Partnering With Families In Continuous Quality Improvement .
Partnering With Families in Continuous QualityImprovement: The Maternal, Infant, and Early ChildhoodHome Visiting ProgramTip SheetAugust 2017Continuous quality improvement (CQI) is most likely to be successfulwhen it includes a variety of perspectives. 1 That is why CQI teams aretypically multidisciplinary, with members who cut across programadministration and service delivery roles. Some programs have foundinnovative ways to include another important stakeholder group on CQIteams: program participants and their families. Participants and familiescan offer valuable insight into how home visiting services are received andhow they could be improved.Participants and Families as Accelerators ofContinuous Quality ImprovementInvolving participants and families in CQI may represent a shift inphilosophy for some programs—from improving services for families toimproving services with families as partners. 2 3 However, it is not a newconcept. 4Partnering with participants and their families is part of a growingmovement in health care and social services. 5 Parent engagement isintegral to the Maternal, Infant, and Early Childhood Home VisitingProgram (MIECHV) and to programs like Head Start, and is included in theNational Association for the Education of Young Children code of ethicalconduct. The Institute of Medicine names patient-centered care as a keyquality dimension of improving health care, 6 and the U.S. Centers forMedicare and Medicaid Services has developed a strategic plan aroundperson and family engagement. 7 There is growing evidence that engagingor partnering with participants accelerates improvement in outcomes. 8 9 10 11The Maternal, Infant, andEarly Childhood HomeVisiting Program (MIECHV)supports voluntary,evidence-based home visitingservices to improve the livesof children and families. Aspart of that effort, MIECHVinvests in continuous qualityimprovement (CQI). This tipsheet explains the benefits ofincluding participants andfamilies in CQI and providesstrategies for engaging themas partners.OPRE Report #2017-47
There are many potential benefits to partnering withparticipants in CQI:Collaboratively setting goals helps CQI teamsprioritize work that provides direct value toparticipants. Reducing efforts that do not addvalue may reduce costs.Transparent data sharing with participants maybuild trust and increase ownership of results.New innovations that stem from lived experiencemay be developed and tested.Expanding the team’s capacity can help frontlinehome visitors, who often feel overstretched.Participants provide a constant reminder of whyhome visiting is important, which may motivateteams to sustain their CQI work.Strategies to Partner withParticipants in Continuous QualityImprovementCQI teams may feel nervous at first about engagingparticipants in CQI. Team members may haveconcerns about airing program issues in front ofparticipants, exposing their data, or burdeningparticipants. They may worry the team dynamic willchange or participants will not be the right fit for CQIinitiatives. These are valid concerns.Finding the right family partners, developingrelationships, and building trust all happen over time.Below are strategies and resources to use as youwork along a continuum toward engaging familypartners to actively lead or co-lead CQI initiatives.Stages of Family Partnership EngagementThe continuum of strategies below for engaging participants in CQI work is based on a scale created byCincinnati Children’s Hospital and Medical Center. 121Team engagesfamilies in adhoc ways2Team preparesto involvefamilies in CQI3Team learnshow to involvefamily partnersin CQI throughexperimentation4Family partnersactively lead orco-leadimprovementinitiatives2
The stages are not always linear. Teams with familypartners who actively lead CQI initiatives may stillneed to survey a broader proportion of participants,recruit additional participants, and experiment withdifferent ways to engage new team members. Not allfamily partners will want to participate regularly on aCQI team or actively lead an initiative, but they maystill want to contribute. Develop a variety of ways forparticipants to contribute, and find the rightopportunity for each person.1Stage 1: Team Engages Families in AdHoc WaysEarly efforts to involve family voices might include adhoc or short-term methods to learn from participants’experience. Focus groups and surveys are fast,convenient methods to gather information. Beloware examples from MIECHV awardees.Administer surveys. Surveys are a way to gatherinformation from a large group. For example, HealthyFamilies America at the East Bay Community ActionProgram in Rhode Island used surveys to support thedevelopment of an infant feeding curriculum. Theteam surveyed families who were receiving homevisits to understand their perceptions onbreastfeeding versus formula feeding and learn howhome visiting