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Maternal, Infant, and Early Childhood Home Visiting 1 (MIECHV , also known as the Federal Home Visiting Program ) grantees are required to submit a continuous quality improvement ( CQI ) plan. 2 The plan helps grantees assess their CQI efforts and use the lessons they have learned to inform next steps. This brief can he lp you develop a CQI plan and communicate it to others in your organization. It explains what the plan should cover and includes a sample outline and template for drafting your plan. What is a CQI plan? roadmap for improving its services, processes, capacity, and outcomes. 3 It guide s the organization and its key collaborators and stakeholders through the process of monitoring services and using data as part of everyday practice to improve outcomes. A CQI plan allows you to describe your approach to CQI, assess your capacity to carry out CQI, summarize past CQI efforts, and identify lessons learned. States, territories, tribes, communities , and children and families have unique needs. Y our CQI plan should therefore be flexible and specific to your organization while including the following general components: Description of an o rganizational system and support to maintain ongoing CQI work A clear guiding mission for the CQI work M easurable goals and objectives to improve outcomes C hanges that will be disseminated to local implementing agencies (LIAs) for testing and adaptation CQI methods and tools you will use M easures and a data collection plan for track ing , assess ing , and guid in g improvement Process for monitoring the CQI plan and assess ing progress Design Options for Home Visiting Evaluation ( DOHVE ) provides research and evaluation support for th e MIECHV Program. DOHVE is funded by the Administration for Children and Families (ACF) in collaboration with the Health Resources and Services Administration (HRSA). Creating a Continuous Quality Improvement Plan CQI Brief Design Options for Home Visiting Evaluation July 2016

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2 Organizational System and Support The structure of the CQI team can vary from one organization to another. The CQI plan should describe the team and define roles, responsibilities, and tasks. Exhibit 1 provides considerations for developing a team t o support CQI. Support for CQI Team s Teams function best when they are confident that 3 Your CQI plan should describe how you will support the state (or territory) and local CQI team s to strengthen CQI competencies. For example, your state team may have expertise to share with local teams about CQI models and methods, such as applying the Model for Improvement ( including Plan – Do – Study – Act c ycles ) or LEAN/ Six Sigma. Support for state CQI teams may include the following: Ensuring sufficient staffing and time to support local teams Providing ongoing training and coaching in advanced CQI methods Providing opportunities for peer – to – peer learning with other CQI experts Linking with the DOHVE team for grantee – level coaching and training Roles, Responsibilities, and Tasks Examples Who is accountable for CQI processes at the grantee level? Data collection and analysis Team coaching Dissemination Ongoing improvement, planning, and coaching Often, this will be a CQI team that includes members such as a grantee CQI specialist and a stat e data manager . Who is responsible for ongoing improvement and planning within the local CQI teams? K ey members of local teams may include an LIA administrator, data manager, supervisor, home visitor(s) , and clients. What are the timeline and methods for reviewing and sharing findings? Monthly, quarterly Monthly Webinars facilitated by the state team to review data and share changes tested with local teams How will you provide ongoing training and support to LIAs? Ongoing learning collaborative Virtual training Coaching sessions T elephone support as requested How will you engage community and family members in the CQI work? Parents and partners join local CQI team What human and financial resources are available to sustain CQI work? Project budget and staffing for CQI activities How will you recognize and celebrate results? Monitoring of monthly collaborative run charts Attainment of SMART aims Monthly newsletter with highlights of results from teams Annual home visiting conference with team presentations, recognition, and celebration How will you share successful strategies with other programs? Online forum Newsletters Webinars Conferences Exhibit 1. Roles, Responsibilities, and Tasks for Supporting CQI

