CONTINUOUS QUALITY IMPROVEMENT IN CHILD WELFARE

Transcription

1 CONTINUOUS QUALITY IMPROVEMENT IN CHILD WELFARE MODULE 1: AN INTRODUCTION TO CQI NORTHERN CALIFORNIA TRAINING ACADEMY CENTER FOR SOCIAL SERVICES RESEARCH, UC BERKELEY CHAPIN HALL AT THE UNIVERSITY OF CHICAGO CENTER FOR HUMAN SERVICES CONTINUING AND PROFESSIONAL EDUCATION

2 Welcome to an introductory course on Continuous Quality Improvement in child welfare services. This training was produced by the Northern California Training Academy at the UC Davis Extension s Center for Human Services. It was developed in cooperation with the California Department of Social Services, the Center for Social Services Research at the UC Berkeley School of Social Welfare, and Chapin Hall at the University of Chicago. Slide 2 This course provides a brief overview of the philosophy and process of Continuous Quality Improvement or CQI. The course was designed for county administrators, managers, and supervisors who are interested in gaining an introductory level of understanding of CQI. The modules will provide participants with a basic understanding of the key processes involved in using evidence to inform decision making and efforts to improve outcomes for children and families served by social service agencies. 1

3 Slide 3 By the end of this module, participants will be able to: Understand the process of CQI Differentiate CQI from traditional Quality Assurance Describe and understand applications of the Plan-Do-Study-Act or PDSA cycle Describe the roles of child welfare stakeholders in the CQI process Understand the underlying philosophy of CQI 2

4 Slide 4 To meet these learning objectives, this session addresses the following topics: A brief history of CQI What CQI looks like in a child welfare context The differences between CQI and Quality Assurance (QA) The goals and underlying philosophy of CQI A review of the basic CQI cycle: Plan-Do-Study-Act An overview of minimal CQI system requirements, the importance of creating a CQI culture, and what CQI means for agencies and stakeholders Steps that participants can take to begin creating a CQI culture within their own agencies 3

5 Slide 5 During this session you will watch a handful of video excerpts from a presentation by Fred Wulczyn, Ph.D., a Senior Research Fellow at Chapin Hall at the University of Chicago and a leader in field of public child welfare research and Continuous Quality Improvement. The clips were taken from a 2013 Multidisciplinary Collaborative Leadership symposium during which Dr. Wulczyn reviewed the fundamental elements of the CQI process and provided an in-depth explanation of how the CQI process applies to child welfare. Dr. Wulczyn s full presentation is available at 4

6 Slide 6 To understand the relevance of CQI to the field of child welfare it is important to understand a little bit about CQI s origins. While several people throughout history have made important contributions to the development and establishment of CQI, the foundational concepts date back to the 1930s, with the work of W. Edward Deming, a statistician and teacher of some of the top business managers of the manufacturing industry. Deming and a few others developed Total Quality Management (TQM), an approach to problem solving that evolved into the Continuous Quality Improvement process as we know it today in child welfare: a method for continuously assessing and improving quality over time. 5

7 Slide 7 The original concept of TQM included the following tenets: Quality is defined by the customers. Everyone is responsible for continuously improving quality. Quality of process and products must be measured and then improved. Continuous improvement is always possible. Leadership must be involved. Cross functional cooperation across agency subunits must be enhanced. Employee empowerment and teamwork is paramount. 6

8 Slide 8 W. Edward Deming is also credited with articulating the time-tested stages of the CQI process Plan-Do- Study-Act which we ll explore shortly. Deming crafted these stages to address the needs of the manufacturing industry as it innovated toward increased efficiency and effectiveness. As we move forward in understanding CQI and its application to child welfare, consider the challenges to efficiency and effectiveness that the child welfare field confronts and consider this quote from Deming: Put everybody in the company to work to accomplish the transformation. The transformation is everybody s job. Or, put differently, CQI is not just the job of child welfare administrators or data analysts; rather CQI requires the active inclusion, participation, and devotion of staff members at all levels of an organization including children, families, and stakeholders throughout the system. 7

