Quality Services Reviews: A process for understanding and promoting best child welfare practice

1. Quality Services Reviews:A process for understanding and promoting best child welfare practice Your Role as a “Shadow” Tennessee Department of Children’s Services

2. Goals for New “Shadows”Pre-Review • Become familiar with how TN QSR reflects the practice model • Become familiar with the logistics and time commitment in reviewing a case via the QSR process • Learn what the roles “Lead” and “Shadow” involve • Learn general information about “scoring the case.” • Learn how to become a Lead Reviewer

3. TN Guiding Principles • Unified Purpose • Urgency of Child’s Needs • Individualized Planning for Permanency • Family Centered Casework and Case Planning • Systemic Continuity of Care • Constructive Organizational Culture • Equal Access to Services • Reduction of Trauma to Child • Best Interests of Child as Paramount

4. Tennessee Model for Family-Centered Practice Engagement Tracking & Adaptation Team Formation Implementation Assessment & Understanding Planning

5. What is the Quality Service Review? The Quality Service Review process is a method for organizing the conversation with our communities in terms of : • the results we want for children and families served, and • understanding how child welfare practice can be improved to get those results.

6. Key attributes of the QSR Process • Language used is transparent to a wide audience • Underlying values as to child and family safety and well-being are broadly held • Practice model reflects a coherent approach to supporting and sustaining change in families • Process promotes learning at all levels in the organization, as well as in the larger community

7. QSR Uses a Record Review and Interview Format • We evaluate outcomes and best practice. • Record is reviewed at the beginning to gain basic understanding of the case. • Much more importantly: Additional information is gained through interviews with family members, the child, the caseworker, service providers, etc. • Last interview with caseworker to share and update information and findings.

8. Quality Service Reviews: Common Understanding of Good Results for Children Served • Traditional Audit: • Were investigations timely in accordance with policy? • Are child’s educational needs reflected in case plan? • Is there documentation in the record that ongoing therapy (if recommended) is being provided? • Quality Review: • Are children safe from current, manageable risks of harm? • Is the child learning and progressing at a rate commensurate with his/her age and ability? • Is the child doing well, emotionally and behaviorally?

9. Quality Service Reviews: A Different Way of Looking at Practice • Qualitative Review • Is the plan relevant to family needs and goals, coherent in selection and assembly of strategies, supports, services, and timelines? • Was the family effectively engaged in assessment and service planning, and tracking? • To what degree are service implementation and results routinely monitored, evaluated and modified? Traditional Audit • Is there a plan in the file? • Was the plan signed by the parents? • Was the permanency goal presented to the court at the dispositional hearing?

10. How the Review Process Works • Random but purposeful sample of cases selected in each region (younger and older children, children in care for varying lengths of time and with different permanency goals), reflective of regional custody demographics • Family permission obtained to participate in review and information releases obtained • Key informants in each case identified and appointments scheduled • Lead reviewers and “shadows” conduct the interviews, beginning with the caseworker.

11. How the Review Process Works, continued • Answers are reviewed and scored in each indicator and domain • Feedback session with caseworker and supervisor to provide immediate feedback and elicit further suggestions for next steps on case • Presentation of stories at debriefing sessions during the week • Exit conference at end of week to present and discuss findings • Case Story or Scoring Summary for each case reviewed • Final report which includes aggregate data and case stories.

12. What about the logistics of a case review? • A “case review” involves a full two days of activities. • Half of the cases are reviewed on Monday & Tuesday, the other half on Wednesday & Thursday. • Monday & Wednesday are therefore called “Day 1” and Tuesday & Thursday are called “Day 2” • Case activities begin at 8:00 am on Day 1, at a designated location in the region. Lead Reviewers and Shadows often meet for the first time here. • The first case activity is a review of the case file, followed by interviews with existing or potential Child and Family Team members.

13. What about the logistics of a case review? - continued • QSR is a very rewarding process. However, be prepared for its demands as well! • There is often significant travel, especially in our rural regions. • Interviews on Day 1 may run late into the evening, occasionally as late as 10 or even 11 at night. • Interviews on a case normally continue on Day 2, concluding by mid-day, then are followed by other review activities. • Review activities on Day 2 normally end around 6:00 pm. • Lunch may be a luxury during a review. Don’t be surprised if there isn’t one! Take advantage of the snacks provided at the review – take along portable foods such as bananas, apples, granola bars, etc. as you head out for the day.

14. What do the terms “Lead Reviewer” and “Shadow” mean? • QSR employs a “pair reviewer” system in the belief that two heads are better than one! • Each case will be assigned a Lead Reviewer and a Shadow Reviewer. • A Lead Reviewer is a person who has been trained in the entire QSR process, including QSR-style interviewing skills, the use of the QSR Protocol, the debriefing/feedback session with the caseworker and supervisor, and all other QSR-related activities.

15. What do the terms “Lead Reviewer” and “Shadow” mean? continued • The Lead Reviewer will take the “lead” role during interviews and other review activities. The Shadow is expected to actively observe and learn from the Lead. • The Lead will choose when and how to ask for the Shadow’s input during interviews and other case activities. • “Shadowing” on even one case review (a full two-day process) can offer a tremendous learning opportunity.

