Continuous Quality Improvement

What is Continuous Quality Improvement?

Simply stated, continuous quality improvement (CQI) involves the continuous evaluation and re-evaluation of a service delivery system. A well-developed continuous quality improvement system is one that is continuous, circular in design, and dynamic enough to promote, encourage and affect change. Quality improvement must cycle through all the steps of its quality improvement framework in order to be effective.

What is the Purpose of Continuous Quality Improvement?

The purpose of Nevada's Child Welfare Quality Assurance (QA)/ Continuous Quality Improvement (CQI) system is first and foremost to improve outcomes for children and families. To this end, it is a system that identifies strengths in effective practices as well as areas that need further improvement that are formalized in an ongoing plan for program improvement. Also, it is a system that ensures child welfare services are delivered in accordance with best practice standards and State and Federal requirements. The system should critically examine the quality of assessments and information gathering throughout the child welfare system: the Nevada Intake System, Child Protective Investigations, and Case Management service delivery.

Existing federal regulations require States to describe the quality assurance (QA) system the State has in place to "regularly assess the quality of services under the Child and Family Services Plan (CFSP) and assure that there will be measures to address identified problems" as part of the CFSP (45 CFR 1357.15 (u). In addition to the CFSP requirement, title IV-E requires title IV-E agencies to monitor and conduct periodic evaluations of activities conducted under Title IV-E program and to implement standards to ensure that children in foster care are provided quality services that protect the safety and health of such children (sections 471 (a) (7) and 471(a) (22) of the Act), respectively.

What is a formalized Quality Improvement Framework?

A formalized Quality Improvement (QI) framework is a systematic method for incorporating quality into agency practice. It refers to the integration of monitoring efforts and change initiatives into the existing system. A comprehensive framework provides for review of all aspects of agency service delivery by ensuring that:

There are outcome answers which address the questions, "Are we doing the right things?" and there are process results that respond to, "Are we doing things right?"
Agency data, information and outcomes are used to make improvements to practice and policy and to ensure adherence to regulations and standards.
The process of QI engages numerous stakeholders, such as staff at all levels, children and families served, and community partners.

What are the Functional Components of Continuous Quality Improvement?

Foundational Administrative Structure

It is important to have strong administrative oversight to ensure that a CQI system is functioning effectively and consistently, and is adhering to the process established by the agency's leadership. A functioning CQI system will ensure that:

The State applies the CQI process consistently across the State and the single State agency has oversight and authority over the implementation of the CQI system; there is a systemic approach to review, modify, and implement any validated CQI process.
The State establishes written and consistent CQI standards and requirements for the State, counties, and any other public agencies operating title IV-E programs on behalf of the State, as well as any private agencies with case management responsibilities.
There is an approved training process for CQI staff, including any contractor or stakeholder staff conducting CQI activities.
There are written policies, procedures, and practices for the CQI process even when the State contracts out any portion of the CQI process.
There is evidence of capacity and resources to sustain an ongoing CQI process, including designated CQI staff or CQI contractor staff.

Quality Data Collection

Collecting quality data, both quantitative and qualitative, from a variety of sources is the foundation of CQI systems. For data to be considered ―quality‖ it must be accurate, complete, timely, and consistent in definition and usage across the entire State. It is important for States to use data to identify areas of strengths and concerns, establish targeted strategies for improvement, and track progress toward desired outcomes. States that meet the quality data collection component will be able to demonstrate the ability to input, collect, and extract quality data from various sources, including the Statewide Automated Child Welfare Information System (SACWIS) or other information management systems, case reviews, and other sources of data. States will also be able to ensure that data quality is maintained as the State submits data to Federal databases or reports, such as the Adoption and Foster Care Analysis Reporting System (AFCARS), National Child Abuse and Neglect Data System (NCANDS) National Youth in Transition Database (NYTD), the Child and Family Services Plan, among others. A functioning CQI system will ensure that:

The State's case level data shows that the instruments and ratings are completed in a way that is consistent with the instrument instructions and consistent across reviewers.
There is a clear process that the State uses to collect and extract accurate quantitative and qualitative data, and the process is consistently and properly implemented across the entire State.
The collection and extracting processes are documented, and an audit mechanism is in place to verify that the process is being followed.
There is a clear process that the State uses to identify and resolve data quality issues and informs the Children's Bureau (CB) as appropriate regarding data quality issues. For example, there are processes to: identify if data are being under-/over-reported and/or not being entered into the State's information system; evaluate if data entry is reliable or unreliable and if unreliable, why; (e.g. clarity of instructions, definitions, and/or data entry screens).
There is a process in the State for the collection of quantitative and qualitative data that addresses key issues important to the State and demonstrates how the State is functioning on systemic factors, such as training staff and resource parents, functioning of the case review system, and service array.
The State monitors existing federal requirements or guidelines and uses appropriate quality utilities and tools to ensure that data is accurate, including, but not limited to:
- The most recent AFCARS Assessment Review findings documents and/or AFCARS Improvement Plan (AIP), if applicable, indicates whether the State is accurately collecting, mapping, and extracting the AFCARS data in accordance with the requirements in the AFCARS regulation at 45 CFR 1355.40 and steps the State is to take to correct its AFCARS collection. This includes steps to improve the accuracy of the data through ongoing training, oversight, and incorporation into a quality assurance process.
- The most recent NCANDS data, or other safety data that impact the outcome indicators being measured, meet any CB quality guidelines.
- The most recent data profile used for the CFSR accurately reports the status of the child welfare program as indicated by data errors falling below acceptable thresholds.
- NYTD data meets the regulatory requirements at 45 CFR 1356.80 - 86 and other CB quality guidelines.

