Category Six: Quality Overview INTRODUCTION

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1 Category Six: Quality Overview Quality Overview focuses on the Continuous Quality Improvement culture and infrastructure of the institution. This category gives the institution a chance to reflect on all its quality improvement initiatives, how they are integrated, and how they contribute to improvement of the institution. INTRODUCTION Lincoln Land Community College s (LLCC) six strategic goals guide all improvement initiatives at the College: Student Access and Success Community Engagement Financial Strength Diversity and Cultural Competency Economic Responsiveness Operational Strength The President and President s Cabinet select improvement projects which align with these six strategic priorities. Once selected and approved by senior leadership, the Vice Presidents implement these initiatives in their respective units. An improvement initiative may be in response to developments external to the College but more commonly emerge from internal stakeholders recognizing the potential for a process or procedural improvement. At times, improvement projects meet the College s general guidelines for the AQIP Action Projects. When this occurs, projects are proposed to and approved by the College s AQIP steering team. Members of President s Cabinet oversee all AQIP Action Projects as project sponsors. The President s Cabinet meetings provide a forum for discussing progress on all improvement initiatives, whether declared as an Action Project or not, and evaluating the impact of each. LLCC s commitment to its six Strategic Goals helps assure alignment between the Systems Portfolios, Action Projects, Quality Check-Up, and Strategy Forums, because the College s AQIP-related efforts are also guided by the Strategic Goals. LLCC aligns all AQIP Action Projects with one or more of these Strategic Goals. It is the College s general commitment to quality improvement that led to LLCC s application to the AQIP pathway for accreditation. Since that acceptance in 2009, the College has purposely selected Action Projects considered foundational to CQI. Some of those initial Action Projects included a professional development program for CQI principles as well as process mapping. We are now working to embed those concepts into the Administrative Services, Academic Services, and Student Services units via program review and assessment processes. Key Process Process Maturity Results Maturity 6.1 Quality Improvement Initiatives Aligned Systematic 6.2 Culture of Quality Systematic Reacting Note: Planned improvements are highlighted in grey Planned Improvements. The College has three active Action Projects, two which were launched in April and May of The College is currently reviewing its strategic plan. A team has been working since summer 2016 on that process. Thus, during the academic year, there may be some adjustment to LLCC s Strategic Goals. Finally, the College will continue to work to embed the PDSA cycle into many of its annual processes such as program review and assessment. 6.1: Quality Improvement Initiatives focus on the Continuous Quality Improvement (CQI) initiatives the institution is engaged in and how they work together within the institution. 6P1. Describe the processes for determining and integrating CQI initiatives, and identify who is involved in those processes. That includes, but is not limited to, descriptions of key processes for: Category Six: Quality Overview Page 1

2 Selecting, deploying, and evaluating quality improvement initiatives Vice Presidents, the CIO, and Executive Directors oversee the selection, deployment, and evaluation of unit-level improvement initiatives and discuss such projects at President s Cabinet. Improvement initiatives arise from a review of the strategic plan, part of the annual planning cycle, or from processes which are separate yet aligned with the strategic plan (see Stage 1 below). College improvement initiatives are selected based on each initiative s alignment with the strategic plan (as described in 4P2). The President s Cabinet creates teams to address improvement initiatives. Given the nature of the improvement, the initiative may be directed to the AQIP Steering team for consideration as an Action Project. An AQIP Steering Team, co-led by the Director of Institutional Effectiveness and a faculty member appointed by the President, oversees a five-stage Action Project process for the College. Stage 1: Generating Action Projects The AQIP Steering team maintains a rolling, prioritized shortlist of Action Projects and aims to have a minimum of 2 approved projects on the ramp. Newly approved projects may leapfrog previously approved projects if the AQIP Steering team deems the benefit to the College to be more significant. Proposals are reviewed twice a year, once in the Fall Semester and again in the Spring Semester, with the understanding that this schedule is sufficiently flexible to address unforeseen contingencies or immediate needs. Possible sources of Action Projects vary widely, including but not limited to (1) campus groups associated with the normal governance process; (2) needs or opportunities