Program fidelity and beyond: multiple strategies and criteria for ensuring quality of assertive community treatment.

OBJECTIVE:In most public mental health systems, assertive community treatment (ACT) is a key service for people with severe mental illness. Although considerable research supports the effectiveness of ACT as an evidence-based practice, other research indicates a failure to adequately implement or sustain ACT, resulting in a diminishing quality of services over time. There have been relatively few attempts to develop and test strategies for implementing new ACT teams and for ensuring their operational and service quality over time. The authors provide a heuristic model for administrators and providers seeking to implement and sustain high-quality ACT programs. METHODS:The authors conducted a selected review of literature about implementation and sustainability of ACT published between January 2000 and May 2011. The review was supplemented by the authors' experiences as researchers, administrators, trainers and consultants, and practitioners. RESULTS:A total of 57 articles were found by searches in PsycINFO and PubMed. The authors propose four major approaches for assessing and ensuring the quality of ACT programs--policy and administrative, training and consultation, team operational, and program evaluation--and identify strategies for achieving the goals in each category. CONCLUSIONS:Although a scarcity of rigorous research makes firm conclusions difficult, the authors conclude that no single strategy is sufficient for ensuring adequate ACT implementation and services of consistently good quality. Rather, it is useful to implement a blend of policy and administrative, training and consultation, team operational, and program evaluation strategies. Additional rigorous research on implementing and sustaining the quality of ACT and other evidence-based practices is needed.