outreach, and transitional employment. The second was initiated in 1995 by the undersecretary for Health and brought changes in mental health service delivery as part of a major system-wide shift from operating as a hospital-based system of care to a community or population-based system of care. In both phases quality and performance measurement were crucial tools in guiding organizational change. A third phase, characterized by system-wide focus on building MH/SA quality is evolving in response to the recent report of the President’s New Freedom Commission on Mental Health.

Quality of VA MH/SA Care

The assessment of quality requires comparison of providers with standards or benchmarks, with risk adjustment for factors that may confound these comparisons. Evaluation of the quality of MH/SA care at VA facilities has been based on comparisons with: (1) VA system average performance, (2) VA performance in prior years, (3) the performance of other systems of care, and (4) comparison of care received by minorities with the majority population. Methods of quality measurement and benchmarking in VA are demonstrated for six aims highlighted in a previous Institute of Medicine (IOM) report: safety, effectiveness, person-centeredness, timeliness, efficiency, and equitability.

Front-Line Experience

Performance management in health care is sometimes experienced ambivalently by front line managers and clinicians. While they often feel empowered by access to data and find it allows them to improve the care they provide, there is also concern that measures are imperfect; that they do not take account of differences across facilities in case mix and in available community resources; that measures can be manipulated or “gamed,” resulting in unfair comparisons; and that managerial pressure to improve performance sometimes creates an atmosphere of personal criticism more than joint problem solving.


The complexity and uncertainty of the health care enterprise must be managed through comprehensive quality monitoring systems used by creative and committed leaders in competent organizations. VA has embraced this challenge.

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