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
ha
nge
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
cen
t Im
pro
vem
ent
in O
utc
om
e C
ost
s*
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:[email protected]