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
Will discuss Talbert House infrastructure as an example only; infrastructure should be tailored to each agency’s vision, needs, and resources.

7. Creating a CQI Infrastructure
This is Talbert House structure; does not imply that every organization should look like this.

8. Written Plan Vision/purpose Definitions Authority to ensure compliance
Objectives
Definitions
Authority to ensure compliance
Compliance procedures/definitions
Documentation of process
Peer Review
Committees
Membership
Satisfaction
Clients
Employees
External stakeholders
Choosing indicators
Use of data
Highlights from Talbert House CQI Plan

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 Quality Issues
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
Significant at p<.05

32. Identifying Key Decision Points
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: