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proliferated to guide clinicians toward optimal decisions through their promulgation of specialized standards for a variety of conditions and medical technologies.

A variety of published and unpublished standards, criteria, guidelines, indicators, and protocols have flooded the landscape of health care, resulting in sometimes differing views about medical appropriateness by various expert panels. Nevertheless, empirically and experientially based clinical standards constitute an essential method by which clinical decisions can be independently evaluated through professional review and indicator-based measurements.

Consumer Satisfaction

Concern about the satisfaction of patients and patients' families with health services by providers or regulators was uncommon until recent years. The growing power of consumers in a competitive market economy has migrated from other areas of business to health care, underscoring the essential importance of routinely assessing what consumers think and feel about their health benefits and services. Health services research has shown that patient satisfaction is one of the most relevant markers for quality, even if it is not always a sensitive indicator. Significant resources are being allocated to refine specific methods of assessing quality through consumer evaluation and to systematically seek customers' opinions in designing clinical services and improving the quality of clinical services.

National and local newspapers and magazines provide consumers with information by comparing different health plans, including the results of consumer satisfaction surveys and other data available from report cards. The media also cover stories about provider “gag rules,” denials of services, problems with care, HMO profits, and other information that have unmeasured effects on disenrollment or other indications of dissatisfaction.

QUALITY MANAGEMENT IN BEHAVIORAL HEALTH CARE

Quality management activities in behavioral health care services have evolved over the past 30 years. They originated with the academic and professional bases of medical quality assurance (Mattson, 1992; Rodriguez, 1988), and have blended with traditional local practice (e.g., clinical privileging), state regulatory (e.g., licensing), and tort interventions to provide implicit and explicit oversight of health care quality.

One of the major initiatives in the accountability of behavioral health care quality was instituted by the U.S. Department of Defense in 1975 to provide explicit oversight over psychiatric residential treatment for child and adolescent services under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). As noted in Chapter 4, this national initiative was the first by a national payer to establish specialized program standards and admission-treatment criteria for mental health services. Its evolution into a national peer review



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