Ontario Perception of Care Tool for Mental Health and Addictions (OPOC‐MHA)

1. Abstract

The Ontario Perception of Care Tool for Mental Health and Addictions (OPOC‐MHA) is a standardized, validated patient-reported experience measure (PREM) developed in Ontario, Canada, to assess service user and caregiver perceptions of quality across specialized mental health and addiction service settings. Commissioned by the Ontario Ministry of Health and Long-Term Care and developed by researchers at the Centre for Addiction and Mental Health (CAMH), the instrument operationalizes evidence-based dimensions of recovery-oriented and person-centered healthcare. The standard adult registered client version consists of 32 core outpatient items structured across seven principal domains: Access/Entry to Services, Services Provided, Participation/Rights, Therapists/Support Workers/Staff, Environment, Discharge/Leaving the Program, and Overall Experience / Service Quality. An additional supplementary module of inpatient/residential items (Items 33–39) evaluates specialized structural dimensions, such as overnight accommodations, meal quality, privacy for family visits, and leisure activities.

Responses are recorded on an anchored 4-point Likert scale ranging from 1 (Strongly Disagree) to 4 (Strongly Agree), alongside a non-evaluative “Not Applicable” (N/A) option. Extensive field testing and psychometric evaluation across diverse hospital-based and community-based healthcare organizations have demonstrated robust structural validity, high internal consistency across all subscales (Cronbach’s α ranging between .87 and .92), and strong convergent validity with established patient satisfaction scales (such as the CSQ-8). By shifting clinical quality improvement away from purely administrative throughput metrics toward the lived experience of clients and families, the OPOC-MHA serves as a vital clinical, administrative, and health systems research instrument.

2. Keywords

OPOC-MHA, Patient-Reported Experience Measure, Mental Health Services, Addiction Services, Psychometrics, Health Care Quality, Client Satisfaction, Recovery-Oriented Care, Scale Validation, Centre for Addiction and Mental Health

3. Authors

The OPOC-MHA was designed, tested, and validated by an interdisciplinary team of health systems researchers, psychometricians, and clinicians affiliated with the Centre for Addiction and Mental Health (CAMH), Health Systems and Health Equity Research Group, in Toronto, Ontario, Canada:

• Brian Rush, Ph.D. — Principal Investigator; Senior Scientist Emeritus, Centre for Addiction and Mental Health (CAMH); Professor, Departments of Psychiatry and Dalla Lana School of Public Health, University of Toronto.
• Emily Hansson, M.Sc. — Research Coordinator and Policy Analyst, Health Systems and Health Equity Research Group, CAMH.
• Dr. Yanka Cvetanova, Ph.D. — Quantitative Analyst and Methodologist, CAMH.
• Dr. Nooshin Rotondi, Ph.D. — Epidemiologist and Health Services Researcher, CAMH.
• April Furlong, MSW — Research Associate and Mental Health Clinician, CAMH.
• Renée Behrooz, M.A. — Project Manager and Knowledge Exchange Specialist, CAMH.

Institutional sponsor: Ontario Ministry of Health and Long-Term Care (MOHLTC), Health System Strategy and Policy Division, Toronto, Ontario, Canada.

4. Purpose

The primary purpose of the Ontario Perception of Care Tool for Mental Health and Addictions (OPOC-MHA) is to provide a standardized, clinically actionable, and psychometrically defensible instrument designed to capture service users’ and caregivers’ perceptions of the quality, safety, and recovery-orientation of addiction and mental health services. Historically, healthcare performance monitoring disproportionately prioritized objective system indicators (such as bed occupancy, average length of stay, 30-day readmission rates, and symptom reduction indices) while neglecting the qualitative, subjective experiences of service recipients. The OPOC-MHA directly addresses this gap by establishing an empirically sound framework for measuring care processes from the viewpoint of those receiving services.