services could support them. Theresults were instrumental in developing an infantfeeding team structure and curriculum. Later, theteam asked families for feedback on ideas to improveinfant feeding. The surveys helped the team betterunderstand and meet the needs of families.Conduct focus groups. A focus group of 6–10participants provides a structured way to gatherqualitative information for CQI. For example, KentCounty Healthy Families America in Michigan wantedto increase enrollment of eligible families. The teamheld two focus groups, one with families whoenrolled in home visiting and another with familieswho did not enroll, to identify factors thatcontributed to the decision to enroll or not. The teamlearned that clear messaging about the importance ofhome visiting was a critical factor. The programrevised its brochure and enrollment messaging andtested refined protocols for providing information.Resources for conducting focus groups can be foundonline. 13The Michigan Home Visiting Initiative (MHVI) sharedanother strategy. As local CQI teams generate newideas to test, they ask families for brief feedbackduring home visits. For example, a team created newmarketing materials and asked families forsuggestions to improve the materials.Ad hoc methods are relatively easy ways to gaininsight across a participant population or from asmaller group and to start involving participants aspartners. However, these methods are limited in thatthey are short-term initiatives rather than long-termpartnerships, and they typically share information inone direction only. Such methods can also be biased:participants are asked to explore only topics andquestions deemed relevant by the frontline provider,rather than those developed together by providersand participants.2Stage 2: Team Prepares to InvolveFamilies in Continuous QualityImprovementBefore inviting participants and families to join theirefforts, CQI teams should internally take steps toensure smooth integration. Below are strategiesteams have found helpful.Consult readiness assessment tools. 14 Thebibliography includes tools that can help CQI teamsidentify areas where they feel ready to engageparticipants and families and areas of concern they3
can address. The tools can open a dialogue amongteam members to explore the extent to which they—Believe families bring unique perspective andexpertiseCan listen to family partners and act respectfullyAre prepared to treat family partners as full andvalued team membersCan describe clear expectations for theparticipation and role of family partnersFeel comfortable sharing power and leadershipwith family partnersAre committed to supporting family partners insharing their voice and perspectiveRecruit family partners. Examples of recruitmentletters and materials can be found online. 15 16 Try toinclude at least two family partners on the CQI team.Providing “strength in numbers” gives partnersconfidence to share their opinions and concerns.Teams should strive to continually recruit new familypartners and offer a variety of ways for them toparticipate. This helps teams increase engagement,withstand turnover, make family participation morerobust and representative, and avoid burnout. Ifbeing a full team member is too much of acommitment for a good candidate, consider asmaller, short-term role, as discussed in stage 1.Although all participants bring valued experience andknowledge, it is important to find family partnerswho are—Willing to share both positive and negativeexperiences in a respectful wayAble to contribute their lived experienceWilling to operate with discretion and not shareconfidential informationGenerally have a positive viewpoint and are ableto listen to others, even when they disagreeExcited about being an advocate to improvehome visiting services for other familiesPrepared to commit the time necessary toparticipate on the teamStaff who work directly with families often canidentify those who might be interested in a partnerrole. It is important, however, not to underestimate afamily’s ability to participate or make that decision ontheir behalf. It is best to explore the opportunitydirectly with the family to determine their interestand readiness.Clearly describe the role. Explain to partners theirpotential role on the CQI team and the time it wouldtake. Examples of role descriptions can be foundonline. 17 18 19 Common roles for family partnersinclude—Leading or co-leading improvement projects,depending on time and interestParticipating in regular CQI meetingsGuiding the team in setting improvement goalsthat are important to familiesInteracting with stakeholders in the home visitingsystem, including local implementing agencies,partners, and awardeesSharing new ideas from their experience andbuilding on the ideas of othersHelping teams consider data and interpret theresultsSharing their experiences as a family partner inCQI and potentially engaging others inimprovement initiativesOffer training. Family partners should understand thefundamentals of CQI so they can contribute theirideas during team meetings and perhaps eventuallylead improvement initiatives. They may need trainingon CQI. MHVI, with the Early Childhood InvestmentCorporation and the Michigan Public Health Institute4
