Continuous Quality Improvement Project
Georgia
Interview with Shelley Cyphers, Director, Office of Quality Management sacyphers@dhr.state.ga.us • 404‐657‐3325
and Mary Franklin Barmore, CQI Unit Manager mfbarmore@dhr.state.ga.us • 706‐621‐3708
January 18, 2012
CONTINUOUS QUALITY IMPROVEMENT (CQI) STRUCTURE Department Structure
Although CQI as a process is not new to Georgia, the CQI Unit was very recently created. The CQI Unit is based out of the Central Office and consists of one manager and four CQI staff members (two
designated for social services and two designated to the Office of Family Independence). The four CQI staff member positions are brand new, having been filled in January 2012. The salary and travel budget for this unit is approximately $500,000 annually. This Unit works solely on CQI related activities and is within the Office of Quality Management (OQM). There are seven units within OQM. All of the review processes that the Department of Family and Children Services (DFCS) run are done through the OQM.
This includes a CFSR quality assurance type review, data pieces of AFCARS and NCANDS, and reviews for the Kenny A. Consent Decree. The CQI process and two federally mandated Office of Family
Independence review processes are also run through the OQM.
Georgia has recently implemented regionally‐based CQI Teams. Though staff working on CQI has been very good at gathering data and telling the State how they’re performing practice wise, they have historically not been involved in being part of the solution to resolve deficits. They felt this was a role they should be a part of so a CQI process was launched. This process started three years ago and at that time there were 17 regions. State staff working on CQI and a representative from each region attended a monthly meeting to share their struggles and promising practices. During these meetings, participants went through everyone’s tools, monitoring and measuring strategies, and examined every time a QA review was conducted within the State that mirrored the CFSR process. Regional representatives would share what they did to prepare for the reviews, outcomes would be shared, and they would talk about what they learned from the process, what they would do differently next time, and what their plans were going forward. During these meetings they also discussed systemic issues throughout the State with their SACWIS system (SHINES), resource issues, and many other topics that had to do with
improving practice or barriers to doing the work. These monthly Statewide meetings occurred for three years. They hoped that the regional representatives would then turn around and mirror this process within their own regions. Although these meetings were beneficial, they decided they weren’t having a true CQI process because it was not consistently being used within the regions. Some participants had embraced this process and used it well within their regions where other times it stayed with the one
person who came to the meetings. Because of this, last spring they proposed launching regionally‐based CQI teams throughout the State.
There are now CQI teams within all of the regions led by a Regional Facilitator. The facilitator has other jobs within the region in addition to their CQI related activities. The State provided targets for regional CQI team membership by asking them to have representation from all levels within the organization covering all program areas, with an emphasis on frontline staff involvement. Regions could make their teams as small or large as they felt they needed to be in order to have continuity and integrity in the process. The CQI Unit have monthly calls with all of the regional facilitators and quarterly face to face meetings that the CQI Unit funds, structures, manages, and facilitates.
The regional CQI facilitators are supervised within the regions, but report on CQI related activities to the CQI Unit Manager. Preliminarily, they had requested the regional CQI facilitators send their meeting minutes to the CQI Unit Manager. The regional facilitators are required to set a baseline and begin measuring their progress now that they’ve completed training and the State CQI Unit is staffed. Because they feel buy‐in is extremely important, they did not want to take all of the decision making away from the facilitators. They have the ability to develop their own baseline around what they felt like was the high value target for them in terms of performance, and should devise their own way to monitor and measure their progress. These are in the process of being produced. Once things are underway, reports will be submitted to the CQI Unit Manager.
Staff Qualifications and Responsibilities
State CQI Unit staff were required to have a minimum of one year experience in Georgia’s Family and Children Services as a supervisor. They were required to also have a college degree, with experience able to be substituted with a Master’s Degree depending on the number of years.
