2006-2010 Statewide Comprehensive Plan for Mental Health Services
Chapter 1
Measuring Performance to Drive Transformation

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This 2006-2010 Statewide Comprehensive Plan continues to build on the strengths of the two previous Plans for the 2004-2008 and 2005-2009 planning cycles. In particular, this year's Plan lays out performance measurement as a priority, reflecting emphasis-not only at the national level, but also by New York State Governor Pataki and his Executive Staff, and Office of Mental Health (OMH) leadership and stakeholders-with accountability for and the quality of mental health services. It presents further refinements to OMH's strategic planning model using input obtained from stakeholders who participated in the 2005 forums and who also offered input through the many other opportunities provided, such as meetings held by Commissioner Carpinello around the State. Information gathered through a review of the literature to examine the changing external environment in which the public mental health system operates was also used in advancing the planning process. Importantly, this year's Plan describes the adoption and implementation by OMH of a management best practice to drive its performance management processes.

This Chapter provides an overview of the national and State perspectives on transforming mental health systems. Chapter 2 presents an overview of the major components of the OMH Strategic Plan Framework to enhance understanding of the performance measurement system as well as refinements made after careful consideration of stakeholder input and national developments. The Framework is foundational to promoting services consistent with the mission and values of OMH.

The maturation of the OMH strategic planning process has been stepwise and orderly with the addition in 2005 of a best practice model of performance management called the "balanced scorecard." The balanced scorecard approach to performance management and its relationship to transforming the State mental health system are discussed further in Chapter 3.

Chapter 4 goes on to describe OMH accomplishments in further enhancing the agency strategic planning infrastructure and strengthening its strategic planning processes. In particular, it highlights the perspectives of stakeholders gathered during strategic planning forums held across the State during 2005; diverse views of consumers and their families, providers, researchers, program staff, and policymakers; and the systematic incorporation of these many perspectives into the ongoing planning process.

Based on the aims developed as a result of stakeholder input, Chapter 5 offers a national overview of their importance for quality care. Chapter 6 articulates major environmental trends and challenges faced by the national and State public mental health systems and priorities developed in response to them, while Chapter 7 focuses on OMH's balanced scorecard performance measurement system.

Chapter 8 describes future actions to advance and refine the performance management approach, and initiatives that will be supported by the 2006-2007 Executive Budget and how their progress will be measured.

The State Focus on Measuring Performance

A central role of government is to develop policies and provide services and programs that promote the well-being of its citizens. As a society we depend upon our government agencies to guide public policy in a way that enables each of us to live full, productive and meaningful lives. We also rely on government institutions to provide an array of vital programs and services that protect and enhance our health and mental health. As citizens we also expect the best value for our investment of public funds.

As part of his Government Reform initiative for the 2005 Fiscal Year, Governor Pataki noted the "obligation of government to act prudently in its stewardship of public funds."¹ He directed all State agencies to take actions that would promote accountability, improve performance management, transform government operations through structural and service enhancements and improve efficiency using technology. Among the key management reforms advanced by Governor Pataki has been the recommendation to institute State agency strategic planning processes to define goals and priorities and to attend to the relationship between performance outcomes and financial decision making. The Governor called for the inclusion of performance requirements and outcome measures in contracts with localities and not-for-profit providers in targeted program areas, implementation of a long-term project to transform the State's financial management practices and initiation of an integrated statewide financial management system.

Because of the strength of planning processes under way, OMH, the Office of General Services and the Department of Taxation and Finance were selected as State pilot performance management sites for 2005. Under Commissioner Carpinello's leadership, OMH has made great strides in creating model performance management processes that are designed not only to advance the agency's planning efforts but also to be of value for developing similar processes at other State agencies.

National Focus on Quality and Performance

Within the Federal, state and local governments around the country, more and more attention is being paid to how much return taxpayers are receiving for their social investments. In response, all levels of government are beginning to publicly report outcomes associated with the services they provide. These performance reports typically give stakeholders a picture of how well the government agencies are doing in meeting their mission, goals and objectives.² Within the public mental health field, success can best be demonstrated by how evidence-based services improve outcomes within the context of recovery and resiliency for children with serious emotional disturbance and adults with serious mental illness.

