CQI in County-Administered or Privatized States

In county-administered States where the various counties operate with some degree of autonomy, as well as in States that have largely privatized their child welfare services, States should continue to have consistent expectations statewide regarding continuous quality improvement (CQI). The State agency should establish basic requirements that are uniform for the entire State, while considering negotiation with counties or private agencies on issues that may allow some flexibility (such as less frequent reviews for areas that consistently perform well).

The CQI focus will be on ensuring that the CQI process is comprehensive, contains a robust case review process, that collected data are uniform statewide, and that there is consistency throughout the State in CQI processes and casework standards and practices. In the case review process, CQI staff, whether centrally supervised or supervised from their counties/regions, will assess practice more objectively and consistently in their review of cases if they are dedicated to CQI activities. Having dedicated CQI staff who work closely with the State’s CQI administrative oversight division will also help ensure that case record reviews are conducted with necessary frequency, meet quality standards, and adhere to other policy requirements.

If the counties in county-administered States have their own CQI staff, then the State’s CQI oversight staff could either pair with the county staff for case record reviews or have close involvement in planning and overseeing the reviews in a county or region to help ensure a quality process. If that is not possible, then county reviewers could cross-review with other counties and the State’s CQI oversight division could take steps to ensure consistency and quality, such as the provision of QA for case review instruments. Likewise, in the case of private agency contractors who have their own CQI staff, the State’s CQI oversight staff might pair with the reviewers, at least on initial reviews, and/or take steps to ensure accuracy, quality, and objectivity such as providing QA review for case review instruments completed by contractors.

Oversight of county and private agency QA case reviews by the State’s oversight division should be strong enough to ensure that review-related procedures are being followed, including that:

  • County, regional, or contractor reviewers are qualified and appropriately trained
  • The necessary degree of objectivity exists
  • Inter-rater reliability is assured
  • Reviews are being completed on schedule
  • A back-up plan is in place when conflicts of interest are identified with a reviewer, private agency, or county
  • The case sample is randomly identified and the size is correct
  • Required review results are drawn up and dispersed in a timely way

If CQI staff are county-based and -supervised, they should receive uniform training (and re-training as needed) coordinated by the CQI oversight division, as should private agency staff. 

It is critical to ensure that private agency contractors have a thorough understanding of the State’s CQI efforts and requirements and that they be held to the same standards as agency staff regarding:

CQI expectations, processes, and outcomes should be clearly articulated in private agency contracts, and should be closely overseen. Contractor performance, on an ongoing basis, should be monitored by the State agency’s program staff or contract managers or both, as should action plans for contractors to correct any deficiencies. Diligent monitoring and oversight of contractor activities will help ensure quality and integrity in their CQI programs. Enthusiasm for and commitment to the CQI process should be just as high in the private agencies as it is in the State agency.