Case Record Review Data and Process

Case Reviews are just one component of an adequate CQI system and in addition to collecting and analyzing quantitative data, it is also critical that State CQI systems have an ongoing case review component that includes reading case files of children served by the agency under the title IV-B and IV-E plans and interviewing parties involved in the cases. Case reviews are important to provide an understanding of what is "behind" the safety, permanency and well-being numbers in terms of day-to-day practice in the field and how that practice is impacting child and family functioning and outcomes. A CQI system will ensure that:

Cases of children are reviewed on a sampling universe of children statewide who are/were recently in foster care and children statewide who are/were served in their own homes. Samples should be sufficiently large enough to make statistical inferences about the population served by the State. The universe of cases reviewed will also include the title IV-B and IV-E child population directly served by the State agency, or served through title IV-E agreements (e.g. with Indian Tribes, juvenile justice, or mental health agencies).
The sample is stratified to include a proportion of cases that reflect different age groups, permanency goals, and other considerations, such as varying geographic areas of the State, as appropriate.
Case Reviews are conducted on a schedule that takes into consideration representation of the populations served by the State, including the largest metropolitan area, and the significance of other demographic and practice issues.
Case reviews collect specific case-level data that provides context and addresses agency performance.
Case reviews are able to detect the quality of services for the children and families served and therefore focus on the assessment and monitoring of how child and family functioning is progressing in relation to the services provided.
Case reviews include the completion of interviews specific to each case, such as the child/youth, birth parent, caregiver, caseworker or supervisor, and as indicated, health, mental health and other service providers, educators, and guardian ad litem (or child's attorney).
Case reviews are conducted by staffs who go through a uniform and consistent training process and whom the State determines are qualified to conduct reviews, with a preference for staff and stakeholders with direct service experience.
The process prevents reviewer conflict-of-interest and promotes third-party (unbiased) review of cases, i.e. cases are not reviewed by caseworker or supervisor responsible for cases or who had previous involvement in the cases, as well as those who may have a personal interest in the case.
Policies, written manuals, and instructions exist to assist in standardizing completion of the instruments and the implementation of the case review process.
Inter-rater reliability procedures are implemented to ensure consistency of case ratings among reviewers.
There is a process for conducting ad hoc/special reviews targeting specific domains when analysis and other data warrant such reviews.

Analysis and Dissemination of Quality Data

A functioning CQI system will ensure that:

There are consistent mechanisms in place for gathering, organizing, and tracking information and results over time regarding safety, permanency, well-being outcomes and services (at the child, caseworker, office, regional and state level, as appropriate) .
There is a defined process in place for analyzing data (both quantitative and qualitative), and training is provided to staff and determines that they are qualified to conduct such analyses.
Data is aggregated statewide and local data is made available to stakeholders for analysis.
Agency decision makers, courts, tribes, and other stakeholders are involved in analyzing and understanding the data and in providing feedback on analysis and conclusions.
Results are translated (trends, comparisons and findings) for use by courts, tribes, and a broad range of stakeholders, and the data is disseminated through understandable or reader-friendly reports, websites, etc.

Feedback to Stakeholders and Decision-makers and Adjustment of Programs and Process

Collecting information and analyzing results are important steps in CQ and how data is used is a critical component to driving change within the organization and is important to improving outcomes for children and family functioning CQI system ensures that:

Results (i.e., trends, comparisons and findings) are used by agency leadership/top management, courts, tribes, entities with title IV-E agreements, and other stakeholders to help guide collaborative efforts, inform the goals and strategies of the CFSP and other State plans for federal funds such as the Court Improvement Program strategic plan, and to improve practice, services and monitor/track progress toward goals.
Supervisors and field staff understand how results link to daily casework practices; results are used by supervisors and field staff to assess and improve practice.
Results are used to inform training, policy, practice, community partnerships, service array (service gaps, quality, etc.), automated system development, and other supportive systems.
The CQI process itself is adjusted as needed over time as results indicate a need for additional study, information and/or analysis.

Continuous Quality Improvement Annual Reports

To view the Annual Reports for Continuous Quality Improvement, please follow the link below.

Annual Reports