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 a ssessing quality. For research and clinical pur poses a reductionistic appr oach is inevitable. Approaches for ensuring and improving quality of commun ity mental health care, such as outcome management, ISO 9000 guidelines, an d total quality management, are critically reviewed. Quality management app roaches in mental health care have led to the conclusion that programmes de veloped 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 aspect s. For various reasons, managing quality on the basis of external standards and through external pressure alone is likely to fail. It is argued that c onfidence of staff and the quality of their relationships with patients nee d to be considered, and a model for distinguishing interventions on three l evels is proposed.