Child & Youth Services

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One Small Step at a Time: Implementing

Continuous Quality Improvement in Child and
Youth Mental Health Services

Nicole Chovil

To cite this article: Nicole Chovil (2010) One Small Step at a Time: Implementing Continuous
Quality Improvement in Child and Youth Mental Health Services, Child & Youth Services,
31:1-2, 21-34, DOI: 10.1080/01459350903505561

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Child & Youth Services, 31:21–34, 2009
Copyright # Taylor & Francis Group, LLC
ISSN: 0145-935X print=1545-2298 online
DOI: 10.1080/01459350903505561

One Small Step at a Time: Implementing

Continuous Quality Improvement in
Child and Youth Mental Health Services

NICOLE CHOVIL
The F.O.R.C.E. Society for Kids’ Mental Health, West Vancouver, British Columbia, Canada

Continuous quality improvement (CQI) is increasingly being

adopted by health care, including child and youth mental health
services. As part of the commitment to ongoing quality improve-
ment, child and youth mental health teams in the Fraser region
in British Columbia undertook CQI projects over a one year period
(2007–2008). The projects covered a range of domains and service
features and staff gained experience in developing projects.
Patience, management support and ongoing dialogue were key
elements in the implementation of CQI. Three projects are
highlighted to illustrate how teams developed their own unique
projects and the outcomes.

KEYWORDS child youth mental health services, continuous

improvement, continuous quality improvement, staff engagement

Without careful monitoring, there is no effective way to judge how well

services are being delivered, whether they are meeting the needs of children
and families, and if they result in the desired outcomes for children and
families. Continuous quality improvement (CQI) is one model by which orga-
nizations can build quality improvement into their services. CQI begins with a
strong commitment to client satisfaction. A second key component of CQI is
the involvement of staff, youth, and families in the planning and implement-
ing of changes and improvements with the goal of services that meet or
exceed expectations of clients. CQI was first championed in business and is
increasingly being incorporated into health services, including mental health
as a means to help ensure and demonstrate high quality services (Bailie,

Address correspondence to Nicole Chovil, The F.O.R.C.E. Society for Kids’ Mental Health,
P.O. Box 91697, West Vancouver, BC, Canada V7V 3P3. E-mail: nchovil@shaw.ca

21
22 N. Chovil

Donoghue, & Dowden, 2007; Blau, Fisher, & Sheehan, 2007; Harrigan, 2000;
Hyrkas & Lehti, 2003; LeBrasseur, Whissell, & Ojha, 2002; Pruett, Johnson, &
Keefe, 2007; Shortell, Bennett, & Byck, 1998). CQI involves the use of assess-
ment, feedback, and application of information as a way to improve services.
Use of CQI strategy enables an organization to be proactive rather than
reactive by relying on a continuous evaluation of processes and outcomes.
Creating a continuous feedback loop is the foundation for CQI (Lyons,
Howard, O’Mahoney, & Lish, 1997). Data is systematically collected and
guides the changes or interventions which are re-assessed for improvement.
This helps demonstrate the effectiveness and accomplishments of the organi-
zation and highlight areas of concern, which need improvement. One CQI
model is the Plan-Do-Study-Act (PDSA) cycle. Step I involves planning the
quality improvement project. This includes identification of indicators and
measures. Step 2 is to collect data and determine what changes or intervention
is needed that will lead to improvement. Step 3 involves implementing the
change and re-assessing the effects. If the change has the desired effects of
improving the process or outcome, then step 4 is to implement the change
on an ongoing basis. If the intervention was not successful, the CQI process
returns back to step 1. The aim is to work continuously towards small changes
that lead to improvements in the quality of services delivered. CQI is not about
single changes but, rather, about trying new ideas to see if they work.
Although there is an abundance of information on best practices,
frameworks and necessary elements for the successful introduction of
CQI (e.g., Bertram, 1991; Birleson, 1999; Claus, 1991; Heller & Arozullah,
2001; Steenbarger & Smith, 1996), there is a dearth of published literature
available on organizations’ experiences with implementing CQI, parti-
cularly community based child and youth mental health services. Most
information exists mainly in the form of very limited documentation on
organizations’ Web sites. The aim of this paper is to report on the experi-
ence of a public government child and youth mental health agency in
implementing CQI. This information will help to inform other agencies
who may be looking to implement CQI and are seeking information to
guide these efforts.

