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Article Excerpt
The quality of our nation's social services system continues to gain attention. Funding groups aim to invest in programs shown to work (Hatry, 1997), while journalists' stories on the perceived failures of social services systems are rewarded with front-page space and even Pulitzer prizes (for example, Levy, 2002). Social workers need to tackle issues of quality not just to avoid bad press. Professional social work assumes that quality service matters. Although the lives of some social services consumers may improve with poor service and some may not improve even with the best service, the likelihood of improving the lives of consumers should rise as the quality of service rises. If this is not the case, the need for our profession diminishes.
Important literature on quality has been developing in administrative social work (see Kettner, 2002), and recently a research agenda on the quality of social services was proposed (McMillen et al., 2005). But quality of care is important to all social workers, not just researchers and administrators. Social work practitioners who want to participate fully in efforts to improve the quality of social services need to understand what is meant by quality of care, grapple with its complexity, and learn how to identify and leverage the key factors most likely to influence it. To this end, this article introduces a conceptual model that reflects major influences on service quality and that is designed to lend specificity to social work's dialogue on quality and efforts to improve it. This work is designed to help individual social workers understand the influences on quality in their service settings and identify leverage points for quality improvement.
SOCIAL WORK AND QUALITY
The discussion of quality in social work has differed from that of other professions and disciplines, such as retail service (where the customer is, or at least used to be, king), manufacturing (where variance is evil and should be eliminated), and medicine (where the talk is about quality crises, safety, and disparities). Social work's engagement with issues of quality has been more diverse and has led to fewer accepted pronouncements about the scope and definition of quality problems. For the most part, like other professions, social work has historically used what quality scholars call "the professional model" to ensure high-quality service provision (Morris, 2000). In this approach, each social worker is essentially responsible for his or her own quality control (Palmer & Adams, 1993), with limited corrections introduced through licensing and sanctions, and moderate controls in some settings from supervisors and personnel actions (Palmer & Adams).
In the past 20 years, the increasing use of government purchase of service contracts to provide social services (Government Performance and Results Act of 1993) (P.L. 103-62) and an accent on accreditation have propelled a management interest in quality (Kettner, Moroney, & Martin, 1999). Writers in social services administration have imported quality-focused management frameworks from business into social work (see Kettner, 2002). Much of this has focused on total quality management (TQM) (Deming, 1982). TQM emphasizes top management's commitment to quality, customers' definition of quality, measurements of consumer satisfaction, assessment and correction of variance, and change through quality teams. But other frameworks have been used as well, such as Peters and Waterman's (1982) principles for excellence derived from case studies of successful corporations.
Quality efforts in social work have taken other directions as well. One of these is data driven, including emphases on program evaluation (for example, Chen, 1993; Devaney & Rossi, 1997) and monitoring of consumer outcomes (for example, Poertner, Smith, & Fields, 1991). Other social workers have emphasized professional standards (Shlonsky & Berrick, 2001; Usher, Locklin, Wildfire, & Harris, 2001) and compliance with ethical codes.
In the social services, as in health care (for example, Michel & Johnson, 2002), the word "quality" is likely viewed by some in political terms because of its implicit ties to issues of transparency and change, power and control, and money. An interest in quality implies an interest in unveiling poor-quality care. This transparency is naturally feared by those who worry that their efforts will not meet someone else's definition of quality and that they will be blamed or asked to change entrenched practices. Quality-of-care work also implicates power mechanisms. Power goes to those who successfully define what quality of care means in a particular practice setting or field. Social workers may also fear a movement that could be viewed as wishing to replace the autonomy of the professional model of quality control with a more bureaucratic one. With this, social workers may fear that their allegiances will be drawn farther from their clients and more toward meeting external standards. Finally, quality issues are intertwined with a host of financial ones. It likely costs more, at least up front, to provide higher quality care. As soon as quality is defined and measured, providers who deliver quality care want to be paid more than those who do not (for a review of pay for performance, see Rosenthal & Frank, 2006). Finally, payers may have little interest in purchasing low-quality care at any cost.
Rather than fleeing from quality issues because of these political fears, social workers need to be fully engaged in efforts to define quality practices, understand the root causes of quality problems, and become proficient at methods to improve quality care. The conceptual model of quality that we offer here is designed to aid these efforts.
A CONCEPTUAL MODEL OF THE INFLUENCES ON QUALITY OF SERVICES
The social services literature has lacked a systematic, overarching framework for envisioning and assessing the influences of quality operating in specific practice settings. Without such a framework, our efforts to understand quality tend to be focused on the end points of what could be viewed as the two extremes of a complexity continuum. On one end, social workers are left to our intuitional sense that things seem to be going well or poorly in a certain practice setting....
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