IlLINOIS DEPARTMENT OF CHILDREN AND FAMILY SERVICES

CHILD AND FAMILY SERVICES PLAN
FY2000-FY2004

QUALITY IMPROVEMENT

ISSUE

What measures can be taken to ensure that the Department provides high quality programs, services and functions?

The delivery of quality service and its continual evaluation directly relates to the Department’s ability to successfully contribute to the achievement of the desired outcomes of safety, permanency and well-being identified for children and families served by the child welfare community. Additionally, commitment to these outcomes provides the Department a structure upon which to build or enhance current practices dedicated to achieving and maintaining accredited status. While the responsibility for quality lies with all members of an organization the difficulty is integrating the administrative, program and support components which comprise the agency. Additionally, various units and divisions measure quality from different perspectives, each valid in their own way. The challenge is to integrate the various monitoring and measurement mechanisms in such a way that they support the Department’s mission to achieve the appropriate desired outcomes for the children and families that it serves while providing quality services. All-inclusive participation, collaboration in problem solving and a continuous improvement mindset, all characteristics of a high performance agency, are just a few of the key elements which provide the foundation upon which the Department may successfully address this challenge. The ability of the Department to dedicate staff to the development and continual support of a process of all-inclusive continuous quality improvement (CQI) utilizing quality assurance data should contribute to the success of the Department and our clients.

A vital step which exemplifies the Department’s commitment to quality is the ability to provide to its internal and external consumers and stakeholders the ongoing plan for achieving, assessing, and maintaining a level of performance which meets or exceeds Department Rule and Procedure, industry standards as defined by the Council On Accreditation, and best practice.

 BACKGROUND

The Department since its inception, has utilized some form of quality assurance. The concept of quality assurance has been developmental. In the early stages, the focus was on the collection of data both through automated reporting systems and the results of independent case record reviews. The process became more formalized with the advent of the B.H. Consent Decree at which time a Bureau of Quality Assurance was established which organized Administrative Case Review, Quality Assurance, Program Review and the Ombuds (now Advocacy) Office into one functional unit. The reviews conducted by this Bureau were effective in identifying problems and issues of performance and service delivery, although substantive planning to address the issues was at times lacking. During this time, the Department’s Quality Assurance process continually reported on both quantitative and qualitative measures of performance, but continued to see tremendous caseload growth along with escalating costs and increased length of stays in out-of home care. Additionally, large numbers of families who were served as intact were oftentimes not experiencing expeditious service delivery or cases remained open far beyond the appropriate service period. A re-focusing of Department staff on quantitative and qualitative issues resulted in a restructuring of the Bureau which has subsequently allowed the focus to further shift to an increased emphasis on action planning and accountability.

For the purpose of clarity it is important to understand the intrinsic difference between quality assurance and quality improvement. Quality Assurance (QA) are those activities and processes which measure compliance with internal/external policy and procedures, industry standards and/or best practice. These activities include but are not limited to record reviews, program evaluation and data collection and analysis. Quality Improvement (QI) are actions taken which most often are predicated upon the review and analysis of information which is obtained from quality assurance activities. They are actions taken which lead to incremental improvements in the methods of delivering services or in the actual services provided to consumers. These actions are usually conceptualized and implemented by staff.

The Department has had available for use various reporting systems and review processes. These have included the following:

Monthly Statistical Reports - These reports provide statistical information on several key program areas of the Department service array: The Executive Statistical Summary, Caseload Counting Summary Report, Monthly Analysis of Investigative Team Performance, Child Abuse Neglect Statistics and Home of Relative License Report.

Automated Case Tracking and Reporting Systems - Automated systems have been developed for on-line access beginning in 1985 with a preliminary version of the CANTS Log Tracking System. Since that time several additional systems have been developed using NOMAD as a platform. These have included the Computerized Case Counting System (CCCS) used to monitor and track case load counts from the region to the case worker level and the Performance Outcome Tracking System (POTS) including a recent enhancement of that system which allows for reporting to the team level. The POTS system provides information to the team level relative to outcomes.

 

Other Quality Assurance Reports - Statistical reports are provided on a weekly basis and distributed via e-mail. These reports provide data on the state and regional level for the program areas of Child Protection and Foster Care. Other reports are produced at differing intervals but include areas such as Wards Abused and or Neglected in Substitute Care; Wards Experiencing Three or More Placement Moves; Sibling Report of Children in Care; Child Fatality Report; Annual Abuse/Neglect Report; etc. These reports provide program data which can be used for quantitative measurement; evaluating the efficacy of some service components; and provide data for short and long-term planning.

