Quality of care: expanding the social work dialogue.
Megivern, Deborah M. ; McMillen, J. Curtis ; Proctor, Enola K. 等
The quality of our nation's social services system continues
to gain attention. Funding groups aim to invest in programs shown to
work (Hatry, 1997), while journalists' stories on the perceived
failures of social services systems are rewarded with front-page space
and even Pulitzer prizes (for example, Levy, 2002). Social workers need
to tackle issues of quality not just to avoid bad press. Professional
social work assumes that quality service matters. Although the lives of
some social services consumers may improve with poor service and some
may not improve even with the best service, the likelihood of improving
the lives of consumers should rise as the quality of service rises. If
this is not the case, the need for our profession diminishes.
Important literature on quality has been developing in
administrative social work (see Kettner, 2002), and recently a research
agenda on the quality of social services was proposed (McMillen et al.,
2005). But quality of care is important to all social workers, not just
researchers and administrators. Social work practitioners who want to
participate fully in efforts to improve the quality of social services
need to understand what is meant by quality of care, grapple with its
complexity, and learn how to identify and leverage the key factors most
likely to influence it. To this end, this article introduces a
conceptual model that reflects major influences on service quality and
that is designed to lend specificity to social work's dialogue on
quality and efforts to improve it. This work is designed to help
individual social workers understand the influences on quality in their
service settings and identify leverage points for quality improvement.
SOCIAL WORK AND QUALITY
The discussion of quality in social work has differed from that of
other professions and disciplines, such as retail service (where the
customer is, or at least used to be, king), manufacturing (where
variance is evil and should be eliminated), and medicine (where the talk
is about quality crises, safety, and disparities). Social work's
engagement with issues of quality has been more diverse and has led to
fewer accepted pronouncements about the scope and definition of quality
problems. For the most part, like other professions, social work has
historically used what quality scholars call "the professional
model" to ensure high-quality service provision (Morris, 2000). In
this approach, each social worker is essentially responsible for his or
her own quality control (Palmer & Adams, 1993), with limited
corrections introduced through licensing and sanctions, and moderate
controls in some settings from supervisors and personnel actions (Palmer
& Adams).
In the past 20 years, the increasing use of government purchase of
service contracts to provide social services (Government Performance and
Results Act of 1993) (P.L. 103-62) and an accent on accreditation have
propelled a management interest in quality (Kettner, Moroney, &
Martin, 1999). Writers in social services administration have imported
quality-focused management frameworks from business into social work
(see Kettner, 2002). Much of this has focused on total quality
management (TQM) (Deming, 1982). TQM emphasizes top management's
commitment to quality, customers' definition of quality,
measurements of consumer satisfaction, assessment and correction of
variance, and change through quality teams. But other frameworks have
been used as well, such as Peters and Waterman's (1982) principles
for excellence derived from case studies of successful corporations.
Quality efforts in social work have taken other directions as well.
One of these is data driven, including emphases on program evaluation (for example, Chen, 1993; Devaney & Rossi, 1997) and monitoring of
consumer outcomes (for example, Poertner, Smith, & Fields, 1991).
Other social workers have emphasized professional standards (Shlonsky
& Berrick, 2001; Usher, Locklin, Wildfire, & Harris, 2001) and
compliance with ethical codes.
In the social services, as in health care (for example, Michel
& Johnson, 2002), the word "quality" is likely viewed by
some in political terms because of its implicit ties to issues of
transparency and change, power and control, and money. An interest in
quality implies an interest in unveiling poor-quality care. This
transparency is naturally feared by those who worry that their efforts
will not meet someone else's definition of quality and that they
will be blamed or asked to change entrenched practices. Quality-of-care
work also implicates power mechanisms. Power goes to those who
successfully define what quality of care means in a particular practice
setting or field. Social workers may also fear a movement that could be
viewed as wishing to replace the autonomy of the professional model of
quality control with a more bureaucratic one. With this, social workers
may fear that their allegiances will be drawn farther from their clients
and more toward meeting external standards. Finally, quality issues are
intertwined with a host of financial ones. It likely costs more, at
least up front, to provide higher quality care. As soon as quality is
defined and measured, providers who deliver quality care want to be paid
more than those who do not (for a review of pay for performance, see
Rosenthal & Frank, 2006). Finally, payers may have little interest
in purchasing low-quality care at any cost.