identified by the College s divisions; (3) the Systems Portfolio process (act of writing the Systems Portfolio, reviewing peer feedback in the Appraisal, and subsequent campus feedback sessions); (4) the Quality Checkup process; (5) Strategy Forums; and (6) the College s annual planning process. Stage 2: Choosing and Prioritizing Action Projects Action Project ideas are drafted into formal proposals and discussed by the AQIP Steering team. All Action Project proposals are scrutinized through six lenses: demonstrable benefit to the College s mission; breadth of positive impact on the college (numbers of people affected/engaged); direct benefit to students; completeness and comprehensiveness of proposal; congruence with the broader AQIP process; and timeliness. Proposals receive one of four possible designations: judged a viable Action Project; rejected; returned for revision, combing with another proposal and/or resubmissions; or directed to another (non-aqip) College process for follow-up or implementation. Stage 3 Staffing the Action Project Team and Creating an Action Project Charter Once an Action Project is chosen, the Action Project Sponsor is selected by the President. The Sponsor typically holds a seat on the President s Cabinet and oversees a unit of the College. This ensures that needed resources for Action Projects enter the annual budgeting process for approval by President s Cabinet and that Action Project team recommendations are implemented. The Project Sponsor recommends Action Project team leaders. The AQIP Steering team then affirms the selection(s). Volunteers from the college community are solicited to staff each Action Project team. The team size varies by the nature of the project. Once established, the Action Project leaders work with the Project Sponsor to write the Action Project Charter. Completed Charters are reviewed by the AQIP Steering team and used to create the Action Project Declaration. Stage 4 Implementation of Action Project Project implementation rests largely with the Action Project team and Project Sponsor. The Project Sponsor regularly updates the AQIP Steering team on the Action Project team s progress. Action Project updates are written by the Action Project team and reviewed by the AQIP Steering team before submission. Each subsequent feedback report is then discussed during an AQIP meeting to determine any needed action by the Action Project team. Project Sponsors communicate such actions to the Action Project leader(s). Category Six: Quality Overview Page 2

3 Stage 5 Evaluating and Documenting Improvements Reporting and documenting progress are considered fundamental to the AQIP process. At all stages in the life of an Action Project, it is the joint responsibility of the Action Project Team Leader(s), Project Sponsor, and the AQIP Steering team to ensure this documentation process. The Director of Institutional Effectiveness, co-chair of the AQIP Steering team, (a) documents improvement projects in the College s Systems Portfolio and (b) ensures that the nature, membership, and status of Action Projects is reported both internally (via the AQIP at LLCC web page) and externally (via HLC-designed AQIP processes). Aligning the Systems Portfolio, Action Projects, Comprehensive Quality Review, and Strategy Forums LLCC s unit leaders are members of the President s Cabinet, and most have standing seats on the AQIP Steering team. This works from an infrastructure perspective because it links LLCC s annual planning and budgeting process with its AQIP processes. The College s five-stage action project process demonstrates AQIP s alignment with other existing processes at LLCC. LLCC has launched 10 Action Projects since being accepted to HLC s Academic Quality Improvement Program (AQIP) in Seven of the projects have been completed. One of the initial Action Projects emerged from participation in the College s first Strategy Forum. Of the 7 launched since the 2010 Strategy Forum, four have emerged from AQIP processes with the other three stemming from institutional processes. Table 6.1 Action Project by Source # Action Project Source Cycle* 1 Continuous Quality Improvement Other AQIP Institutions (AQIP Colloquium) 2 New Student Experience 2010 Strategy Forum and Foundations of Excellence Self-Study 3 Shared Governance Structure Institutional Improvement Processes 4 Strategic Plan - Transformation Institutional - Planning Processes 5 Electronic Portfolio HLC Assessment Academy 6 Process Mapping Writing of the 2013 Systems Portfolio 7 Using Multiple Measures in Placement Institutional Improvement Processes 8 Student Employment Process Institutional Improvement Processes and the 2014 Strategy Forum 9 Program Review and Assessment 2013 Systems Appraisal and 2014 Strategy Forum 10 External Stakeholder Needs Writing the 2013 Systems Portfolio, 2013 Systems Appraisal, and 2014 Strategy Forum 11 Developing a Data Framework AQIP institution presentation at the HLC Annual Conference; a chronic frustration at LLCC 12 Textbooks Institutional Improvement Processes * Cycle when Action Project was launched 6R1. What are the results for continuous quality improvement initiatives? 2013 Systems Portfolio 2017 Systems Portfolio Active or completed Action Projects, the goal of each, and the associated outcomes, launched or completed since the 2013 Systems Portfolio, include the following: Category Six: Quality Overview Page 3