(MPHI), hosted a one-day conference to informparents about CQI, discuss their contribution to theCQI process, and share information on effective teammembership. It may be important to offer training inother areas as well, such as empathy building (e.g.,using Walk-a-Mile cards 20 to understand oneanother’s perspectives), active listening, storytelling,and conflict resolution. 21Address other barriers as needed. For example,some teams encounter legal or institutional barriersto involving participants as partners. It may benecessary to address issues of participantconfidentiality through training or by ensuring thatinformation remains anonymous. Strive to make theprocess for obtaining permission and access forparticipants as smooth as possible. The Institute forPatient- and Family-Centered Care offers guidance. 223Stage 3: Team Learns How to InvolveFamily Partners in Continuous QualityImprovement ThroughExperimentationAs teams invite and include family partners, they mayneed to adapt some of their habits to ensure thatfamilies participate regularly and feel theircontributions are valued. This may involveexperimentation to find what works best. Here arefactors to consider:Compensation. While it may not be possible tocompensate family partners for their participation,especially early on, consider how to recognize theirtime. Some programs offer a modest honorarium. Forexample, Michigan has cross-agency policies toensure that parent participation is acknowledged andcomes at no cost to the family. The policies includean hourly honorarium rate, child care, and mileagereimbursement. Other reimbursements are providedas necessary for parents who participate in state andlocal activities and are part of a larger statewideParent Leadership Initiative.Community. MHVI provides a bimonthly learningcommunity for family partners to gather, learn fromeach other, and provide insight and information toMichigan’s home visiting system. The community isvaluable to the partners and helps sustain familyengagement, even when there is turnover inindividual roles.Meeting time and space. While the CQI team mayalready have a set meeting time and space, this mayneed to be revisited to meet the needs of familypartners. For example, holding meetings duringschool drop-off or pick-up times or after school mightnot be ideal. For working parents, daytime hoursmight be difficult as well. Virtual participationmitigates some of these issues, but in-personmeetings are also important for building communityand trust. Ask family partners what works best, andstrive for a balance with other team members.Active family participation. At first, it may be difficultfor family partners to speak up and share theirexperiences. They may worry about affecting theirrelationship with the home visitor, or they may notyet fully understand their role. Teams can trydifferent strategies to encourage family partners tocontribute. For example, one program sharedmeeting agendas with family partners in advance toget their feedback and discuss logistics. Someprograms assign a team member to be a liaison to thefamily partners and to advocate for them duringmeetings—for example, asking for their opinions andreminding the team to avoid speaking in jargon.5
4Stage 4: Family Partners Actively Leador Co-lead Improvement InitiativesAs family partners’ participation becomes steady andtheir confidence grows, teams may encourage themto assume more active leadership. One way to do thisis to provide opportunities for family partners to leador co-lead an improvement project that is of interestto them and important to the team. For example,some Michigan programs asked family partners tosupport outreach to other program participants.Other examples include collaboratively planning forhome visits, leading information technologyinitiatives, and engaging other families in communitybuilding events.Family partners bring their experience as participants,but they also contribute their own professional skillsand personal strengths. Providing leadershipopportunities for those who are interested can helpthem grow while expanding your team’s capacity.As teams formalize the role of family partners, theymay decide to create structures to support ongoingparticipation, such as a family advisory council. 23Some teams have created salaried roles (part- or fulltime) for family partners.ConclusionPartnering with families in CQI offers enormousbenefits. Families can help improve services they feelare important and make them even more effectivefor other families. Partnering with families alsoexpands the capacity and perspective of the CQI teamand allows the team to see why its work is critical.Over time, programs can develop true partnershipswith families to improve quality and outcomes. Thesepartnerships can be fostered throughout the stagesof engagement, all while building confidence andtrust between providers and families as they worktogether toward a common goal.This tip sheet reflects the experiences of the following MIECHV participants in the Home Visiting CollaborativeImprovement Network (HV CoIIN):Lac Courte OreillesTribal Mino Maajisewin Home Visitation Program, WIMichigan Home Visiting Initiative, MIEast Bay Community Action Program, RIChildren’s Friend, RIMeeting Street, RINortheast Florida Healthy Start Coalition, FLCarolina Health Centers, SC6
