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Field Notes

How Do You Shape Your Work To Improve Lives And Reduce Disparities? Field Notes from Guilford County, Part IV

July 7, 2020

Across North Carolina’s Guilford County, leaders and community members are partnering to ensure that the county’s 37,000 0 to 5-year olds, and the 6,000 children born each year, are on a path to lifelong success when they begin Kindergarten.

Led by Ready for School, Ready for Life and The Duke Endowment, the Get Ready Guilford Initiative (GRGI) aims for population-level outcomes and reduced disparities for young children and their families.

To get there, GRGI is building a county-wide system of care. Root Cause is contributing by helping 13 early childhood programs strengthen their measurement capacity, improve program quality, connect their work, and tackle the big systemic issues affecting Guilford families.

We are striving to shape our work so it matters for Guilford’s children and their families. This is a play-by-play of how we are doing and what we are learning. We’re questioning everything. It’s complex. It might take a while. There’s local energy and commitment to tap into. This is what working toward community-level change looks like in real life.

This post is written by Anand Dholakia, a Principal at Root Cause and member of its Guilford County project team. Anand works with early childhood and county health programs on continuous quality improvement, facilitates a Community of Practice, and contributes to the project’s strategic direction.

Part 123⎮ 4  5

Window of favorite local work and meeting spot, the Green Bean coffee shop on Elm St. in downtown Greensboro. They are now offering contactless pickup.

When we started working to build measurement capacity and service quality among early childhood programs in Guilford County, NC, we set out to make sure our work matters to families. We learned about people’s daily lived experience in order to decide how to shape our work so it helps at least one child be more ready for school and supports the ultimate end of population-level early childhood success.

What we learned about families’ early childhood experiences was complex, expansive, and did not all fit neatly within our role. Guilford’s young families have big visions for their children’s success and appreciate many services and providers, but also run into many complex barriers along the way. These barriers include what our partner Ready for School, Ready for Life (Ready Ready) refers to as “the big 3” – limited housing, reliable transportation, and access to high quality child care – which are not exclusive to Guilford County but show up here in unique ways. 

We faced the philosophical question that must have plagued Lewis and Clark, the Apollo 11 crew, the Wright Brothers, and countless other visionary leaders and teams over the centuries in times of unfathomable adversity and ambiguity: Um, %*&@!…, now what do we do?”

Our answer: If we were going to hold true to our Principles of Engagement and ensure our work matters to people, we were going to have to approach this work differently than we might have approached it in the past, and go beyond common approaches in our field.

1. We Defined Program ‘Quality’ Around What Matters for Families

So what do we mean by program ‘quality’ anyway?

Initially, Root Cause’s role was to strengthen the measurement capacity and service quality of early childhood programs using a framework for Continuous Quality Improvement (CQI). 

CQI originated in the manufacturing sector and subsequently spread to healthcare services and other sectors. So, in one sense, CQI is not new – a quick Google search turns up many well-crafted process guides, case studies, etc.  At Root Cause, we have spent more than a decade helping direct service programs better use data for continuous improvement, and so we also had a solid foundation on which to build this CQI initiative. 

Despite all this, we did not have a formal starting definition for ‘quality’ in Guilford County. Another Google search turns up numerous approaches to defining it across various industries and sectors, many of which are fairly vague. We realized that CQI in a social service setting is actually an under-developed approach with much room for interpretation.

We combined existing research with our local learning to define program quality around six components that matter to families’ daily lived experience:

A.  Accessibility:  Maximize families’ ability to effectively participate in your services, both before and while they engage with your program.

B.  Family Engagement:  Engage families directly in making key decisions around the strategy, planning, evaluation of your services.

C.  Referral Processes Ensure that families connect with the other programs and resources that your program refers them to.

D.  Staff Performance & Support:  Ensure organizations and programs prioritize staff supervision, development, and retention initiatives with the aim of ensuring that staff have the support and preparation they need to deliver quality services.

E. Trauma-Informed Approach:  Optimize your services to gauge and account for families’ experiences that can lead to trauma.

