711052

research-article2017
APY0010.1177/1039856217711052Australasian PsychiatryDavidson et al.

Australasian
Forensic psychiatry Psychiatry
Australasian Psychiatry

Key performance indicators for 2017, Vol 25(6) 609­–613

© The Royal Australian and
New Zealand College of Psychiatrists 2017

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DOI: 10.1177/1039856217711052
https://doi.org/10.1177/1039856217711052

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Fiona Davidson  University of Queensland, Brisbane, QLD, and; Queensland Forensic Mental Health Service, Brisbane, QLD,
and; NHMRC Centre of Research Excellence in Offender Health, University of New South Wales, Sydney, NSW, Australia
Ed Heffernan  University of Queensland, Brisbane, QLD, and; Queensland Forensic Mental Health Service, Brisbane, QLD,
and; NHMRC Centre of Research Excellence in Offender Health, University of New South Wales, Sydney, NSW, Australia
David Greenberg  NHMRC Centre of Research Excellence in Offender Health, University of New South Wales, Sydney, NSW,
and; Justice and Forensic Mental Health Network, State-wide Clinical Court Liaison Service, Sydney, NSW, Australia
Tony Butler  NHMRC Centre of Research Excellence in Offender Health, University of New South Wales, Sydney, NSW, Australia
Philip Burgess  University of Queensland, Brisbane, QLD, Australia

Abstract
Objectives: The aim of this paper is to describe the development and technical specifications of a framework and
national key performance indicators (KPIs) for Australian mental health Court Liaison Services (CLSs) by the National
Mental Health Court Liaison Performance Working Group (Working Group).
Methods: Representatives from each Australian State and Territory were invited to form a Working Group. Through
a series of national workshops and meetings, a framework and set of performance indicators were developed using
a review of literature and expert opinion.
Results: A total of six KPIs for CLSs have been identified and a set of technical specifications have been formed.
Conclusions: This paper describes the process and outcomes of a national collaboration to develop a framework and
KPIs. The measures have been developed to support future benchmarking activities and to assist services to identify
best practice in this area of mental health service delivery.

Keywords:  performance indicator, court liaison, diversion, benchmarking

M
ental health Court Liaison Services (CLSs)
emerged in Australia in the late 1990s to iden-
tify mentally ill individuals at the post-charge,
pre-sentence stage of the criminal justice pathway. Their
key function is the timely provision of mental health
assessments and court reports to support judicial deter-
minations. They aim to reduce delays in court proceed-
ings, to minimise remands in custody1 and provide
advice regarding mental health diversion options.
The early identification and provision of care to men-
tally ill people coming into contact with the criminal
justice system is supported in national mental health
policy,2 however, there is limited research into how
these services should be delivered and what models are
effective. A recent national survey of CLSs3 indicated
that while there are differences among jurisdictions (e.g.
size of service, geographic coverage, legislation for diver-
sion), the aims and basic functions of each service are
comparable. Given this, it becomes feasible to compare
service performance of CLSs through a benchmarking
process. For benchmarking to occur, key performance
indicators (KPIs) need to be agreed by service providers.
Why measure the performance of CLSs?
The use of reliable and valid performance measures ena-
bles services to determine whether their processes are
working well. Increasingly there is an expectation that
publicly funded services are efficient and accountable
and the development and dissemination of performance
measures can assist in communicating progress towards
organisational goals.4
Corresponding author:
Fiona Davidson, Queensland Forensic Mental Health Service,
Brisbane, QLD, Australia.
Email: fiona.davidson@health.qld.gov.au

