Rarely does the public get a glimpse into the working of quality improvement systems in place in a public social service. In 2012, the National (Child Welfare) Resource Center on Organizational Improvement (NRCOI), conducted semi-structured phone interviews with 31 state child welfare quality improvement leaders. NRCOI has now published a number of reports from these interviews on their website. They suggest a quality improvement workforce with expertise in child welfare, but not in quality improvement.
Their data suggest that the child welfare quality improvement workforce is not affiliated with professional training or certification in the quality field. No state reported requiring a certification in quality for any quality improvement position. Only two states required a master’s degree for quality improvement work. Most states required prior child welfare experience, and many states required supervisory experience in the child welfare agency (which in some states may require a master's degree). These data suggest that public child welfare agencies promote to quality improvement positions from within their agencies, ensuring a quality improvement workforce that knows child welfare, but not a workforce that knows quality improvement.
If states are not hiring quality professionals from outside their agencies, then they must train newly promoted child welfare professionals in quality improvement. But, the NRCOI study revealed that no state has a systematic quality improvement training program. Two states reported that their quality improvement staff members were trained in a specific quality improvement model: Iowa on Lean and Georgia on Gilbert’s Behavior Engineering Model. Several states described nonexistent training, as exemplified by quotes like this: “There is no formal training program for QA unit staff. There is self-directed learning.” Several more states said they relied on on-the-job training. One state provided training in SPSS (a statistical software package).
We have little doubt that the child welfare professionals being promoted into these positions are smart people who know child welfare. But no one naturally knows how to do QI. Child welfare QI often requires skills in data: determining indicators of quality, measuring them accurately and reliably, analyzing trends over time, assessing variation in quality indicators for outliers indicative of places where things are going particularly right or particularly wrong. It also involves work in improvement: chartering and preparing teams for improvement projects, access and managing data related to the problem, and how to conduct a root cause analysis. Child welfare quality improvement pros need to know how to use data to assess whether change has occurred and how to be effective at leading team meetings through a variety of tasks.
It is unclear the extent that the QI workforce in child welfare is exposed and experienced in these areas, but these are hard skills to learn on the job. This might be the teacher in me, but this requires some preparation and study. Without this preparation, we simply have good people doing their best.
Even the worst gardener can get a flower to bloom every once in a while. And a rookie gardener can get better through trial and error. It doesn't take a master gardener to make a beautiful garden, but the novice gardener needs advice and education. She needs to learn from the efforts of other gardeners. QI training can provide the seeds, tools and a garden plan. Properly trained quality professionals and administrators can pollinate QI throughout an agency if they so desire. Let's build quality gardens and not be satisfied by the rare flower.
I congratulate the NRCOI for conducting the ground breaking work. This work has likely influenced the U.S. Children's Bureau to issue a funding opportunity announcement train the child welfare quality improvement workforce. The NRCIO work gives the field a baseline from which to measure growth.
Finally, I would like to challenge NRCOI to analyze this data in a scientific manner and publish the results in peer-reviewed publications or a in a formal document that can be widely distributed. The first step is knowing we have a problem. And we have a problem training the social service QI workforce.