Following publication of the U.S. Surgeon General's Report of 1999,³ which noted the range and proven efficacy of mental health treatments, the landmark Institute of Medicine Crossing the Quality Chasm report of 2001 noted the wide gulf between the quality of health care we should and do receive. It provided a framework for transforming the health care system and improving the quality of care, and recommended the adoption of six aims to drive the transformation. It proposed that health care services should be safe; based on scientific knowledge; guided by the preferences, needs and values of the client; timely; efficient; and equitable with respect to personal characteristics such as ethnicity or gender.⁴

Importantly, the report acknowledged the critical role of monitoring and assessing progress, thereby enabling consumers, providers and other stakeholders to determine where strategies for improvement were being successful and where more work would be essential. To stimulate performance improvements and evaluate progress, the report urged the development of monitoring and tracking processes.

Two years after the release of the Institute of Medicine report, the President's New Freedom Commission on Mental Health⁵ recommended a fundamental transformation of how mental health care is delivered. At the heart of this transformation has been a focus on the needs of consumers and families and the core values of facilitating recovery and enhancing resiliency. In a transformed system of care, consumers and family members would have access to timely and accurate information to promote learning, the ability to self-monitor, and accountability. Health care providers would rely on current knowledge to provide care resulting in the best outcomes.

Such a transformation, however, depends to a large part upon having the structure and capacity to measure and act upon the performance and outcomes of public mental health services. Performance data are seen as crucial to the course of transformation.⁶

In particular, in his testimony before the United States Senate in 2004, Dr. Howard Goldman, noted psychiatrist and mental health services researcher from the University of Maryland School of Medicine, argued persuasively for the development of accountable systems of care to measure and monitor service outcomes. Such data permit continual refinement of programs, he added, allowing providers and stakeholders to monitor who they are and are not reaching and identify where modifications would be necessary to improve effectiveness. "There is consensus and remarkable consistency across jurisdictions and stakeholders regarding the outcomes that mental health systems and services are intended to achieve: reduction in symptom distress; building social supports; community participation; improvement in work or, in the case of children and adolescents, age-appropriate functioning; reduced homelessness and inappropriate hospitalization; improved health status; and decreased contact with criminal and juvenile justice systems." ⁷

Dr. Goldman acknowledged the complexity and expense of devoting resources to identifying and putting in place measures for planning, monitoring and improving the quality of care. Nonetheless, he urged quick action, saying that the future of mental health hinges on our ability to attend to the quality and accountability of our mental health systems. Within the set of actionable steps recommended in the Federal Mental Health Agenda and framed by the New Freedom principles to guide transformation, for example, are a number of recommendations for using data to improve access to services; facilitating sound decision making by consumers, families, providers, administrators and policymakers; and holding state and local levels of government accountable for results. ⁸ An infrastructure to support performance and outcomes measurement is seen by many as necessary for public accountability, and for ultimately helping people with mental illness to recover and live fully in their communities.

National leaders in health care and mental health care are increasingly focusing on the importance of accountability, outcomes measurement and performance management in advancing the science-to-practice agenda and ultimately in promoting the achievement of person-centered recovery. Among leading health and mental health organizations, the Joint Commission on Accreditation for Healthcare Organizations, ⁹ the National Association of State Mental Health Program Directors,¹⁰ and the Center for Mental Health Services-supported Mental Health Statistics Improvement Program¹¹ are taking active roles in promoting processes that facilitate the creation and implementation of evidence-based practices, performance and outcomes measurement and continuous quality improvement. Moreover, the Substance Abuse and Mental Health Services Administration is organizing and guiding efforts to engage stakeholders in developing models of care and change at the systems level, including the creation of recovery-oriented performance measures, to support the delivery of consumer-driven, effective community-based services.¹² Professional and advocacy organizations, such as the Federation of Families for Children's Mental Health,¹³ also acknowledge the critical nature of collecting and using data to improve practices and outcomes for individuals with mental illness.

Most recently, the National Institute of Medicine, in its Quality Chasm Update, pointed out that a performance management infrastructure for mental health and substance use care is not as well developed as it is for the general health care system. To ensure high-quality care, the Institute recommends a more coordinated approach to addressing the gaps in the base of evidence; a corresponding approach to disseminating scientific knowledge, relying upon evidence-based practices to improve success in doing this; better strategies to conduct assessment and diagnosis; a sturdy infrastructure for measuring the quality of care and reporting on it; and promotion of quality mental health and substance use clinical practices.¹⁴ These are all strategies to which OMH historically has been and continues to be committed.

