2006-2010 Statewide Comprehensive Plan for Mental Health Services
Chapter 8
Looking Forward - Working Together to Continue on the Path toward Transformation

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Consistent with the Governor's directive to promote accountability, improve performance management and transform government operations, the Office of Mental Health (OMH) continues to be committed to working side-by-side with all stakeholders of the public mental health system to achieve these goals. Feedback related to the Strategic Plan received from stakeholders during 2005 has substantially improved the planning process and strengthened the foundation for future progress toward fostering hope, wellness and recovery from mental illness for all of New York's citizens.

In selecting the balanced scorecard approach as its best practice in promoting performance and outcomes management, OMH is making an effort to build on its successes and do an even better job in systematically attending to the critical elements of transformation. These elements include having:

• A clear and compelling mission and vision
• Leadership that embraces and communicates the mission and vision at all levels of the organization
• An environment that fosters change and growth
• Strategies customized to the needs and desires of the various perspectives of the public mental health system
• Ongoing processes to maximize progress and overcome barriers to it
• Continuous quality improvement mechanisms to monitor outcomes
• Data-driven scientific and experiential knowledge to adjust processes to achieve recovery and wellness goals

This Plan has presented an overview of the steps taken to move the planning process forward; more effectively align the Strategic Plan mission, vision, aims, goals and objectives with the various public mental health system perspectives, such as the stakeholder and day-to-day business processes; and measure and influence better performance and outcomes. Encompassed within these activities is the fundamental understanding that OMH is strongly committed to actively combating the stigma associated with mental disorders. It will continue to value quality services and supports, embrace the use of data to continuously improve quality, and measure success through the monitoring of outcomes focused on recovery and wellness. Finally, OMH will maintain its commitment to developing organizational structures to support and sustain the delivery of evidenced-based practices by knowledgeable professionals and peers.

With respect to performance management activities during 2006-2007, OMH will begin introducing an initial set of performance indicators on its public web site in March 2006. The introduction of these performance indicators and their relationship to continuous quality improvement is best understood within the context of a multistage development process.

A Staged Approach to Striving for Continuous Quality Improvement

The familiar proverb "Rome wasn't built in a day" would certainly apply to the process of bringing together a balanced scorecard approach and performance management, particularly the development of a performance measurement system. Just as any valuable endeavor takes time, Hermann and colleagues have also noted the time necessary to develop a strong, focused and accountable quality management system. They have characterized the maturation of such a system as occurring in three stages.¹

• The first stage essentially is formative, whereby measures that shed light on the utilization of services as well as systems and infrastructure issues are the primary concern. Major analytic activities center on accessing these data, linking data sets, checking the integrity of the data, and ascertaining methods to display data clearly and meaningfully. From an organizational perspective, this is the time when staff and managers are being introduced to the new system and leadership is provided in creating and initiating committee structures that foster collaboration through ongoing and regular meetings and discussion.
• In the second stage, attention is focused to a large part on process measures and the degree to which treatments and supports achieve the desired outcomes. These measures provide an indication of the proportion of individuals receiving interventions consistent with practices based on the best scientific evidence.² Clinically relevant measures may be constructed from survey or other available data. While outcome measures may begin to be introduced during this phase, their use is reserved until the agency has acquired a facility for utilizing data effectively. Outcome measures are critical to providing insight into the end results of mental health treatment and support. Quality improvement activities center on making use of data to identify opportunities for improvement, organize priorities, recommend improvement strategies, and monitor progress. A desired outcome of these activities is a cascading throughout the organization of a focus on continuous quality improvement.
• The third stage represents the development of a "learning organization."³ This occurs when a culture of continuous quality assessment and improvement is prevalent day to day. The process of systematically gathering and reporting data is designed to meet the ongoing information needs of the key perspectives of the organization, for example, the stakeholder and financial views and concerns. Importantly, within the organization, continuous quality improvement and evaluation activities result in quantifiable improvements in areas of high priority and meet the goals and objectives established within the organization's strategic plan.

The stages are not separate, but overlap, indicating the dynamic process of developing such comprehensive systems. Within OMH departments and divisions, much work generally described in Stages 1 and 2 has been accomplished over the past few years and makes possible the integrated, agency-wide balanced scorecard. While specialized evaluation efforts will continue, the time for nurturing the "learning organization" is now.

