Best Practices

Managing Performance Indicators

for Physicians in Community
Mental Health Centers
James G. Baker, M.D., M.B.A.

I n a recent column for this series,

Glazer (1) discussed the need for
psychiatrists and other mental health
carriage makers fought this transition,
and surely they grieved the change,
for it brought along a loss of autonomy
payers in our burgeoning industry will
not hear our message about clinical
best practices unless we, as practi-
workers to reestablish control of the and the personal relationships that tioners, demonstrate our ability to
patient-provider relationship in this these artisans had developed with keep our financial house in order.
era of managed care. He suggested their customers. Unable to compete
that methodologies to identify and financially, the artisans gave way to The setting
implement best practices might go a unionized workers on assembly lines. The performance indicators and man-
long way toward achieving that goal. The old-fashioned carriage makers agement methods were developed for
He also argued that the collective (including my grandfather) had to find the psychiatrists serving adult con-
cottage-industry mentality of psychia- another way to make a living. sumers in our large community men-
try and other mental health disciplines Psychiatrists and other mental tal health center in Houston. Most of
is an obstacle to regaining profession- health professionals currently walk a the center’s adult mental health ser-
al autonomy. The effects of this men- similar plank toward the same fate. As vices are provided through six outpa-
tality are critically important in the we do, we bemoan the sight of “man- tient community mental health clinics
changing world of medicine. Medi- agers with clipboards” walking in the located throughout the county.
cine is indeed in the midst of a transi- opposite direction—those faceless bu- Each clinic has from three to six full-
tion from an old-fashioned cottage in- reaucrats perceived as more con- time psychiatrists, each of whom pro-
dustry into a truly industrialized busi- cerned with money than with quality vides clinical leadership to a multidis-
ness. This change is not unexpected, who nonetheless seem to be taking ciplinary treatment team. One of the
for such transitions occur in the natur- control of our industry (2). If we are to psychiatrists at each site also serves as
al history of all business sectors. avoid that fate, we must learn to man- clinic medical director. The members
Many examples of this process can age ourselves with those same clip- of each team together care for about
be found in history. The experience of boards. If we do not, then the business 300 patients. The diagnoses of patients
one well-known cottage industry is in- and congressional leaders who foot and the severity of their illness are fair-
structive. Before Henry Ford’s devel- the bill for health care will continue to ly consistent across treatment teams.
opment of the automobile assembly turn to others—not to psychiatrists Almost all patients have a diagnosis of
line, local artisans working at the be- and other mental health profession- schizophrenia, major depression, or
hest of individual customers built au- als—for advice on how to manage bipolar disorder. The team-based
tomobiles and other carriages. But mental health care. If we do not learn physicians also serve as the primary
Ford’s model for the industrialization how to manage our work financially as source of referrals to other rehabilita-
of automobile manufacture led to a well as clinically, then we will be tion services provided by their team or
significant transition for that business turned into technicians and relegated by other programs in the center.
sector and its practitioners. Surely the to the same fate as previous genera-
tions of cottage industry practitioners. Performance indicators and
This column presents a method the management process
Dr. Baker is medical director at Magellan used by the physician leadership in The performance indicators have
Behavioral Health of Texas, 1349 Empire our community mental health center been described previously (3). Briefly,
Central Drive, Suite 600, Dallas, Texas
to think like managers with clip- the indicators measure a series of pa-
75247 (e-mail, jbaker@magellanhealth.
boards. Specifically, it describes the rameters related to productivity, out-
com). The work for this paper was com-
pleted while Dr. Baker was affiliated management process for financial comes, and appropriateness of care.
with the Mental Health–Mental Retarda- and clinical performance indicators At the end of each month, a new set of
tion Authority of Harris County in Hous- for our center’s psychiatric staff. It is performance data is collected for each
ton, Texas. William M. Glazer, M.D. is critical that we focus on both financial physician. Except for scores from re-
editor of this column. and clinical performance, because views of the quality of medical rec-
PSYCHIATRIC SERVICES ♦ November 1999 Vol. 50 No. 11 1417
Table 1
Physician performance indicators for a sample month

N patients in % of direct Treatment plan Medical records % of caseload re- % of case-

caseload (end service time delinquency rate monitoring score ferred to acute load closed
Physician of month) (this month) (% end of month) (% year to date) care (year to date) (year to date)

