Developing a quality management system for behavioral health care: the Cambridge health alliance experience

The rapid pace of change in the health care system presents tremendous challenges for clinicians and managers charged with the delivery of mental health and substance abuse services. Declining reimbursement, new incentive structures, and increasing competition are placing unprecedented pressure on providers to deliver care efficiently. Regulatory scrutiny, consumer dissatisfaction, and a growing awareness of gaps between actual and ideal practice have led to intensifying pressure to improve quality. Yet system change has also presented new opportunities for managing cost and quality of care. Consolidation of facilities and practices into integrated networks, developments in information systems technology, and the emergence of models to facilitate change have led to the rise of "quality management," a framework for assessing and improving clinical, operational, and financial performance within a health care organization. This article reviews some of the precipitating factors and theoretical structures underlying quality management and then, through a case study of one organization's experience, describes the implementation of a quality management program in a behavioral health care delivery system. The case study emphasizes how theoretical frameworks were operationalized and how organizational structure and process were shaped to address challenges well known in quality management, such as authority, accountability, and follow-through. A multiphase model of quality management program development is formulated and used to provide context for this program's development.