4 Table 6.2 Impact of Action Projects Title Goal Outcomes Determine the utility of Taskstream s electronic portfolio software as a means of improving program-level assessment planned assessment efforts Electronic Portfolio Pilot Project Process Mapping: Systematic Documenting of Key Processes Using Multiple Measures in Mathematics Placement Student Employment Process Development and Documentation of Program Review/ Assessment Process External Dynamic Stakeholder Inventory Process: Informing Agile Decision-Making to Meet Stakeholder Needs Establishment of a systematic mapping processes to (a) understand whether current operations are effective, efficient, and transparent and (b) facilitate continuity of operations Design a new student placement process which incorporates multiple measures Create an efficient, accessible, and consistent student employment process Revise the Program Review/ Assessment process to (a) increase faculty participation, (b) produce data that can inform improvement, and (c) facilitate program-level aggregation Conduct a systematic survey of formal (contractual) relationships with stakeholder groups Establish a regular, periodic review process to ensure continuing effectiveness of the relationships, identify potential gaps and ensure that the data generated continue to inform college decisions. Table 6.3 Impact of Quality Improvement Projects Assessment of Academic Support Processes Developing an Survey data revealed overall dissatisfaction with the Taskstream software; a mismatch for the institution s Participating faculty members recommended against widespread implementation of Taskstream All processes in the Institutional Research department were mapped Created a three-element process mapping template for college-wide use Developed mathematics placement option for non-stem majors Revised the high school grade cut since initial implementation Actively monitoring students utilizing the non-stem placement option Defined student employment Assessed the need for student employees Created a student employee position job description Designed a method to communicate on-campus employment options to students Developed an internal process for recruiting, hiring, and tracking student employees Reviewed and standardized the student employee pay rate Adopted a definition for "program Communicating program outcomes via the Catalog and academic program websites Modified the three-year assessment cycle to a five-year assessment cycle Adopted an Academic Program Assessment Matrix to determine program assessment maturity Adopted a LLCC Campus-Wide Aggregation Report Adopted a Program and Course-Level Assessment Report Communicating program assessment findings on the academic program s website Modified the program review cycle to include a more robust assessment cycle Still an Active Project Impact TBD Project Goal Outcomes Develop an assessment process for the academic support units that (a) continuously examines its services Developed the structures necessary to support and sustain assessment in the Student Services unit: institutional effectiveness model; assessment handbook; common vocabulary; planning template/implementation schedule; Category Six: Quality Overview Page 4

5 Infrastructure to Sustain Assessment and programs and (b) informs needed improvement channels for sharing assessment processes, findings, and improvements Developed unit goals and outcome statements Developed department assessment plans, including outcomes statements, performance indicators, outcomesbased assessment approaches, and timelines 6I1. Based on 6R1, what quality improvement initiatives have been implemented or will be implemented in the next one to three years? LLCC identified and developed an action project to strengthen the College s foundation for quality improvement. The Developing a Data Framework project was approved by the AQIP steering team and formally entered into the Action Project E-Network in April. The primary deliverable is a metrics inventory. This inventory will target LLCC s creditbased instruction and include information such as the data points generated, the cycle on which each data is collected, who is responsible for collecting the data, and where the data resides. As a Category 5 and Category 6 project, the metrics inventory is foundational to understanding whether the College s data structure adequately supports its datainformed decision-making needs. 6.2: Culture of Quality focuses on how the institution integrates continuous quality improvement into its culture. 