A 265 47 10 100 11 28
B 296 69 10 100 5 27
C 324 55 11 100 13 18
D 292 50 2 100 11 14
E 278 44 10 100 7 21
F 270 44 3 89 4 47
G 284 47 5 78 6 36
H 271 34 11 89 8 26
J 267 39 3 33 10 31
K 311 56 10 64 7 23
L 320 65 4 75 8 28
M 343 47 4 60 6 17
N 291 49 3 85 7 27
P 316 42 7 92 7 11
R 302 54 9 75 11 20
S 292 45 4 92 7 23
T 300 39 9 75 11 24
V 312 61 4 73 4 21
W 266 66 5 89 4 17
Y 324 51 4 94 6 24
Z 327 42 3 94 7 20
Average 298 50 6 84 8 24
SD 23 9 3 17 3 8
Correlation with
caseload (r2) .20 –.11 –.06 .01 –.47

ords, all of the data required for the standard deviation are calculated by their performance. Responses may
indicators are available from reports the computer-based spreadsheet for lead to systemic interventions at the
generated by the center’s information all physicians throughout the center. team level, within the clinic, or even
systems department. All physicians receive the entire throughout the center. Descriptions
Table 1 shows examples of the spreadsheet each month. Because of procedures that have enhanced
physician performance indicators for many systemic problems can affect performance are communicated to
a sample month in a spreadsheet dis- individuals’ performance, physicians the entire physician staff through an
play. The indicators are listed at the are asked to comment on their per- e-mail network.
top of the columns. Physicians are sonal indicators that fall more than Similar indicators can be developed
listed by name in the left-hand col- one standard deviation outside the at the clinic level. Examples of such
umn (although the names have been mean for the group as a whole. High- indicators and sample data are shown
removed for this report). For each performers are asked for feedback on in Table 2. In this spreadsheet display,
performance indicator, a mean and local procedures that have facilitated the various clinics are named across

Table 2
Clinicwide performance indicators for a sample month1

All clinics

Indicator Clinic A Clinic B Clinic C Clinic D Clinic E Clinic F Mean SD

Physician caseload per full-time-equivalent physician 317 315 294 380 291 346 324 34
Value of physician services (thousands of dollars) $17 $15 $13 $20 $18 $13 $16 $3
Psychiatric assessments per physician 11 12 17 10 22 7 13 5
Psychiatric assessment no-shows per physician 9 6 12 9 11 5 9 3
Medication maintenance no-shows per physician 28 16 37 42 19 95 40 29
Patients lost to follow-up for at least 90 days 12 0 0 0 0 0 2 5
1 Presented as mean values except where indicated

1418 PSYCHIATRIC SERVICES ♦ November 1999 Vol. 50 No. 11

the top of the columns, and the sam- job of engaging and retaining patients quality and fiscal responsibility. Once
ple performance indicators are listed in treatment? These questions may be this commitment has been demon-
in the left-hand column. Again, means addressed through data collection and strated, adversarial relationships will
and standard deviations for the entire trending analyses that augment the diminish. In their place, new alliances
center are calculated using the com- basic performance indicators. can form among providers and payers
puter-based spreadsheet. Like the that will not only ensure high-quality
data on the individual performance Conclusions care for our patients in the present,
indicators, the clinic-level data are Managed care has changed the nature but also secure our professional au-
shared with the medical directors of of the relationship between psychia- tonomy in the future. ♦
all clinics. The directors of clinics with trists and other mental health workers
outlying data are asked to comment and their patients. Payers in this new References
on possible reasons for the high or low era insist on the types of performance 1. Glazer W: Defining best practices: a pre-
performance, and plans for improve- indicators described in this column to scription for greater autonomy. Psychiatric
Services 49:1013,1016, 1998
ments are generated, if indicated. ensure the quality and efficiency of
The impact of simply monitoring the services they fund. They also insist 2. Pate D: Observations on Britain’s National
Health Service. Psychiatric Services 49:
the individual physician productivity that clinical leadership address the 1014–1016, 1998
indicators and sharing the results with kinds of quality assurance questions
the center’s physicians appears to have raised by collected data. We, as men- 3. Baker J: A performance indicator spread-
sheet for physicians in community mental
been significant. An increase in pro- tal health professionals, must demon- health centers. Psychiatric Services 49:
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