609

KPIs can inform local and national quality improvement
processes, service planning and contribute to evidence-
based practice. Moreover, a unified approach to perfor-
mance measurement enables comparison among CLSs
in each Australian jurisdiction.
Performance measurement in mental
health – Australia
Since 1992–1993 Australia’s mental health sector has
undertaken a process of mental health information
development, including performance indicators.5 While
Australia has gained worldwide recognition in the area
of performance measurement,6 the majority of the
efforts in reporting on indicators of mental health
reform have focused on the specialised public mental
health sector (i.e. acute inpatient and community men-
tal health services).7 To date, the framework has been
developed without reference to discrete target popula-
tions (e.g. children and adolescents, older persons, and
forensic patients).
A nationally agreed set of mental health system perfor-
mance domains has been developed over the past 25
years and presented as the National Mental Health
Performance Framework (NMHPF).5 Tier 1 of the NMHPF
covers ‘health status’ (e.g. prevalence rates of disease);
Tier 2 ‘determinants of health’ (e.g. health behaviours);
and Tier 3 ‘health system performance’. With respect to
Tier 3, nine domains were identified: effective, appropri-
ate, efficient, accessible, continuous, responsive, capa-
ble, safe, and sustainable. Within each domain,
subdomains are further identified (e.g. for effective: con-
sumer and carer outcomes).
While there has been some focus on performance meas-
urement specifically for forensic mental health services
(FMHSs), through a National Mental Health Benchmarking
Project (NMHBP) conducted between 2005–2008, only
four States and Territories participated in the project. The
NMHBP provided an opportunity, however, for the
nationally agreed KPIs and the process of benchmarking
to be evaluated for these services. Those services con-
cluded that the nationally agreed KPIs were not suffi-
ciently tailored to forensic organisations.7
International approaches
A review of the international literature with regard to
CLS performance measurement found that, while some
guidelines have been developed in Canada8 and the
United Kingdom,9–12 there are no nationally endorsed
indicators for performance measurement for CLSs.13, 14
The available evidence indicates that there is an absence
of performance indicators for FMHSs both in Australia
and internationally. Given the importance national
mental health policy places on developing, evaluating
and benchmarking service performance it is critical that
FMHSs focus on this endeavour. There is a need to
610
Australasian Psychiatry 25(6)
develop a set of nationally agreed measures that are
meaningful and that can identify and respond to emerg-
ing issues. In this paper, we present the first national
collaboration leading to the development of a frame-
work and KPIs for CLSs in Australia.
Method
The National Mental Health Court Liaison
Service Performance Working Group
The National Mental Health Court Liaison Service
Performance Working Group (Working Group) was
established in February 2016 to assist in the develop-
ment and technical specification of a performance
framework and KPIs for specialised mental health CLSs.
The group consisted of representatives from CLSs from
each Australian jurisdiction, an Aboriginal and Torres
Strait Islander representative and project investigators
from the NHMRC Centre of Research Excellence in
Offender Health. All Working Group members were cli-
nicians (psychiatrists, nurses and a social worker) with
experience in the area of court liaison. Representatives
had varied roles and responsibilities including jurisdic-
tional forensic mental health oversight (two), CLS clini-
cal directors (three), team leaders (two) and CLS team
members (two).15 The group’s objectives were to develop
(i) a framework specific to CLSs; and (ii) a set of KPIs that
complement Australia’s existing national mental health
performance measurement approaches.
Materials were distributed to the Working Group
including: findings from the first national survey of
court-based mental health services;3 an overview of the
national approach to performance measurement for
mental health services; a literature review of interna-
tional and national approaches to CLS performance
measurement; and proposed principles to guide the
process. A national workshop was conducted with
Working Group members, followed by a series of tel-
econferences to progress the development of the frame-
work and KPIs.
A series of questions was considered by the members of
the Working Group:
•• Are the nine domains of Tier 3 of the NMHPF rel-
evant to CLSs?
•• Are domains equally important?
•• Are the existing KPIs relevant for CLSs?
•• For each of the domains of the NMHPF, can we
apply this concept to a CLS? For example, what
would an accessible CLS look like?
° What
be?
would the ideal measure for each domain
° Can this be measured with our currently avail-
able data? If not, is there a suitable alternative
measure?
Davidson et al.

Table 1.  Importance rating and ranking of National Mental Health Performance Framework Tier 3 domains for
CLSs

Domain Definition Total rating Rank

Effective Care, intervention or action achieves desired outcome. 22 1
Accessible Ability of people to obtain health care at the right place and right time 22 1
irrespective of income, geography and cultural background.
Safe Potential risks of an intervention or the environment are identified and avoided 19 2
or minimised.
Appropriate Care/intervention/action provided is relevant to the client’s needs and based on 16 3
established standards.
Continuous Ability to provide uninterrupted, coordinated care or service across programs, 15 4
practitioners, organisations and levels over time.
Capable An individual or service’s capacity to provide a health service based on skills 14 5
and knowledge.
Efficient Achieving desired results with most cost-effective use of resources. 13 6
Responsive Service provides respect for persons and is client orientated: respect for dignity, 13 7
confidential, participate in choices, prompt, quality of amenities, access to
social support networks, and choice of provider.
Sustainable System or organisation’s capacity to provide infrastructure such as workforce, 10 8
facilities and equipment, and be innovative and respond to emerging needs
(research, monitoring).