6P2. Describe how a culture of quality is ensured within the institution. This includes, but is not limited to, descriptions of key processes for: Developing an infrastructure and providing resources to support a culture of quality Quality is at the core of LLCC s mission to provide district residents with quality educational programs and services that are accessible, affordable, and responsive to individual and community needs. The College s Student Access and Success goal furthers emphasizes quality in its programs, noting LLCC will promote academic access and success as well as personal development for all students by: Preserving access for all students; Focusing on student success; Establishing clear educational pathways; Enhancing quality programs; Narrowing the achievement gap; and Initiatives addressing the Common Core Standards. Some tenets of continuous process improvement are relatively new to LLCC, but the institution has made great strides since submitting its AQIP pathway application in Joining the AQIP Pathway has been a driver of cultural change. After its acceptance to the Academic Quality Improvement Program, the AQIP Steering team recognized the need to develop its continuous quality improvement (CQI) infrastructure. Two early Action Projects were launched in response: Continuous Quality Improvement: Learning to Make Informed, Systematic Decisions and Process Mapping: Systematic Documenting of Key Processes. The CQI Action Project team developed a curriculum grounded in advancing the vision, achieving the mission, and deploying the values of LLCC. The curriculum is designed to develop employee skills related to advancing the College s improvement efforts. During the year, 236 LLCC employees completed the two-day curriculum. The CQI training is still offered at the College, with these sessions now targeting primarily new employees. With the CQI Action Project in an implementation phase, the College launched its second foundational Action Project to address a knowledge gap in process mapping. The experience of drafting the College s initial Systems Portfolio highlighted the variance in how key processes are documented across the units and divisions. This Action Project team oversaw the development and implementation of a process model that can be replicated by units and divisions Category Six: Quality Overview Page 5

6 throughout the College. Systematic mapping of processes was needed to (a) ensure that current operations are effective, efficient, and transparent and (b) facilitate continuity of operations at the institution. Using data to inform decision-making is foundational to a quality culture. Consequently, the College invested in ZogoTech s data warehouse and associated analytic tools, so employees could manipulate student and institutional data for decision making (see 5P1). The software pushed analytics into the hands of front-line staff, so they could isolate groups of students and follow their progress over time, demonstrate the success of interventions or changes in programming, and generally leverage data to support planning initiatives. All contribute to developing an evidencebased culture. Ensuring continuous quality improvement in making an evident and widely understood impact on institutional culture and operations LLCC annually maps its quality improvement projects to its strategic plan. The primary mechanism for this is the College s planning database, which houses all departmental/unit strategies for the current and upcoming planning and budgeting cycle (see Table 4.3 in 4P2). Each planned quality improvement project is (a) linked to a department goal as well as one of the College s goals at time of submittal and (b) subsequently approved by the appropriate member of the President s Cabinet. Subsequent progress and accomplishments are documented and updated semiannually. The database also captures the eventual outcome. Each of these quality improvement efforts are openly discussed during the proposal stage at the College s annual Leadership Planning Roundtable. Each budget manager has continuous access to all the quality improvement initiatives included in the planning database. Impact is then measured via annual updates to the College s strategic dashboard (see 4P2 and 4R2). [5.D.1] Ensuring the institution learns from its experiences with CQI initiatives The College s infrastructure, with strategic priorities focused on student success and KPIs established to measure progress, is being constructed to facilitate the selection of targeted improvements. Faculty and staff use the annual budgeting and planning process to align quality improvement efforts with LLCC s strategic priorities. Assessment is a primary driver of these efforts (see Figure 6.1). As demonstrated in a recent Action Project, faculty use the academic program review process as an assessment mechanism to (a) determine strengths and weaknesses and (b) develop targets for continuous improvement (see 1P2 and 1I2). The Students Services staff is engaged in a similar program of review, a non-academic process grounded in the Council for the Advancement of Standards for Higher Education (i.e., the CAS self-study process). Academic support assessment plans with outcome statements are being developed to drive improvements in both operational effectiveness and student learning/development (see Table 6.2), and structures to sustain the effort are being developed. Increased access to data, especially when coupled with process mapping and CQI principles for improvement, further illuminate opportunities for initiatives with the potential to enhance the College s effectiveness and efficiency in serving