1. Every Program, Every Agency: A CQI Solution to Meet the Needs of All Organizations
Hannah Hirschland, LMSW, Managing Director of Analytics & Evaluation
Kelsey Louie, MSW, MBA, CEO
GMHC
6/17/16

2. What is Continuous Quality Improvement?
A management philosophy or approach for identifying ways to improve efficiency and effectiveness of services
A continuous process ultimately improving service delivery
Focuses on program-level (NOT the time to talk about individual’s performance)
Well-executed quality improvement projects can lead to drastic improvements in service delivery, client outcomes, client and staff satisfaction

3. Purpose: Overall Role of CQI
Sometimes organizations don’t meet the goals they set for themselves
Ensure that the highest quality of care is provided to our clients
Ensure highest quality of service is provided to customers who are users of that service
Foster a work culture that values self-reflection, evaluation, learning and creativity
Opportunity to have an open, honest, productive discussion that leads to creative solutions using institutional expertise
Identify barriers, then implement and test solutions for better service delivery

4. Main Purposes of CQI Prepare for audits
Monitor progress toward agency-wide goals
Address “biggest problems”

5. Key Components of CQI Involvement of staff Process/systems approach
Continual improvement
Data-driven approach to decision making

6. Who is involved in a CQI process?
CQI teams should include representation from all levels of the staff members within each program and in other relevant departments
Senior Leadership – support data-driven learning culture
Manager – identify problem and guide process
Direct Service/Line Staff – participate in brainstorming session and implementation of action items
Evaluator – supports manager, facilitates root cause analysis, provides outside perspective

7. What are the steps of CQI?
Problem identification & data collection
Brainstorming possible root causes of the problem
Work Plan Development
Execution of solutions and continued data collection
Monitoring and evaluation
Make changes, as needed, and repeat

8. When do you use CQI? Reserve CQI for addressing biggest problems.
Prioritize based on things like:
'Keeping the lights on’
Agency mission
Program mission
Funder directives and other external stakeholder demands
Use Program Dashboards as a guide

9. Institutionalizing Change
Permanent solutions: implement and maintain real system changes
Monitor Performance

10. Tools for Root Cause Analysis and CQI
Fishbone Diagram
Affinity Diagram
PDSA
Work Plans
7 Why’s

11. Fishbone/Ishikawa Diagram

12. Mental Health Dashboard 2016
6/14/2016
1/1/2017
FY Target
FY Start Date
FY End Date
Jan-16
Feb-16
Mar-16
Target
Actual
Program or Department Operations
Treatment/Clinical Docs Completeness (per audit)
100%
1/1/2016
12/31/2016
94%
92%
Eligibility Docs Current and Acceptable (per audit)
93%
98%
Funder Trainings 6 1 2
Program or Department Service Delivery
# of active clients in the program
130
118
128
131
# of cases with no activity of more than 30 days 5
avg days from outreach to 1st intake appt scheduled 8 16
avg days from intake appt completed to Initial Tx session 15 14 26
% no show of on-going scheduled appointments
10%
18%
27%
24%
Contract Deliverables
Care Coordination - Primary Care Provider 51 23 19 39
Group Counseling - MH
332
168
119
164
166
203
Individual Counseling - MH
263
132
207
221
257
Treatment Adherence Counseling - Individual 60 31 29 42 30 34
Reassessment 24 10
Service Plan Development 20 7 12
# of Program Contract Reports Submitted on Time
Contract or Budget Management
# of Variance Meetings
Budget Spent
$ 191,790.00
$ 38,860.50
$ 38,254.18
$ 39,783.00
$ 38,023.00
$ 38,408.00
Spending Rate Variance
+/-1% 2%
-2%
-1%
Triad Management
Data Driven Administrative Supervision (#)
Skills Building Supervision Hours
120 22
# of CQI Meetings
descriptive D
# of open CQI projects with a workplan
# of Triad Meetings
Human Resources
# of Management Positions Vacant
# of Line Staff Positions Vacant
# of Staff on Progressive Discipline
# of Terminations
# of Resignations with <30 Days Notice

13. Example – Mental Health Services Root Cause Analysis
Policies
Procedures
Staff
Customers
Environment
Equipment

14. Example – Mental Health Services CQI Work Plan
Obj #
Objective
Task # (A,B,C)
Task Name
Step # (1,2,3)
Steps
Responsible Parties
Start Date
Deadline
Time Frame (days)
Days to Deadline
Status A

15. How CQI fits into management paradigm
Administrative Data-driven Supervision:
Staff-level assessment (broad) of service delivery
Continuous Quality Improvement:
Program/department-level assessment of service delivery, testing and implementation of quality improvement activities
Skills Building: Staff-level assessment (focused), clinical skills building and training

16. Questions???
Thank you!