Regional Directors were responsible for selecting the CQI facilitators and were given specific criteria from the State. The teams are intended to be as close to the frontline as they could get, without direct involvement from the directors. Directors were asked to select people who would be natural leaders and people that they felt the teams would respond well to. The facilitators are expected to be culture bearers and change agents for their region and county. They will develop practice‐based behavior goals and tasks and be responsible for supporting transfer of learning for these within their sphere of
influence. Desired qualifications included: self motivated with a strong ability to motivate others; has a vision for how things could be better in the future regardless of what is happening today; understands casework; has the ability to lead; has the ability to clearly articulate their perspectives; demonstrates a commitment to child welfare learning.
Training
As the process of implementing regional CQI teams was rolled out, very specific training was provided to regional CQI facilitators. They were trained on Gilbert’s Performance Engineering Model which
promotes the idea that before you start to build your solutions, you have to drill down to find out what the problem really is. All facilitators were asked to use this model for the first year to work on issues
around well‐being. They understand that the nuts and bolts of their work relies in services to families and quality of contacts with children, parents and providers so felt that well‐being would be the best area to focus on initially. Facilitators were also provided a pure facilitation skills training as well as an overview of implementation science.
Committees
There are currently no CQI committees within Georgia.
CQI PLAN Expectations, Missions, and Objectives
Georgia is in a very new process in regards to CQI. Their new approach is improvement based and should help them move away from the compliance mentality. They do not currently have a formal manual or missions for CQI, although this is part of their long term plan. They do, however, follow a performance model developed for the CQI process in conjunction with Georgia’s Education and Training Department and Georgia State University.
CQI Policies
There are currently no CQI‐specific policies within Georgia.
ELEMENTS OF THE CQI SYSTEM Qualitative Reviews
• Internal CFSR
Each region in Georgia is reviewed every 18 months. The State has just gone from 17 to 15 regions and added on additional CQI staff, so this schedule may change in the future. They use a comprehensive review tool that mirrors the Federal CFSR instrument with additional elements added particular to Georgia. They have added questions specific to Family Team Meetings, safety resources, and other Georgia specific items. There is also an added data piece where they are looking not just at the quality of the review but also the integrity of the data in the SACWIS system. This data piece is done
simultaneously with the case review but is a separate set of information.
A different section within the Office of Quality Management (OQM) pulls a random sampling of cases;
they try to conduct sampling similar to the Federal CFSR. Within every region they read 12 Child Protective Services cases and 12 foster care or placement cases (along with any investigations or foster homes attached to those cases). To address inter‐rater reliability and ensure consistency across reviews, they have a second level review and in some situations a third level review. The CFSR team within the OQM is responsible for conducting these reviews. Within the CFSR team there is a Unit Manager that reads the same cases the reviewers are reading, with the Program Director reading a sample. Interviews are conducted on every case with the caseworker, supervisor, and other stakeholders.
There is a debriefing on each and every case with the caseworker and supervisor. During these
debriefings they may also bring in other caseworkers doing similar work so that they can also learn from the review. Individual debriefings are done on ever case at the county level to try and transfer learning.
Exit interviews are conducted for all counties with county leadership and an overall exit interview happens with the region leadership.
The reviewers are selected through an interview process and are required to have a minimum of 1 year Georgia‐specific supervision experience. They also have to have strong foster care, child protective services, and adoption knowledge. Typically, they’re able to hire staff that have been in the system for quite some time and have proven themselves in their field. Periodically, Federal staff have provided training to reviewers but generally they receive on the job training. There is a mentoring structure in place so that new hires may job shadow and work alongside an experienced reviewer for a minimum of six months. There are approximately 12 reviewers on the CFSR team.
• Kenny A. Consent Decree
Georgia has two specific units within the OQM that are dedicated to conducting reviews specific to the consent decree. One unit conducts reviews specifically for the 31 outcomes involved in the decree and produces information for the Court Monitoring Report. There are approximately 10 reviewers on this team. The second unit, consisting of six reviewers, reads cases specifically for permanency, looking at children that have been in care at 9 months, 13 months, and 25 months to determine what else needs to happen to move them to permanency. Staff conducting these reviews also sit in on permanency roundtables. This is any ongoing review where they spend approximately three months reviewing the previous six month time period (January‐June; July‐December). Georgia also conducts targeted reviews every other period specific to things like diligent search and sibling placement.