9 Slide 9 According to Casey Family Programs, Continuous Quality Improvement is the complete process of identifying, describing, and analyzing strengths and problems and then testing, implementing, learning from, and revising solutions. This concept must be deeply rooted into the overall mission, vision, and values of each agency. CQI is not just an initiative with a beginning and an end, but rather an iterative problem solving process that guides the way an agency does business. Slide 10 For a more thorough explanation of how CQI unfolds in a social service context, watch this video in which Dr. Wulczyn defines CQI and the critical elements of the process. Highlights from this clip: CQI is the deliberate approach to the use of research evidence. CQI requires the conversion of data into evidence. Data must be converted into evidence in order for it to inspire action in the CQI context. CQI depends on the observation of variability; some children have different outcomes than others. CQI is an effort to understand the reason for and eliminate that variation. CQI requires developing and testing hypotheses about what will bring about improved outcomes for children and families. CQI requires doing something different in order to bring about change. That something different can be a change to process, quality, and/or the capacity to deliver care. The CQI cycle is fueled by the use of research evidence. 8

10 Slide 11 As Dr. Wulczyn states, Those who seek clarity before taking the first step will find confusion. Those who accept confusion as a first step will find clarity. In the CQI process, we have to accept that not every intervention we try will work in the way we hypothesize. We must be open to addressing problems with new hypotheses, allowing the evidence generated from data to support our decisions along the way. 9

11 Slide 12 The Children s Bureau has identified five essential components of a functioning CQI system. Those five components are: 1. An administrative structure to oversee effective CQI system functioning 2. Quality data collection 3. A method for conducting ongoing case reviews 4. A process for providing feedback to stakeholders and decision-makers 5. A method for adjusting programs and process as needed Later in the session, we will look closer at the system elements necessary to support and sustain CQI. As you learn more about what the CQI process requires, consider how these general components might support the work. 10

12 Slide 13 The list of CQI stakeholders in child welfare is extensive and diverse. Some primary stakeholders include courts, tribes, families, youth, caregivers, contract providers, other public entities, community partners, and individuals within the child welfare organization including administrators, caseworkers, supervisors, program managers, policymakers, and training staff. This list of stakeholders is not exclusive. The roles of child welfare agency stakeholders will be addressed in more detail later in this course. 11

13 Slide 14 Understanding the application of CQI to child welfare also requires a discussion of the difference between CQI and a Quality Assurance approach. Over the past decade or so, child welfare has focused increasingly on Quality Assurance (QA) a process that is largely focused on assessing agency compliance with established standards. Quality Assurance has been reinforced through various methods and procedures, such as the federal Child and Family Service Reviews (or CFSR) process. While compliance still certainly has its place, CQI adds value by enabling the agency to explore the processes that contribute to outcomes for children and families. CQI supports that type of inquiry and action by calling for the development of actionable evidence and applying that evidence to decisions that affect outcomes. 12

14 Slide 15 To further differentiate between CQI and QA, let s look at Quality Assurance and what it entails. Over the years, Quality Assurance has been primarily used as a method for monitoring compliance in child welfare. Toward that end, historically, the CFSR has had three purposes: 1. To ensure compliance with federal regulations. 2. To determine what is happening with children and families served by child welfare. 3. To enhance the capacity of states to achieve positive outcomes. To achieve those purposes, the CFSR instituted Program Improvement Plans that require states to improve outcomes and build systemic capacity; states then worked through these plans in an effort to make progress on measurable goals to avoid financial penalties. However, the CFSR s historic focus on compliance led states to focus more on monitoring and reporting outcomes, rather than on using evidence about outcomes to inform efforts to improve. [This has changed recently with the advent of new CFSR measures, which we ll touch on later in this series.] 13