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3 S upport for local CQI teams may include the following: Building system leaders for CQI at the LIA level Allocating time to participate in CQI work Staying abreast of innovations Providing ongoing training and coaching in CQI methods Providing opportunities for peer – to – peer learning (e.g. , collaborative, office hours) Exercising authority to remove barriers to full participation and innovation Local Structures and Supports You may share guidance with LIAs on efforts such as forming local CQI teams as they work to create local capacity. Local teams should have members with different roles and perspectives on the processes identified for improvement. When possible, they should in clude input from the end user the family. Examples of local team members include the following: Agency – level lead Day – to – day supervisor Data coordinator/analyst Home visiting supervisor Home visitor(s) Family member(s) Organizational Challenges Early chi ldhood services are interconnected . I mproved outcomes in home visiting often depend on addressing external challenges and barriers such as the following: Conflicting eligibility criteria Inconsistent interpretations of regulations Competition between servi ce agencies Fragmented delivery systems that provide services for the same families in different institutional structures Services that put the responsibility on families to navigate rather than on the service providers to communicate and coordinate To implement improvements and innovations successfully, you should demonstrate both the will and the organizational capacity to ease such barriers. In the past decade, many states have used their early childhood comprehensive system councils, early childho early childhood cabinets to solve problems that previously seemed intractable. CQI Mission Your CQI plan should state the guiding mission of change you want to see in your programs. For example, you may decide to focus on improving duration of breastfeeding across home visiting programs. E xplain how you identified your CQI mission: Did you gather information from baseline data, self – assessment, surveys, or other formal methods to identify gaps in services? Did you include consumer input to identify areas that need improvement, and if so, how? How does your mission align with MIECHV priorities? How do you generate support for improvement work? The Bottom Line: Plan Requirements for Organizational System and Support List the participating LIAs and describe how program participants will be involved. Identify state – level staff that will support LIAs in their CQI work and describe the support. Identify how data will be used for ongoing learning (e.g., as part of monthly state – facilitated meetings with local teams to review progress). Identify areas of priority support the DOHVE team could provide to state – level staff . Identify organizational challenges, if any, that coul d be barriers to CQI efforts.

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4 Your plan should also identify CQI topics that will be addressed at the LIA level and align with your mission. Goals and Objectives Your CQI plan should succinctly describe your CQI goals and objectives for the year, which should align with your CQI mission and be informed by program data . Goals identify your general intentions , such as Objectives are clear and measurabl e targets set to meet the overall goal(s). The objective(s) for each goal must be SMART identifying what you are trying to accomplish, how much, and by when (see box below) . That will help you determine whether the objectives have been met at the end of the year. For example B y July 31, 2017 ( by when ), we will retain 65 percent ( how much ) of all enrolled families for 3 months or more ( what you are trying to accomplish ). Many organizations find it useful to set 90 – day goals and track quarterly progress toward accomplishing annual objectives. A limited set of measures (e.g., 5 10) allows data to be displayed and reviewed at least monthly to spur reflection and testing of new ideas. Changes t o Be Tested Your CQI plan should descr ibe the changes teams will make to achieve the CQI g oals and objectives , and how teams will test the changes to adapt them to their local context . The changes should reflect practices that have already been shown to be effective or promising in the field or that build off of your evaluation findings . If your changes need further input and developme nt , describe how you will accomplish that. Testing cycles ( Plan – Do – Study – Act ) can generate knowledge quickly and minimize risk that a change will have unintended effects or create resistance . SMART Aims Are S pecific: Ensure objective is defined and clear. M easurable: Check for a clear benchmark and target. A chievable: Set a n objective that can reasonably be at tained. R elevant: Ensure objective is agreed upon by the team and aligns with values and mission. T imely: Set timeframe for meeting the objective . Source: Home Visiting Collaborative Improvement and Innovation Network (HV COIIN) Examples of Changes to Address Family Retention Gather feedback from families on the first 3 months of enrollment using a check – in card with guided questions: continue to participate in the home visiting Try a variety of communication strategies to enhance the relationship between the home visitor and family: Motivational interviewing Active listening Develop family service plans that focus on one or two key goals identified by the family. The Bottom Line: Plan Requirements for CQI Mission Include a list of topics of focus for each LIA. Explain why those topics were chose n and how they align with state priorities. The Bottom Line: Plan Requirements for Goals and Objectives Include SMART aims for your CQI work.