Rather than fleeing from quality issues because of these political
fears, social workers need to be fully engaged in efforts to define
quality practices, understand the root causes of quality problems, and
become proficient at methods to improve quality care. The conceptual
model of quality that we offer here is designed to aid these efforts.
A CONCEPTUAL MODEL OF THE INFLUENCES ON QUALITY OF SERVICES
The social services literature has lacked a systematic, overarching framework for envisioning and assessing the influences of quality
operating in specific practice settings. Without such a framework, our
efforts to understand quality tend to be focused on the end points of
what could be viewed as the two extremes of a complexity continuum. On
one end, social workers are left to our intuitional sense that things
seem to be going well or poorly in a certain practice setting.
Unfortunately, this sense is not specific enough to lead to
recommendations on where quality improvement efforts should be aimed. On
the other end of this continuum are accreditation processes, in which
agencies engage in lengthy self-studies and external reviews on
potentially hundreds of standards designed to eventually determine
whether an agency is functioning "well enough" to be
accredited. Such processes typically fail to capture the big picture on
quality and are too expensive and too focused on details for regular
use. Accreditation offers too many quality improvement targets, too far
removed from an agency's central quality issues. An integrated
heuristic model of quality, grounded in the realities of life in the
social services, can help social workers see the bigger quality picture
and identify quality improvement targets in a manageable number of
domains.
The prevailing model of quality used in health care is a simple
three-part model based on Donabedian's (1988) contention that
quality can be viewed through three interrelated conceptual lenses:
structure, process, and outcomes. In this view, quality is reflected in
favorable client outcomes, and superior outcomes result from
high-quality processes. High-quality social services agencies, in other
words, get results because they do the right things the right ways.
These processes are influenced by certain structures (such as funding
streams, physical plant, organizational structure) that hinder or
support quality. This model has generated substantial research in health
care, but is too underspecified for application. What structures? What
processes? What outcomes? What factors influence structure? What are the
leverage points?
TQM, on the other hand, is all application and no theory. It
focuses on processes designed to uncover and address quality problems.
It advocates using data to search for signs of problems, such as
variations in outcomes, processes, and consumer satisfaction, and uses
employee teams to try to remedy them. It offers little guidance on the
etiology of quality problems or suggested actions for quality
improvement. Social work needs a conceptual model of quality that helps
explain quality problems, allows assessment of the influences on
quality, and provides meaningful targets for quality improvement.
Informed by the multiple literatures on quality of care, we
developed a model to specify key influences on the delivery of quality
social services (Figure 1). Numerous conceptual and theoretical
perspectives inform the model, given the complexity of quality in
service provision. Attree, 1996; Donabedian, 1972, 1986, 1988, 2003;
Lennox & Mansfield, 2001; Markson & Nash, 1995; McGlynn,
Norquist, Wells, Sullivan, & Liberman, 1988; Persico & McLean,
1994; Salzer, Nixon, Schut, Karver, & Bickman, 1997; Selber &
Streeter, 2000; Sowa, Selden, & Sandfort, 2004). No single component
of this model would likely be considered novel to social services
practitioners or researchers, but existing models of quality fail to
integrate its many components. We view this model as purposely designed
to be relevant to the social services, sufficiently well specified to
identify factors that influence quality in social services, and
generalizable to a wide range of social services practice settings.
[FIGURE 1 OMITTED]
Defining Quality Care: Technically Proficient and Sensitively
Delivered
The designation of a model of quality requires a clear definition
of quality service to specify what may affect it. Defining quality,
however, has vexed scholars in business, manufacturing, medicine, and
the human services for decades. Our definition of quality, offered
momentarily, is based on three foundations:
1. Quality services must affect client outcomes. Most definitions
of quality and related concepts have some focus on outcomes. For
example, Kettner and colleagues (1999) defined excellence in the social
services as "the extent to which social programs and social
services are effective in achieving positive changes in the lives of the
clients they serve" (p. 3).
