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G2.6 Continuous Quality Improvement (CQI) and the Case Review Process

Legal Authority

Introduction

Existing federal child welfare regulations require states to describe the quality assurance (QA) system the state has in place to regularly assess the quality of services under the Child and Family Services Plan (CFSP) and assure that there will be measures to address identified problems as part of the CFSP (45 CFR 1357.15(u)). In addition to the CFSP requirement, Title IV-E of the Social Security Act requires agencies to monitor and conduct periodic evaluations of activities conducted under the Title IV-E program and to implement standards to ensure that children in foster care are provided quality services that protect the safety and health of such children (sections 471(a)(7) and 471(a)(22) of the Act), respectively. The Children’s Bureau considers having a method for conducting ongoing case reviews as essential to a state having a functioning CQI system in child welfare. In addition, in response to the April 2011 Federal Register notice [76 FR 18677] requesting public comments on improving the process of reviewing titles IV-B and IV-E through the Child and Family Services Review (CFSR), states and other stakeholders suggested a strengthening of states' overarching QA systems to encompass continuous quality improvement (CQI) methods. Commenters suggested that such systems should play a prominent role in federal monitoring of conformity with Title IV-B and Title IV-E requirements and state-driven assessment, refinement, and improvement.

In addition to collecting and analyzing quantitative data, it is also critical that state CQI systems have an ongoing case review component that includes reading case files of children served by the agency under the Title IV-B and Title IV-E plans and interviewing parties involved in the cases. Key to the efficacy of a state CQI system is an ongoing case review component that includes a comprehensive review of case files of children, adults, and families served by the agency. Case reviews are important to provide an understanding of what is behind the safety, permanency, well-being, and self-sufficiency numbers in terms of day-to-day practice in the field and how that practice is impacting child, adult, and family functioning and outcomes.  Case reviews are utilized to assess the quality of services for those being served and, therefore, focus on the assessment and monitoring of how child, adult, and family functioning is progressing in relation to the services provided. 

CQI case review processes at each level ensure a sampling universe of persons served statewide and should be sufficiently large enough to make statistical inferences about the population served and stratified to include a proportion of cases that reflect different age groups, goals, and other considerations, such as varying geographic areas of the state, as appropriate.  Case reviews are conducted by qualified staff that go through a uniform and consistent training process that helps ensure inter-rater reliability.  The process prevents reviewer conflict-of-interest and promotes third-party (unbiased) review of cases.

For a complete overview of DCBS’ CQI process, please refer to the CQI State Plan and Procedures Manual.

Practice Guidance

A quality review consists of a deep dive into the case to ensure that services are being provided that improve safety, permanency, and well-being. The review should also ensure that families are engaged in decisions around services and case-planning.
To ensure an unbiased review within first-level case reviews, and to align with federal guidance, regions will assign first-level case reviews to a family services office supervisor (FSOS) not assigned to supervise the case.
The TWS-M112, randomized TWIST generated monthly report, identifies the cases available for review. CQI specialists should not assign extra cases in addition to the four (4) first-level and eighteen (18) second-level cases assigned by CQI-CARES (Case Automated Review and Evaluation System) 2.0. However, for coaching and mentoring and evaluation purposes, additional cases may be reviewed outside of CQI-CARES 2.0.
Each new FSOS should meet with the CQI specialist who will train them on CQI-CARES 2.0 and the TWS-M112 monthly report prior to the assignment and completion of case reviews. The FSOS should also meet with their direct supervisor to discuss the clinical and supervisory elements of the case review and how to utilize the Case Review Strengthening and Mentoring Form with their staff.
The period under review (PUR) for first and second-level case reviews is twelve (12) months prior to the date of the review.
For additional guidance and instructions for completing first and second-level case reviews, please refer to the CQI Case Review Instructions.

Procedure

For first-level case reviews, the FSOS:

Is automatically assigned four (4) cases per month, within their program area and region, in CQI-CARES 2.0 for review;
Utilizes TWIST and the hard copy case file, when needed, to complete a quality review of each assigned case, answering each question within CQI-CARES 2.0;
Completes the reviews in CQI-CARES 2.0 by the twenty-fifth (25th) of each month;
Completes the Case Review Strengthening and Mentoring Form; and
Reviews the Case Review Strengthening and Mentoring Form with the social service worker (SSW) and FSOS assigned to the case, to include a discussion of the strengths, areas needing improvement, and action planning.

The CQI specialist:

Begins monitoring the completion of first-level case reviews on the twenty-sixth (26th) of each month;
Notifies regional leadership and FSOS of case reviews that have not been completed; and
Provides technical assistance to FSOS during the case review process, as needed.

For second-level case reviews, the second-level case reviewer:

Is assigned cases manually by the CQI specialist monthly, from within their region, in CQI-CARES 2.0 for review;
Reviews the Case Review Strengthening and Mentoring Form received from the FSOS for theassociated case 1;
Utilizes TWIST and the hard copy case file, when needed, to complete a quality review of each assigned case, answering each question within CQI-CARES 2.0;
Completes the reviews in CQI-CARES 2.0 by the twenty-fifth (25th) of each month; and
Provides feedback to the SSW and FSOS around strengths and areas of improvement identified within the case.

The CQI specialist:

Utilizing the CQI Case Review Instructions, assigns eighteen (18) cases for review, divided among each designated second-level case reviewer, in CQI-CARES 2.0;
Begins monitoring the completion of second-level case reviews on the twenty-sixth (26th) of each month;
Notifies regional leadership of case reviews that have not been completed; and
Provides technical assistance to second-level case reviewers during the case review process, as needed.

For central office reviews:

Cases for the Kentucky CFSR (KY CFSR) are identified through a different set of criteria that meet federal requirements;

Three (3) cases are reviewed per reviewer, per month;
Eighteen (18) in-home cases are selected for review, per month;
Twelve (12) out-of-home care (OOHC) cases are selected for review, per month; and
Thirty (30) cases are reviewed for the KY CFSR, per month.

For additional information regarding the KY CFSR please refer to The Kentucky Child and Family Services Review Procedures Manual.

Contingencies and Clarifications

If reassignment of a case is required for any reason, the CQI specialist will manually unassign the case in CQI CARES 2.0 and reassign the case to the appropriate reviewer or provide a substitution. To determine when a case is eligible for substitution, please refer to CQI Case Review Instructions.
CQI specialists will unassign cases in which staff from the rapid response team is listed as the case manager for the case in TWIST. If the case is only shared with the rapid response team, the case will be reviewed at both first and second-level, if selected.

Footnotes

If the case is selected for second-level review, the second-level case reviewer will be responsible for obtaining the Case Review Strengthening and Mentoring Form and will send the form back to the assigned supervisor after the second-level review has been completed if there are additional comments.