Quality Indicators for Independent Living Services: Quality Improvement
Based on IL Principles
2001
by Maureen Ryan
Overview
The Wisconsin Coalition of Independent Living Centers (WCILC) has developed
the Quality Indicators for Independent Living Services (QUILS), a peer
review tool designed specifically for community-based, nonprofit centers
for independent living. QUILS consists of both a document and a process.
The document describes Quality Indicators which are derived from current
federal standards and assurances for centers for independent living (CILs)
but which further detail quality visions of best practice. Indicators
often exceed federal standards or propose benchmarks for service or practice.
The people who developed these indicators made a conscious decision to
go beyond minimum requirements for compliance with federal or state standards.
The quality indicators are intended to be signposts for CILs in the pursuit
of excellence.
CILs can use the document to perform an internal self-assessment or as
the framework for an external assessment by a team of peers. The results
of a survey using the instrument can provide a great foundation for a
strategic plan.
The second component of QUILS is a facilitated, on-site review by members
of a peer review team. The peer review utilizes extensive interpersonal
contact with consumers, board and staff members to assess Quality Indicator
achievement. When talking with board members, staff and consumers, peer
review team members focus on such issues as customer satisfaction, equal
involvement of consumers in setting the direction of the center, consumer
control of services and whether or not the community is becoming more
accessible and providing more opportunities for people with disabilities.
Centers have control of the QUILS process. They choose if and when they
want to have a peer review, who is on their peer review team, who their
facilitator is, and how and with whom they share the verbal and written
feedback. The center decides which recommendations and strategies they
will implement and when they will be implemented.
Although the Wisconsin SILC provides funding for the peer reviews, the
SILC does not require centers to report on the results. Centers can take
advantage of this opportunity for quality improvement without fear that
the SILC, the DSU or any funding agency is going to use any peer review
information against them.
Every center has strengths and weaknesses. The peer review process typically
finds things that are very strong and areas that need improvement. This
process allows for the centers to be open because no one gets the information
without going through the center. The result is honesty between the team
members and those associated with the center and a true picture of the
CIL's performance. This honest assessment can then lead to useful recommendations,
realistic goals and outstanding service.
Background
QUILS was developed over a two year period by representatives of all
Wisconsin CILs, the Office of Persons with Physical Disabilities, and
the State Independent Living Council. The first step with QUILS was the
development of a tool and a process that clarified our values and our
definition of quality. The State Independent Living Council committed
financial support for the peer reviews. For the first three years, the
SILC provided funding for two peer reviews a year.
To date, all of the CILs in Wisconsin have received at least one peer
review, and by the end of this year, half of the CILs in Wisconsin will
have received their second peer review. The number of peer reviews scheduled
per year is dependent on the amount of SILC funding. SILC is now funding
one review per year, so we cooperatively designate which center will receive
the next year's review at our final board meeting of each year. Each center
knows where they are within the rotation of the eight centers.
The QUILS tool is reviewed annually and revisions to that tool have been
made based on input received from peer reviews. Presentations on QUILS
have occurred at the annual NCIL Conference and at the Region V Conference,
with discussion at the annual SILC Congress. This tool has been sold to
three other states and eight have expressed a strong interest in its purchase.
The Plan
QUILS is a powerful, practical and flexible tool in the pursuit of independent
living excellence. QUILS is not intended to be used for comparative "rating,"
but rather as an internal tool for quality improvement. Previous participants
in the process have stated the following reasons to have a peer review:
- to clarify your values and your definition of quality, and then measure
yourself by that;
- to really see your center's performance from the customer's perspective;
- to challenge your center to go beyond compliance;
- to provide important input to planning;
- to open up new possibilities instead of continuing to do things the
way they have always been done;
- to take initiative and be proactive (fix it ourselves, before someone
fixes it for us).
A center planning a QUILS review would receive the Quality Indicators
document, which lists the indicators and includes a list of materials
that should be made available to the review team and suggested schedules
for the site visit. The center has the opportunity to become familiar
with the indicators by which the peer review team will evaluate their
performance. As noted above, a center may also choose to use the indicators
to conduct their own self-evaluation.
Centers have a responsibility to address the issues in their own communities.
Federal reviewers often do not to look at this aspect. QUILS, however,
weighs this aspect heavily. There are quality indicators that address
how a CIL assesses the needs of the community, methods of responding to
the local needs and how a center determines the impact of its activities
in relation to the community needs.
For a peer review to be successful, the center, facilitator and peer
review team must prepare in advance of the actual site visit by the team.
The center prepares by choosing a team and a facilitator, making logistical
arrangements (meeting space, accommodations, meals), gathering materials
and obtaining release of information forms from consumers. The process
for a peer review starts three to four months before the review.
The center controls who is on the peer review team. The team should include
center staff, representatives from both management and direct services,
persons with varying expertise and at least one or two members with experience
in the process. The average number of people on a peer review team is
five and the average peer review takes five days. Upon completion of the
review, the CIL staff and board are provided with both verbal and written
reports regarding the peer review findings.
The facilitator and team prepare by studying the Quality Indicators document
and becoming familiar with the indicators and their definition of quality.