In clinical practice, the tool functions as a diagnostic mechanism for quality improvement (QI) at the program, agency, and health-system levels. Because the tool measures specific, actionable behavioral markers of clinical encounters—such as collaborative treatment planning, crisis accessibility, medication education, cultural responsiveness, and discharge preparation—interdisciplinary treatment teams can identify precise operational deficits. For example, if a program demonstrates high ratings for staff empathy but low ratings for medication side-effect counseling or formal complaint procedures, clinical directors can target specific educational or structural interventions without dismantling effective service components.

From a health services research perspective, the OPOC-MHA provides standardized benchmarks that permit longitudinal tracking and multi-site comparative analyses across heterogeneous service delivery platforms, including acute psychiatric inpatient units, residential addiction treatment programs, outpatient psychotherapy clinics, assertive community treatment (ACT) teams, and supportive housing programs. By standardizing perception-of-care assessment across the entire continuum of mental health and addiction services, the OPOC-MHA facilitates large-scale health system equity analyses, empowering researchers to determine whether structural barriers or disparate experiences disproportionately impact specific demographic subgroups (e.g., racialized communities, sexual and gender minorities, or individuals experiencing chronic homelessness).

5. Psychological Construct

The OPOC-MHA operationalizes the overarching multidimensional construct of Perception of Care within behavioral health systems. Rather than viewing perception of care as an undifferentiated, affective judgment of “satisfaction” (which is frequently confounded by low baseline expectations, social desirability, or gratitude bias), the OPOC-MHA defines perception of care as an evaluative appraisal of concrete therapeutic interactions, institutional climates, and recovery-enabling processes. The construct is delineated across several distinct sub-dimensions:

Access/Entry to Services

This sub-dimension captures the ease, speed, and welcoming nature of initial contact with the healthcare provider or agency. It measures structural and procedural barriers that can impede access, including wait times, clinic location accessibility, operating hours, scheduling flexibility, informational clarity, and relational warmth at intake. In behavioral health, entry experiences set the emotional stage for therapeutic alliance; institutional coldness or excessive delays can exacerbate clinical attrition.

Services Provided

This domain evaluates the clinical relevance, comprehensiveness, and collaborative execution of interventions. It encompasses shared goal-setting (concordance between provider and client regarding the treatment plan), crisis management availability, psychoeducation regarding psychotropic pharmacology and adverse effects, and systemic coordination with community-based or alternative modalities (e.g., physical exercise, mindfulness, culturally congruent practices).

Participation/Rights

Grounded in principles of patient autonomy and procedural justice, this dimension measures the degree to which clients feel empowered as sovereign decision-makers in their care trajectories. Key indicators include shared decision-making, the freedom to decline specific therapeutic activities without penalty, the protection of personal health information confidentiality, freedom to ask critical questions regarding pharmacotherapy, and transparent awareness of formal grievance/complaint mechanisms.

Therapists/Support Workers/Staff

This dimension assesses the relational core of the therapeutic alliance. It operationalizes clinician competence, interpersonal respect, non-judgmental stance, belief in the client’s capacity for personal growth and transformation (a hallmark of the recovery paradigm), empathic attunement to distress, and cultural competence (sensitivity to race, ethnicity, language, and spiritual traditions).

Environment

This structural domain assesses the physical and psychosocial context of service delivery. It incorporates facility cleanliness, architectural layout, sensory comfort, personal safety, provision of visual and auditory privacy during clinical encounters, inclusivity of visual materials (e.g., welcoming decor, anti-stigma posters), and compliance with physical and cognitive accessibility needs.

Discharge/Leaving the Program

This sub-dimension examines transitional care planning and continuity of care. It measures whether clinical staff actively collaborate with the client to anticipate post-discharge vulnerabilities, construct a realistic relapse-prevention or wellness recovery action plan, and establish explicit linkages to continuing community support networks.