CLS: Court Liaison Service

Working Group members rated the Tier 3 domains with
respect to their relative importance to CLSs. Each par-
ticipant, individually, provided a rating of: ‘1’ for the
three domains that were considered to be the least
important to CLSs; ‘2’ for the three domains considered
to be somewhat important to CLSs; or ‘3’ for those con-
sidered to be the most important to CLSs. Participants’
ratings were collated and a total group score was deter-
mined by summing the ratings.
Results
Are the domains of the NMHPF relevant to
CLSs?
The concepts that comprise the Tier 3 domains and all
nine domains were considered to be relevant dimen-
sions to the performance of Australian CLSs. No addi-
tional domains were identified.
Are there any domains that are more
important than others?
While each of the domains was acknowledged to be rel-
evant to CLSs, the domains concerning ‘effectiveness’
and ‘accessibility’ were rated as the most important by
the Working Group. The ratings and rankings of Tier 3
domains are shown in Table 1.
Are the existing subdomains and KPIs
relevant for CLS?
None of the national KPIs, as defined, were considered
to be relevant for the specialised area of court liaison,
due to the unique aspects of the service model. These
services were acknowledged to perform a unique role
within the criminal justice and mental health systems.
They operate on a consultation liaison model with short
term consumer contact and do not provide ongoing
mental health care, rather they providing linkages with
other care providers and social services. Accordingly, a
process of developing suitable measures commenced.
KPIs for Australian mental health CLSs
Working Group members considered the review of inter-
national literature and local approaches to performance
measurement. Expert opinion was then applied to form
a set of KPIs that represented the best approach for each
domain. While the types of routinely collected informa-
tion and reporting capacity varied between the services
in each jurisdiction, consensus was reached for each of
the indicators described in Table 2. A set of technical
specifications was subsequently developed by the
Working Group.15 A total of six quantitative KPIs were
identified across five domains (i.e. effective, accessible,
safe, continuous, efficient), in addition to a set of quali-

611
 Australasian Psychiatry 25(6)

Table 2.  National KPIs for Australian CLSs

Domain Subdomain CLS KPIs Concepts for possible future

­development
Effective Consumer outcomes Diversion to non-custodial CLS impact on court processing time
mental health treatment CLS reports to courts
Accessible Access for those in need Court attendees who receive  
Local access a mental health assessment
Comparative area resources
Safe Provider safety CLS staff assaults Risk assessment
Community safety Recidivism
Consumer safety Privacy of consumer information/
Carer safety informed consent
Appropriate Compliance with standards * CLS-specific standards for practice
Continuous Cross-setting continuity Post-CLS mental health service Detailed pathways of care pre and
contact post-CLS contact
Capable Provider knowledge and skill Descriptive information  
Efficient Consultation liaison care Average cost of CLS Cost savings of diversion
assessment
Responsive Stakeholder experience * Magistrate perceptions of service
Sustainable Descriptive information  

*No measures proposed that can be collected currently.

CLS: Court Liaison Service; KPI: key performance indicator

tative questions for two domains (i.e. capable, and sus-
tainable).
Several concepts were identified as future information
development priorities for CLSs. A consistent approach
to the measurement of consumer and stakeholder per-
ceptions of services is one area that warrants further
attention. While there are national principles for
FMHSs,16 the Working Group identified that a set of
nationally agreed standards for CLSs would be worth-
while. Other broader system performance measures were
noted by the Working Group as being of relevance, such
as measures of continuity of care, recidivism and a meas-
ure of the impact that CLSs have on court processing
times. These measures, however, rely on information
not readily available to CLSs and would require informa-
tion from other systems such as providers of ongoing
mental health care and the criminal justice system.
collect and construct, in order to maximise each organi-
sation’s capacity to focus on understanding findings and
to implement improvements. The Working Group iden-
tified a number of areas that may warrant future explora-
tion, with a standardised approach to consumer and
stakeholder perceptions identified as a priority.
For specialised areas of mental health such as CLSs, there
are particular benefits to national collaboration.
Approaches to performance measurement developed
through that process are more likely to be acceptable
and valued. The KPIs for Australian CLSs represent a first
step in a broader process that will involve benchmarking
of services.
Disclosure
Fiona Davidson receives a PhD stipend from the NHMRC Centre of Research Excellence in
Offender Health (1057492), Kirby Institute, University of New South Wales, Australia.

Discussion
To date, there has been strong commitment by Australian
CLSs to work together to develop an accountable and
transparent approach to performance measurement, and
to compare service models. A small set of streamlined
measures of performance that are considered to be impor-
tant from a clinical and service management perspective
was identified by the Working Group. A key issue was the
need to develop indicators that would not be onerous to
Funding
Fiona Davidson disclosed receipt of a PhD stipend from the NHMRC Centre of Research
Excellence in Offender Health (grant number 1057492), Kirby Institute, University of New
South Wales, Australia
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