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5 You will need to evaluate the changes and identify the ones that are most promising in leading to improved outcomes. Then you will disseminate those changes across LIAs through mech anisms such as an online forum , monthly reports, and monthly W ebinars . Methods and Tools Your CQI plan should i dentify the CQI method s and tools and you will use. T ools may include benchmarking, fishbone diagram s , root – cause analys i s , process mapping, and key driver diagrams. Several widely used methodologies are shown below (exhibit 2) . Measurement and Data Collection Your CQI plan should describe how your organization will measure improvement and how you will collect, monitor, and analyze data. Measures To assess whether your changes lead to improvement, identify measures that address specific outcomes. Measurement for improvement seeks to gain knowledge to improve practice and adapts the intervention as new knowledge is generated. Measurement for learnin g and process improvement does the following : B ring s new knowledge into daily practice Rel ies on m any sequential, observable tests Gather s “just enough” data to learn and complete another cycle Involve s a series of s mall tests of changes to accelerate the rate of improvement Collect s , analyze s , and review s data in an o ngoing way (at least monthly) A balanced set of measures will include outcome measures (impact on population) and process measures ( system performance). For example, an The percentage of weekly or biweekly visits are expected, the percentage of families with 21 or more days between This is based on the theory that missed or infrequent visits are an early sign of disengagement that predicts dropout. 4 Methodology Description Plan – Do – Study – Act ( PDSA ) Develop plan, implement, study results, act on lessons learned Six Sigma Two models: Define, measure, analyze, improve, control (to examine existing processes) Define, measure, analyze, design, verify FADE Focus, analyze, develop, execute, evaluate Model for Improvement Ask three questions to identify goal, measures, and changes; uses PDSA cycles The Bottom Line: Plan Requ irements for Changes to be Tested Include a description of changes to be tested based on evidence – based and/or promising practices. Exhibit 2. CQI Methodologies Methodology Description Plan – Do – Study – Act ( PDSA ) Develop plan , i mplement , study results, a ct on lessons learned Six Sigma Two models: Define, measure, analyze, improve, control (to examine existing processes) D efine, measure, analyze, design, verify FADE Focus, analyze, develop, execute, evaluate Model for Improvement Ask three questions to identify goal, measures, and changes ; uses PDSA cy cles Exhibit 2 . CQI Methodologies The Bottom Line: Plan Requirements for Methods and Tools Describe your CQI methods and tools.

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6 Data Describe your strategy for collecting, entering, storing, analyzing, presenting, and interpreting measurement data at frequent intervals ( e.g., monthly). I dentify methods for clearly communicating with state and local team members about how data will be used to inform practice . Describe how you will incorporate learning based on data into staff training and technical assistance for LIAs. Transparency may encourage participation by assuring staff that the data are not being collected to monitor them . Data Collection and Storage The measures you select might be measures LIAs already collect for reporting purposes, or they might be measures LIAs will administer to test a change. In either case, the CQI plan should describe how you will collect and store the data so they can be easi ly analyzed and frequently shared. Data Analysis D escribe your analytic methods. For each data source, identify the method that will be used to analyze it, the kind of information the method will produce, and how the information relates to your goals. Dat a Interpretation Describe how LIAs will receive feedback in a timely manner (e.g., monthly) to keep the improvement process on track. Explain who will receive which data reports. Sharing data transparently and frequently helps facilitate learning and ra pi d spread of improvements. Specify how LIAs are expected to use the reports and what ongoing support will be provided to ensure that data are used to make improvements (e.g., training and orientation). The CQI plan may also describe succinct, easy – to – interp ret formats for sharing data. Visual presentations of data, such as graphs or run charts, may be an effective way to quickly communicate results (see exhibit 3 ). F indings from data analysis can suggest whether a particular change is related to improvement. D escribe your plan to modify the process and continue testing changes when findings sugge st that a change is not working . Also d escribe your plan to implement and spread change s that did work so they become standard , permanent process es . Communication D escribe how you will regularly communicate your work throughout the organization. It is important to communicate with all staff, including state – level partners, LIA leadership, frontline staff , and families. This will keep all parties in the home visiting system actively engaged in the improvement work. Plan regular updates about CQI plan implementation, training activities, and improvement charting. Document CQI progress u sing activity logs, issue identification logs, meeting minutes, and other tools. Communicate your progress using methods such as the following: Kickoff meetings or all – staff meetings Local learning sessions (for states conducting quality improvement collaborati ves) Storyboards or posters displayed in common areas Routine s haring of CQI findings and lessons learned Left axis : S cale for blue diamonds indicating percent age of enrolled families active in home visiting at 3 months Right axis : S cale for green dots indicating percentage of families enrolled 3 months ago X axis: D ate of data submission and number of LIAs submitting data each month Source: HV C o IIN Exhibit 3 . Sample Run Chart Exhibit 6. Sample Run Chart 0 20 40 60 80 100 120 0 10 20 30 40 50 60 70 80 90 100 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 Percentage of Enrolled Families Active in Home Visiting at 3 Months