 

Independent Review Reports - The field review unit audits case file content for quantitative and qualitative content. They include all direct service program areas utilizing both internal and external measures of compliance. Reports, which summarize the results of the activity, are generated and distributed to those individuals directly involved in the case work process as well as those having line authority over the case work. These reviews may be team specific, management group specific, or at a sub-region or regional level.

 

Regional Reviews - Beginning in 1994, under the leadership of the Department Director, these reviews comprehensively have addressed both quality and improvement within the Department?s six geographic regions. The Offices of Quality Assurance and Budgets compile various statistical profiles relevant to clients, service delivery, supervision, and management within each region. This information plus reports generated by the region are distributed for review. The reviews provide a forum for discussion of the information within a context of the Department’s goals and desired outcomes as well as impediments to effective service delivery.

 

Regional Management Agreements - In collaboration with the Division of Administrative Services, Budgets and Regional Managers performance targets are established for the various program areas. These targets are related to the overall outcomes of safety, permanency, child well-being, as well as some additional areas of specific programming. These agreements are updated quarterly to reflect each region's progress toward meeting their individual negotiated goals, thus providing an intermittent tool to determine if regions are on target.

 

Caseload Tracking Meeting - These semi-monthly meetings provide a consistent opportunity for key individuals from the regions and central office to discuss and analyze program evaluation data. These meetings focus primarily on the substitute care population and issues of permanency surrounding that population. Various issues are raised from a region’s status as it relates to meeting those permanency outcomes associated to performance contracting, to staffing and vacancy patterns and their potential contributing factors.

 

Outcome Report - Quality Assurance distributes on a semi-annual basis an outcome report providing information at the state and regional level on the outcomes of safety, permanency and child and family well-being.

 

Consumer Satisfaction - The Department has surveyed parents, children and foster parents. Information from parents and children has been gathered and reported on by Wilson and Associates and the University of Illinois Research Center. The former survey was subsequently abandoned in 1997 and the latter was intended to be a one time point-in-time activity. Northern Illinois University has been involved in the surveying of Department Licensed Foster Homes and has provided information regarding those providers satisfaction, knowledge, and understanding of the various service arrays available to them and the children for whom they provide care. This information is sorted by both Region and Field Service Management Group and enables middle-managers, supervisors and direct service workers to ascertain what is perceived to be their strengths and areas which require enhancement.

 

 

CURRENT AND FUTURE STEPS

In 1996 the Department elected to seek accreditation through the Council on Accreditation (COA).

The standards set forth by the Council requires an agency to have a fully-integrated quality assurance and quality improvement model which provide for full inclusion and participation of agency staff. The agency at that time in consultation with the Florida Institute of Quality Improvement, began to strategize and develop a plan which would enhance the current quality processes already in place and embed in the agency a model of continuous quality improvement which is fully inclusive and participatory. At the same time, the quality assurance and improvement process must also support measurement and enhanced compliance with State, Federal and judicially mandated requirements. Currently, quality assurance and improvement activities have attempted to meet various mandates, and steps have been undertaken to begin to integrate the following multiple processes:

 

State and Regional Quality Assurance Plans -

Current Status - In order to implement a QA/QI process which is planful in nature, the State and six Regions have authored plans which outline both statewide and regional perspectives on the development and implementation of an all-inclusive CQI process. They delineate both the methods of collecting data and the process by which the data is analyzed and acted upon for the purpose of making quality improvements. Currently, the State QA/QI plan is under revision and several regional plans have been recently revised.

 

Future Steps - The planning process is on-going, requiring that a plan’s efficacy be constantly evaluated and therefore revised in order to reflect those processes which are found to work most effectively within a given environment. As the QA/QI process is integrated into all Divisions in the Department and at all functional levels additional plans will need to be developed.

 

Continuous Quality Improvement Structure -

Current Status - The Quality Improvement model chosen by the Department for implementation provides for a process which crosses all functional areas and is all-inclusive. The above referenced plans describe both the statewide and regionally based structures by which all staff participate in the collection, analysis and examination of information and the subsequent planning, acting, and evaluating of steps towards goals which improve the overall delivery of service and the performance of the agency.

Staff participate in the QI process through membership on quality improvement teams. Each direct service team currently acts as a local QI team. Individuals are selected by their local QI teams to act as representatives to a site based quality council. This group in turn selects individuals to represent each site on the Regional Quality Council. The implementation of this structure varies from region to region. All regions however have Regional Quality Councils and many have site and local quality teams operating. These teams, too, are in different stages of development as QI is process oriented and staff need to be afforded the time to learn, understand, and integrate the process.