2. Differing stakeholders will hold varied views on quality. In
other words, as Martin and Kettner (1996) argued, quality is in the eye
of the beholder. As Kettner (2002) elaborated, accrediting bodies,
business customers, managers, and federal commissions that give awards
for quality have offered widely differing views of what quality service
means.
3. Quality is likely a multidimensional concept. Martin (1993), a
social work scholar, proposed 15 dimensions to quality in social
services organizations, including such varied aspects as access to
services, conformity, courtesy, and reliability. Donabedian (2003)
offered seven attributes of quality (in health care), including equity,
two related to outcomes of quality (efficacy and effectiveness), two
related to the balancing of costs and quality (optimality and efficacy),
and two related to stakeholder views of quality (legitimacy and equity).
Informed by these multiple sources, we developed the following
definition of quality in social services: "The degree to which
interventions influence client outcomes in desired ways in applicable
domains while being delivered in a sensitive manner consistent with
ethical standards of practice and the best available practice
knowledge." The first part of the definition requires little
explanation as it derives from our first two definitional foundations.
The second part of our definition--"while being delivered in a
sensitive manner consistent with ethical standards of practice and the
best available knowledge"--reflects the multidimensionality of
quality. Providing competent social work interventions involves blending
interpersonal skills, cultural competence, and technical knowledge. In
other words, high-quality care is both technically proficient and
sensitively delivered.
Technically proficient service refers to providers' knowledge,
judgment, and use of appropriate and effective intervention methods
(Donabedian, 1988). This definition is intended to encompass several of
Martin's (1993) domains (competence, conformity, performance, and
reliability) and Donabedian's (2003) legitimacy. In some
circumstances, it can also be viewed as service that is concordant with
existing practice guidelines or service that has fidelity to a specified
intervention.
The social services require engagement from consumers, meaning that
technically proficient service that is delivered insensitively cannot be
considered quality service and will not likely yield desired effects.
Technical care must be delivered sensitively. In our use of the word,
sensitivity encompasses several of Martin's (1993) quality
dimensions (assurance, courtesy, humaneness, and responsiveness) as well
as cultural sensitivity and ethically based practice.
Technically proficient care (Figure 1, box H) and sensitively
delivered care (box I) are two related concepts located in the heart of
our quality model. The other elements of the model reflect those factors
that we believe are key to supporting and influencing the delivery of
technically proficient, sensitively delivered services and the elements
that we think are affected by the delivery of technically proficient,
sensitively delivered services. In the next few sections, we introduce
the other elements of this model.
Macrosystem Engagement
Macrosystem influences (Figure 1, box A) vary widely in the degree
to which they encourage, promote, or demand high quality in the services
they support and regulate. Funders, regulators, accreditors, and
professional associations and external governing boards have the
potential to engage a social services agency related to issues of
quality. They can, for example, insist on evidence of desired outcomes
in exchange for their investments of time and money (Horton, 1987;
Salzer et al., 1997), help define quality care processes and insist they
be implemented, and fund services at a level that increases the
likelihood that quality outcomes are achieved. Without sufficient
funding or support for programming, the quality of services may be
compromised through staff shortages and heavy caseloads (Donnelly,
1999).
Advocacy
Both the actions of social services providers and the policy
decisions of macrosystem agents are frequently swayed through the work
of advocates (Figure 1, box B). Thus, the presence of a strong advocacy
organization can be, and often is, a significant source of influence on
quality of care. Sunley (1997) wrote, "Advocacy should be
considered one of the paramount activities for responding to a
fragmented, haphazard social service structure" (p. 86). Advocacy
groups can influence quality by targeting the macrosystem for policies
and procedures that encourage quality, demanding the availability of an
evidence-based intervention (technically proficient care) or more
attention to the cultural realities of consumers served (sensitively
delivered service). They can educate consumers and their families on
what high-quality service should look like and how to ask for it.
Organizational Receptivity
Although some social workers work independently, an agency or
organization remains the practice setting for most social workers.
Within these settings, organizational culture either allows for openness
to new ideas or maintains the status quo. Poole and Colby (2002)
characterized organizations on a continuum from static to dynamic, with
dynamic organizations reflecting greater flexibility, openness to change
and innovation, and responsiveness to consumer input and local needs.
Quality improvement efforts are most likely to succeed in organizations
that are receptive to them (see Figure 1, box C). Accordingly, a
willingness to adopt new organizational practices, such as the
introduction of evidence-based methods of treatment or service delivery,
is a critical component of quality of care (Ferlie, Fitzgerald, &
Wood, 2000; Thyer & Myers, 1999). Organizations that have developed
a process for evaluating and improving services likely have a culture
that is receptive to change (Barriere, Anson, Ording, & Rogers,
2002; Detert, Schroeder, & Mauriel, 2000; Larson, 2002).
Organizational Capacity
It is not enough that organizations be willing to provide quality
services. They must also be capable of doing so. Several aspects of an
organization's capacity (Figure 1, box D) can influence its
receptivity toward quality improvement activities (Glisson & James,
2002). Sowa and colleagues (2004) defined organizational capacity to
include structure and process components. Among the key structures
identified as part of organizational capacity are adequate funding
(Poole & Colby, 2002), an adequate number of trained staff (Flood,
1994), a mission statement or goals (Poole & Colby; Sowa et al.), a
workable strategic plan (Sowa et al.), a climate of low conflict and
high cooperation (Glisson & Hemmelgarn, 1997), and information
technology systems (Poole & Colby; Sowa et al.). In our view,
adequate funding and staffing are the most important, as shortages in
either not only discourage the full scrutiny of quality of services, but
also lead to employee burnout and high staff turnover (Mor Barak,
Nissly, & Levin, 2001; Wagner, Van Reyk, & Spence, 2001). Among
the many processes that reflect capacity are the ways the organization
uses these structures to influence practitioner behavior. In other
words, do employees know the agency's mission or use the
agency's technological capabilities?
Provider Receptivity and Attitudes toward Quality Improvement
Providers' receptivity and attitudes toward evaluating, and,
if necessary, changing their practice methods, affect quality of care
(Figure 1, box G) (Kramer & Glazer, 2001). Some social services
professionals are highly motivated to improve service delivery. Others
may be more invested in doing things the way they have always been done.
Higher quality services are more likely to be offered by providers who
systematically evaluate their own practice than by those who do not
(Landon, Reschovsky, Reed, & Blumenthal, 2001). Also, providers who
are more receptive to scientifically based intervention methods have
been observed to provide services that are more congruent with
established standards of care than those who are not as receptive
(Chassin, 1990; Saturno, Palmer, & Gascon, 1999).
Historically, circumstances have sometimes served to frustrate
practitioners, perhaps diminishing receptivity to quality improvement.
Some of the misgivings providers have voiced about evidence-based
practices, for example, include the absence of evidence in numerous
areas of practice, practitioners' skepticism about the need to
improve services, and concerns about the validity of the science
underpinning the study of practices (Dixon, 2004; Steinberg & Luce,
2005). Scientific "best practices" have sometimes led to
micromanaging, wherein providers are expected to conform to standards,
regardless of their agreement with the prescribed methods (Long, 2001;
Phelan, 2001; Thompson, 2002). Moreover, some practitioners have
resisted quality improvement as a "movement" because it has
led to cost cutting rather than the introduction of better services
(Aspen Institute, 1999; Manderscheid, 1998).
Family Engagement
Engaged families can be important proponents of quality service. In
some areas, this has long been understood. For example, families of
nursing home patients are encouraged to become actively involved in the
care of their elderly or ill loved ones. Family engagement (Figure 1,
box E) is defined as family participation and involvement in the
management and delivery of care for another family member. Engaged
families can advocate on behalf of their family members, encourage their
family members to participate actively in services, support family
members in times of change, and work with advocacy groups to encourage
system improvements. Social workers have a long history of working with
families and encouraging family involvement in care, and this may be one
quality leverage point for which social workers are particularly well
suited (Wells & Brook, 1988).
Consumer Engagement
Consumer engagement (Figure 1, box F), defined as the participation
and involvement of consumers in the services they receive, influences
quality of care (Clancy, 1999; Darby, 2002). Vulnerable social services
consumers have not traditionally demanded quality (Hopps, 2000) or been
trained on how to do so. However, research in medicine has shown that
actively engaged clients are more likely than less actively engaged
clients to receive empirically based interventions throughout the course
of their treatment (Meredith, Orlando, & Humphrey, 2001; Orlando
& Meredith, 2002). Practitioners may be more motivated to provide
quality services to consumers who are interested in the process, express
their motivation to improve their life circumstances, and are willing to
form working relationships with providers (Shipon & Nash, 2000).
Facilitating access to quality services may be achieved through
consumer education about elements of quality and consumer empowerment to
advocate for change (for example, Domenighetti, Grilli, & Liberati,
1998). An educational method is commonly implemented to increase
consumer engagement and to assist consumers with understanding their
care and the role they can play in the services they receive (Roter et
al., 1998). This method has been used successfully to improve treatment
of depression in medical settings (Katon et al., 1996, 1999).
Resources Provided by Other Agencies, Organizations, and Systems
To improve their circumstances, people often need the services of
multiple agencies, organizations, and service systems. Thus, sectors of
care often depend on the resources of organizations outside their own
sector to complete service delivery (Figure 1, box J). When service
delivery systems are characterized by numerous interrelated transactions
that occur over time in multiple organizations (as described in Miller
& Bovbjerg, 2002), a single encounter with poor service may affect
consumer outcomes.
Interagency collaboration affects the quality of service delivery.
If agencies operate as independent, disconnected "silos,"
consumers may experience gaps in the continuity of care they receive.
Consumers may not need just a single quality service organization. They
may need chains of interconnected service organizations, each of high
quality.
Consumer Outcomes
Generally, it is assumed that higher quality services lead to
greater achievement of desired outcomes than do poor-quality services.
Within the social services, there are three primary desired outcomes for
consumers (Noser & Bickman, 2000; Salzer et al., 1997). First,
sustained improvements in functioning (Figure 1, box K) reflect
consumers' abilities to perform in multiple life domains at their
maximal potential over time. Reduction in problems (Figure 1, box L) is
defined as a decrease in the presenting problem. Reduced symptomatology will typically enhance consumer functioning and is likely to increase
the subjective well-being of consumers (Figure 1, box M). The
stakeholders of the social services system, including funders,
advocates, providers, family, and consumers, evaluate consumer outcomes.
The evaluation of outcomes becomes the basis for the satisfaction, or
lack thereof, of stakeholders (Figure 1, box M). Leverage points for
quality include increasing the amount and direction of feedback on
consumer outcomes. If funders, providers, consumers, family members, and
advocacy groups knew how little improvement was generated by
poor-quality services, each group would likely be motivated to improve
quality.
Social Service System-Level Outcomes
Quality services should not only change individuals, but also help
systems meet their goals. Social services agencies and systems also have
mandates, such as increasing rates of permanent placements for child
welfare or rates of former recipients above the poverty line, for the
income maintenance system. Ideally, quality service should assist social
services organizations in meeting these mandates. Some sectors of care
have begun to develop their list of desired outcomes and means for
measuring these outcomes (Egnew, 1997). Although the challenges in
demonstrating individual-level change as a result of system change have
been discouraging for some, the fact that system-level changes have
produced differing system-level outcomes has been encouraging (Farmer,
2000).
Feedback from Stakeholders
The provision of quality social services is a dynamic process.
Therefore, stakeholder assessment of structure, process, and outcomes
becomes the basis for feedback to the system (Figure 1, box N). This
feedback is expected to influence the elements of care delivery at
multiple points by changing the priorities and expectations of funders,
advocates, organizations, providers, families, and consumers.
Implications of the Model
We see three distinct advantages of this quality model. First, it
is more fully specified than other models, leading to identification of
a manageable number of target domains for quality improvement
intervention. Quality improvement interventions can be aimed toward
consumers, families, practitioners, organizations, and macrosystem
forces, such as funders and legislative bodies. Quality improvement
efforts should start where there is the greatest feasible effect for
change. Second, the model makes explicit that all stakeholders, from
legislators to practitioners to consumers, have a role in improving and
sustaining quality service. Quality improvement is not the sole
responsibility of agency administrators. Third, it reflects the
real-world complexity of delivering high-quality social services.
Quality service is multiply determined. It suggests that for an
organization to deliver quality care consistently, it has to engage a
variety of stakeholders and work across systems to create the resources
and processes that result in high-quality service.
