Building a Sustainable CQI Framework for Quality Improvement in Infrastructure

1. CQI 101:Building and Sustaining an Effective Infrastructure Kimberly Gentry Sperber, Ph.D.

2. 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.

3. Quality Assurance (QA) • Retrospective review process • Emphasis on regulatory and contract compliance • Catching people being bad leads to hide and seek behavior

4. 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

5. 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

6. Creating Infrastructure • Dedicated position • Use of committees • Written CQI plan • Designated process requirements • Inclusion in strategic plan • Positioning within agency • Role of external stakeholders

7. Creating a CQI Infrastructure

8. 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

9. 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

10. 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

11. 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.

12. 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

13. Establishing Indicators • Relevant to the services offered • Align with existing research • Measurable • No “homegrown” instruments • Reliable and valid standardized measures

14. 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.

15. 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.

16. 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

17. Operationalizing the Process • Distribution and collection of surveys • Coding, analysis, and reporting of data • Use of data

18. Establishing Thresholds • Establish internal baselines • Compare to similar programs • Compare to state or national data

19. Action Plans • Plan of correction • Proactive approach to problem-solving • Empowers staff • Using objective data to inform decision making

20. 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

21. 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

22. 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?

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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)

29. 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

30. The Role of QA/QI in Community Corrections(based on UC Halfway House and CBCF study)

31. NPC Research on Drug Courts

32. Getting Started Identifying Key Decision Points

33. Looking at Infrastructure • Identification of those with powers for decision making and resource allocation • Current capabilities • Ideas for infrastructure • Planned needs

34. Documentation Review • Feasibility of documentation review • Identify sources of review elements • Operationalize routine file reviews • Who • When • How many

35. Choosing Indicators • Identify possible measures • Value of measures • Methods of measurement • Operationalize data collection

36. Creating a Client Satisfaction Process • Identify sample survey items • Prioritize items • Operationalize distribution and reporting • Identify staff responsibilities • Mechanisms for sharing results

37. Program Evaluation • Examples of past projects • Were they beneficial? • Ideas for new process and outcome evaluation projects • Available data • Required resources

38. 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

39. Questions and Answers Contact Information: Kimberly.Sperber@talberthouse.org