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  • 标题:Quality of care: expanding the social work dialogue.
  • 作者:Megivern, Deborah M. ; McMillen, J. Curtis ; Proctor, Enola K.
  • 期刊名称:Social Work
  • 印刷版ISSN:0037-8046
  • 出版年度:2007
  • 期号:April
  • 语种:English
  • 出版社:Oxford University Press
  • 摘要: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.
  • 关键词:Medical care

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.

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