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

Legal Authority

42 USC 671: State plan for foster care and adoption assistance ...

42 CFR 1357.15 Comprehensive child and family services plan requirements ...

Introduction

The agency’s continuous quality improvement (CQI) and case review processes are part of the quality assurance system in place to regularly assess service quality and ensure measures are in place to address any identified problems. These processes allow the agency to regularly monitor and conduct periodic evaluations of services to ensure quality service provision and the safety and health of children in care.

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

Practice Guidance

The CQI process includes analysis of quantitative data, case reviews, and interviews of 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 for complementing quantitative data on key measures such as safety, permanency, well-being, and self-sufficiency by providing further insight into practice and how it affects child, adult, and family functioning and outcomes.  Case reviews are used to assess the quality of services for those being served and, therefore, focus on assessing and monitoring 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 who undergo a uniform, consistent training process to help ensure inter-rater reliability.  The process prevents reviewer conflicts of interest and promotes third-party (unbiased) review of cases.
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 about services and case planning.
To ensure an unbiased review within first-level case reviews, and to align with federal guidance, regions 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, mentoring, and evaluation purposes, additional cases may be reviewed outside of CQI-CARES 2.0.
The period under review (PUR) for first and second-level case reviews is twelve (12) months prior to the date of the review.
Cases shared with the rapid response team may still be reviewed at both the first and second levels.
For additional guidance and instructions for completing first and second-level case reviews, please refer to the CQI Case Review Instructions.
Cases for the Kentucky Child and Family Services Review (KY CFSR) are identified by criteria that meet federal requirements, including:

Three (3) cases are reviewed per central office 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.

Procedure

For first-level case reviews, the FSOS:

Receives training from the CQI Specialist on CQI-CARES 2.0 and the TWS-M112 monthly report prior to the initial assignment and completion of case reviews;
Meets 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, prior to case reviews being assigned for the first time;
Is automatically assigned four (4) cases per month, within their program area and region, in CQI-CARES 2.0 for review;
Utilizes TWIST 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.

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;
Obtains and reviews the Case Review Strengthening and Mentoring Form received from the FSOS for the associated case;
Utilizes TWIST 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, and returns the Case Review Strengthening and Mentoring Form to the FSOS if there are additional comments.

The CQI specialist:

Utilizing the CQI Case Review Instructions, assigns eighteen (18) cases for second-level review, divided among each designated second-level case reviewer, in CQI-CARES 2.0;
Begins monitoring the completion of first-level and second-level case reviews on the twenty-sixth (26th) of each month;
Notifies FSOS and regional leadership of case reviews that have not been completed;
Provides technical assistance to the FSOS or second-level case reviewers during the case review process, as needed;
Manually unassigns the case in CQI CARES 2.0 and reassigns the case to the appropriate reviewer or provides a substitution, if reassignment of a case is required for any reason. (To determine when a case is eligible for substitution, please refer to CQI Case Review Instructions); and
Unassigns cases in which staff from the rapid response team is listed as the case manager for the case in TWIST.

Central Office CFSR Reviewers: