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

Creating a CQI Infrastructure

Executive CQI Committee

Risk Management Committee

Safety Committee Human Subjects Committee

Diversity Committee Corporate Compliance Committee

Cluster CQI Committees

Program Peer Review Committees

Morbidity & Mortality Conference

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?

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 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)

6

1

0

2

4

6

8

Internal QA No Internal QA

% C

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in R

ecid

ivis

m

NPC Research on Drug CourtsDrug Court Uses Evaluation Feedback to Make Modifications

11%

44%

0%

10%

20%

30%

40%

50%

YesN=4

NoN=6

* "Percent improvement in outcome costs" refers to the percent savings for drug court compared to business-as-usual

Per

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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