For more information about partnering with families in CQI, contact the DOHVE team: Susan Zaid, M.A., DeputyProject Director, James Bell Associates, szaid@jbassoc.com.This brief is in the public domain. Permission to reproduce is not necessary. Suggested citation: Zeribi, K.,Mackrain, M., Arbour, M., & O’Carroll, K. (2017). Partnering with families in continuous quality improvement: TheMaternal, Infant, and Early Childhood Home Visiting Program. OPRE Report #2017-47. Washington, DC: Office ofPlanning, Research and Evaluation, U.S. Department of Health and Human Services. Produced by James BellAssociates.This tip sheet was developed by James Bell Associates under Contract No. HHSP233201500133I. It does notnecessarily reflect the views or policies of the Office of Planning, Research and Evaluation; the Administration forChildren and Families; the Health Resources and Services Administration; or the U.S. Department of Health andHuman Services. For more information, see Langley, G. L., Moen, R., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approachto enhancing organizational performance (2nd edition). San Francisco: Jossey-Bass Publishers.2 DeBronkart, D., & Sands, D. Z. (2013). Let Patients Help! A “patient engagement” handbook—How doctors, nurses, patients andcaregivers can partner for better care. CreateSpace Independent Publishing Platform.3 Fritz, C., Jofriet, A., Moore, L., Myers, S., Nocito, S., Opipari-Arrigan, L., . . . Siedlaczek, R. (2014). Working together to improve care now.Co-Production Change Package.4 Batalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-Arrigan, L., & Hartung, H. (2015). BMJ Quality & Safety, 1–9.doi:10.1136/bmjqs-2015-0043155 Berwick, D. (2009, May 19). What “patient-centered” should mean: Confessions of an extremist. Health Affairs. Retrieved w555.full6 Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.7 Centers for Medicare and Medicaid Services. (2016). Person and family engagement strategy. Baltimore, MD: U.S. Centers for Medicare& Medicaid Services. Retrieved from Info/Person-and-Family-Engagement.html.8 Siracusa, C. M., Weiland, J. L., Acton, J. D., Chima, A. K., Chini, B. A., Andrea, J. H., . . . McPhail, G. L. (2014, April). The impact oftransforming healthcare delivery on cystic fibrosis outcomes: A decade of quality improvement at Cincinnati Children’s Hospital. BMJQuality & Safety, 23, 156–163.9 Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001, November). Improving chronic illness care:Translating evidence into action. Health Affairs, 20(6), 64–67.10 Institute for Patient and Family-Centered Care. (n.d.). Bibliographies and supporting evidence. Retrieved html11 Conway, J., Johnson, B., Edgman-Levitan, S., Schlucter, J., Ford, D., Sodomka, P., & Simmons, L. (2006). Partnering with patients andfamilies to design a patient- and family-centered health care system: A roadmap for the future. Retrieved s/PartneringwithPatientsandFamilies.aspx12 Myers, S., Powell, J., Fritz, C., Jofriet, A., Moore, L., Monti, L., . . . Opipari, L. (2015). Co-production change package: Catalyzingcommunity input v3.0.13 Duke University. (2005). How to conduct a focus group. Retrieved How to Conduct a Focus Group.pdf7
Institute for Healthcare Improvement with the National Initiative for Children’s Healthcare Quality and the Institute for Patient- andFamily-Centered Care. (n.d.). Patient and family center care organizational self-assessment tool. Retrieved ol.aspx15 Family Ties of Massachusetts. (2015, March). Words of advice: Checklist for parents serving as advisors. Retrieved fromhttp://www.massfamilyties.org/pdf/Words of Advice EIPLP.pdf16 Popper, B. K. (2013, January). Who you gonna call? Boston, MA: Federation for Children With Special Needs. Retrieved fromhttp://medicalhome.nichq.org/resources/family engagemen
Continuous Quality Improvement . Involving participants and families in CQI may represent a shift in —from improving services . forfamilies to improving services withfamilies as partners. 2 3. However, it is not a new concept. 4. Partnering with participants and their families is part of a growing movement in health care and social services. 5
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