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. The individual and the organization should be linked in a formal framework designed to continually improve quality.

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) 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 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 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.

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

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

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 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 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.

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

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 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 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 Distribution and collection of surveys Coding, analysis, and reporting of data Use of data

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

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

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 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 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 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 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 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 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 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? 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 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

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

NPC Research on Drug Courts Significant at p<.05

Identifying Key Decision Points Getting Started Identifying Key Decision Points

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

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

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

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

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 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

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