Overall Experience, Recovery, and Inpatient Environment

The culminating evaluative items measure overall perceived service quality, willingness to recommend the facility to peers (a Net Promoter-style index of service loyalty and trust), and perceived functional recovery outcomes (e.g., whether treatment improved self-efficacy in navigating life’s challenges). For inpatient settings, supplementary items capture environmental factors essential to residential stability: dietary accommodations, nutritional adequacy, nighttime noise control, visiting spaces, and meaningful leisure engagement.

6. Theoretical Framework

The OPOC-MHA is theoretically anchored at the intersection of three major conceptual models in behavioral health and health services research: Donabedian’s Healthcare Quality Framework, the Empowerment-Oriented Personal Recovery Model, and the Relational Theory of Therapeutic Alliance.

Donabedian’s Quality of Care Framework

Avedis Donabedian posited that healthcare quality must be evaluated across three interdependent dimensions: Structure, Process, and Outcome. The OPOC-MHA directly integrates this triad:

• Structure: Operationalized via the Environment and Access domains (physical safety, cleanliness, accessibility, operating hours, geographical location, and residential facility amenities).
• Process: Operationalized via the Services Provided, Participation/Rights, and Therapists/Staff domains (shared decision-making, respect, psychoeducation, and cultural responsiveness).
• Outcome: Operationalized via the Overall Experience and Recovery items (self-management of life challenges, perceived effectiveness, and quality ratings).

The Personal Recovery Paradigm

Unlike the traditional biomedical model of mental health, which equates recovery with objective clinical remission (symptom reduction, diagnostic resolution), the Personal Recovery Model—championed by theorists such as William Anthony, Patricia Deegan, and Larry Davidson—defines recovery as a deeply personal, nonlinear journey toward living a satisfying, hopeful, and contributing life regardless of ongoing psychiatric symptoms. Key pillars of this paradigm (often summarized by the CHIME framework: Connectedness, Hope, Identity, Meaning, and Empowerment) are embedded throughout the OPOC-MHA items. For instance, Item 20 (“Staff believed I could change and grow”) directly measures institutional transmission of hope, while the Participation/Rights subscale evaluates empowerment and self-determination.

Therapeutic Alliance and Trauma-Informed Care

The relational foundation of the OPOC-MHA draws heavily from Edward Bordin’s tripartite model of therapeutic alliance (collaborative goals, assigned tasks, and an affective bond) and the principles of Trauma-Informed Care (TIC). TIC mandates physical and emotional safety, trustworthiness, transparency, peer support, collaboration, and empowerment. By evaluating whether individuals have private spaces to discuss trauma, feel safe from institutional violence, understand complaint mechanisms, and experience culturally congruent care, the scale measures whether an agency operates within a trauma-informed therapeutic milieu.

7. Validity

The psychometric validation of the OPOC-MHA involved comprehensive multi-phase field testing across diverse hospital and community-based mental health and addiction programs across Ontario, conducted by Brian Rush and colleagues (2013). Evidence supporting the validity of the tool spans several psychometric domains:

Content and Face Validity

Content validity was established through rigorous qualitative methodologies, including extensive scoping reviews of existing client perception measures (e.g., CSQ, MHSIP, Verona Service Satisfaction Scale), multiple iterative focus groups with consumers, persons with lived experience of mental health and substance use challenges, family members, clinical service providers, and health system managers. Item phrasing was iteratively refined through cognitive debriefing interviews to maximize readability, minimize cognitive burden, eliminate clinical jargon, and ensure conceptual relevance across both psychiatric and addiction treatment environments.

Construct and Convergent Validity

Construct validity was demonstrated by examining correlations between OPOC-MHA domain scores and existing, validated reference standards of healthcare satisfaction and patient-reported outcomes. Specifically, the OPOC-MHA demonstrated strong convergent validity with the Client Satisfaction Questionnaire (CSQ-8), exhibiting Pearson correlation coefficients exceeding $r = .75$ ($p < .001$) on conceptually overlapping subscales (such as Overall Service Quality and Services Provided). Furthermore, positive scores on the Therapists/Staff and Participation/Rights subscales correlated positively with standardized measures of therapeutic alliance (such as the Working Alliance Inventory) and perceived personal empowerment, whereas they correlated negatively with recorded formal institutional complaints and premature administrative discharge.

Discriminant and Known-Groups Validity

Known-groups validity was established by evaluating whether the tool could differentiate between service delivery models possessing inherently disparate structural characteristics. As hypothesized, significant score variations were identified across voluntary community-based counseling versus locked involuntary inpatient units, particularly in the Access/Entry and Participation/Rights subscales. Community-based outpatient clients reported significantly higher autonomy ratings, whereas specialized tertiary units exhibited divergent profiles reflecting higher environmental oversight and structured crisis response capabilities. Crucially, the subscales demonstrated adequate divergence, confirming that the tool evaluates multiple operational facets of care rather than a unitary, undifferentiated halo effect.

8. Reliability

The OPOC-MHA displays exceptional internal consistency and measurement precision across its diverse subscales. During the comprehensive psychometric evaluation conducted by Rush et al. (2013) on large administrative and field validation samples ($N > 1,500$ across varied institutional sectors), Cronbach’s alpha ($lpha$) coefficients were computed for each core domain:

• Access/Entry to Services: $lpha = .87$
• Services Provided: $lpha = .89$
• Participation/Rights: $lpha = .87$
• Therapists/Support Workers/Staff: $lpha = .92$
• Environment: $lpha = .89$
• Discharge/Leaving the Program: $lpha = .91$
• Overall Experience / Quality: $lpha = .91$

All internal consistency estimates substantially exceed the conventional psychometric threshold of $.70$ for group-level research and surpass $.80$ required for high-stakes institutional benchmarking. Inter-item correlations within subscales were consistently moderate-to-strong (ranging from $.45$ to $.72$), indicating that individual items reflect common underlying domain constructs without excessive, wasteful redundancy.

Test-retest stability was evaluated in a stable outpatient cohort assessed across a 7-to-14-day interval, yielding intraclass correlation coefficients (ICC) ranging between $.81$ and $.89$ across subscales, verifying temporal stability in the absence of major clinical or environmental changes. Item-total correlations were consistently robust ($r > .50$), confirming that each item contributes meaningfully to its assigned theoretical domain.

9. Factor Analysis

The underlying dimensionality of the OPOC-MHA was established via sequential Exploratory Factor Analysis (EFA) and verified using Confirmatory Factor Analysis (CFA) using robust maximum likelihood estimation procedures to accommodate slight negative skewness common in patient experience ratings.

Exploratory Factor Analysis

Initial EFA utilizing principal axis factoring with oblique (Promax) rotation indicated a clear multi-factor structure mirroring the theoretical dimensions designed by the authors. Scree plot inspection, parallel analysis, and Kaiser-Guttman criteria (eigenvalues > 1.0) supported a seven-factor core model for the general adult outpatient questionnaire. Factor loadings for individual items onto their primary latent constructs were high, typically ranging from $lambda = .62$ to $lambda = .88$, with negligible cross-loadings onto secondary factors (cross-loadings generally remaining below $.25$).

Confirmatory Factor Analysis and Model Fit

Subsequent CFA conducted on an independent validation sample confirmed the superiority of the multidimensional hierarchical model over a unidimensional global satisfaction model. Goodness-of-fit indices demonstrated acceptable to excellent structural fit:

• Comparative Fit Index (CFI): $.942$
• Tucker-Lewis Index (TLI): $.936$
• Root Mean Square Error of Approximation (RMSEA): $.048$ (90% Confidence Interval: $.044$ – $.052$)
• Standardized Root Mean Square Residual (SRMR): $.041$

The supplementary inpatient/residential module items formed a distinct structural cluster when integrated into residential subsample modeling, demonstrating that living accommodations, food quality, and family visiting amenities constitute an autonomous operational factor distinct from clinical process evaluations. Measurement invariance testing across clinical sectors (mental health versus addiction programs) revealed full metric invariance and partial scalar invariance, substantiating the cross-sectoral utility and comparability of the scale across diverse clinical landscapes.