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8 Appendix A: Sample CQI Plan Outline 1. Organizational System and Support a. L ist LIAs or CQI teams that will participate in CQI activities and the extent to which LIA management supports direct involvement in CQI activities . b. Describe the extent to which program participants are included in CQI teams and encouraged to lead quality improvement work . c. List state/territory personnel assigned to CQI teams, including their relevant experience and skills . d. Summarize financial support for CQI work , including allocation of resources and staff time at the state/territory and local level s . e. Describe how you will generate buy – in and support for your CQI work . f. Describe training and coaching activities planned to strengthen CQI competencies for state/territory and local teams . g. Describe how you will incorporate learning based on data into staff training and technical assistance provided to LIAs . h. Highlight training or coaching the DOHVE team could provide to the state/territory team . i. Identify organizational challenges, if any, that could be barriers to CQI efforts and include an approach to addres sing those challenges. 2. C QI Mission a. Include topic(s) of focus for each LIA, a justification for why those topics were selected, and an explanation of how those efforts will align with state/territory priorities . 3. Goals and Objectives a. Include SMART aims for t he CQI projects proposed or underway at each LIA . 4. Changes t o Be Tested a. Describe evidence – based or promising practices teams will test . 5. Methods and Tools a. Identify CQI methods that will be used to assess progress. b. Describe CQI tools the state/territory team will use to support local CQI work , such as a CQI team charter, a driver diagram that displays the theory of change, process and outcome measures used to track progress, process maps, and run charts. 6. Measurement and Data Collection a. Include a plan for data collection (what to collect and how often), display, and dissemination at the local and state/territory levels for CQI purposes. b. Describe LIA or CQI team capacity to track progress, determine if tested changes resulted in improvement, identify the need fo r course corrections, and use data to drive decision making. c. Describe how you will communicate and spread CQI learning. 7. Grantee Monitoring and Assessment of Progress a. L ist active and completed CQI projects at the state/territory level including topic s , SMA RT aim s , successes, and lessons learned . b. Include a plan to routinely monitor CQI efforts and reassess efforts moving forward.

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9 Appendix B: Sample C QI Plan Template Date: 1. Organizational System and Support A. Participating Local Implementing Agencies a. Indicate number of federally funded LIAS in your state/territory b. Indicate number of LIAs participating in the CQI plan c. For those participating LIA s , complete the following table. LIA Name CQI Team Members /Roles ( e.g. , Ms. Johnson , Home Visitor ) LIA M anagement Lead CQI Topic (e.g. , family retention, breastfeeding) Notes: Tip: If home visiting program participants are not on local CQI teams, explain how they will play an active role in CQI work. I n the notes section , identify administrative support for CQI work. B. Grantee Personnel to Support Local Implementing Agencies State/Territory Personnel Assigned to CQI Teams Experience With CQI Skills Specific to CQI Work Professional Development/ Support Needed to be Successful in This Role LIAs/CQI Teams Supported ( List ) Staff Time Allocated To Supporting CQI Teams (e.g. , .25 FTE) Notes: Tip: If personnel are not already identified, share your plan for securing personnel to adequately support local CQI work.

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10 C. Ongoing Support for Teaching, Coaching , and Using CQI Data to Inform Improvement Method Frequency Additional Comments Indicator(s) of Effectiveness 1. Describe point person and training methods planned to strengthen CQI competencies for state/ territory and local teams . E xample : Name of point person : Methods: Annual CQI conference Virtual topic calls 1:1 team coaching Group c oaching E xample : M onthly calls 1:1 check – in with each team monthly Group coaching and 1:1 per requests within 72 hours Add specific information on the type of training that will be done . How will you know that teaching/ coaching is effective? Add examples to explain methods used for collecting data on efficacy and satisfaction. 2. Describe how you will encourage learning based on data into training and coaching . E xample : C ollaborative r un charts and small multiples with LIA – identified data shared in monthly topic calls Storyboards with annotated run charts created by : Team data used in 1:1 and group coaching E xample : M onthly Every 6 months Check – ins monthly with LIAs 3. Identify areas of anticipated priority support you would like to receive from the DOHVE team to provide optimal support to local CQI teams. Notes:

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11 D. Organizational Challenges Describe organizational challenges, if any, that you feel may impact your CQI outcomes (e.g. , competition between service agencies, inconsistent interpretations of regulations, fragmented delivery systems for families). Challenge(s) Possible Solutions Is this an area you would like to request TA support? (yes or not right now) 2. CQI Mission Clearly s see in your programs, such as or depression . C omplete the table below to illustrate th e rationale for your CQI mission . Evidence of Need for Improvement Topic #1 ( e.g., Enrollment ) Topic #2 1. Explain how you chose the topic(s) for improvement. For example, d id you gather information from baseline data, self – assessment, surveys, or other formal methods to identify gaps in services? 2. Did you include consumer input to identify areas that need improvement, and if so, how? 3. How does your mission align with MIECHV priorities?

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