 

Future Steps - While quality teams are currently in place and developing in the Regions, these teams primary focus is on ensuring that quality services are provided and outcomes are met relative to the consumers that they serve, e.g., children, families, foster parents, etc. It is important to recognize that these teams do not function in a vacuum. These individuals are consumers of other internal divisions of the Department e.g. Clinical Services, The Office of the Guardian, Employee Services, etc. In order to integrate the Department’s program areas and those divisions responsible for support to direct service staff, these Divisions must become actively involved in the QI process. Therefore, these Divisions must begin to develop and implement a quality assurance and improvement process which includes the development of a QA/QI plan which defines the scope of their internal work processes, the primary evaluative components of those processes and an all-inclusive CQI structure.

As the regional QA/QI processes continue to develop and the central office divisions begin to develop the formation of the State Quality Council becomes imperative. It will provide the overarching structure, system and process by which the Department will utilize information gathered from formal and informal quality assurance activities for the purpose of improving organizational performance and overall outcomes.

Peer Review -

Current Status - Peer review is the process by which caseworkers, supervisors and mangers review and evaluate the quality of casework practice using both quantitative and qualitative measures. Reviewers are precluded from reviewing cases in which they have direct involvement or over which they have line authority. It involves a random selection of cases in which each office and every team is reviewed on a quarterly basis. Regional peer reviews have been occurring quarterly since the fall of 1997. As with the CQI process regions implemented peer review in different ways. Unfortunately in some cases, their decisions were contrary to the statewide expectations as they failed to review their full array of service components and in some instances failed to preclude review by those involved in the casework decision making.

Future Steps - The development of a uniform peer review document has been undertaken and is near completion. This document requires that a predetermined consistent set of queries be made on investigations, intact cases, placement cases (including adoption) and licensing records. The document also allows regions, sites, or local teams to add to the protocol at their discretion. The predetermined elements will be aggregated through the use of a mainframe program and allow for the review findings to be aggregated from the team to site to region and ultimately to the state. The field review unit of the Quality Improvement Division will on a regular basis do a validation review of the regional aggregate findings to report to the State Quality Council.

Under development is peer review for non-direct service units such as the Advocacy Office, Division of Administrative Case Review, Office of Child and Family Policy, and Division of Administrative Case Review.

Consumer Satisfaction -

Current Status - Northern Illinois University has surveyed Department Licensed Foster Homes and has provided information regarding those providers satisfaction, knowledge, and understanding of the various service arrays available to them and the children for whom they provide care. This information is sorted by both Region and Field Service Management Group and enables middle-managers, supervisors and direct service workers to ascertain what is perceived to be their strengths and areas which require enhancement.

Representatives from the Regional Quality Councils and Quality Improvement together with the University of Illinois Research Center have recently completed surveys for use with parents, children, and foster parents to determine their level of satisfaction with Department services. Recently work has begun on the development of an employee survey

Future Steps - The surveying of consumers and staff must occur in a planful way. Work with each region must be undertaken to ensure the confidentiality of information as well as the responsibility for reporting and acting upon the information which is obtained. Mechanisms other than paper and pencil surveys, such as focus groups, are to be explored. Currently, one region has elected to conduct such a group. There has been a substantial commitment of time to ensure confidentiality and to obtain the appropriate consents and releases required. While efforts are underway to obtain information at a local level the process of obtaining information on a statewide level must also be developed. Additionally, accreditation standards for foster care require that clients and foster parents be surveyed at a minimum of every six months to determine their satisfaction levels with the services that have been delivered. This process must be conducted six months subsequent to case closing also. To be in compliance with this standard, this must be completed on 90% of the population. Currently the Department has no system in place to collect this level of data. While ACR may be one of the most viable venues to gather this, the Y2K moratorium on systems development precludes additions to their review packet. The most viable approach will be to embed this component into the SACWIS system as it begins development.

Unusual Incident Reporting (UIR) -

Current Status - An automated system has been available to staff both in the Department and private sector to report incidents and accidents. Due to the nature of this reporting and that some incidents/accidents may be considered closed at the time of the reporting and that others require additional follow-up, the current system has not always provided the necessary flexibility for seamless tracking. Data is currently aggregated from this system and used in the CQI process, but with caveats citing limitations. Local QI teams often develop internal mechanisms to collect this information to ensure its accuracy and act upon that data.

Future Steps - A workgroup has been formed whose charge is to refine the UIR reporting system and amend current rule. The goal is to develop a system which allows for easy tracking and monitoring of final outcomes as they relate to incidents and accidents.