15 Slide 16 In contrast, the theory underlying the CQI process is that better fidelity to casework process and quality standards is associated with a measurable effect on child and family level outcomes. The premise is that we can use what we know about system performance to make informed changes to the way we work changes to the process, quality, and capacity to deliver care and that those changes, in turn, will bring about positive outcomes for children and families. One of the key principles introduced by Deming in his book Out of Crisis, was: Cease dependence on inspection to achieve quality. Eliminate the need for massive inspection by building quality into the product in the first place. This is precisely what we are trying to do in social services today; rather than merely inspect after the fact whether services are effective, we want to use evidence to drive improvements to those services so that they become more effective. Slide 17 The specific goals of CQI are unlimited; but in relation to child welfare, the overall goal is to help us improve services to better the lives of the children and families served by our local agencies. Of course, we know it s not that simple. The next video clip features Dr. Wulczyn s further expansion on the goals of CQI. 14

16 Slide 18 Highlights from this clip: To conduct CQI effectively: o Increase staff s CQI knowledge about and awareness of the value of CQI. Staff must understand the Plan, Do, Study, and Act phases of the CQI cycle and what they entail. o Increase staff s skills required to carry out CQI processes with fidelity. CQI itself is an intervention. Staff must have role-specific ability to develop and test hypotheses. o Build the structures and capacities required to support CQI and implement CQI action plans. For example, the agency must build infrastructure needed to collect and analyze high quality data. 15

17 Slide 19 In the previous video clip, Dr. Wulczyn mentioned the Plan and Do parts of the CQI cycle. In this section, we will review what that means. The basic building blocks comprising CQI are the acts of Plan Do Study Act, or PDSA. The steps of the PDSA process provide agencies and stakeholders with a structure for identifying and implementing efforts aimed at improved outcomes. In the Plan phase, we define the problem and intervention. In other words, we determine which outcomes need improvement and select interventions, supported by a theory of change, that we believe will bring about that change. In the Do phase, we implement the intervention. In the Study phase, we assess whether the intervention was successful. In the Act phase, we use evidence from the Study phase to make decisions about what to do next. Slide 20 In the next video clip, Dr. Wulczyn breaks down each of the components of PDSA, and how they contribute to the process of CQI. 16

18 Slide 21 Highlights from this clip: Plan: Define the problem and define the intervention. Do: Implement the intervention considering the quality, process, and capacity standards required to implement. Evidence-based interventions are those where specified processes, quality standards, and capacities (e.g., training, etc.) have been shown if implemented according to the specifications (i.e., with fidelity) to improve outcomes. Study: Measure the outcomes, monitoring implementation (i.e., fidelity), and provide feedback to decision makers. Act: Adjust the intervention as needed. This may mean returning to the Do phase to scale up, continue, adjust, or discontinue the intervention. In some cases, evidence from the Study phase requires us to go back to the Plan phase and reconsider how we defined the problem or selected the intervention in the first place. 17

19 Slide 22 This slide shows a graphic representation of the PDSA cycle. Fidelity to this cyclical process is necessary if high-quality CQI is to take place. A first step toward fidelity is engraining the model into agency culture. Slide 23 CQI improves outcomes by manipulating the various elements of the child welfare system. In the next clip, listen to Dr. Wulczyn discuss the structures and functions that comprise the child welfare system and how CQI has the potential to influence that system. 18

20 Slide 24 Highlights from this clip: The key interrelated system functions of a child welfare system are: Structures: Relationships between system components and actors. Functions: Governance, management, and enforcement. Capacities: Human resources, infrastructure, and funding, etc. The continuum of care: Services that promote healthy families and communities, prevent maltreatment, and respond in cases of maltreatment. The process of care: Processes for reporting, referral, investigation, assessment, treatment, and follow up. Accountability: Data collection, quality standards, research, analysis, communication, etc. 19

21 Slide 25 California s counties have a multitude of tools available to them that can support them in promoting the use of evidence throughout the CQI process. Some of the tools and methods that support CQI include: SafeMeasures Structured Decision Making Case reviews UC Berkeley s Child Welfare Indicators Project (data reports) Chapin Hall s Multistate Foster Care Data Archive Peer Quality Case Reviews System Improvement Plans Research, literature reviews, and evaluations The Plan, Do, Study, Act cycle 20