A KEYSTONE OF CONTINUOUS QUALITY IMPROVEMENT

Quality is achieved through participation of all members of team, not just

leaders or experts. (Lees, 2005, p. 1)

The CQI process regards those closest to the work (staff, children, youth,
parents=caregivers, and community partners) as the key ‘‘experts’’ in the
work. CQI enables Child and Youth Mental Health Program (CYMH) to work
in partnership with clients and families in assessing the delivery and out-
comes of practices, programs and policy and in making and monitoring
 Implementing Continuous Quality Improvement 23

improvements. Their experiences inform how the system impacts families

and if the care provided is consistent with the key principles underlying
services and meets needs of families.
Involving staff in the design and monitoring of service quality is a way to
formally honour the expertise they bring to child and youth mental health
care. The approach is consistent with evidence that suggests that staff need
to ‘‘own’’ quality improvement initiatives and embed them into everyday
practice (O’Connor, Ward, Newton, & Warby, 1995). CQI has resulted in
not only improved client=family outcomes but has improved staff morale
and retention because of increased empowerment (Wish, 2001).
Embedding CQI into an existing organizational structure is a process
that is unique to each organization. CQI must be adapted to fit the specifics
of the organizational culture and sufficient time needs to be allotted to deal
with barriers. Watson (2005) suggested that the implementation of CQI will
go through several stages of evolution and development. Creating the
change in an organization from a bureaucratic culture to one that is driven
by quality and input from those on the front line is a lengthy process, requir-
ing an evolutionary and not a reactionary approach (Claver, Gascò, Llopis, &
Gonzàlez, 2001; Tomkinson, 2006).

THE FRASER REGION CHILD AND YOUTH MENTAL HEALTH

PROGRAM (CYMH)

In British Columbia, child and youth mental health services are delivered
through the Ministry of Children and Family Development (MCFD),
which is divided into five regions. The Fraser region is the largest of the five.
The CYMH Program, operated through MCFD, offers assessment, treatment
and support services that are delivered through multi-disciplinary teams.
CYMH works in partnerships with schools, community agencies, hospitals,
and the broader medical community to provide services to children, youth
and their families. In addition to the CYMH Program, MCFD contracts with
various community agencies to deliver additional mental health services.
In 2003 the Government of British Columbia announced the Child and
Youth Mental Health Plan with the aim of enhancing treatment and support
services, reducing risk, building capacity and improving performance. The
Plan resulted in rapid expansion of staffing and contracted services, specia-
lized programs and evidence-based training, as well as new procedures
and information systems. Improving performance including increased
accountability and outcome monitoring was a key part of the plan. The goal
was ‘‘a comprehensive provincial children’s mental health information
system that can be used to monitor outcomes and evaluate activities in all
related programs and sectors, and that can be linked with larger databases
in health and education’’ (British Columbia Ministry of Children and Family
Development, 2003, p. iv).
24 N. Chovil

Prior to the adoption of the Plan, CYMH had no outcome measures,

client satisfaction survey, or other systematic feedback mechanism for
monitoring system improvements. Common outcome measures were being
considered, but had not yet been implemented (Tomkinson, 2005).

THE FRASER REGION CQI FRAMEWORK

Proceed slowly, educate, participate, use CQI to develop CQI. (Lees,

2005, p. 1)

In 2004 regional management support for CQI was obtained and the Fraser
region filled its first mental health practice analyst position, with a mandate
to develop continuous quality improvement into the CYMH program. CQI
was appealing as it provided a means to monitoring and improving quality
of services and an opportunity to develop a locally-defined evidence base that
was reflective of the specific needs of clients and families and how services are
delivered within communities in the Fraser region. This knowledge base would
complement already utilized evidence bases such as evidence-based treatment.
The possibility of future accreditation which required evidence of continuing
quality improvement processes also influenced the decision to implement a
CQI process within the region. The practice analyst was responsible for over-
seeing the CQI implementation and to provide support to teams and clinicians
to engage in CQI. The initiative was given provided with a small annualized
budget that funded research and contracts with partnering agencies.
The introduction of CQI to the CYMH program was greatly aided through
the work of four graduate students. The first master’s thesis (Tomkinson, 2006)
involved focus groups with clinicians on the topic of CQI and revealed an
environment of distrust and caution about the intentions of management with
respect to new initiatives. The results strongly suggested that clinician involve-
ment was crucial to efforts at system measurement and improvement.
The first implementation of CQI was a peer-led audit that consisted of
staff interviews using a standardized audit tool that had been created by a
cohort of clinician-colleagues. The audit provided an initial mechanism by
which feedback from staff could make its way through various levels of the
organization in a timely fashion. The high level of participation and follow up
were seen as a positive response to the efforts at clinician ownership and
‘‘voice’’ in the process (Lees, 2004).
In the next phase, the Fraser region focused on exploration of key domains
and indicators to use in building CQI projects. Clinicians, parents, and youth
participated in focus groups, surveys and interviews to explore what indicators
of service should be measured (Chovil, 2007, 2008; Latimer, 2006; Littlefield,
2009; Sharma, 2008). Two mental health organizations, The F.O.R.C.E. Society
for Kids’ Mental Health and the Canadian Mental Health Association Delta
Branch, facilitated youth and parent=caregiver involvement in CQI.
 Implementing Continuous Quality Improvement 25

The development of indicators was based on the domains identified

through the Canada-wide study on Continuous Quality Improvement in
Primary Mental Health Care (Warrich, 2005). These domains were
(a) Accessibility, (b) Client Centeredness, (c) Competence, (d) Continuity,
(e) Effectiveness, and (f) Appropriateness. The criteria for selection were that
indicators needed to be meaningful and feasible. The items generated
through the focus groups were incorporated into surveys that were
completed by the three stakeholder groups. Interviews were also held with
parents and youth about helpful and unhelpful aspects of their experience
with child and youth mental health services. The results revealed a shared
agreement amongst the three stakeholder groups that Client-centeredness
and Competence were priority key domains.
In phase three, the CYMH teams were given the challenge of developing
their own CQI projects. The CYMH teams were represented by a clinician
‘‘CQI Lead’’ who was responsible for attending CQI meetings and facilitating
team engagement in the CQI process. The CQI Leads were given training on
the basic principles of CQI and a review of domains and indicators identified
through the stakeholder surveys. The two domains of Client-centeredness
and Competence were used as the starting point for team planning discus-
sions. The teams were encouraged to begin with these domains but could
also choose another domain, depending on the interests of their team. The
CQI Leads worked with their respective teams to decide on a domain and
indicators that would form the basis for the teams’ projects. A research
consultant was available to any team wanting assistance in developing their
project. Senior management attended the training and demonstrated their
commitment to the process and support for teams to engage in CQI.
One constraint in this process was that projects had to be designed
and implemented using existing staff resources. Most of the projects were
completed without any additional funding. However, because of the
intensive staff involvement needed for the day treatment program, some
financial resources were provided to their team in order to facilitate data
collection and analysis. During the development of the team projects, the
CQI leads met periodically to provide updates on their team’s progress in
selecting a domain, measures and method of data collection. The group
also engaged in a dialogue around issues about CQI that came up in their
individual team’s discussions. In June 2008, the CQI leads reconvened and
presented their projects to the CQI group.

TEAM PROJECTS

A summary of the domains and projects is presented in Table 1. Teams

developed projects that covered four of the six domains: accessibility,
client-centeredness, competence, and effectiveness. A number of projects
 TABLE 1 Overview of Projects Chosen by CYMH Teams

Domain

Accessibility Client-Centeredness Competence Effectiveness

Examination of Cancelled
Referrals
Determining Client Populations
Not Reached
Doctors’ Awareness and
Reducing ‘‘No Show’’ Rates:
Telephone Reminders and
Follow-up Calls
Clients’ Experience of Being
Heard= Understood
Client=family Satisfaction with
Evaluation of an In-House
Dialetical Behavioral Therapy
Training
Evaluation of a Structured Peer
Supervision Model
Youth Day Treatment Program:
Quality of Life Outcomes and
Youth Program Feedback

26
Knowledge About the CYMH
Program
Service Determination Patterns
for ‘‘Urgent’’ Referrals
Determining Need for
Family-based Interventions
Clinical Services
Client Satisfaction: Using Miller’s
Client Ratings to Provide
Feedback to Therapists
Client Feedback on Helpfulness
of Therapeutic Sessions
Client & Family Satisfaction with
Services: Involvement in
Assessment & Treatment
Planning
 Implementing Continuous Quality Improvement 27

sought client feedback about treatment effectiveness and engagement in the

treatment process. Client and parent=caregiver satisfaction with services was
surveyed by three teams. Within the accessibility domain, teams chose to
investigate reasons behind cancellations, barriers to keeping appointments,
community awareness of the CYMH Program, referral patterns, and assessing
the need for family based interventions. The usefulness of training in an
evidence-based practice, effectiveness of peer supervision, and the effective-
ness of a specialized program for youth were additional areas of interest.

INDICATORS=METHODS

There were a number of considerations that went into teams’ decisions about
data collection. Feasibility was emphasized in discussions with clinician CQI
leads about CQI projects. Teams typically chose to develop their own mea-
sure or adapt an existing measure to meet the objectives of their project.
They sought ways to minimize the impact on clinician and administrative
staff’s time, and it became clear that the process needed to be one that could
be feasibly implemented into the daily routine of the office. A number of pro-
jects incorporated rating questionnaires or surveys and the teams learned that
the measures needed to be easy to understand and use. The heavy workload
of clinicians necessitated minimizing the amount of time needed to collect
data. Teams decided to collect data for a specific time period, for example,
during one or two week period which was repeated over the course of a
few months.

FINDINGS

One of the main findings from this process was that engaging teams in CQI
required time, patience, and a commitment to ongoing dialogue with the CQI
Leads and team leaders, and within the teams themselves. Strong leadership
support greatly facilitated teams’ engagement in building CQI into their work
with families. CYMH had always functioned as a top-down management
driven organization. The organization had undertaken many new initiatives
and there was some questioning of a long term commitment to CQI. Given
that there is no roadmap for CQI implementation; there was a range of ideas
of what CQI meant and how it should be conducted. This created some
tension when the general process was perceived to be inconsistent with
the philosophy behind CQI (e.g., being directed to engage in CQI even
though it was emphasized as a ‘‘grassroots’’ process).
Although all the clinicians valued the importance of quality, not all
teams initially were enthusiastic about developing projects. There was a
diverse response to the initial introduction of CQI with some teams immedi-
ately seeing how they could incorporate CQI into their office; others
28 N. Chovil

required time before they became comfortable with the idea. CQI leads
used several different approaches: including CQI as a regular part of their
team=staff meetings, engaging one-on-one discussions with colleagues,
and having a representative from Service Quality attend a staff meeting.
Over time clinicians became increasingly more comfortable with CQI. In
team meetings, the clinicians and team leaders engaged in discussions
about service quality and CQI in general. This resulted in the generation
of creative ideas about what to look at and explorations of ways to collect
the information they needed. Some teams found they initially struggled
with decisions as to the direction of their individual projects. However, over
the course of the projects, team discussions resulted in more concrete
suggestions about the focus and implementation. Team leader support
for the CQI process greatly facilitated the team projects. Team leaders’
commitment to CQI provided another demonstration of leadership’s
commitment to the initiative.
The initial goal of the process was not to produce a set of completed
CQI projects but, rather, to introduce the process and give opportunity
for teams to explore and discover both the benefits and challenges of
CQI. All results were useful, even if they did not always result in improve-
ment changes in the delivery of services. For some teams the projects
provided an opportunity to test measures and data collection procedure.
The results informed decisions about measurement tools to use in future
CQI projects. Other teams learned how they needed to be more specific
in the questions asked and examined ways they could increase
sample size and increase efficiency in collecting information. The experi-
ence provided ideas for future projects or how the process could be
improved. A few projects led to changes in the service delivery process.
For example, when one team observed how telephone reminders reduced
their no show rates, they decided to continue with the reminders as part
of their service.
One of the greatest challenges was overcoming the perception that CQI
was an added work piece that took away from valuable time for clinical
work. Although staff agreed that service quality is important, the workload
and urgent needs of clients made it challenging to put CQI into practice.
The time required to implement CQI seemed to affect the smaller teams
and specialized programs more than other larger offices.
The data collection process required careful consideration. A number of
team projects involved the collection of data from clients. Although the clin-
icians were keen on collecting the data, teams sometimes found it challeng-
ing to remember to give the questionnaire to clients or record the data. Most
of the projects were limited by small, nonrandom sample sizes that limited
the team’s ability to draw meaningful conclusions from their project. Some
teams initially expressed concern about collecting client=family feedback
about sessions; particularly negative feedback about individual clinicians.
 Implementing Continuous Quality Improvement 29