From the Winds of Change toward Transformation

Even before the Final Report of the President's New Freedom Commission was issued, OMH undertook a multi-layered, multi-year quality agenda. With the development of its Winds of Change campaign in 2001, quality became the cornerstone of the agency's Strategic Planning Framework, with the aim of strengthening the foundation for providing access to services of high quality. Also in 2001, steps toward transformation occurred with the implementation of evidence-based practices, when OMH convened a panel of experts to discuss how best to apply research findings to everyday settings, honor culture, incorporate consumer and family perspectives, and use performance and outcomes measurement data to support transformation.¹⁵

Performance measurement represents the linchpin in quality management, the key to holding together the critical elements of system transformation - relying on evidence-based practices to close the gap between scientific knowledge and practice, improving service quality, and enhancing public accountability. Performance and outcomes management is the data-driven process that provides a structure for promoting the development and delivery of high-quality products and services. Using data to systematically improve decision making, manage performance, and stimulate quality improvements has been at the heart of OMH's ongoing management initiatives, particularly when it created a foundation for public-sector managed behavioral health care data management in the late 1990s.¹⁶

Just as the nation is being challenged by the vision conveyed in the New Freedom Commission Report, New York State is also reflecting on its role in transforming the public mental health system to encourage and sustain services and supports that facilitate recovery and enhance resilience for all of its citizens, particularly for children with serious emotional disturbance and adults with serious mental illness. Balancing this imperative with the need for cost-effective and efficient services is in part why OMH is so committed to embracing best practices for strategic planning.

OMH has been striving to incorporate essential elements of transformation into its Strategic Plan Framework and its selection of the balanced scorecard approach to strategic planning is designed to facilitate such transformation at the State level. Seven elements of transformation that have been identified include:

• Development of a clear and compelling vision of the desired outcomes;
• Establishment of leadership capabilities and organizational capacity to communicate the vision and lead the transformation;
• Creation of an environment or climate of working that is receptive and amenable to the transformation;
• Development and communication of a strategy that is tailored to the context and the roles, capabilities, and interests of the various stakeholder groups;
• Identification and mobilization of champions or change agents to implement the activities required to achieve the desired outcomes;
• Development of an ongoing process to maximize opportunities and overcome obstacles; and
• Monitoring outcomes and adjusting processes based on learning from experience. ¹⁷

As part of its strategic planning efforts, OMH has been considering these elements and the recommendations of the New Freedom Commission. It has taken the lead in communicating a vision of transformation and opening up the process of defining "transformation" of the mental health system in New York State. In the fall of 2005, Commissioner Carpinello articulated such a vision and invited New Yorkers¹⁸ to provide their feedback to the content of a new booklet, What Might a Transformed Mental Health System Look Like, which describes this vision of and attributes for a transformed system of care (see Figure 1.1).

The booklet was prepared by tapping into the wisdom of the New Freedom Commission and major stakeholders of the public mental health system. Commissioner Carpinello's booklet, in summary, provides a picture of a transformed public mental health system as one that combats societal stigma, values quality care, embraces the use of information for continuous quality improvement, measures success using outcomes specific to individual recovery, develops organizational structures to support reliance on culturally and linguistically competent evidence-based practices, and stresses adequate and satisfying housing, employment and social integration. Underlying this picture is "hope, the one variable that can truly transform the system."

To date, feedback has been thoughtful and supportive of a transformed system of care. Suggestions include establishing a mechanism that draws upon the expertise of peer educators to improve provider, consumer, family member and stakeholder knowledge of the principles of recovery at all levels of the system and ways to access services and supports; continuing to strengthen the services and supports for adolescents transitioning from the child to adult system of care; providing integrated services for individuals with co-occurring substance use and mental illness disorders; and attracting clinical staff members who by their actions embrace the values espoused by OMH and its stakeholders. Recommendations such as these are clearly consistent with the Strategic Plan Framework adopted by OMH, will continue to be incorporated into the agency's strategic planning, and will guide the process of transformation within the New York State public mental health system.