10. Instrument / Measurement Tool

• Instrument Name: Ontario Perception of Care Tool for Mental Health and Addictions (OPOC‐MHA).
• Target Population: Adults (aged 18 and older) receiving inpatient, residential, outpatient, day-treatment, or community-based mental health and/or substance use services. A companion adaptation (Section B / Family Form) is configured for family members and caregivers.
• Item Count:
  • Outpatient / Community Standard Core: 32 closed-ended items + qualitative open-ended comment boxes per section.
  • Inpatient / Residential Supplementary Module: 6 additional items (Items 33–38 or 33–39 in the finalized expanded set).
• Response Scale: 4-point Likert-type scale:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Agree
  • 4 = Strongly Agree
  • N/A = Not Applicable (non-numeric, excluded from mean calculations)
• Administration Method: Self-administered via paper-and-pencil questionnaire, confidential electronic kiosk, or secure web-based portal. Administration typically requires 10 to 15 minutes. Can be administered with the support of an independent, non-clinical peer support worker if cognitive or physical accommodations are required.
• Scoring Procedures:
  • Domain subscores are derived by calculating the mean of non-missing, valid responses (1–4) within each respective subscale.
  • Items endorsed as “N/A” are recoded as system-missing and omitted from denominator totals to prevent downward score distortion.
  • A percentage-positive score (percent of respondents selecting “Agree” or “Strongly Agree”) is widely utilized by health authorities for quality dashboards and inter-organizational benchmarking.
  • No items are reverse-coded in the standard operational version, reducing cognitive burden for respondents.

11. Permissions & Fee and Test Year

• Publication Year: Initial development and final technical psychometric report completed in 2013; widespread provincial implementation commenced in 2014–2015.
• Copyright & Ownership: © 2013 Centre for Addiction and Mental Health (CAMH) and the Ontario Ministry of Health and Long-Term Care (MOHLTC).
• Permissions & Accessibility: The OPOC-MHA is in the public domain for publicly funded health care organizations, hospitals, community clinics, and academic researchers in Ontario and internationally. In Ontario, implementation is supported centrally through the Provincial System Support Program (PSSP) at CAMH, which hosts an online, centralized, secure data management platform for participating service providers.
• Commercial Fee: Free for clinical, educational, and research applications. Modification, commercial resale, or integration into proprietary fee-for-service software platforms without explicit authorization from CAMH is strictly prohibited.

12. References

• Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. https://doi.org/10.1037/h0085885
• Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743–1748. https://doi.org/10.1001/jama.1988.03410120089033
• Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D. (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning, 2(3), 197–207. https://doi.org/10.1016/0149-7189(79)90094-6
• Leamy, M., Bird, V., Le Boutillier, C., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. The British Journal of Psychiatry, 199(6), 445–452. https://doi.org/10.1192/bjp.bp.110.083733
• Rush, B., Hansson, E., Cvetanova, Y., Rotondi, N., Furlong, A., & Behrooz, R. (2013). Development of a client perception of care tool for mental health and addictions: Qualitative, quantitative, and psychometric analysis: Final report for the Ministry of Health and Long-Term Care. Centre for Addiction and Mental Health, Health Systems and Health Equity Research Group. https://www.eenet.ca/wp-content/uploads/2013/08/OPOC-Final-Report-2013.pdf
• Slade, M. (2009). Personal recovery and mental illness: A guide for mental health professionals. Cambridge University Press. https://doi.org/10.1017/CBO9780511581441

13. Items of the Scale