The facilitator and team members will also review materials sent in advance
by the center. These materials might include policies and procedures,
mission statement, brochures and newsletters, board minutes, job descriptions
and consumer demographics.
QUILS emphasizes the examination of the CIL's strategy and outcomes in
the context of their own environment. During the site visit, peer review
team members will interview consumers, staff and board members using interview
questions suggested in the QUILS document and other questions developed
by the team. They will review consumer records and other center documents.
They will look at the center's goals and objectives and will assess how
successful the center has been in accomplishing its goals in the view
of these stakeholder groups.
At the end of the site visit, the peer review team will share their preliminary
findings and recommendations with the executive director, staff, board,
and any others that the center wishes to include. The facilitator sends
a final written report to the center after the site visit has been completed.
The Wisconsin CILs do not have to provide the SILC with the full written
report, but following a peer review, each CIL provides a presentation
on the QUILS process at a SILC meeting. This presentation consists of
the impact that the peer review had on the center, feedback on the process
itself and a general summary of the overall experience. The SILC has no
intention of using the information provided at the presentations in a
negative manner toward the center, but rather as an informative tool on
the process and as a means to keep abreast of the issues that the centers
are facing in their communities.
The Success
The Wisconsin CILs have used QUILS to identify strengths and weaknesses
and to make changes. CILs that have participated in QUILS have provided
the following feedback:
- "[QUILS] provided direction and support to board and staff."
- "[The review] helped us identify weak areas of provision of
the IL core services."
- "[The process] helped us see the need to clarify roles and responsibilities
of management, staff and board."
- "[QUILS] highlighted different organizational weaknesses and/or
outsider perceptions that were of great benefit in improving our advocacy
services."
- "The issues identified by the Peer Review became target points
for our short and long range planning."
- "The recommendations assisted staff to convince the board of
a project direction or fiscal expenditure."
- "We just completed our second Peer Review. The first one was
an impetus to become free standing and was a part of our strategic plan.
The most recent reaffirmed what we did and that we truly are free standing.
The Board will use the peer review to determine how to fill some of
the areas that need improvement. Many of these will require substantial
fiscal allotments. Management and staff will use the peer review for
quality improvement for service delivery."
- "The QUILS process has been useful in giving our ILC needed external
feedback in a time of transition to new management personnel. We also
used the QUILS guidelines in creating new directors for the core services
we deliver and helping us on updating our consumer satisfaction process.
The process was thorough, confidential and respected by our staff and
Board of Directors because it was conducted by our peers across the
state."
Peer review team members put in a great deal of time and energy and receive
a great deal in return. Many people have said being on a peer review team
was their best experience in IL. Team members have expressed that their
knowledge of new resources and methods of service delivery have been enhanced
by being a peer reviewer. Peer reviewers have the opportunity to see and
hear what other centers do well and how they do it, what they have tried
in the past and their future plans. The centers in Wisconsin are very
eager to share their resources and information and we try not to reinvent
the wheel. We are our own peer mentors and we are only as strong as our
weakest center.
Funding/Cost of QUILS
The cost of a peer review in Wisconsin ranges between $3,000 - $6,000,
depending on the size of the CIL and the travel distance and accommodations
of the peer review team. As mentioned previously, the SILC provided funding
for two peer reviews in the state for the first three years and thereafter,
for one peer review per year. Since many of SILC's objectives in the State
Plan were related to improving IL services and supporting the general
operation of CILs, the QUILS process was strongly supported by the SILC.
WCILC holds the copyright on the QUILS tool, but states may replicate
a process similar to the QUILS. "Reinventing the wheel" is usually
not cost- and time-effective, but a state may want to put their own spin
on a similar process after experiencing the QUILS. We suggest that QUILS
be purchased by a state as opposed to one CIL, although either option
is available. It is more effective if purchased by a state as the cost
can be shared and you will have the statewide commitment for peer review
team members.QUILS is unique and the facilitator needs to be specifically
trained on the QUILS tool and process. Wisconsin currently has five trained
available facilitators. The facilitator can provide a "train the
trainer" approach on the entire QUILS process so that a state may
be ready to go on their own after one facilitated peer review.
The cost for QUILS is $5,000 plus expenses per state. This includes the
cost of the facilitator for one peer review and statewide use of the tool.
If a state requests a facilitator for a second or additional peer review,
the cost is $3,000 plus expenses per review. A suggestion is to have the
QUILS peer review included in your State Plan for Independent Living and
have the SILC contribute to this commitment. WCILC encourages anyone who
is interested in QUILS to contact us and sign up to be part of a peer
review team in Wisconsin.
Contact Information
Maureen Ryan
106 East Doty Street, Suite 3A
Madison, WI 53703
608-251-9151 v/tty
608-251-9152 - fax
mryan@gdinet.com
About the Author
Maureen Ryan is the executive director of the
Wisconsin Coalition of Independent Living Centers. Prior to that, she
was the director of independent living at a Wisconsin CIL for eight years.
She was involved in the development of the QUILS and has been on six peer
review teams, including the first peer review. She was the recipient of
a peer review and is a trained QUILS facilitator.
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