Why Quality Improvement Needs to be Trauma Informed

Tristan Keelan
Jan 11, 2021 12:20:18 AM

Quality Improvement scares a lot of people.  Data scares a lot of people.  And not without good reason.  In Health and Human Services there are a number of reasons why, but the fact remains that talking to the average caseworker about Quality Improvement can create a lot of anxiety.

In order to have a successful Quality Improvement program you need to have buy-in from the entire agency.  Its simply not enough to have a QI Department that is ready and willing to lead the charge.  It takes the program directors being receptive and willing to support data collection, analyzing report measures, and dedicating time to testing possible improvement changes. Next, front line workers need to contribute to the change ideas, after all, they will be the ones that have to execute any new processes and procedures.

Whether or not your agency has adopted Trauma Informed Care, consider adopting a Trauma Informed Approach to Quality Improvement

When presenting Quality Improvement to new hires, it's important to openly talk about the trauma that a lot of health and human services workers have experienced relative to data, reporting, and Quality Improvement projects.  Acknowledging these traumas creates an atmosphere of understanding where QI staff become program partners, not program watchdogs.

Consider discussing the following through a Trauma Informed Care lens during new hire orientation before living them in practice every day.PQI is Trauma Informed

Software Systems

It's important to openly acknowledge that agency employees are likely to encounter a few different types of software.  Old, New, and Bad.  This isn't an assault on the software providers that serve health and human services - the electronic migration for these agencies is relatively new, and the industry tends to attract companies of a smaller size who are desperately trying to keep up with the changing needs of human services.

The results however; are a group of people that often feel as if technology has failed them.  For example, if they have been asked why their progress notes are not completed on time by people who are unaware and unsympathetic to recent system outages, that creates the feeling of unreasonable expectations. Or, when they are expected to turn in data that is not readily available in their systems and have to "bean count" from individual caseload files. 

At the same time you have people battling the "bad" or "old" software, you also have new people learning your systems all the time.  Many jobs require employees to master multiple platforms, which can take time, and being asked to produce something that is difficult for a newbie but commonplace for veterans is one of those scenarios that can put new employees on their heels.

The QI Responsibility for Software

First, understand the systems your agency is using.  You don't have to be an expert in all of them, but familiarity is important.  Know who uses what, and the quality of the system and how people feel about it.  Do as much reporting as possible with source data from software to reduce the amount of "bean counting" required to create data.  If the data you need isn't there, consider working on system manipulations that will eliminate manual counting in the future. When it comes time to initiate a Plan Do Study Act project you won't get eyes rolling about having to collect the data, AND improve it.

When you approach software in this way it puts Quality Improvement staff on the same team as program staff who are working with difficult software.  If they have to struggle with it, be in the struggle with them.  

Regulatory Reporting Burden

The regulatory burden on Health and Human Services is substantial.  All levels of government, private foundations, insurance companies, it feels like it never ends.  The trauma comes from short turnaround times for data requests, data requests that are not easily pulled together, and poor definitions. 

This last one is a biggie.  "Please provide your average program length of stay for the period" for example, yields so many questions.  Do you want only cases "closed" during the period? Open during the period?  If open cases and closed cases are to be included together, what should I use as an end date for calculating open cases?  On top of other possible difficulties, there a lot of pressure to produce numbers when its unclear how they should be derived.

QI Responsibility for Regulatory Burden

Quality Improvement Staff should absolutely support program personnel in producing regulatory reports.  If there is no good definition, you can help create one, and then help calculate it.  Its helpful simply to not be alone in the work.  It helps create a partnership where Quality Improvement personnel are perceived as those who help relieve anxiety, and therefore not people who create it.

Reducing a colleague's anxiety is value added to your agency.

Time to Create Reports

One of the largest stressors for program staff is when they have to make time for creating reports or submitting data.  The average worker in the Health and Human services faces the type of work days and work weeks that often make it difficult to set aside the time required to pull numbers together.  One of the main goals for QI support to program staff should be to help reduce the time it takes to pull their numbers.

There is a lot of stress created when a worker knows they have to pull numbers together, they know the numbers of labor intensive, and they are unsure of how to find the time in the schedule required to do so.  For a monthly report for example, someone is experiencing this trauma recurring monthly.

The QI Responsibility for Reporting Time

Work with program staff to invest in procedures that will reduce the amount of time it takes to get their numbers together.  Look for opportunities to get numbers directly out of system exports.  Try to help create custom report views, formulas, or workflows that are repeatable and get the answers faster.  This is the ultimate support, reducing the time it takes to get from zero to report answers.

Learn how to speed up your time to report by using source data exports and formulas with our How-to in Power BI resources.

Quality Improvement as a Safe Space

It is so important that Quality Improvement is presented as a safe space.  Encourage all agency staff to want to be better, but then also make sure there are mechanisms for it from top to bottom.  The best place for Quality Improvement ideas to come from is the program staff who are doing the work.  Make sure they know that if they see an opportunity for improvement they should bring it to program directors or QI staff.  Its important to state that not every idea can always be PDSA effort, but every idea should be received with respect and consideration.

One of the best ways to create a safe space around quality improvement is using data and reports.  Create regular data reviews for front line staff where there is no Quality Improvement project involved.  Show them the metrics that programs keep track of and discuss them in non threatening terms.  Explain how the metrics are calculated, why they are important, and look for opportunities to praise existing measures that are at high performance.  All of this helps diffuse the idea of Quality Improvement as a watchdog for individual performance.