In addition, there were concerns about how to ensure that clients=families

could freely choose to participate.
Over the project period there were a number of personnel changes in
the clinician CQI Leads. Lead turnover made it difficult to transfer knowledge
of CQI projects and to maintain team commitment to process. An important
learning was the need to develop a process by which to document the his-
tory of projects. Transferring this history to new CQI Leads was not always
reliable and, in some instances, it was difficult to locate documentation on
projects.
In spite of all the challenges, the Fraser region CQI projects reflected the
commitment of the teams to ensuring quality services for their clients and
families. In the next section, three team CQI projects are highlighted.

SHOWCASING CYMH CQI PROJECTS

Project 1: Effectiveness of an in-House Dialectical Behavioral

Therapy (DBT) Training Event
Domain: Competence.
Indicator: Clinician ratings of training and implementation.
Purpose and Method: The Abbotsford team identified a trend in their referrals
with respect to a high number of referrals for emotionally dysregulated
youth. Two team members (previously trained in DBT) developed an
in-house five day training to increase the team’s effectiveness in meeting
the needs of their clients. Evaluation processes were built into the training
and a six week follow-up survey in order to assess the quality of the training
and its impact on clinical application.
Results: The highest rated modes of teaching utilized experiential elements
(e.g., mindfulness exercises and clinical role-plays). The majority of clinicians
reported using an ‘‘Informed DBT’’ approach and, ideally, using an ‘‘Inte-
grated DBT’’ approach. The results also indicated the training had a signifi-
cant impact on their theoretical approach and clinical practice when
working with high risk youth. The following barriers were identified by
the clinicians with respect to implementing the training: lack of time; lack
of practice support; and competing roles as clinicians.
Next Steps: One year follow-up on implementation of training and a repli-
cation of training.

Project 2: Decreasing ‘‘No-Show’’ Rates

Domain: Client-Centeredness (Engagement with Clients: Barriers to
Attending Sessions).
30 N. Chovil

Indicator: Percentage of missed appointments=total number of appointments.

Purpose and Method: A specialized services team (Burnaby) identified
ccontinuity and consistency of care as critical to the efficacy of treatment.
The team began by first monitoring no-show rates for appointments in
order to establish a baseline and then implemented a ‘‘reminder’’ call to
clients 48 hours prior to their appointment. A follow-up survey with
clients who had missed an appointment (within 48 hours of the missed
appointment) was also implemented which inquired about barriers to
keeping appointments.
Results: Baseline results revealed that 23% of the appointments were
‘‘no-shows.’’ Higher rates were observed at the beginning and end of the
month (45%), with the lowest rate at mid-month (20%). With the introduction
of the telephone reminder, the no-show rate dropped to 20% and was steady
over the entire month. When the follow-up call was implemented, no-show
rates dropped to 14%. There was also an increase in number of phone calls
from clients needing to cancel and reschedule their session. The survey did
not reveal any consistent patterns regarding barriers.
Next Steps: The team decided to implement the telephone reminders as part of
the service process and to continue to monitor using surveys and CQI reviews.

