title: Quality indicators for the referral process from primary to specialised mental health care: an explorative study in accordance with the RAND appropriateness method.
abstract: Communication between involved parties is essential to ensure coordinated and safe health care delivery. However, existing literature reveals that the information relayed in the referral process is seen as insufficient by the receivers. It is unknown how this insufficiency affects the quality of care, and valid performance measures to explore it are lacking. The aim of the present study was to develop quality indicators to detect the impact that the quality of referral letters from primary care to specialised mental health care has on the quality of mental health services.
  
  
  
  Using a modified version of the RAND/UCLA appropriateness method, a systematic literature review and focus group interviews were conducted to define quality indicators for mental health care expected to be affected by the quality of referral information. Focus group participants included psychiatrists, psychologists, general practitioners, patient representatives and managers. The existing evidence and suggested indicators were presented to expert panels, who assessed the indicators by their validity, reliability, sensitivity and feasibility.
  
  
  
  Sixteen preliminary indicators emerged during the focus group interviews and literature review. The expert panels recommended four of the 16 indicators. The recommended indicators measure a) timely access, b) delay in the process of assessing the referral, c) delay in the onset of care and d) the appropriateness of the referral. Adjustment was necessary for five other indicators, and seven indicators were rejected because of expected confounding factors reducing their validity and sensitivity.
  
  
  
  The quality of information relayed in the referral process from primary care to specialised mental health care is expected to affect a wide range of dimensions defining high quality care. The expected importance of the referral process for ensuring 'timely access'-one of the six aims of high-quality health care defined by the Institute of Medicine-is highlighted. Exploring the underlying mechanisms for the potential impact of referral information on patient outcomes is recommended to enhance quality of care.
  
  
  
  ClinicalTrials.gov: NCT01374035 (28 April 2011).
authors.affiliation: Research Network on Integrated Health Care in Western Norway, Helse Fonna Local Health Authority, Helse Fonna HF, Box 2170, 5504, Haugesund, Norway. miriam.hartveit@helse-fonna.no.|Department of Global Public Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway. miriam.hartveit@helse-fonna.no.|Leuven Institute for Healthcare Policy, School of Public Health, University of Leuven, Leuven, Belgium. miriam.hartveit@helse-fonna.no.
authors.forename: Miriam
authors.identifier: 0000-0002-7143-2236
authors.initials: M
authors.lastname: Hartveit
authors.affiliation: Research Network on Integrated Health Care in Western Norway, Helse Fonna Local Health Authority, Helse Fonna HF, Box 2170, 5504, Haugesund, Norway.|School of Public Health, KU Leuven, University of Leuven, Leuven, Belgium.|Department of quality management, University Hospitals Leuven, Leuven, Belgium.|Leuven Institute for Healthcare Policy, School of Public Health, University of Leuven, Leuven, Belgium.
authors.forename: Kris
authors.initials: K
authors.lastname: Vanhaecht
authors.affiliation: Department of Global Public Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.
authors.forename: Olav
authors.initials: O
authors.lastname: Thorsen
authors.affiliation: Research Network on Integrated Health Care in Western Norway, Helse Fonna Local Health Authority, Helse Fonna HF, Box 2170, 5504, Haugesund, Norway.
authors.forename: Eva
authors.initials: E
authors.lastname: Biringer
authors.affiliation: Department of Global Public Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.
authors.forename: Kjell
authors.initials: K
authors.lastname: Haug
authors.affiliation: Department of Global Public Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.|Department of Radiology, Haukeland University Hospital, Bergen, Norway.
authors.forename: Aslak
authors.initials: A
authors.lastname: Aslaksen
mesh_terms: D017144:Focus Groups; D006297:Health Services Accessibility / Q000592:standards; D006801:Humans; D001523:Mental Disorders / Q000453:epidemiology / Q000628:therapy*; D008605:Mental Health Services / Q000458:organization & administration* / Q000592:standards; D009664:Norway / Q000453:epidemiology; D011320:Primary Health Care / Q000458:organization & administration* / Q000592:standards; D058996:Quality Improvement / Q000458:organization & administration*; D019984:Quality Indicators, Health Care / Q000592:standards; D012017:Referral and Consultation / Q000458:organization & administration*
keywords: Mental health services; Process assessment (health care); Quality indicators, health care; Quality of health care; RAND appropriateness method; Referral and consultation