certification, credentialing and privileging, and the use of practice guidelines, performance measures, report cards, and other means. Thus, the array of quality improvement approaches resembles a complex patchwork, reflecting the fragmented system that delivers the care and the wide variety of evidence and opinions about quality of care.

In the spring of 1995, the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA), asked the Institute of Medicine to convene an expert committee that would consider issues related to quality assurance and accreditation in managed behavioral health care. The charge to the committee was to develop a framework to guide the development, use, and evaluation of performance indicators, accreditation standards, and quality improvement mechanisms. The framework could then be used to assist in the purchase and delivery of the most effective managed behavioral health care at the lowest appropriate cost for consumers of publicly and privately financed care. The 17 members of the committee were chosen for their expertise with national accreditation processes and procedures, public and private managed care organizations, employee assistance programs, corporate and public purchasing of mental health and substance abuse services, public and private medical administration, and health services research. The committee also included individuals who had experience as direct consumers of behavioral health care or who were family members of consumers.

The committee met five times between February and July 1996. To gather information to assist in their deliberations, the committee convened two public workshops. In addition to these workshops and presentations, liaison panels were formed with more than 150 representatives of national accreditation groups, national professional associations, consumer and advocacy groups, managed care industry groups, and federal and state agencies.

Many interested parties are using a variety of methods to protect consumers and improve the quality of care in this environment of rapid change. The charge and focus of this committee is on managed care, although the committee recognizes that other issues such as licensure of practitioners and state inspection and certification of provider agencies play critical roles in consumer protection. Furthermore, in its focus on managed care, the committee has been particularly concerned with two prominent strategies: accreditation of managed care entities and the use of performance measurements. At the same time, it has considered complementary strategies that can aid in consumer protection and quality improvements, such as consumer choice of health plans, better integration of research and practice, and especially, reducing the flaws in the organization of behavioral health care.

To provide a framework for the study, the committee adapted the work of