Measuring Parenting to Promote Quality Improvement in Family Services

As someone who once taught Continuous Quality Improvement (CQI), I am pleased to hear the term more frequently used in family services circles (for detail see Childwelfare Information Gateway, The Casey Foundation, or Management Sciences for Health).  CQI, or Total Quality Management as it is sometimes called, derives from the work of W. Edward Demming.  Stated most simply, CQI is the use of information to guide improvement.  As an evaluator, I find the notion of using statistically valid results to guide services very attractive.  After World War II, Demming was unable to get much traction in the United States for his concept of making decisions based on consciously collected data. However, war-ravaged Japan welcomed him.  Thanks to Demming, Made in Japan went from being synonymous with junk to becoming an expectation of high quality.

CQI thinks in systems, comprised of inputs and outputs, with processes in the middle.  In family services, we can think of the inputs as parents, siblings, extended family members. The term output doesn’t fit services programs, so the term outcome is commonly used.  The ultimate long-term outcome for many service programs are healthy, productive, well-adjusted adults.  But for this discussion, we are speaking of the desired immediate outcomes for many service programs that often include healthy, well-adjusted children who are attached to their parents, and satisfied parents who show strong relationships with their children and are prepared to nurture their children through to adulthood.  What are the processes?  The processes are the actions family service programs take toward the goal.  A few examples could be home visits, parenting classes, parenting groups, child care, preschool, and/or family therapy.  

Prior to the CQI movement, manufacturing focused on inspecting products after production.  When inputs of unknown quality came in, and were acted on by poorly controlled processes, it resulted in many defective products.  Similarly for family services, measuring child attachment or child development at the end of services gives us the outcomes at the far end of the “production line.” The information doesn’t directly guide improvement while services are being delivered.  Measuring outcomes without assessing intermediate processes and outcomes results in what is termed a black box.  You know what comes out, but you can’t tell why. 

CQI focuses much attention on processes that can be controlled and improved.  By understanding and improving the processes, we can achieve better outcomes, whether they are manufacturing or child development outcomes.  Central to CQI is the Shewhart Cycle or the Plan, Do, Study, Act Cycle (PDSA).  In the Plan stage one designs a means of assessing a process.  In the Do stage one conducts an experiment and collects results.  In the Study phase one analyzes the results.  Finally, in the Act stage one reflects on the results and makes changes accordingly.  This often leads to another PDSA cycle aimed at gaining further improvement.  One beauty of CQI is the development of a system of procedures and tools that puts the ability to conduct these investigations into the hands of the people actually doing the work.  The use of CQI in family services has great potential.  We can use the tools and processes of CQI to improve the service quality in many ways.

Following the analogy with manufacturing, healthy child development is the desired outcome.  We want to focus on the major influencers having the biggest impact on reaching the desired outcome of healthy child development.  Since parenting has major influence, measuring parenting should be the highest priority.   Using a parenting assessment, like KIPS, in partnership with a family can  inform a series of PDSA Cycles leading to improvement, and leading to our desired outcome.  After all, it is the parents who do most of the process of nurturing their children.  With a parenting assessment, CQI can inform the means of how we effectively partner with parents in working to improve the process of parenting.  It is improved parenting that most influences our desired outcome, healthy child development.

All analogies eventually break down, and so does the comparison of manufacturing with family services.  Fundamental to CQI in manufacturing is starting with controlled inputs.  Reducing the variability in the inputs proves key to success in quality manufacturing.  In sharp contrast, family services programs seek to serve families in need.  Each family has its own unique set of strengths and needs, and treating them as standard inputs is a mistake.  Family service programs must assess the strengths and needs of each family and tailor their services to most effectively serve that family.  Thus, a standardized process is not the aim of family services.  Instead, adapting services to meet each family’s specific needs will yield greater success.  Validated assessment tools are key to effectively adapting services to best serve each family.