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September 2010Vol. 11, No. 7Quality Assurance in Missouri

In 2005, the Children's Division (CD) in the Missouri Department of Social Services set out to achieve accreditation through the Council on Accreditation (COA). Along the way, the Division built a comprehensive quality assurance (QA) system that today involves every member of the child welfare workforce, as well as consumers and stakeholders.

The Division began with the establishment of a QA unit—with a State-level manager and regional QA specialists—to deal with numbers, data, and analyses and to create a Continuous Quality Improvement (CQI) system. In 2007, a QI unit was added to help managers implement changes that came out of the CQI. Today, the CQI structure draws on a wide variety of components to monitor cases and processes and ensure accountability across the entire Division. These CQI components include:

  • Input from every child welfare worker through a local CQI team. Local teams feed into teams at the site, area, and State levels. The majority of issues that arise are resolved at the local-level meetings, where teams examine data on outcomes and create improvement plans.
  • A statewide CQI quarterly newsletter, In Focus, which spotlights a particular issue from the State's Child and Family Services Review that sets the agenda for local CQI meetings. The newsletter is also used to recognize achievements.
  • Consumer surveys, which are completed by all foster care providers, all youth, and a percentage of parents who receive services. Families can also file grievance reports, which become part of the data.
  • Peer record reviews using a protocol that allows workers to identify strengths and challenges of a particular case record. Completed mainly by frontline workers, the reviews provide feedback to those who completed the record and valuable experience to the reviewers.
  • Supervisory reviews, which consist of case record reviews by supervisors specifically assessing areas of practice related to CFSR outcomes. Supervisors use the results for clinical consultations with their staff.
  • An annual survey of staff that is completed online. Results are available on the CD intranet and can be broken down by region and job function.
  • Monthly management reports of relevant CD statistics, such as investigations and services.
  • Quarterly outcome reports on 20 outcome measures related to safety and permanency.
  • Visits by the QI unit staff to check on local COA progress or maintenance and local Program Improvement Plans.

In cases where feedback needs to be provided (such as peer record reviews), data are entered into a database, and a report is generated and shared with the appropriate recipients. Regional QA Specialists regularly monitor local outcomes from the various data sources and identify trends to bring to the attention of local managers regarding areas needing improvement. Other components, such as outcome reports, are made available through the CD intranet so that all workers can access them.

An important tool for the CQI process is the Plan of Change form. QI staff introduced the form around the State as a way to document planned change. A completed form includes action steps for change, as well as a timeline. It can be used by a supervisor to help a worker make changes or by a manager to help a supervisory unit implement change.

Has all of the hard work paid off? In January of this year, the CD's achievements were recognized when Missouri's Children's Division became fully accredited—one of only seven States to do so. The accreditation process was a painstaking effort that required each of the State's 45 circuits to meet all of the COA's 800+ requirements. In order to maintain the accreditation, the Division has built a maintenance plan into its CQI.

The Missouri Children's Division doesn't plan to slow down its QA process just because accreditation has been achieved. Instead, the Division is looking toward a number of new improvements. One of the biggest changes will be the Results-Oriented Management (ROM) digital dashboard application. In partnership with Casey Family Programs, the State will make the ROM accessible to all workers, so that everyone will have access to data at all levels.

This is another step in integrating data into the child welfare culture and ensuring that data drive the decisions that are made through the CQI process, leading to better safety and permanency outcomes for Missouri's children.

To learn more about Missouri's Children's Division, visit the website:

Or, contact Susan Savage, Deputy Director of the Children's Division, at

Many thanks to Susan Savage, Deputy Director of the Children's Division, Meliny Staysa, QA Unit Manager, and Linda Miller, QI Unit Manager, who provided the information for this article.