Electronic Thesis and Dissertation Repository

Thesis Format



Master of Arts




Stewart, Shannon L.


In Ontario, one of the primary ways children and youth access mental health services is through community-based agencies. Due to the lack of homogeneity in how these agencies operate and report data, agencies, governments, and policymakers face significant barriers in accurately assessing, monitoring, and comparing the quality of services delivered across the province. This leads to difficulties in macro-level understanding of service delivery quality and the appropriate allocation of resources. A solution to this is the use of quality indicators (QIs) to measure specific components of healthcare quality and the risk adjustment of these QIs to allow for accurate agency comparisons. This pilot study examined existing interRAI data holdings across Ontario, in an attempt to develop three pilot QIs to measure multiple aspects of depression symptom outcomes at a systematic level. The interRAI Child and Youth Mental Health Assessment, a widely used tool implemented in over 100+ Canadian agencies, was used for its homogeneity of reporting and quantity of data. This QI was then risk-adjusted, a process which controls for factors outside the agency's control (e.g., age), and then compared across agencies in Ontario, Canada. Following the introduction of selection criteria, eighteen agencies were included for analysis. Results show support for using interRAI tools in children’s mental health QI development at the agency level. One QI showed extensive variation between agencies, indicative of successful development, while two other QIs showed some variation. Risk adjustment strategy development showed little changes in raw and adjusted QIs. This pilot study will be valuable in informing future QI development initiatives, providing valuable in informing the next steps for quality assessment in Ontario children’s mental healthcare and the development of further interRAI children’s mental health QIs.

Summary for Lay Audience

Children and youth mental healthcare is currently at the forefront of concerns for public health. In Ontario, children and youth can access mental health services through community-based services. Because of the varied ways these organizations operate and record data, agencies, governments, and policymakers face significant barriers in accurately assessing and comparing the quality of services delivered across the province. It is nearly impossible to assess the quality and compare how agencies are performing without sharing a uniform reporting style. A uniform understanding of quality in children’s mental health care (e.g., wait times, mental health outcomes) would help inform decisions about resource allocation, actionable suggestions for improvement, and the tracking of agency improvement. Quality Indicators (QIs) offer the potential to do just that. QIs are used to measure various components of health services. For example, a QI could measure the proportion of clients who improve their depression symptoms. This QI could then be risk-adjusted, a process that controls for factors influencing outcomes outside the agency's control leading to fair comparisons of quality of care between agencies to be made.

This pilot study developed a small set of preliminary QIs to measure depression outcomes in Ontario agencies using widely implemented mental health assessment tools developed by the non-profit organization, interRAI. This is done to test the utility and feasibility of these assessments to measure quality at the inter-agency level. A risk adjustment strategy, controlling for various external influences like age and sex, was developed to complement these QIs.

This research used available data to develop three QIs, which measured various aspects of depression symptom outcomes and detected some differences in depression outcomes at the between-agency level in Ontario. The results of this study suggest that these assessment tools are an appropriate choice to assess and monitor the quality of children’s mental healthcare through quality indicators. This study led to important considerations and next steps for further QI development initiatives.

Creative Commons License

Creative Commons Attribution-Noncommercial 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 License

Available for download on Thursday, April 16, 2026