title: Do integrated mental healthcare organisations facilitate process quality in the treatment of people with schizophrenia and related psychoses?
abstract: OBJECTIVE
  The objective of this study is to investigate the influence of mergers of ambulatory and mental healthcare organisations on the process quality of care for persons suffering from schizophrenia or related psychoses.
  
  
  BACKGROUND
  On the basis of the theory of Donabedian we assume the relationships between three types of quality in healthcare: structure quality, process quality and outcome quality. This study focuses on the influences of structure quality, i.e. years since merger and catchment area size upon process quality.
  
  
  METHODS
  Criteria according to Tugwell for evaluating healthcare were used to describe the process quality of schizophrenia care, resulting in a process quality questionnaire with 6 subscales and 21 items. Leading psychiatrists of 31 Dutch mental healthcare organisations, covering 89% of the country, answered the questionnaire. Both programmes and documents from the responding institutions and schizophrenia projects were analysed. Correlations of two determinants, age of the merged organisation and catchment area size, were made with total scale scores and the sub scores of the questionnaire.
  
  
  RESULTS
  The response rate was 97% (31/32). Twenty-two organisations (71%) had a score of more than 50% on the used scale, 8 (29%) scored less. Two evidence-based interventions were implemented in more than 50% of the organisations, three in less than 50%. A low degree of implementation occurs in establishing care for people with schizophrenia from ethnic minorities, standardising diagnostic procedures and continuity of care. No significant relationship between the age of the merged organisation ('age') and the total process quality of schizophrenia care was found, however, the relationships between age and the subscales availability of interventions and integrated treatment were significant. No association was found between the size of the MHO's catchment area and any of the used subscales.
  
  
  CONCLUSIONS
  The age of integration of residential and ambulatory mental health institutions correlates significantly with two subscales of process quality of schizophrenia care, i.e. availability of interventions and treatment. Catchment area size is not significantly associated with process quality or any of the subscales. Despite the mentioned positive effects, the overall picture of schizophrenia care is not very positive. Additional forces other than merely integration of ambulatory and residential services are needed for the further implementation of evidence-based interventions, diagnostic standards and continuity of care. The development of a national 'schizophrenia standard' (like in other countries) in relation with implementation plans and strategies to evaluate care on a regional level is recommended as well as further research on patient outcomes in relation to mergers of mental healthcare organisations.
authors.affiliation: General Psychiatric Hospital Robert Fleury, Leidschendam, The Netherlands. DP.Ravelli@wxs.nl
authors.forename: D P
authors.initials: DP
authors.lastname: Ravelli
authors.forename: V J A
authors.initials: VJ
authors.lastname: Buwalda
authors.forename: C J A J
authors.initials: CJ
authors.lastname: Slooff
authors.forename: A J P
authors.initials: AJ
authors.lastname: Schrijvers
authors.forename: H
authors.initials: H
authors.lastname: van Engeland