OMH is drawing on much of its work in developing its data warehouse and related resources, upgrading applications, and creating departmental indicators to move forward with the balanced scorecard. Additionally, it is tapping into its wealth of knowledge in evaluating programs and initiatives, using data to improve processes and promote positive outcomes, and developing new indicators for tracking progress toward the goals and objectives in the Strategic Plan. With movement into Stage 3, OMH will rely on its Performance Improvement Committee (PIC) to foster alignment between the Strategic Plan Framework and financial decision making.

As the next year progresses, the PIC, which serves in an advisory role to the Commissioner and her Cabinet, will be instrumental in monitoring fidelity of agency activities to its mission, vision and values. In particular, the diversity of the population served in New York's public mental health system makes clear the need for culturally and linguistically appropriate, recovery-focused treatment and support services aimed at preventing mental illness and promoting mental well-being. By maintaining a focus on population-based assessment and planning through the PIC, OMH is endeavoring to systematically view each indicator through a "cultural lens," with the intention of better understanding the role specific population characteristics play in eliminating mental health disparities. It is expected that collaborating with the Commissioner's Multicultural Advisory Committee and other experts in the field of cultural and linguistic competence will serve to further enhance the quality of performance management activities and ultimately the overall quality of care to New York's diverse communities.

Identifying and developing performance indicators will continue to take time and will likely be challenging, but the expected dividends will be invaluable in moving toward transformation.

The first performance indicators will be introduced in March 2006. At the same time, mandated information on the AOT program will be made available. Thereafter, data from new initiatives to address strategic priorities, particularly in the area of services and supports for children with serious emotional disturbance and their families, will be updated quarterly. Three major tracks of activity that will take place during 2006 include the:

• Initial implementation of the web-based balanced scorecard in March
• Introduction of mandated AOT data in March
• Addition of new measures to the scorecard on a monthly basis

Initial Set of Performance Indicators for Introduction in March 2006

Using the balanced scorecard approach to measure and monitor progress presents challenges and opportunities for anyone with an interest in the public mental health system. The PIC is currently considering recommendations for a small set of performance indicators to use in monitoring progress toward goal attainment. The Committee is working closely with the Commissioner's Cabinet to fine tune the set of indicators and target values to be used cross-divisionally and by key stakeholders.

The plan includes introducing a parsimonious set of management objectives and their associated performance indicators that align with the OMH Strategic Plan and strategic priorities on or about March 1, 2006. Consistent with the balanced scorecard methodology, this set of indicators is being kept to a small number to permit OMH to focus on what matters. It also signifies a beginning point for building the balanced scorecard, which is aimed ultimately at engaging all stakeholders in working together to maintain and improve the quality of services and supports. Additionally, the identification of indicators is being informed by considering which data elements are available within the architecture of OMH's data warehouse. Table 8.1 shows the set of indicators under final consideration. It provides the management objective for each indicator as well as a statement of its relationship to the Strategic Plan goals and objectives. The table also notes the rationale for including each indicator and a description of what each indicator is designed to tell us. This set of indicators is organized by the three domains that comprise the Strategic Plan.

These, as will be the case for all management objectives and indicators incorporated into the balanced scorecard, relate directly to the Strategic Plan goals and objectives and areas of strategic priority.

Assisted Outpatient Treatment (AOT) Data for Introduction
March 1, 2006

The June 2005 amendment to the legislative extension of Kendra's Law includes a provision to make performance information available beginning March 1. Using the same portal technology that underlies the balanced scorecard, a set of indicators specific to the AOT program will be made available to the public. The State and County AOT data to be reported are:

• Characteristics and demographics of individuals served by AOT, including the incidence and duration of homelessness, hospitalization and incarceration of individuals before and during AOT
• Outcomes of judicial proceedings, including the number of AOT petitions granted by the court
• Number of service enhancements or voluntary agreements not ordered by the court
• Treatment referral outcomes, including the time frames for service delivery
• Number of removals for examination pursuant to subdivision (n) of Section 9.60 of the Mental Hygiene Law and the number of persons who are hospitalized beyond the period of examination
• Reasons for closed cases
• Data reported pursuant to subdivision (b) of Section 9.47 of the Mental Hygiene Law
• Other data related to the AOT program deemed appropriate by the Commissioner

Performance Measurement and the 2006-2007 Executive Budget Initiatives

Key management reforms advanced by Governor Pataki in 2005 have strengthened the OMH planning process through a strategic planning partnership with the Division of Budget (DOB). This collaboration has led to an enhanced integration of performance measurement and financial decision-making activities. As part of the OMH-DOB pilot initiative described in Chapter 1, OMH presented strategic planning information to DOB during the 2006-2007 Executive Budget development process in a new way, which is reflected in Chapter 6. This new method aligns the strategic goals and objectives (which were informed by stakeholder input) with environmental trends, priorities and potential Executive Budget initiatives. The process is also presented schematically in Figure 6.1.

