cqi 101 building and sustaining an effective infrastructure
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CQI 101: Building and Sustaining an Effective Infrastructure

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CQI 101: Building and Sustaining an Effective Infrastructure. Kimberly Gentry Sperber, Ph.D. Achieving Quality. Responsibility for quality falls on both the organization and the individual.

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achieving quality
Achieving Quality
  • Responsibility for quality falls on both the organization and the individual.
  • The individual and the organization should be linked in a formal framework designed to continually improve quality.
quality assurance qa
Quality Assurance (QA)
  • Retrospective review process
  • Emphasis on regulatory and contract compliance
  • Catching people being bad leads to hide and seek behavior
continuous quality improvement cqi
Continuous Quality Improvement (CQI)
  • CQI is a prospective process
  • Holds quality as a central priority within the organization
  • Focus on customer needs; relies on feedback from internal and external customers
  • Emphasizes systematic use of data
  • Not blame-seeking
  • Trust, respect, and communication
  • Move toward staff responsibility for quality, problem solving and ownership of services
objectives of cqi
Objectives of CQI
  • To facilitate the Agency’s mission
  • To ensure appropriateness of services
  • To improve efficiency of services/processes
  • To improve effectiveness of directing services to client needs
  • To foster a culture of learning
  • To ensure compliance with funding and regulatory standards
creating infrastructure
Creating Infrastructure
  • Dedicated position
  • Use of committees
  • Written CQI plan
  • Designated process requirements
  • Inclusion in strategic plan
  • Positioning within agency
  • Role of external stakeholders
written plan
Written Plan
  • Vision/purpose
    • Objectives
  • Definitions
  • Authority to ensure compliance
  • Compliance procedures/definitions
  • Documentation of process
  • Peer Review
  • Committees
    • Membership
    • Objectives
  • Satisfaction
    • Clients
    • Employees
    • External stakeholders
  • Choosing indicators
  • Use of data
why examine documentation
Why Examine Documentation?
  • Clinical Implications
    • Documentation is not separate from service delivery.
    • Did the client receive the services he/she needed?
  • Operational Implications
    • Good documentation should drive decision-making.
    • Means of communication
  • Risk Management Implications
    • If it isn’t documented, it didn’t happen.
    • Permanent record of what occurred in the facility
  • Source of Staff Training
  • Reflection of the provider and organization’s competency:
    • EBP
    • Outcome of care
peer review committees
Peer Review Committees
  • Requires standardized, objective method for assessing charts.
  • Random selection of charts and monthly reviews
  • Goal is to identify trends and brainstorm solutions
  • These staff serve as front line for corporate compliance, risk management, and quality documentation
peer review measures
Peer Review Measures
  • Completeness of Records checks
    • Assessment is present and complete.
    • Service plan present and complete.
    • Consent for Treatment present and signed.
  • Quality Issues
    • Services based on assessed needs.
    • Progress notes reflect implementation of service plan.
    • Documentation shows client actively participated in creation of service plan.
    • Progress notes reflect client progress.
peer review process
Peer Review Process
  • Identification of review elements
  • Assigning staff responsibilities
    • Workload analysis
  • Creating process for selecting files for review
  • Determining review rotation
  • Reporting and use of data
establishing indicators
Establishing Indicators
  • Relevant to the services offered
  • Align with existing research
  • Measurable
    • No “homegrown” instruments
    • Reliable and valid standardized measures
examples of indicators
Examples of Indicators

Process Indicators

  • Percentage of clients with a serious MH issue referred to community services within 14 days of intake.
  • Percentage of clients with family involved in treatment (defined as min. number of face-to-face contacts).
  • Percentage of clients whose first billable service is within 72 hours (case mgt).
  • Percentage of positive case closures for probation/parole.
  • Percentage of high risk clients on Abscond Status for probation/parole.
  • Percentage of restitution/fines collected.
  • Percentage of clients participating in treatment services.
examples of indicators1
Examples of Indicators

