Quality Measurements Hold Key to Accountability in Mental Health

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If psychiatrists and other mental health professionals don't actively measure their effectiveness, they typically don't know things have gone awry until it's too late, said Mark Zimmerman, MD, director of Outpatient Psychiatry and the Partial Hospital Program at Rhode Island Hospital.

If psychiatrists and other mental health professionals don’t actively measure their effectiveness, they typically don’t know things have gone awry until it’s too late, said Mark Zimmerman, MD, director of Outpatient Psychiatry and the Partial Hospital Program at Rhode Island Hospital.

“No one tells me why they’re leaving. They just don’t come back,” said Dr Zimmerman, who is also professor of psychiatry at Brown University. His talk, “Measuring Quality: Why You Should Do It and How You Can Do It,” took place Saturday at the US Psychiatric and Mental Health Congress, being held at the Rosen Shingle Creek Hotel in Orlando, Florida.

It’s rare for a mental health patient to volunteer that he or she didn’t like what a doctor said, according to Dr Zimmerman. Many of these cases involve episodes of “transference,” in which the patient associates the doctor’s challenge with an unwelcome authority figure from the past. For most psychiatrists to know how they’re doing — and improve over time – they must take measurements, which can include everything from the quality of the initial contact with the patient to the cleanliness of the waiting room. Good outcomes measurement follows key principles:

  • It must be clinically meaningful and quantifiable
  • Data collection cannot interfere with work flow
  • Information gathered must be used to improve service delivery
  • When possible, measures must be supported by existing empirical evidence, to demonstrate their validity.

The basic reasons to measure quality are to grow professionally and to improve patient outcomes, Dr Zimmerman said. But as his talk progressed, he also warned that if the mental health field must embrace managed care principles and start measuring quality on its own. Otherwise, it will become “the victim” of measurements imposed by government agencies or insurers, on behalf of taxpayers and employers who are paying for care. Dr Zimmerman, for his part, doesn’t fear a reimbursement model based on quality instead of fee-for-service.

“I look forward to the day when we get paid for outcomes,” he said. “I embrace pay for performance.”

Some stumbling blocks remain to a performance-based model remain, he said; in particular, such a model would have to recognize variations in case mix severity — in other words, some psychiatrists handle more patients with complex or hard-to-treat diagnoses, while other patients with mild depression are treated by their primary care physician.

Measures of both patient satisfaction and clinical outcomes exist, including those published by the American Psychiatric Association Handbook and the American Board of Psychiatry and Neurology. But that second measure had key weaknesses, including a failure to ask patients whether they would refer the doctor to a friend or relative. Also, most other measures waited until a patient had received care for about 3 months, after which many patients had already stopped showing up for care.

Dr Zimmerman’s practice developed quality measures to assess satisfaction with the initial encounter, which the physicians felt was critical in predicting patient retention and outcome. The Clinically Useful Patient Satisfaction Scale, or CUPSS, is designed to do this. Dr Zimmerman presented data, not yet published, which showed that of 158 patients who have taken the CUPSS survey, less than 7% found it a “moderate” to “large” burden.1

Scales also exist to assess clinical outcomes, including the Patient Health Questionnaire (PHQ) and the Quick Inventory Depressive Symptomatology Self-Report (QIDS-SR). Zimmerman’s group has developed an alternative assessment for depression, known as CUDOS, for Clinically Useful Depression Outcome Scale. Dr Zimmerman’s team has published research asserting that CUDOS takes less time to complete, and, thus, is more practical for use in a busy practice.2 Perhaps more importantly, CUDOS is less arbitrary as QIDS-SR in particular about assigning patients to severe depression status, which could result in them taking more medication than necessary.3

What are the obstacles to greater use of measurement in clinical practice among mental health professionals? Don’t believe what you may have heard about “Patients don’t want to do it,” Dr Zimmerman said. “You may have anecdotes, but you don’t have data,” he said.

“Clinician acceptance — that’s the problem.”

There are ways to address concerns about how to measure across multiple disorders, he said. A basic measure of depression and anxiety can be done at each visit, much as the rest of medicine takes a patent’s weight, blood pressure and pulse no matter what the condition. As for staff time and data collection challenges, Dr Zimmerman’s group has developed an online version of both the assessment and the data collection and analysis, which he said patients prefer taking and even trust more. Better still, the online program also reminds patients of their next appointment.

Patients, he said, should have the ability to research which psychiatrists have the best success in treating depression and other mental health conditions, and they should able to do so with available data. “I hope that happens,” Dr Zimmerman said. “I really do hope that happens.”


  1. Zimmerman M, et al. Clinically Useful Patient Satisfaction Scale. Presented at US Psychiatric & Mental Health Congress, September 20, 2014; Orlando, FL.
  2. Zimmerman M, McGlinchey JB, Depressed patients’ acceptability of the use of self-administered scales to measure outcome in clinical practice. Ann Clin Psychiatry. 2008;20(3):125-129
  3. Zimmerman M, Martinez, JH, Friedman M, Boerescu DA, Attiullah N, Toba C. How can we use depression severity to guide treatment selection when measures of depression categorize patients differently? J Clin Psychiatry 2012;73(10):1287-1291.