Appeals/Client Grievances -

Current Status - An automated system has been recently developed to allow for the tracking, monitoring, and reporting of requests to appeal decision making involving investigations, in-home services, foster care and licensing. This system is in its formative use and the majority of time is currently being spent with staff responsible for maintaining the system’s data integrity.

Future Steps - Within the next few months the first set of reports which provide information down to the team level on the types of appeals/grievances and their outcomes will be made available. These reports will be utilized in the CQI process at each level from local teams to the State.

Program Evaluation -

Current Status - The activities, processes, data systems, and reports described in the section entitled Background are continually utilized by the Department to support a continuous quality improvement process. Three of these (Regional Reviews, Caseload Tracking Meeting, and the Outcome Report) will in the future be further enhanced, taking on some additional aspects to support the CQI process. Additionally, an external foster care review process has also been created.

Future Steps - Regional reviews were temporarily suspended but will commence again in the near future. These reviews will continue to focus on information and data relevant to performance. A particular focus will be placed on action planning and at subsequent reviews evaluating the efficacy and implementation of those plans

The semi-monthly Caseload Tracking Meetings are a primary venue for review, analysis and discussion of program evaluation data. As the State Quality Council is formed, this group would be appropriate to be the Program Evaluation Subcommittee of that Council.

Outcomes and managing to outcomes has experienced increased attention in the child welfare community. Both the Federal Government and other national stakeholders in the child welfare community have suggested outcomes by which an agency should measure certain aspects of their performance. The Department is undertaking a process of adding those outcomes not already in the current report. Also, the ability to report these outcomes at the team level is a priority. A record review protocol is also to be implemented which collects information on eight specific outcomes related to foster care and in-home protective services. Seven of these outcomes are consistent with those identified in the Federal Child and Family Review. Achievement of these outcomes will be reported for inclusion in each region’s CQI process and for inclusion in the published outcome report. Establishing benchmarks relative to the outcomes is the next phase.

The external foster care review process is independent of the Department and is in the early stages of development. This process will involve reviews of both Department and private agency cases and the information obtained in this process will be used for both program monitoring and quality improvement.

Partnership with the Private Sector -

Current Status and Future Steps - The Department in collaborative partnership with private agencies is committed to supporting organizations which demonstrate a commitment to commencing or enhancing a process of internal quality assurance and continuous quality improvement.

Additionally, the Department has created a quality assurance unit within the Purchase of Service Division. The private agencies will also obtain data for their CQI process from the external foster care review process. Agency books are being developed which provide program data that is available in the Department’s automated systems. Expanding this data to also provide information on outcomes would additionally enhance an individual agency’s ability to measure and improve performance where needed.

Accreditation -

Current Status - The Department continues to pursue its efforts to be accredited by the Council on Accreditation of Services for Families and Children. Twenty-three of sixty-five field sites and all central office functions have been accredited. The Department has required that all private agencies who manage foster care cases become accredited. Sixty-two agencies are accredited and forty-two have applied. The Department has made available to the private sector technical assistance and training to support this process. The Department has also put reimbursement incentives in place by paying for the accreditation processing and reimbursing up to an equal amount for related training and changes. Another such incentive is that private agencies that are accredited may keep half of their excess reimbursement.

Future Steps - The Department is committed to having all sites and functions accredited. The State will be accredited once the six regions successfully complete accreditation activities scheduled for 1999. This requires that the sixteen field offices identified successfully pass the review of their foster care and child protective services programs and that each region’s adoption program also successfully pass the survey for that service. Sites that have achieved accredited status must maintain their level of performance and those sites not yet accredited individually will have to prepare for future years.

LONG RANGE GOALS AND OBJECTIVES

Establishing an environment where excellence and pride in performance is present and supported at all levels and in all divisions is the long range goal of an effective continuous quality improvement process. While these attitudinal shifts occur they should be evident through

  • Full accreditation of the State and all Department sites with on-going continued re-accreditation;
  • A fully operational all-inclusive continuous quality improvement process which includes all staff participating on quality teams, a process which integrates all operational aspects of the Department (direct service, administration, human resources, business support, etc.) and a process that by its effectiveness would continue even without external supports thus having achieved "a life of its own";
  • Outcome measures for all areas of service and a process of management to the desired outcomes;
  • Monitoring of programs which is consistent and based upon measuring defined outcomes with clearly established benchmarks;
  • Constantly evaluating and re-evaluating the quality of service and the agency environment in which it is delivered resulting in children and families experiencing improved outcomes relative to safety, permanency, and well-being; and
  • Meeting or exceeding those standards of practice and organizational requirements present in Department policy; industry standards; state, federal and judicial mandates; and best practice.