students. [5.D.2] President s Cabinet directs the annual planning process, facilitating stakeholder input and involvement, providing the forum for budget decisions to ensure appropriate resource allocation (in support of institutional priorities), and monitoring improvement initiatives and institutional progress (i.e., KPI s and the strategic dashboard). Members of President s Cabinet approve and oversee major improvement initiatives. The cross-divisional composition of this group helps ensure that improvement initiatives are coordinated and communicated across the institution. Improvement initiatives arise from both internal and external sources. A current AQIP Action Project structuring a student employment process for the College is exemplary of one emerging from an internal process. A review of the College s federal work-study program showed a consistent pattern of having to return unused funds. A subsequent review of the budget revealed that a significant amount of institutional funding was used to fund student work positions on campus. This paradox, that the federal work-study program was being underutilized in a time when institutional funds were shrinking, spurred concern at the President s Cabinet. Discussions of how students access federal work study funds suggested that the College s departments recruited, hired, trained, and evaluated student workers differently. From the student s perspective, the many pathways to a student employment position was Category Six: Quality Overview Page 6

7 Effectiveness Program and Operational Assessment PDSA Cycle Strategic Lincoln Land Community College June 2017 unwieldy and confusing. The College s haphazard approach to student employment was viewed as an improvement opportunity, and the Student Employment Process Action Project was launched in early The team is designing a college-wide process that will allow the institution to assess the need for student employees, create job descriptions, standardize pay rates among student employees, facilitate usage of federal work study funds, and reduce budget expenditures. [5.D.2] Figure Framework for Aligning Planning Initiatives with Assessment College Mission and Core Values Facilities Master Plan Strategic Plan Performance Funding Metrics IBHE/ICCB Technology Plan Performance Indicators Regional Accreditation Standards Division Plans, Goals, and Outcomes External Stakeholders Specialized Accreditation Standards Program Goals Internal Stakeholders Outcomes and Measures Performance Indicators Analysis of Data Assessment PDSA Cycle Action Plans for Needed Improvements General Education Outcomes, Graduate Follow-Up Surveys, CCSSE, SSI, Program Review Reports Institutional Effectiveness Reports and Recommendations for Improvement Performance Indicators Category Six: Quality Overview Page 7

8 The external environment may also spur an improvement initiative. In recent years, student completion rates has become a priority in higher education, and this completion agenda has been supported with best practices grounded in research. The College discussed the development of meta-majors or a guided pathways Action Project at the 2014 Strategy Forum. At this time, a data review suggested that LLCC students take excessive credit hours before graduating, a large number of students test into but do not complete a developmental education sequence, and many leave without graduating or completing a credential. LLCC s student persistence rates have been flat (see 4R2) while a goal of the College is to see these rise. Over the past five years, fall-to-fall retention fluctuated between 44% and 50% while semester-to-semester retention hovered at 71%. This is despite institutional efforts to improve these rates, such as mandating new student orientation, implementing a pilot early-alert process, and moving to a new advising model. This Action Project proposal made the College s shortlist and remains a consideration as a Persistence and Completion Academy project. It is presented here as an example of an improvement initiative which responds to the external stimulus yet aligns with a data-informed local need. [5.D.2] Regardless of whether an improvement initiative emerges via an external stimulus or an internal process, President s Cabinet determines how the opportunity will be addressed and oversees its implementation. Members of the President s Cabinet, as project sponsors, oversee all current AQIP Action Projects. Once a course of action has been set by President s Cabinet, the appropriate vice president or executive director ensures appropriate design and implementation of the initiative within the division. This commonly includes reliance on the directors or deans who report to them. Progress on improvement initiatives is discussed at monthly President s Cabinet meetings. Reviewing, reaffirming, and understanding the role and vitality of the AQIP Pathway within the institution The role and vitality of AQIP at LLCC is reviewed every two years with the College s CQI Culture survey, every three years with the PACE Climate Survey, and every four years when a Systems Portfolio is completed (see Tables 6.1 and 6.2). When viewed collectively, the AQIP Steering team and the President s Cabinet can develop an understanding of how efforts in the AQIP Pathway have made a difference at LLCC. LLCC is striving to develop a culture where assessment and improvement is just the way we work. The process improvements documented in Table 6.6, when coupled with its pre-aqip infrastructure, demonstrate LLCC is committed to developing an integrated system to support a quality culture which encompasses AQIP Pathway principles and processes. 