Quality Assurance and CQI Activities

In many child welfare agencies, quality assurance (QA) case record reviews, along with the collection and review of aggregate data, may be the only or primary components of the States’ continuous quality improvement (CQI) systems. However, an agency's CQI program can and should become much broader to include many activities at many levels where case practice is reviewed, recommendations are made and carried out with the goal of achieving better outcomes for families and children, and data are generated. States should be creative in determining their practice elements that fit this criterion.

Normally, in the QA case review process, individual or paired staff members serve as case reviewers, and they periodically examine a group of selected cases in different areas of the State. They provide feedback about their findings, and this feedback most immediately impacts caseworkers, supervisors, and the next level of management. Over the years, with the implementation of the Child and Family Services Reviews, many agencies have moved from primarily monitoring compliance in their QA case reviews to assessing quality of services and child and family outcomes.

Some agencies with well-functioning QA case review systems may question why an expanded CQI program is needed, now that they have progressed beyond compliance monitoring. It is important to remember that a full CQI system involves analyzing data from case reviews and numerous other sources to identify what is working well and what is not so that the agency can constantly improve practice. With the relatively new focus on CQI in child welfare, agencies are broadening their improvement efforts to permeate every aspect of the agency. Thus, QA case reviews should represent an important, but not necessarily the primary, component of States’ multi-faceted, agency-wide CQI efforts that drive needed changes on a continual basis.

The table below is adapted from Alan Dever's 2003 book, Public Health Practice and Continuous Quality Improvement, and outlines the major differences between QA and CQI:

Differences Between QA and CQI

QA

CQI

is a separate activity

is an integrated activity

is reactive

is proactive

is “top down”

bridges both horizontally and vertically

improves the performance of those whose cases are being reviewed 

improves performance agency-wide

focuses on meeting specific compliance and outcome criteria 

focuses on improving multiple processes and outcomes

measures standards that are established by professionals 

uses fluid, constantly changing standards that are established by stakeholders and consumers working alongside professionals 

is event based 

is based on an ongoing process 

is management focused (directing) 

is employee, stakeholder, and consumer focused (involving) 

involves selected staff and functions

is agency-wide and crosses all functions

Thus, QA uses standards established by professionals that define acceptable or unacceptable levels of performance. As a reactive or retrospective process, it assesses practice that has already occurred. QA results direct the behavior and practice of child welfare practitioners toward improved outcomes “after the fact” through a specific event, such as a scheduled case review with selected staff, that occurs outside of other improvement processes.

QA case reviews are a necessary element of a child welfare agency’s overall CQI system. Although both QA and CQI seek to improve quality, CQI proactively tracks, analyzes, and corrects ongoing, interrelated, and interconnected processes (including QA case reviews) in an effort to constantly improve systems and practices. In CQI, it is these multiple processes and systems, not the performance of specific practitioners, that are the focus of improvement. A comprehensive CQI process sends a strong signal to agency staff, external stakeholders, and consumers that their involvement is crucial to the agency’s continued learning, exploration of new ways of doing things, and improvement.

Consequently, a well-functioning CQI system encompasses a wide range of processes and facilitates the launching of targeted activities to meet identified needs. These may be major initiatives or smaller-scale projects. When data show concerns in specific practice areas or parts of the State, the agency may choose to implement family team meetings in a targeted area, or large-scale statewide initiatives such as trauma-informed care. In another situation, mentoring and coaching frontline staff on higher quality worker-child visits statewide might have a significant positive impact on safety, placement stability, timely permanency, and other areas. Varied, smaller-scale activities can occur concurrently, as long as they are being overseen, assessed, and well-managed through an analysis of the data they are generating.