conditions. However, the impact on patient health status is less consistent. Most of the published studies evaluated PROMs as a one-off screening technology and measured only provider behaviours and patient health outcomes.

CONCLUSIONS

The pattern of results suggests a general lack of clarity in the field, especially regarding appropriate goals for PROMs and the mechanisms by which they might achieve them. To fully evaluate their role in routine practice, studies need to use PROMs that capture issues of importance to patients and to measure impacts relating to the patient-provider relationship and patient contributions to their well-being. Until studies evaluate PROMs as a means facilitate patient-centred care, their full potential in clinical practice will remain unknown.

Quality indicators for international benchmarking of mental health care

OBJECTIVE

To identify quality measures for international benchmarking of mental health care that assess important processes and outcomes of care, are scientifically sound, and are feasible to construct from preexisting data.

DESIGN

An international expert panel employed a consensus development process to select important, sound, and feasible measures based on a framework that balances these priorities with the additional goal of assessing the breadth of mental health care across key dimensions.

PARTICIPANTS

Six countries and one international organization nominated seven panelists consisting of mental health administrators, clinicians, and services researchers with expertise in quality of care, epidemiology, public health, and public policy. Measures. Measures with a final median score of at least 7.0 for both importance and soundness, and data availability rated as 'possible' or better in at least half of participating countries, were included in the final set. Measures with median scores </=3.0 or data availability rated as 'unlikely' were excluded. Measures with intermediate scores were subject to further discussion by the panel, leading to their adoption or rejection on a case-by-case basis.

RESULTS

From an initial set of 134 candidate measures, the panel identified 12 measures that achieved moderate to high scores on desired attributes.

CONCLUSIONS

Although limited, the proposed measure set provides a starting point for international benchmarking of mental health care. It addresses known quality problems and achieves some breadth across diverse dimensions of mental health care.