Applications of the Model
The conceptual model on the influences of quality can be used in
multiple ways. Most practically, it can be used immediately for
assessment purposes. Administrators, governing boards, individual social
workers, accreditors, consumer groups, and advocacy organizations can
use the model to assess specific practice settings in an effort to
identify areas of strength and potential quality improvement targets.
Each element in our model will vary across practice settings, suggesting
different priorities for quality improvement. We offer three assessment
examples.
A mental health agency one of the authors recently visited had a
sparkling new building, an involved board, an inspiring leader, and
ample caring staff devoted to their jobs. But no one could articulate
what actions the practitioners took to bring about change in their
clients. Pressed to name an intervention, the clinical director said,
"We do genogram therapy," explaining that social workers
completed a genogram on each client. Using our model, this is an agency
with ample organizational capacity, delivering care sensitively, but
without any technical proficiency and no current personnel capacity to
deliver better services. Quality improvement efforts could include
educating consumers, family members, the external board, executive
director, and clinical director about available treatments for their
population. Alternatively, similar efforts could be aimed at consumers
and family members to increase demand for treatments that work.
Another agency is knowledgeable about numerous evidence-based
treatments for its consumers and possesses a workforce capable of
delivering these interventions and leaders who want to implement them.
But with limited resources, it has no money to train staff, so the
agency continues to provide the same services it has for decades, while
knowing it should do better. This agency is receptive to change, but
does not have the capacity to do so at this time. Quality improvement in
this case could be targeted toward engaging consumers, family members,
and advocacy organizations to lobby the external funders (macrosystem)
to provide money for staff retraining.
A third agency, now closed, lacked funding from the macrosystem as
it was reimbursed a small fraction of the cost it took to deliver
high-quality service. It underpaid employees and provided them few
supports and, therefore, struggled to attract and retain quality staff
and leadership, had no money for structural investments such as in
information technology or training, made no visible attempt to deliver
technically proficient service, and achieved poor outcomes for its
clients. It was a part of a large faith-based conglomerate, but was not
subsidized by it and did not have its own external board to advocate for
it or raise money. It had few advocate supports and made no efforts to
involve its consumers in practice, administration, or advocacy. Its only
notable strength, using this model, was that it treated its clients
sensitively.
The conceptual model introduced here can guide research efforts to
assess the associations among model variables in and across practice
settings. This effort should lead to refinement of the model. We
encourage development of measures that will adequately capture key
aspects of these concepts. The model can also serve as a logic model for
quality improvement research efforts.
CONCLUSION
Jacobson (2001) challenged social work to reclaim its place as a
profession by "promoting transformation in the way human services
are delivered" (p. 51). We strongly encourage social workers to
become fully engaged in discussions about quality in their practice
settings and use their voices for quality social services
transformation. To ignore this opportunity is to allow others to define
quality social work practice and perhaps to blame social workers for the
failures of larger systems. Applying the conceptual model presented in
this article may be an important step for evaluating the quality of care
provided in practice settings, identifying the leverage points for
improving quality therein, and strengthening social work's voice in
quality improvement efforts.
Original manuscript received May 6, 2005
Final revision received February 22, 2006
Accepted August 8, 2006
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Deborah M. Megivern, PhD, is mental health practitioner, People
Incorporated, St. Paul, MN. J. Curtis McMillen, PhD, is professor, and
Enola K. Proctor, PhD, LCSW, is Frank J. Bruno Professor of Social Work,
George Warren Brown School of Social Work, Washington University, St.
Louis. Catherine L. W. Striley, PhD, MPE, ACSW, is research instructor,
School of Medicine, Washington University, St. Louis. Leopoldo J.
Cabassa, PhD, is assistant professor, School of Social Work, University
of Southern California, Los Angeles. Michelle R. Munson, PhD, CSW, is
assistant professor, Case Western Reserve University, Cleveland. Send
correspondence related to this article to Dr. McMillen at
cmcmille@wustl.edu. The development of the quality-of-care model was
supported by the National Institute of Mental Health (R24 50857, P30
068579, T32 19960). An earlier version of this article was presented at
the Society for Social Work and Research, January 2004, New Orleans.