22 Slide 26 In this clip, Dr. Wulczyn discusses what CQI culture means for child welfare stakeholders and the contexts in which they work. He explains how an agency s deeply rooted commitment to CQI is essential if CQI is to be effective over time. Highlights from this clip: In a CQI culture we expect people to develop and test hypotheses and make adjustments to their efforts as they learn evidence from those tests. This means that individuals must have personal attributes that make them inclined to use evidence. It also means that agencies and the eco-political climate in which they operate must support evidence use, for example, through leadership and by way of the resources that agency, government, and community entities deploy to support evidence use. Slide 27 In 2005, Casey Family Programs put forth a set of practices that leaders can implement to embed a CQI philosophy in their agency. Changing or shifting thought processes can always be a challenge, but leaders who can support a continuous learning environment by setting clear direction and expectations should be more successful. Effective leaders should provide opportunities for staff and stakeholders at all levels to be engaged in the CQI process and strategic planning. In order to involve everyone, leaders must clarify and articulate values and principles of their agency, not only to staff, but to the community, as well. Communication must occur regularly and keep stakeholders abreast of outcomes, setting the expectation that the results are to be used for making improvements, which may result in changes in policies, practices, programs, and/or training. All of these elements are crucial in creating an agency culture that values Continuous Quality Improvement and embraces the value of CQI to improve the lives of families. 21

23 Slide 28 Another key component to effective CQI is clarity regarding the roles of the stakeholders at all levels. What does CQI really mean for each stakeholder within the child welfare system, from administrators to caseworkers to community members to children? In the slides that follow, we review the roles of stakeholders within the child welfare agency itself. 22

24 Slide 29 Administrators: Here we refer to those that hold structural responsibility for the CQI process, such as the executive and deputy directors. Before even considering CQI, the administrative structure of the agency must be very solid. The administration must value scientific literature and research in order to create a culture that embraces the application of evidence to decision making. The administration is also responsible for allocating resources to support the use of evidence. Reflecting on CQI in healthcare in 1998, Helen Darling concluded that, the most important factor for ensuring successful change would be the installation of a relentlessly driven, high level chief executive or financial officer, who would act as a powerful champion of the process. Child welfare administrators approach to CQI should be no different. Administrators must also consider the greater community in their campaign for CQI and consider how agency investments, organization, structure, and personnel issues play a role in promoting CQI. 23

25 Slide 30 Managers: Managers are likely to be the program directors or program managers in the majority of counties, especially smaller counties. They are subunits of the administration and are key in staff development and the adaptation of reform. Like administrators, managers must value research and be able to frame the benefits of CQI for staff so that staff understand how CQI will help them in their work to serve the children and families in their communities. Managers are required to bridge the gap between administration, supervisors, and caseworkers by taking policy and putting it into action. For that reason, managers must be adept at using evidence to understand the effect of policies in their jurisdictions, and must communicate those links to frontline staff, as well as back up to administrators. Given this role, managers are essential in championing the CQI process. 24

26 Slide 31 Supervisors: Supervisors oversee, monitor, mentor, and guide the caseworkers that work directly with the children, families, courts, and service providers. Supervisors are responsible for assuring their direct reports are practicing high-quality casework, and they assist their direct reports throughout the processes of their daily work. Supervisors role in communicating evidence to caseworkers on the front line is crucial to the CQI process. They are in a unique position to influence the learning process, worker action, and worker commitment to evidence based decision making. Supervisors are responsible for active participation in training and supporting their staff in implementing new skills by coaching them through the implementation process. And while supervisors work closely with the caseworkers, they are also able to communicate up the hierarchy, to managers and administration, to provide information regarding barriers to evidence use. 25