Outcome Indicators

  • Clients will demonstrate a reduction in antisocial attitudes.
  • Clients will demonstrate a reduction in LSI scores.
  • Clients will demonstrate an increase in treatment readiness.
  • Clients will obtain a GED.
  • Clients will obtain full-time employment.
  • Clients will demonstrate a reduction in Symptom Distress.
  • Client will demonstrate sobriety.
client satisfaction
Client Satisfaction
  • Identify the dimensions
    • Access
    • Involvement in treatment/case planning
    • Emergency response
    • Respect from staff
    • Respect from staff for cultural background
  • All programs use the same survey
  • Items are scored on a 1-4 Likert scale
  • Falling below a 3.0 generates an action plan
operationalizing the process
Operationalizing the Process
  • Distribution and collection of surveys
  • Coding, analysis, and reporting of data
  • Use of data
establishing thresholds
Establishing Thresholds
  • Establish internal baselines
  • Compare to similar programs
  • Compare to state or national data
action plans
Action Plans
  • Plan of correction
  • Proactive approach to problem-solving
  • Empowers staff
  • Using objective data to inform decision making
who creates action plans
Who Creates Action Plans?
  • Anyone and everyone can create action plans
  • Focus should be on who has knowledge or expertise to contribute
  • Focus should not be on the person’s title
focus on causes not symptoms
Focus on Causes not Symptoms
  • Focus on processes/systems rather than individuals or specific errors
  • Identification of risk points and their contribution to the problem
  • Identify changes in these processes that reduce risk of re-occurrence
process evaluation
Process Evaluation
  • Are we serving our target population?
  • Are the services being delivered?
  • Did we implement the program as designed (tx fidelity)?
  • Are there areas that need improvement?
outcome evaluation
Outcome Evaluation
  • Are our services effective?
  • Do clients benefit (change) from the services?
  • Intermediate outcomes
    • Reduction in risk
    • Reduction in antisocial values
  • Long-term outcomes
    • Recidivism
    • Sobriety
minimum requirements
Minimum Requirements
  • Buy-in from staff at all levels of the organization
  • Sufficient resources allocated for staff training
  • Sufficient resources allocated for staff to participate in the process
    • Peer Review Meetings
    • Other relevant committee meetings
    • Data collection
  • Sufficient information systems
barriers to implementation
Barriers to Implementation
  • Agency culture
    • The “black hole” of data that leads to staff cynicism and burnout
    • Conflicting messages about targets/goals in various work domains
    • Problem letting go of old ways
    • “We’re clinicians not statisticians”
  • Costs
    • Staff time
    • IS capabilities
    • Data collection instruments
    • Coordination of the process and dissemination of the data
  • Multiple and sometimes conflicting demands of multiple funders
    • Different priorities
    • Don’t speak the same language causing confusion for line staff
overcoming resistance
Overcoming Resistance
  • Administration must walk the walk
  • Insure early successes to increase buy-in
  • Recognition of staff for using the process
  • Openly acknowledge the extra work required
  • Demonstrate front-end planning to minimize workload issues
benefits of program evaluation
Benefits of Program Evaluation
  • Proof of effective services
      • Maintain or secure funding
      • Improve staff morale and retention
      • Educate key stakeholders about services
  • Highlights opportunities for improvement
  • Data to inform quality improvement initiatives
  • Establish/enhance best practices
  • Monitor/ensure treatment fidelity
why invest in cqi
Why Invest in CQI?
  • A CEO’s Perspective:
    • Because it’s the right thing to do!
    • Better for clients (i.e., better outcomes)
      • Mission-driven
    • Increased staff satisfaction
    • Increased staff retention
    • Improved referral source satisfaction
    • More business for related projects
    • Outcomes to sell to business community and other payers
    • Demonstrates fiscal responsibility (i.e., effective use of dollars)
strategic use of cqi data
Strategic Use of CQI Data
  • CQI data used to provide testimony before legislature
  • CQI data and infrastructure used to secure new contracts and grants
  • CQI data used in newsletters, media relations, levy campaigns, etc.
  • CQI data used to negotiate programmatic changes with stakeholders
getting started

Getting Started

Identifying Key Decision Points

looking at infrastructure
Looking at Infrastructure
  • Identification of those with powers for decision making and resource allocation
  • Current capabilities
  • Ideas for infrastructure
  • Planned needs
documentation review
Documentation Review
  • Feasibility of documentation review
  • Identify sources of review elements
  • Operationalize routine file reviews
    • Who
    • When
    • How many
choosing indicators
Choosing Indicators
  • Identify possible measures
  • Value of measures
  • Methods of measurement
  • Operationalize data collection
creating a client satisfaction process
Creating a Client Satisfaction Process
  • Identify sample survey items
  • Prioritize items
  • Operationalize distribution and reporting
  • Identify staff responsibilities
  • Mechanisms for sharing results
program evaluation
Program Evaluation
  • Examples of past projects
    • Were they beneficial?
  • Ideas for new process and outcome evaluation projects
  • Available data
  • Required resources
creating a work plan
Creating a Work Plan
  • Identify all questions that need answered and who has the authority to answer them
  • Identify beginning tasks
  • Assign responsible parties and deadlines
  • Create written implementation plan