Ensuring and improving quality in community mental health care

The definition of good quality of mental health care is complex. It depends on the perspective, the underlying values and the interest of the person assessing quality. For research and clinical pur poses a reductionistic approach is inevitable. Approaches for ensuring and improving quality of community mental health care, such as outcome management, ISO 9000 guidelines, and total quality management, are critically reviewed. Quality management approaches in mental health care have led to the conclusion that programmes developed for other types of services can be effectively applied to community mental health care, but that the motivation for change and the involvement of all levels of the organization are more important than technical aspects. For various reasons, managing quality on the basis of external standards and through external pressure alone is likely to fail. It is argued that confidence of staff and the quality of their relationships with patients need to be considered, and a model for distinguishing interventions on three levels is proposed.