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The number of organizations using quality indicators to benchmark care across different practices has grown substantially since the development of quality indicators, with tiffany money clips on sale countries taking the lead to develop and implement mental health performance measures as part of their nationalized health systems.9-12 In a systematic review of governmental and nongovernmental organizations in the United States, Herbstman and Pincus13 found 36 initiatives that applied quality indicators for mental disorders, ranging from federal and state governments, to health plans, and nongovernmental and professional organizations. Currently, one of the most extensive implementations of mental health quality measures is the International Initiative for Mental Health Leadership Clinical project on mental health quality measurement, described in detail in this issue by Ms Spaeth-Rublee and coauthors. I4In the United States, an important example of quality measurement in mental health is the work of the department of VA, VHA. The VA provides a useful comparator organization in the international sphere given that it is single-payer, national health care program for US veterans.15 Currently, the Altarum Institute and the RAND Corporation are conducting a national evaluation of the VHA' s mental health services, using Donabedian's structure-process-outcomes model of quality measurement. Structure is evaluated by describing the continuum of care available to veterans with 5 tiffany keys on sale mental health diagnoses (that is, schizophrenia, BD, PTSD, major depressive disorder, and SUD) using facility survey and administrative data. Process is evaluated by looking at what services veterans with the 5 targeted mental health diagnoses actually receive using administrative and medical record data. Outcomes measures consist of services received that made a difference to veterans' functioning and quality of life using client survey and medical record data. As part of this work, the Altarum-RAND team has developed and vetted more than 200 quality indicators for the 5 targeted mental disorders. In addition, the VHA Primary Care-Mental Health Integration Program has implemented performance measurement for depression, alcohol, and PTSD screening and management.16Applying Quality Measures

Quality measures are vital for ensuring the uptake and delivery of evidence-based care. Quality of care cannot be improved without monitoring how such care is delivered, from its organization to processes and, ultimately, to patient outcomes. Measuring quality using quality indicators derived from evidence-based practice guidelines is an important step toward implementation of evidence-based care and monitoring quality improvement efforts. Experts have strongly suggested that quality measurement is a key driver in transforming the health care system, and clinicians at the front line need to be actively engaged in the process of improving quality at multiple levels (for example, payment, licensure, and organizational change), and payment systems should reward high quality of care. Standardized measures that allow results to be monitored and tiffany 1837 on sale uniformly over time are the foundation of performance improvement.Moreover, the public reporting of performance is vital for holding health care organizations accountable for improving care. Despite the plethora of quality measures, some health care payers and organizations have realized that they would be ignored unless providers were held accountable for improving care. For example, in Scotland, there are national efforts to measure quality of mental health care through the use of National Targets on readmission rates, AD prescribing, suicide prevention, and dementia screening, as well as benchmarking programs to compare health care providers on performance measures.12 In the United States, the NQF applies quality indicators to rate different private health plans.

Quality measures are also used to evaluate whether differences in care exist across regions or health care providers, and, in the United States and the United Kingdom, they can also be used to reward or reprimand providers financially. Some countries have gone a step further and established financial incentives, such as P4P, for tiffany key rings on sale standards based on quality measures.5 P4P involves financial incentives to providers or health care systems when certain target quality of care measures are achieved within providers' patient panels. Currently, a growing number of financial incentives programs focus on behavioural health in the United States17 and in England.5 In particular, England established P4P for general practitioners in 2004, comprising several chronic disease composite indicators, including mental health, notably focused on psychotropic medication use and appropriate follow-up care.