Table 8.2 delineates Executive Budget Actions identified in Chapter 6 and their associated management objectives and performance indicators and targets, where specified. Table 8.2 is a product of a collaboration between OMH and the DOB. As naturally anticipated for this stage of development, a number of the initiatives require additional information sources, analysis and collaboration with stakeholders before indicators and targets can be determined. These activities will be carried out as part of the balanced scorecard implementation.

Beginning with this year's budget cycle, the PIC will consider each management objective, identify possible indicators, assess their utility for reliably measuring the intended results, and make recommendations for indicators that will best measure progress in the most cost-efficient manner. In some cases OMH will commit the necessary resources to construct new data sets for creating relevant indicators and thoughtfully analyzing and setting performance targets.

OMH will periodically provide updates on these indicators and consider which of them may be appropriate for inclusion in the balanced scorecard and which may be more appropriately communicated through complementary methods.

Balanced Scorecard Work Under Way for the Remainder of 2006

The balanced scorecard portal platform is designed for continuous real-time reporting of performance data. This means that as data are updated in the system, the information will be reflected almost immediately as live reports available on the web site. Real-time reporting on all indicators has begun and will be fully implemented internally within OMH in 2006. While it will not be possible to extend real-time reporting to the OMH public website initially, the balanced scorecard reports made available to the public via the OMH public web site beginning in March 2006 will be updated monthly and real-time reporting will be implemented on the public web site in 2007.

As the PIC and Commissioner's Cabinet consider the 2005-2006 and 2006-2007 strategic and budget priorities, OMH will add the recommended management objectives and indicators to the balanced scorecard. The addition of these objectives and indicators will occur as the performance data become available in line with the reporting intervals established for each indicator.

From the time between the introduction of the online version of the balanced scorecard in March and the regional forums to follow in the spring, stakeholders are invited to seek technical assistance in navigating the scorecard or to send thoughts and comments about the scorecard to OMH using the "How to Contact Us" feature found in the balanced scorecard section of the OMH web site. Individuals may also send written comments to the Balanced Scorecard, New York State Office of Mental Health, Office of Planning, 44 Holland Avenue, Albany, NY 12229. They may also call the OMH Customer Relations line at 1 800 597-8481 (toll free) and ask to speak to the Office of Planning.

Individuals who do not have access to the internet may request a written copy of the current scorecard by calling the toll-free number or writing to OMH and requesting it. In such instances, OMH would also welcome feedback during the regional forums, by phone, or by mail. All responses will be methodically gathered and considered and incorporated as appropriate into scorecard revisions beginning in September 2006.

Continuing Our Productive Collaboration with County Mental Hygiene Directors and the New York City Department of Health and Mental Hygiene (DOHMH)

An ongoing collaboration between OMH, the County Mental Hygiene Directors, through the Conference for Local Mental Hygiene Directors (CLMHD), and DOHMH is a critical element of the revitalized planning process. These organizations continue to work together to develop and implement principles and processes that will guide intergovernmental planning efforts, and refine and strengthen the specific planning roles and functions for the counties, New York City and OMH.

During the 2004-2005 planning cycle, the Conference surveyed its membership to identify priority areas for mental health services planning in their localities. Findings from the survey were shared with OMH and considered in the formulation of the 2005-2009 Statewide Comprehensive Plan. During the 2005-2006 planning cycle, OMH and the Conference has continued its productive partnership to strengthen the planning process.

Key areas of collaboration in 2005 have included the design and production of a model County planning template and the development of county strategic data sets. With technical assistance and joint effort from OMH, CLMHD has completed the County Planning Template and provided technical assistance to County Mental Hygiene Directors in its use. OMH, on the other hand, has sought expertise within the Conference to produce data sets that support County mental health planning efforts. The data sets, which are available for direct use by County planners, are designed to meet the data needs of the counties in finalizing their templates. DOHMH used the Planning Template in the creation of its "New York Local Government Plan - Mental Health Service - 2006," and shared this Plan with OMH in the fall of 2005. OMH has and will continue to evaluate recommendations and work on coordinated approaches to State and City planning with DOHMH.