6R2. What are the results for continuous quality improvement to evidence a culture of quality? Tool Measure Use Frequency Reviews Results Indirect assessment Gauge employees perception of the Every 2 President s Cabinet using 3 custom questions quality culture years on a national instrument Personal Assessment of the College Environment (PACE) CQI Culture Indirect assessment using local survey instrument Gauge employees perception of the quality culture Every 3 years President s Cabinet The improvement projects provided in 6R1 are direct evidence of a quality culture and its ability to work systematically to improve performance at LLCC. The College developed two indirect measures to gauge a cultural change from its CQI professional development program. First, employee perception data is collected as part of its Personal Assessment of the College Environment (PACE) administrations. Three institution-specific questions are included. Second, the College developed and administered a local survey in the fall of Category Six: Quality Overview Page 8

9 Table Indirect Evidence: Quality Culture at LLCC Question Significance/ Effect Size The extent to which institutional teams and work groups use CQI processes and tools ** / 0.24 The extent to which my primary work team uses CQI processes and tools The extent to which the college is committed to continuous quality improvement Source: LLCC 2013 and 2016 PACE Report, using five-point Likert scale where 1=Very Dissatisfied and 5=Very Satisfied ** p <.01 Table 6.5 Indirect Evidence: CQI Survey Qt What effect has LLCC s CQI training had regarding how LLCC employees approach improvement? Employee Group N Mean Median Administrator Classified Faculty Professional All Employees Source: CQI Culture Survey, 2015; Uses four-point Likert scale where 1=None and 4=A Great Deal Table 6.6 Indirect Evidence: CQI Survey Qt How often are you involved in a group which discusses or makes efforts to improve a specific department process? Employee Group N Mean Median Administrator Classified Faculty Professional All Employees Source: CQI Culture Survey, 2015; Uses five-point Likert scale where 1=Never and 5=Frequently Table 6.7 Evidence of Quality Culture Unit/Group Institutional Research (IR) Academic Services Student Services Institution Wide President s Cabinet & IR AQIP Steering team & an Action Project team IR and IT Quality Process Mapped the department s processes; identified a three-element process mapping model (context diagram, flowchart, task documentation) suitable for college-wide replication Action Project to improve the data associated with its assessment and academic program review processes; recommended purchase of a technical solution to facilitate student outcomes reporting and strengthen connection to planning processes Programs created assessment plans with operational and student learning outcomes; instituted an annual assessment symposium where programs share an assessment project, its findings, and the planned next steps; assessment process built around the PDSA cycle Large portion of the employees have completed the College s CQI professional development program; introduced to purpose and use of the affinity diagram, parking lots or issue bins; fishbone diagram; nominal group technique; brainstorming; and plus/delta Annually update and review KPIs associated with the strategic plan Conducted a systematic survey of formal (contractual) relationships with stakeholder groups Establishing a regular, periodic review process to ensure continuing effectiveness of the relationships, identify potential gaps, and ensure that the data generated continue to inform college decisions Purchased and implemented Student Navigator, a module of our ZogoTech data warehouse, to push analytics into the hands of front-line users and increase data access to end users/decision makers 6I2. Based on 6R2, what process improvements to the quality culture have been implemented or will be implemented in the next one to three years? Over the past five years, the College invested financial and human resources into making data more accessible for decision making. Implementation of ZogoTech, the College s data warehouse, was an initial step in creating a culture of evidence. The Research Intelligence module allows for standard and custom reports as well as drill downs. The Student Engagement module, obtained more recently in Spring 2016, facilitates end-user cohort tracking and makes data readily available for early intervention, program design, and program improvement. With data more available for decision making, the next step is educating the college community on how to use the available data to inform a decision or identify needed program improvements. Category Six: Quality Overview Page 9