Quality Assurance and Improvement in Child and Family Services

Background and Purpose: The increased deployment of quality assurance/quality improvement (QA/I) professionals in social services, spurred by accreditation requirements, offers an unprecedented opportunity to strengthen services. This qualitative study, the first on QA/I in social services, addresses three questions:

1.What do QA/I professionals do and what quality issues do they target?

2.Who performs these QA/I roles?

3.What challenges do they face?

Methods: Participants and recruitment. A maximum variation sampling strategy (Kuzel, 1999), identified 18 child and family service agencies in the St. Louis region that employed a designated QA/I employee. Recruitment was through mailed letters followed by phone calls. Sixteen agencies (89%) and their designated QA/I leader participated. Data collection. An in-person interview was used to ask about QA/I activities, how participants came to their jobs, and work challenges. This was followed by a short structured questionnaire. Data analysis. Analysis followed a systematic iterative process of text review, interpretation, and data categorization whereby the analysts identified statements that were relevant to research questions, made inferences, and organized them into codes (Miller & Crabtree, 1999). First, the analysts separately reviewed eight transcripts to develop a codebook by consensus. After the codebook was completed, two analysts coded all the transcripts, and then produced reports for further analysis, interpretation, and synthesis.

Results: What do the QA/I professionals do? The QA/I professionals described their work in markedly different ways. Some saw their work at a high conceptual level, such as development of a QA/I program. Others viewed their work in terms of their main tasks, such as conducting surveys or chart reviews. Several saw their work primarily as helping their agency remain accredited. These professionals were often assigned other responsibilities. "Everything can be seen as quality assurance," said one respondent. Several were monitoring a number of things, of which only a few related to service quality, while others seemed to be measuring almost nothing. Who are they? QA/I professionals were experienced and highly educated. They had an average of 7.81 years of experience in QA/I and 19.42 years of experience in social services. Fifteen had at least a Master's degree (six in social work). The majority were former clinicians. QA/I challenges. The QA/I professionals identified seven challenges: 1) resource limitations, 2) organizational buy-in, 3) competing demands, 4) skills development, 5) continually changing standards, 6) lack of authority within the agency, and 7) research capacity.

Conclusions and Implications: The QA/I professionals varied markedly in their preparation for their work and in the type of work they were performing. They described substantial barriers to their success. In general, we found this group to be intelligent, hard working , and eager to use QA/I tools to improve care. However, many were unprepared professionally for their roles, lacked resources, or worked in agencies where key administrators did not appreciate the QA/I role. QA/I will not likely fulfill its promise to improve services unless the QA/I workforce is professionally trained, supported, and their work is focused on quality service delivery.