Consistent with national and state efforts to foster accountability at all levels of the public mental health system, CLMHD will initiate this month a request to County Mental Hygiene Directors for Local plans using these planning resources. As a result of this multi-year, cooperative planning effort, OMH expects, for the first time in several years, to formally receive county mental health plans in 2006. This important new planning resource, which will enhance and enrich the information base regarding Local planning priorities, will be carefully considered by OMH and incorporated into the 2007-2011 Statewide Comprehensive Plan for Mental Health Services.

Working Together to Improve Quality - Next Steps

As we think ahead to the next Fiscal Year and the planning horizon beyond, it makes sense to remember where we have been.

Before the release of the Final Report of the President's New Freedom Commission in 2003, OMH had already taken a number of steps to advance a multi-layered, multi-year quality agenda to transform its system of care. One of the first steps was to create a foundation for planning through the development of an agency mission, vision, values and priorities. This transformation really began to take shape, however, with OMH's campaign to implement evidence-based practices. A panel of experts was convened to share their perspectives on how to communicate a vision, apply research to real-world settings, prepare for successful change, use outcomes data effectively, integrate cultural and linguistic competence, and incorporate recipient and family perspectives into planning, treatment, and evaluation activities.

Discussions with key stakeholders held across the State indicated a need for both cultural and structural change. The cultural change was needed to create an organization dedicated to continuous learning, quality improvement, the belief that recovery is possible and does occur, and the critical need for reliance on science-based practice. Structural change was needed to improve contracting and regulations, create workforce supports for education and supervision, and to develop uniform standards and procedures for assessment, service planning, and outcomes management. Using input from these sessions, OMH outlined a multi-step, stratified plan to drive the system toward transformation. The primary changes identified included:

• Raising awareness and building encouragement for transformation among stakeholders
• Introducing and developing new evidence-based interventions
• Promoting structural and clinical improvement by incorporating quality measures into individual practitioner and provider performanc
• Being committed to continuous improvement and identifying new areas of promise on an ongoing basis.

This Plan indicates a number of ways in which strategic planning efforts have matured and continued since 2001 to move the agency closer to realizing its vision and transforming the system of care. Moreover, it spells out concrete actions OMH will be taking during the next Fiscal Year and thereafter as it endeavors to enhance and make stronger its planning, performance management and continuous quality processes. Critical to the success of ongoing strategic planning activities is the role all stakeholders of the public mental health system have played and will continue to play in the broader planning process.

The 2006 annual regional planning meetings will emphasize reviewing progress in reworking and strengthening the Strategic Plan, aligning components of the Plan with strategic priorities, and strengthening the performance management and reporting infrastructure. Joining the Deputy Commissioner of Planning at regional forums in 2006 will be the Senior Deputy Commissioner of the Center for Information Technology and Evaluation Research. During the meeting, time will be devoted to discussion of the overall Strategic Plan and the new balanced scorecard approach to monitoring and measuring progress, as well as a live demonstration of the balanced scorecard features. Topics for discussion will include:

• To what degree does the current Strategic Plan Framework reflect the desires and expectation of stakeholders?
• How can balanced scorecard processes more effectively foster alignment between the mission, vision and values of OMH and its day-to-day activities?
• Based on the Strategic Plan and trends in the environment in which OMH operates, what areas should be given high priority in evaluating the quality of services and the outcomes experienced by individuals served by the public mental health system?
• What strategies would be effective in maximizing stakeholder input into the balanced scorecard process?

These questions and others, as well as numerous other opportunities for input, will serve to frame an open dialogue, wherein OMH, led by Commissioner Carpinello, continues to receive and use feedback and recommendations from all perspectives of the organization and from all stakeholders to solidify planning, enhance the quality of treatments and supports, and achieve desired outcomes.

We look forward to a productive and continuing partnership in fostering the sense of hope that translates into a future when everyone with a mental illness will recover, when all mental illnesses can be prevented or cured, when everyone with a mental illness at any stage of life has access to effective treatment and supports-essential for living, working, learning, and participating fully in the community.

Notes

1. Hermann RC, Regner JL, Erickson P, & Yang D. (2000). Developing a quality management system for behavioral health care: The Cambridge Health Alliance experience. Harvard Review of Psychiatry, 8(5), 251-60.
2. Hermann RC. (2002). Linking outcome measurement with process measurement for quality improvement. In W Ishak, T Burt, & L.Sederer. (2002). Outcome measurement in psychiatry: A critical review. Washington DC: American Psychiatric Press.
3. Hermann et al. Developing a quality management system for behavioral health care.

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