Although case‐specific interviews are not conducted for this review, some caseworkers and supervisors may be interviewed about current barriers or challenges. A random sampling is pulled by the Court Monitors (with the exception of maltreatment in care cases as those are all reviewed). Georgia State University read 1/3 of these reviews then come together with the reviewers to talk about where they are consistent, not consistent, etc. The requirements for these reviewers are the same for those on the CFSR Team, though they typically have to have a strong background in permanency.
Quantitative Data
Georgia relies primarily on their SACWIS system, SHINES, for quantitative data. The reports that they produce at the end of their qualitative review process also contain some quantitative data. Individual counties and regions may have different data sources as well. For instance, outside of their SACWIS system regions are specifically tracking how many children they have in care that have been in care for less than 12 months and over 12 months, looking at their permanency goals and progress toward reaching those goals.
USE OF DATA Reports
Reports generated using the SACWIS system are referred to as Lenses Reports. They also generate numerous reports from their qualitative review process which are shared with the regions upon completion of the review. Statewide, they pull SACWIS data to create charts and graphs which are then shared through a PowerPoint presentation. These PowerPoint presentations are sent out to all regional directors and allow them to see where their region falls. The data highlighted in these presentations changes depending on what the current focus is at that time, but typically includes items that can be pulled out and easily measured, such as meeting response times in CPS. They meet with leadership staff monthly to look at where they stand within certain parameters (the next meeting is focusing on where Georgia stands with safety and well‐being measures). During these meetings they talk about what the quality looks like versus the numbers.
Data Software
No specific data software is used to generate reports.
Plan Development and Training
SACWIS data and qualitative review results are regularly used at the State level to generate reports, such as the APSR. At the regional level, there is a requirement that once the region receives their review findings that they are to develop a quality improvement plan within 30‐45 days. They’re currently discussing what the State’s role is going to be in this process, as the newly developed CQI teams are going to be much more instrumental with this than they have been able to be in the past.
There is a separate unit that is specifically charged with Statewide strategic planning that utilizes data.
Also, Georgia’s Office of Quality Management has a very close relationship with the State training unit.
The training unit receives all of the reports generated and engage in ongoing conversations about what is working well, not working well, etc. They have been instrumental in the development of the training program for the regional CQI facilitators, and have expressed a desire to remain involved. They’re very interested in looking at different ways they can transfer learning within the State and are already seeing results from staff exposure to CQI.
Systemic Issues
Using data to look at systemic issues is not specifically a focus or something that’s put into their reports, though they are able to examine systemic issues when they’re out in the regions and can naturally pick up on some of this during the reviews.
Identifying and Correcting Data Quality Issues
Another unit with the Office of Quality Management – Data Integrity Unit – is responsible for working with regions to improve the accuracy and quality of data. There is one data integrity specialist housed
within each region. There is also the data piece attached to the internal CFSR reviews (see qualitative data above for more information). The data integrity specialists and regions receive the results of this data review.
Linking Data Sources
They are able to link data sources by reviewing all of the data and drawing conclusions, but nothing is currently in place where they can do this systematically. They are able to match manual reports with reports generated in SACWIS to make sure what they’re pulling from their data system aligns with what local offices are seeing.
Collaborative Data Analysis Efforts
Georgia works closely with Georgia State University for all aspects of the Kenny A. Consent Decree reviews, including data analysis.
STAKEHOLDER INVOLVEMENT Internal/External Stakeholders
Internal and external stakeholders are actively involved in program improvement at the State level.
Regional and local levels of stakeholder involvement varies, although it is certainly encouraged. The State has a number of avenues to bring in external stakeholders and appreciates the value that their involvement brings.
Georgia’s Office of Quality Management works closely with Georgia State University and collaborates with numerous other State units with an interest in child welfare.
Privatized Systems
Georgia has private agencies that provide residential care for children, but do not privatize their services other than that.
FUTURE PLANS
The CQI process in Georgia is brand new. They’re going to continue to develop this system and work with the regions as they establish their CQI teams.
