Purpose: Human services are increasingly held accountable for the quality of their services. Yet there is little information on how these agencies have responded to the pressures to demonstrate quality and effectiveness. Although calls have been made for more program evaluation, outcomes management systems, and the use of practice guidelines, little is known about the implementation of these recommendations. Despite this new era of accountability, the quality of social services is still not clear. This paper will report findings from Assessing Actions to Assure Quality (AAAQ), a study that explored quality-directed activities and the organizational barriers that impede these efforts.

Methods: Anonymous surveys were mailed to 553 field practicum instructors for a Midwest master of social work program in September, 2004. Forty-two were returned for insufficient address or instructor no longer at the agency. Of the remaining 511 surveys, 211 (54% response rate) were returned completed. The instruments included measures of agency perceived reputation, quality-directed activities, barriers to quality service, and perceived demand for quality care. Information was also obtained about respondents' work setting, organizational size, role, service sector, and agency accreditation status.

Results: Overall, the mean number of quality-directed activities per social service organization was 16 (SD=26.8), based on a possible range of 6-20. The quality-directed activities with the most frequent endorsement included using effective interventions (77%), monitoring behaviors for licensure (70%), and training new employees (67%). One-way ANOVAs comparing quality-directed activities and agency characteristics found significant associations between activities and an agency's auspices F(11,248)=3.00, p<.05, organizational size F(11,248)=2.53, p<.05, and service sector F(11, 248)=6.1, p<.001. Additionally, quality directed activities also varied by the role of the respondent F(11,248)=2.67, p<.05, and perceived reputation with peers F(11,248)=-2.38, p<.05. All subscales were entered into a multivariate regression to predict frequency of quality directed activities. Respondent role, service sector, accreditation status and public reputation were predictive of quality activities (R²=.23, p<.0001). Barriers to quality care were also examined for significance. The barriers most frequently cited included lack of financial resources (54%), not enough staff (48%) and low reimbursement rates (37%). Significant bivariate associations were found with organization size F(4,272)=2.41, p>.05, service sector F(3,272)=2.81, p>.05, and an agency's reputation among the public (t=2.07, p>.05). Multivariate regression analysis indicated that service sector was the only predictor of barriers (F-2.62, p=.009, R²=.076), with mental health service agencies reporting more barriers to quality (ß=.277, t=2.62, p=.009).

Implications for Practice: This study's findings indicate that external pressures related to accreditation and licensing status, funding source and service sector can have positive results, influencing an agency to implement quality improvement activities. Additionally, an agency's size and perceived reputation also affects implementation. The finding that an employee's role has an effect on their awareness of quality-directed activities is significant. It suggests the need for agencies to have more direct-care staff become active participants in the design and implementation of quality-improvement activities. This will facilitate ownership of activities, promote their use, and create a quality-improvement culture throughout the organization.