Quality Assurance
Adhering to Best Practice Standards During Times of Financial Stress
In these tight fiscal times, many programs have made difficult choices
that have impacted program services. The Quality Assurance staff at PCA America
has seen several programs disaffiliate or discontinue services in the
past year due to budget crises, and many programs that have kept their
doors open have had to make difficult program cuts. Across the country,
programs are being asked to serve more families with fewer resources.
In spite of these realities, more programs are going through the credentialing
process than ever before. The reason: completion of an intensive national
accreditation or credentialing process is seen as an important litmus
test to funders and policy makers that tests the credibility and integrity
of a program.
The HFA model is based on intensive home visiting, and that type of service
requires resources. How can a program maintain model fidelity while watching
the bottom line?
Caseload management, and intensity of services
Central to the HFA model is the relationship between a home visitor and
a family. Cyd Wessel, MSW, and Holly Seymour, MS, HFA QA Coordinators
at PCA America, emphasize that programs should be careful not to overburden
staff with caseloads over the recommended maximums (i.e., no more than
15 families at the most intensive service level or 25 at any combination
of service levels per full time worker) or compromise the intensity (i.e.,
weekly home visits for a minimum of six months after the birth of the
baby) of services to families in an effort to save money. If these core
elements are not adhered to, the effect can be crippling for a site. A
staff overburdened by heavy caseloads translates into families not getting
what they need and unsatisfied staff. This dissatisfaction can then affect
the retention of both staff and families. The Quality Assurance
staff recommends that it is better to serve fewer families well than many
families poorly. Once a program has weathered the tough times, it will
be easier to secure funding if fewer families have been served well. Ultimately,
it is recommended that a program reduce their capacity versus lose the
program entirely.
Prioritize families before ratings
Credentialing ratings are on a three-point scale: 3 equates to program
excellence, 2 indicates the program meets the standard and 1 implies that
the program needs improvement. While we all pursue excellence in our work,
it is important that a program is in adherence with a “2”
rating before sacrificing resources to secure a perfect “3”
rating on a certain program element. Put families before “3”
ratings.
For example, one Program Manager wanted to eliminate serving teen mothers
because they are difficult to engage. This would have helped her to reach
the percentage needed on Standard 1-1.B (identifying the participants
in the target population) to be rated in adherence. The philosophy behind
the credentialing process is to encourage best practice to ensure quality
services to families not to encourage programs to make changes to program
delivery to ensure perfect percentages or high ratings. Programs should
be assured that the process is designed to ensure that programs are not
being judged on short-term patterns due to funding issues, but rather
on quality issues over time.
It is more important to ensure that a program offers quality services
than if all the documentation is filed perfectly. If a decision between
good ratings and serving families arises for your program, a coordinator
at PCA America can always be contacted for recommendations on how to handle
the situation.
Look at the big picture
It is easy to get caught up in the minutia of ratings. Programs should
try to use the self-assessment as an overall tool, and not dwell on small
things. Just because a program has been cited on a certain area does not
mean that it is not offering quality services. It is important to keep
in mind that the main tenet of credentialing is the focus on quality improvement.
Built into the credentialing process is a degree of flexibility. If some
selected standards have lower ratings, it will not automatically mean
that a program will be deferred. Rather, the standards are designed to
be guidelines for programs to help ensure quality services to families.
Advice from the HFA Credentialing Panel
At the December 2003 HFA Advisory Credentialing Panel (the Panel) Meeting,
the Panel was asked for advice they could share with programs and state
systems that are struggling with budget issues and seeking to maintain
the integrity of the critical elements in their service delivery. Here
are some of their thoughts:
- Do not panic. Short-term trends due to tough financial shortages can
be pointed out or identified during the credentialing process to distinguish
them from permanent features of the program. Choices can be made that
will maintain program integrity.
- Do not overload supervisors. When supervisors are overloaded, staff
and families do not get what they need. A supervisor is one of the most
cost effective positions in a program site. They are a vehicle for retaining
staff and maintaining the integrity of program policy and practice.
- Consider narrowing the program’s target population or shortening
the length of the program. One way to narrow the program’s target
population is to increase the assessment entry score required to enter
the program or reduce the length of service of the program. For example,
programs may identify that the current target population is far too
large to be screened and assessed based on current resources and staff
time (i.e., serving all births within the county may be narrowed to
all births that occur at hospital A and B). Programs may also consider
reducing a 5-year program to a 3-year program. These are not to be viewed
as opportunities to meet certain standards, but as strategies that keep
best practices at the core of service delivery during tight financial
times.
