Methods in Implementing an Effective CQI Program in a Social Services Setting

Mid-Cumberland Community Services AgencyNashville, Tennessee

Shirley Crawford, MS, RN

Michael Colangelo, MBA

www.mccsa.com

Discussion PointsPROCESS OUTLINE

BENEFITS OF OUR PROGRAM

INITIAL EFFORTS

CURRENT PROCESS

DATA COLLECTION STRATEGIES

ANALYSIS, EVALUATION & REPORTING

TRAINING

IMPACT OF CQI

Process FlowCore Elements

• Identify Goals and Objectives

• Establish Measurable Objectives

• Identify Indicators

• Collect Measurements/Results

• Intervention/Action (if needed)

• Trending/Reporting Quarterly

• Re-measurement

• Conduct an Annual Evaluation

• Develop and Implement Recommendations

• Develop Goals and Objectives for the Next Year

Performance Management Program ProcessCore Elements →Flow Chart

Identify Goals and Objectives

Establish Measurable Objectives

Identify Indicators

Collect Measurements/Results

Analyze and Evaluate

Measurements/Results

Intervention/Action (If Needed)

Trending/Reporting Quarterly

Re-measurement

Conduct an Annual Evaluation

Develop Recommendations

Implement Recommendations

(Defined in Handout)

Benefits of CQI

• Ownership of Program Objectives– Brings about changes in attitudes toward the program.

Employees can see how a set of objectives helps to identify program success or indications that the program is moving in the right direction.

• Inclusiveness/Consistency– Implementation of the program on an organizational-wide

level promotes a feeling of inclusiveness in the organization. Employees can feel part of the team; having similar experiences, using the same CQI tools, as well as organizational wide training.

Benefits of CQI

• Improved Communication/Teamwork– Quarterly program manger meetings involve sharing of

information among programs. Program staff can offer suggestions on interventions for opportunities in other areas to assist in needed improvement. This also fosters teamwork. Reporting format also improves communication throughout the organization.

• Stakeholder Perception– Reporting of trended information allows stakeholders to see

performance levels on a routine basis. They can see that the organization sets goals, evaluates data collected and reviews the impact on organizational programs.

Benefits of CQI

• Proactive vs. Reactive– Performance programs places the organization in a

proactive mode. Programs are aggressively monitored which assists with detecting problems in a timely fashion. Analysis of data helps to distinguish between acceptable performance levels.

Mid-Cumberland Community Services Agency (MCCSA)

Annual Evaluation Format• I. Purpose of the Department

• II. Specific Objectives

– Objective #1:– Outcomes:– Limitations/Barriers:– Recommendations:

• III. Quality Improvement Activities • IV. Recommendations for the Next Year

Mid-Cumberland Community Services Agency

Annual Evaluation

• Conduct an Annual EvaluationAll program areas will do an annual evaluation of all of the goals and

objectives established. Each objective will be evaluated to determine its success.

If an objective did not achieve success, information is reported on the limitations or barriers that prohibited a program

from meeting the goal/objective.

MCCSA Initial Efforts

• Development of Quality Policies and Procedures

CQI policies and procedures were developed using the COA Standards as a guide. A program manager’s structure was implemented to establish a reporting format.

• Program Quarterly Reports (Effective in Dealing with Resistance)

Initially, quarterly reporting was done in an inconsistent format. Program staff were trained individually on developing measurable goals and objectives.

MCCSA Initial Efforts

• Strategic Planning– Used consultant in non-profit area to assist with

development– Involved all program managers – Focus Groups (State Administrators; Board and

Line Staff)– All staff involved in implementation of strategic

plan– Merged strategic plan goals and performance

targets with quality program.

MCCSA Initial Efforts

• Implementation of Performance Program– Assigned designated staff as lead

MCCSA’s Process

• Individually meet with Program Coordinators (Effective in dealing with resistance)

• Use Interviewing techniques/questions to complete the Short Term Objective (STO) form (handout)

• Identify overall program goal(s)

1. “What is your main responsibility?”

2. “What drives your program?”

3. “What specific things do you have to achieve to be successful?”

MCCSA’s Process

• Develop Short-Term Objectives– Establish Measurable Objectives

• Make a list of all major duties • Group like duties and develop

objectives

• Develop Performance Indicators– Enumerate specific data elements with

thresholds/benchmarks for each objective

Our Data Collection Strategies

• Creation of Microsoft Access databases– www.tutorialbox.com

• Development of a Results Scorecard

• Hired an Information Technology Manager

RESULTS SCORECARD

Objectives Indicator Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Program Goal:

RESULTS SCORECARD – Non-Custodial Services Unit

Objectives Indicator Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Increase the percentage of FSS customers who remain out of custody within six months of the case being opened to at least 90%.

Percent remaining out of custody 91.4% 90.3% 92.6% 88.1% 93.5% 92.8% 90.8% 91.6% 91.4%

Increase the percentage of FCIP cases remaining certification free from 95% to 97% at case closure.

Percent certification-free 95.0% 94.3% 96.6% 96.3% 97.8% 98.1% 94.3% 96.6% 98.1%

At least 90% of case recordings will be entered into TNKIDS, as specified by DCS Policies and Procedures

Audit compliance rating 87.1% 92.6% 93.4% 95.6% 94.5% 96.7% 95.4% 93.8% 95.8%

Program Goal: To provide quality, accountable, and focused services to keep children and communities safe while empowering families to remain together by preventing children from entering state's custody.

Analysis, Evaluation, and Reporting

• Directors review scorecards with Program Managers

• Scorecards posted on computer network

• Prepare Trending Graphs and Control Charts– Building Continual Improvement, Donald Wheeler

(ISBN 0-945320-50-7)

• Prepare a Quarterly Report– Who did we serve?– What were our outcomes?

Percent of Clients Remaining Out of Custodyfor at Least Six Months

Stay At or Above 90%

95.5%

88.0%

93.2%92.5%

80%

85%

90%

95%

100%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YTD

Percent of Clients Showing Improvementin Family Functioning Scores

55%

60%

65%

70%

75%

80%

85%

90%

95%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Average = 76.75UCL = 92.46LCL = 61.04

Training

• Full-time Trainer– Microsoft Access, Excel, Word– HIPAA

• Performance Management University– CQI concepts– Data Analysis– Short-term and Strategic Planning

Impact of CQI

• Parents that refuse to participate in program

• Program Budgets

• Telephone Representative Talk times

• Purchasing Policy Compliance

Thank You!