16. Tips for shadows • You are participating to learn about this process, please ask your Lead lots of questions after and between interviews. • Please do not interrupt the Lead during interviews unless the two of you have previously agreed on a “co-interviewing” format, • You provide important local information (translation) and context for the review • Your listening and observation skills will be helpful to the process. • When the Lead asks a question that seems redundant, it isn’t…it’s purposeful. • New information gathered is only shared with the caseworker. We are the collectors of information from other Team members; we are not the givers of information except to the caseworker.

17. What are the Child and Family Status Indicators? • Safety of Child, Family and Community • Stability at Home and School • Appropriate Placement • Health/Physical Well-being • Emotional Well-being • Learning & Development • Caregiver Functioning • Prospects for Permanence • Family Functioning & Resourcefulness • Family Connections • Satisfaction • Overall Child/Family Status

18. What are the System Performance Indicators? • Engagement of Child & Family* • Teamwork & Coordination* • Ongoing Functional Assessment* • Long-Term View* • Child & Family Permanency Planning Process* • Permanency Plan/Service Implementation* • Tracking & Adjustment* • Resource Availability & Use • Informal Supports & Community Connections • Resource Family & Congregate Care Supports • Transitioning for Child & Family • Overall System Performance

19. How the scoring works Each indicator is scored on a scale of 1 to 6.

20. Quality Service Reviews: Focus on Most Recent Segment of Practice • Child and family status indicators look at last 30 days • Exceptions are stability and permanence • Recent performance improvements have some influence on scores • System performance looks at past ninety days • Stability of findings for the next six months is projected

21. Safety always trumps • Safety is the only indicator that trumps • Safety is paramount to any case. • Overall status is acceptable only when Safety is rated in the 4 – 6 range.

22. Example of Scoring Child Status Indicator:Emotional/Behavioral Well-Being • Is the child doing well, emotionally and behaviorally? If not, is the child making progress toward stable and adequate functioning, emotionally and behaviorally, at home and school? • Probe: If the child has presenting problems, has he/she had a mental health assessment? • Score: • (6) Child has been emotionally and behaviorally stable and functioning well and responsible in daily settings for an extended period – at least 6 months. • (1) Child has serious and worsening problems…in home and school settings.

23. Example of Scoring System Indicator:Functional Assessment • Are the critical underlying issues identified that must be resolved for the child to live safely with his/her family, independent of agency supervision or to obtain an independent and enduring home? • Probe: What are the critical issues for the team to assess that will lead to the families independence from DCS? • Score: • (6) The current, obvious and important strengths and needs (including underlying needs) are identified through assessments, monitoring…This pattern of practice has been in effect at least 6 months. • (1) Important strengths of the child and family have not been identified. Essential strengths, underlying needs, risks, or preferences are unknown or misunderstood.

24. “Groundhog Day” Rule • Difference between a Rating of 3 “Unacceptable” and 4 “Acceptable” You may hear fellow Reviewers use the term “Groundhog Day” rule: That means that if this case were frozen in time as it is today, would it be acceptable? (Remember the Bill Murray movie “Groundhog Day” from a few years back – he kept waking up and it was the same day over and over?)

25. Other important QSR Components • Oral Presentation • Case Story or Case Review Scoring Summary

26. Schedule for TN QSR’s Monday – Tuesday Case Reviews -- Complete interviews and scoring for half of cases selected, begin and end interviews with caseworker and supervisor; presentation of oral case stories with Regional staff end of Tuesday. Oral Case Stories are first opportunity to begin identifying themes and patterns of strengths and opportunities for improvement. Wednesday – Thursday Case Reviews -- Complete interviews and scoring for half of cases selected, begin and end interviews with caseworker and supervisor; presentation of oral case stories with Regional staff end of Thursday. Oral Case Stories are first opportunity to begin identifying themes and patterns of strengths and opportunities for improvement. Friday Exit conference and discussion with regional staff, other stakeholders – Review team and local, state stakeholders meet to review and discuss findings.

27. Would you like to become a Lead Reviewer? • There is an “apprenticeship” approach for development as a Lead Reviewer. • A person who wishes to become a Lead Reviewer must first pair with a more experienced reviewer – a “mentor” – who will guide them through the process.

28. Would you like to become a Lead Reviewer? – cont. • An example of this scenario might be for you to “shadow” a more experienced reviewer on a Monday/Tuesday case. Then, you might yourself take the Lead role on a Wednesday/Thursday, under the tutelage/mentoring of the more experienced reviewer.

29. Would you like to become a Lead Reviewer? – cont. • A good “rule of thumb,” realizing that different people have different experiences and starting points, and different learning styles, is that most folks will likely need at least three or four opportunities to Lead with a strong Mentor, and follow-through with a written Case Story, prior to being certified as a QSR Reviewer.

30. And one more very important bit… • If you are already confirmed to participate in a specific QSR: • DCS Central Office will identify a hotel in the review area and will make reservations for participants as needed, beginning with the night prior to your Day 1. • If you are a DCS employee, your hotel costs will be direct-billed to DCS. (Others will need to provide a credit card at check-in; we ask the hotels to allow non-DCS employees to stay at state rate.) • You will be sent hotel and other logistical (and location) info via e-mail approximately one to two weeks prior to the review.

31. Thank you! Thank you for your participation in the QSR process!