Anyone with a continuing interest in the transformation of New York's public mental health system is encouraged to review the booklet, which is considered a living document, and offer feedback online at http://www.omh.state.ny.us/omhweb/transformation/transformationbooklet.htm.

Figure 1.1
What Might a Transformed Mental Health System Look Like

This year's 2006-2010 Statewide Comprehensive Plan for Mental Health Services focuses on unveiling a key component of transformation and the next phase in the OMH Strategic Plan - the performance measurement framework. It presents an overview of OMH's multi-year Strategic Plan, highlights progress in refining the performance measurement system described in the 2005-2009 Plan, and examines program and service initiatives within the context of this strategic planning paradigm. The Plan also sheds light on the transformation processes under way in the New York State public mental health system.

Notes:

1. New York State Division of the Budget. (2005). Managing government performance, NYS 2005-06 Executive Budget: Government Reforms. Albany, NY: Author. Available online at http://www.budget.state.ny.us/pubs/archive/fy0506archive/fy0506littlebook/lb0506.pdf  (PDF).
2. Epstein P, Fountain J, Campbell W, Patton T & Keaton K. (2005). The government service efforts and accomplishments performance reports: A guide to understanding. Norwalk, CT: Government Accounting Standards Board of the Financial Accounting Foundation. Available online at www.seagov.org.
3. U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.
4. Institute of Medicine Committee on the Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.
5. New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report. DHHS Pub. No. SMA-03-3832. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Rockville, MD.
6. Power AK. (2004, Fall). System transformation, strategies for change and databased decision making. National Association of State Mental Health Program Directors Research Institute Outlook, 8-11.
7. Goldman HH. (2004, July 20). Witness testimony: Performance and outcome measurement in substance abuse and mental health programs. Testimony before the U.S. Senate Committee on Health, Education, Labor and Pensions. Available online at http://www.mhreform.org/ .
8. Substance Abuse and Mental Health Services Administration. (2005, July). Transforming mental health care in America. The federal action agenda: First steps. Rockville, MD: Author. Available online at http://www.samhsa.gov/Federalactionagenda/NFC_TOC.aspx .
9. See the Joint Commission on Accreditation of Healthcare Organizations' Approved standards additions for behavioral health services in support of recovery and resiliency. The standards are in effect as of January 1, 2006. Available online: http://www.jcrinc.com/Joint-Commission-Requirements/Behavioral-Health-Care/ .
10. See the National Association of State Mental Health Program Directors Research Institute Center for Mental Health Quality and Accountability. Available online at http://www.rdmc.org/nripms/ .
11. Ganju V, Smith ME, Adams N, Allen Jr J, Bible J, Danforth M, et al. (2005). The MHSIP quality report: The next generation of mental health performance measures. Rockville, MD: Center for Mental Health Services, Mental Health Statistics Improvement Program.
12. Dougherty RH. (2005). Free to choose: Transforming behavioral health care to self-direction. A report of the 2004 consumer direction initiative summit. DHHS Publication No. SMA-05-3982. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.
13. Martinez K, Mezera M, & Osher TW. (2003, September). Understanding and using performance measurement as a tool for advocacy. Alexandria, VA: Federation of Families for Children's Mental Health.
14. Institute of Medicine. (2005, November). Improving the quality of health care for mental and substance-use conditions: Quality chasm series. Washington DC: National Academies Press.
15. Carpinello SE, Rosenberg L, Stone J, Schwager M, & Felton CJ. (2002). Best practices: New York State's campaign to implement evidence-based practices for people with serious mental disorders. Psychiatric Services, 53(2), 153-155.
16. Carpinello S, Felton CJ, Pease EA, DeMasi M, & Donahue S. (1998). Designing a system for managing the performance of mental health managed care: an example from New York State's prepaid mental health plan. Journal of Behavioral Health Services Research, 25(3), 269-278
17. Mazade NA. (2005, January). Concepts of "transformation." Alexandria, VA: National Association of State Mental Health Program Directors Research Institute.
18. New York State Office of Mental Health. (2005, October). What might a transformed public mental health system look like? Albany, NY: Author, Commissioner's Office. Available online at http://www.omh.state.ny.us/omhweb/transformation/transformationbooklet.htm.

Comments or questions about the information on this page can be directed to the Office of Planning.