Project 3: Quality of Service and Youth Outcomes

Domain: Effectiveness.
Indicators: Adolescent Symptom Inventory, Youth Quality of Life Survey, and
Youth and Parent Feedback (interviews and focus groups).
Purpose and Method: The Fraser Youth Day Treatment Program chose to
assess the usefulness of the Adolescent Symptom Inventory and the Youth
Quality of Life Survey as a measure of outcome and to obtain feedback from
clients and parents about the program.
Results: The outcome measures indicated positive changes as a result of
being in the program; however, because of the small number of clients in
the program, it was not possible to test for statistical significance. The timing
of data collection occurred after the program had already started, so
pre-program data was collected by having staff ‘‘think back’’ to when the cli-
ent first entered the program. The focus group and interview data indicated
that youth and their families are very satisfied with the program. Youth and
their families perceived positive changes in their lives and identified areas
where they are still facing challenges.
Next Steps: To assess changes in symptoms and quality of life for clients by
collecting data when clients first enter program and at the end of the program.
 Implementing Continuous Quality Improvement 31

SUMMARY

CQI began with a dedicated practice analyst position and a small annualized
budget. Preliminary research indicated that staff engagement was crucial to
successful adoption of CQI. A peer audit process revealed that staff appreci-
ated the opportunity to develop a feedback loop within the organization.
As part of the ongoing quality improvement, Child and Youth Mental
Health teams engaged in designing and implementing CQI in an effort to
build a quality improvement process into services for clients and their famil-
ies. Each team was represented by clinician CQI lead who received CQI train-
ing and worked with their teams to develop the projects. A number of the
teams chose to focus on client-centeredness while others were interested
in gaining a better understanding of features within the accessibility, compe-
tency and effectiveness domains. Projects included data collection about
service processes and client outcomes.
Teams gained first-hand experience in developing measures, collecting
data and analyzing the results of their projects. CQI became part of the
ongoing dialogue amongst teams and in team meetings. The process resulted
in increased understanding about CQI and its benefits and challenges.
Collectively, the teams recognize the importance of monitoring service
delivery and outcomes. Engaging in the CQI process increased their
knowledge and experience in building CQI into the process of service
delivery. Challenges included time and resource constraints, finding feasible
mechanisms for data collection, and small sample sizes. CQI was facilitated
by strong team leader and overall team support for the CQI process.
Recommendations from the literature emphasize the importance of
financial resources for the successful implementation of CQI. The Fraser
region demonstrated that CQI can be implemented with a small amount of
financial resources. By focusing on small community based projects and
careful consideration of the capacity of teams, it is possible to begin building
CQI into services with limited resources.
Implementation of CQI is a process that over time will lead to effective
improvement strategies. Patience and persistence is needed to allow the CQI
process to evolve in their organizations. CQI is a dynamic process that
requires learning through trial and error. The fact that only a few projects
resulted in improvement changes made it difficult for some staff to see
how the CQI process leads to changes in service quality. Through CQI the
region has learned that it is important to demonstrate that improvements
can occur and the next goal is ensure that future CQI projects ‘‘close the
loop.’’ In addition, examples of other small scale projects are being sought
to serve as examples of what can be done within team. As CQI continues
to be part of service delivery within the Fraser region, there will more oppor-
tunities to observe the beneficial outcomes of CQI.
32 N. Chovil

NEXT STEPS

In addition to the continuation of some team CQI projects, plans

were made to implement a region wide CQI survey on client and
parent=caregiver satisfaction. The project will provide a standardized set
of data for the region on clients’ and parent=caregivers’ perspectives
about the services they receive from the CYMH Program. In Spring
2009, the region engaged in a ‘‘trial run’’ of the survey. The results, along
with the feedback from staff, resulted in a revision of the questionnaire. In
the Fall of 2009, a second data collection was initiated. This ‘‘snapshot’’ of
client and parent=caregiver satisfaction with services will be integrated
with interviews with youth and parents in order to gain a richer under-
standing how services could be improved. The results will be shared
with all teams and will help guide future improvement planning for
the CYMH Program. Plans are also underway to introduce CQI into
Child Welfare, Youth Justice and Guardianship Services. The experience
with CYMH will greatly assist in engaging this group of stakeholders
in CQI.

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