27 Slide 32 Caseworkers: Of course, CQI is not possible without the caseworkers. It is caseworkers decisions and actions with the children and families that will be shaped by the CQI process and, the quality of the services provided ultimately depends on the actions caseworkers take. Additionally, caseworkers are primarily responsible for data entry; therefore, the quality of the data used to develop evidence about system performance depends on the degree to which caseworkers enter accurate information in a timely manner. Within the CQI process, caseworkers are responsible for the process and quality of work with children and families. Caseworkers must be involved in all steps of the PDSA process and be invested in using the evidence to support their work. In CQI, it is crucial that caseworkers carry out their roles with cultural competence. 26

28 Slide 33 Other CQI Professionals: In addition to those carrying out the Plan and Do steps of CQI, we must also consider the professionals who support the Study process such as analysts and program planners. Their role in the CQI process is to help the rest of the organization understand the improvement process and assist with implementation of new or pilot efforts based on evidence. 27

29 Slide 34 Despite the necessary commitment required by leaders and members of an agency, there is no single roadmap for implementation of CQI. There are no directives set in stone or rules that cannot be broken, as the components of CQI are interrelated and will surface in order of importance for each individual agency throughout the process. What is important is that no matter where the child welfare professional is in the agency hierarchy, everyone involved must know what CQI is, how it is important to their work, and what it means in their daily practice. Staff at all levels must use a common CQI language, no matter their position, to contribute to the overall CQI culture of the agency. Remember: Put everybody in the company to work to accomplish the transformation. The transformation is everybody s job. 28

30 Slide 35 As champions of CQI work, administrators must reflect CQI principles in the values and mission of their agencies, communicating a set of expectations for using evidence to make lasting, positive improvements for children and families. The following, adapted from the CQI Readiness Assessment and Process Tool by Dana Bernie, are some key steps to begin mapping the vision of CQI: Clearly define roles and authority of key leaders in change initiative. Identify and reduce the level of fear and blame for mistakes. Identify and remove impediments to cross functional communication and problem solving. Improve how leaders define, communicate, and demonstrate their commitment to meet customer needs. 29

31 Slide 36 Adopt policies to train, encourage, and empower employees to respond promptly and appropriately to customer issues. Reduce the level of bureaucratic controls that limit adoption of best practices and evidencebased improvements. Develop policies and resources for employees to routinely learn about best practices that are related to their work areas and to join professional associations that help support improvement and growth. Share key organizational performance measurements with all employees and teach them how their work processes link to the organizational performance outcomes. 30

32 Slide 37 To assess your agency for its current climate and readiness for implementation of CQI, consider reviewing the Continuous Quality Improvement Readiness Assessment Process and Tool. The tool can be found at 31

33 Slide 38 In conclusion, we must think about the reason CQI is important for child welfare. Consider all that has been covered in this session and how it relates to the work that is done daily with at-risk children and families within our communities. The players and participants in child welfare work hard each day, striving to do the best they can to decrease risks to children and keep families intact. CQI calls on agencies to use evidence to determine the degree to which that work is effective and to adjust practices to maximize that effectiveness. This session has introduced the concept of Continuous Quality Improvement, including its history, underlying principles, minimum system requirements, and relevance to each level of the child welfare system. While this session is only a brief overview, it provides a starting point for introducing the CQI concept to your agency. If you take anything away from this session, let it be this: Continuous Quality Improvement is not a time limited project or initiative. It is an ongoing process by which an agency makes decisions and evaluates its progress. Continuous Quality Improvement is the complete process of identifying, describing and analyzing strengths and problems and then testing, implementing learning from and revising solutions. CQI should be firmly grounded in the overall mission, vision and values of the agency. Perhaps most importantly, it is dependent upon the active inclusion and participation of staff and stakeholders at all levels of the agency. 32

34 Center for Human Services UC Davis Extension University of California 1632 Da Vinci Court Davis, CA Phone (530) Fax (530) This publication was funded by the California Department of Social Services CONTINUING AND PROFESSIONAL EDUCATION