- Focus on the families’ best interests. It is important that
in times of budget constraints, families are receiving the appropriate
dosage of services. If a family is ready to move from Level 1 to Level
2 of service intensity, do so. Sometimes boundary issues arise between
workers and their families in which families can be kept on Level 1
because the worker does not want to let go. Moving families onto Level
2 when they are ready creates new openings for families who need more
intensive services.
- Create a transition plan. If families have to be released from the
program due to reductions in program capacity, create a transition plan
for them. This planning helps both the families and the workers assigned
to them adjust to the premature departure versus cutting off contact
without closure. If you cannot offer intensive services to those families,
suggest group services for higher functioning families. One option would
be to explore PCA America’s Circle of Parents program, a network
of mutual self-help support programs that has begun to collaborate with
HFA. See www.circleofparents.org.
- Keep track of families that have discontinued services. Direct feedback
and numbers will help to demonstrate the need for expanding a program
in the future. Some programs that have had to discontinue services to
families have tracked these families to show the need. This is also
important should a program unexpectedly receive additional funds and
be able to expand their services once again to more families.
- Cross train staff. When it comes to making decisions about possible
layoffs, consider cross training as an alternative. Instead of laying
off an assessment worker, retrain him or her to fulfill another role.
- Emphasize supervision. Supervision becomes more important than ever
when workers have more than one role. One-on-one supervision is crucial
to keep staff feeling supported- especially if they are taking on a
new role. In difficult financial times, supervision is a great opportunity
to encourage staff, thereby increasing morale and helping to reduce
staff turnover.
- Prioritize front line staff. If you must institute layoffs, family
workers should be the last to go. Without them the program cannot function.
- Keep your staff informed. If the financial situation of your organization
is transparent, natural attrition of staff may occur and will not result
in as severe cutbacks. If staff is not informed of financial problems,
there may be incredibly low morale and a potential bailout after the
cuts are made.
- Provide counseling after layoffs. If staff has had to layoff coworkers,
it is important to maintain morale for the staff that remain. Counseling
will help them to deal with their losses.
- Diversify your funding. Most HFA programs exist on a myriad of funding
sources. It is important to diversify your funding sources so that your
program is not vulnerable to the whim of one particular funding source.
Contact your state leaders to learn more about funding or see the HFA
Peer Mentoring Network at: www.healthyfamiliesamerica.org/network_resources/index.shtml.
- Communicate with your advisory committee and/or state system. It is
important that sites are in touch with their state’s advisory
entities and state systems. A state system can only advocate on behalf
of the needs of its sites if it is aware of what is going on at the
program level and how state budget issues are impacting service delivery
to families.
- Communicate to your funders. Funders will be a lot more understanding,
and a lot more likely to continue funding, if it is explained why a
particular service needs to be cut rather than if the funder finds out
after the fact.
- Pay attention to community ties. If a program depends on support from
a community agency whose needs are assessment services, try to not reduce
the assessment capacity. Keep collaborative partners informed of financial
issues and explore ways to further share resources.
- Collaborate with other area agencies. Many programs are faced with
impossible tasks. Families may not be able to be served with limited
resources, but through pooling resources with other agencies, families
that otherwise would be left without services might be served. One agency
might be able to provide assessments, while another could provide home
visitors.
Keep in touch with your QA Coordinator or RRC Director
If a decision has to be made between good credentialing ratings and serving
families, programs and state leaders should feel free to call their respective
Coordinator at PCA America or designated Regional Resource Center (RRC)
Director (http://www.healthyfamiliesamerica.org/network_resources/reg_resource_centers.shtml)
for advice on how to handle the situation. The 12 Critical Elements in
the Self-Assessment Tool were put in place because Program Managers and
state leaders were challenged with the day-to-day operations of programs,
and needed a structure to help maintain the quality of program services.
They exist as a tool for your use.
Budget constraints don’t have to mean the end of the program or
even the quality of the program. Choices can be made that will not compromise
program quality. PCA America and the RRCs understand these challenges
and are here to support programs and state systems through these difficult
decisions.