F.  Use of Evidence:  Examine existing evidence of what works and best practices to inform your own services.

Together, these quality domains reflect the ability of programs to effectively serve clients in the moment, examine the roadblocks clients face before and after engaging with programs, and recognize that families are the experts on their own lives. To vet this last assertion is to consider your own life – does anyone understand it better than you? ‘Nuff said. All three are particularly important given that many programs serve the same families and make connections to other services and resources, so families experience quality both one program at a time and also across an entire system.

After defining the details of each quality domain, we used these as the basis for building a  new CQI assessment and CQI coaching model that we are applying with each program.

2. We Selected Capacity-Building Programs Based on Significance, Reach, and Role

Many grant-making and capacity-building group initiatives select their  participants one at a time based on criteria such as the organization’s needs, interest, and capacity. However, starting with our ‘why’ and considering our ultimate aim, we took a group selection approach with additional criteria to ensure that the selected programs also: (a) collectively represent a cross-section of the early childhood landscape, and (b) have significant reach and influence on early childhood outcomes. Using a process to map the early childhood program landscape across the county, we considered programs’ type of services, the role they play in the early childhood system (e.g., food & nutrition, parent education, prenatal care), and the scale of how many clients they serve.  

To find programs that meet their selection criteria, many local and national initiatives often use an open application and vetting process. There are indeed many legitimate reasons for doing so. Considering our ultimate aim in Guilford County, the Root Cause and Ready Ready teams reached out directly to a shortlist of targeted programs to build our first CQI cohort.

We are now partnering with 13 nonprofit and public programs that provide home visiting, prenatal and maternal/child health care, parenting education, and food/nutrition services, many of which are closely intertwined with government systems and private health providers. Approximately 40,000 parents and children pass through these programs’ doors each year.

3. We Coupled Capacity Building with Collective Action.

In addition to working with programs one-on-one to strengthen their measurement capacity and service quality, we launched a Community of Practice (CoP) for the full cohort of 13 programs. 

Anchored by regular group sessions and an online platform, this CoP enables program leaders to share learning and resources around their individual capacity-building work. It also allows the group to examine how families experience program quality across programs, given how commonly multiple programs serve the same families, The CoP enables the program’s leaders to discuss the big systemic issues participants face on a daily basis, but which go beyond any one program’s scope, affect people’s success, and impact the programs’ service delivery and quality. 

We know that families living in poverty face far more than their fair share of these issues. They also represent the majority of families served by multiple programs and account for one in five Guilford family households with children (ages 0-17). (1)  The 2020 Federal Poverty Level for a family of four is $26,200.  As a more accurate indicator around the scale of the CoP’s early childhood work, more than half (52.2%, nearly 20,000 children) of Guilford children ages 0-5 live under 200% of the poverty level. (2)  And due to longstanding structural racism and the inequities it creates, communities of color are disproportionately represented among these families. 

After broadly outlining this group and Root Cause’s role in facilitating it, we collaborated with the cohort to co-design the group’s purpose, function, and preferred breakfast and lunch orders.

4. We Started to Explore Building a CQI Culture Across the Guilford Early Childhood Landscape.

Local, community-based capacity-building and grant-making efforts often consider the ramifications of directing their supports and resources to a small group of programs, while the need for such resources can be nearly universal. 

Together with our partners we decided that the broad landscape of Guilford early childhood programs, and the families that they serve, could not afford to wait years for Root Cause to complete working with a relatively small group of selected programs. While we were formally tasked to work with distinct cohorts of programs, discussions with Ready Ready leadership quickly revealed the need to make CQI resources available to a far larger swath of programs at the same time as part of the Get Ready Guilford Initiative

To begin making CQI support more broadly available, Root Cause had asked programs about their CQI experiences and capacity-building needs via our program mapping process described above, explored models to deliver the CQI resources, and researched best practices for community-wide capacity-building.  We since launched an effort to share a range of CQI resources including written materials, virtual coaching, and webinars.

The next posts will begin covering the “so what” of all this family-driven shaping of our work: what the work actually looks like as a result.

Until next time.

(1) 19.6%, Family Households with Children Living Below the Poverty Level, ACS 2014-18

(2) Population Below 200% Poverty Level, Children (Age 0-5), Percent by County, ACS 2014-18

Learn more about Continuous Quality Improvement for social service providers at our Continuous Quality Improvement Resource Library.
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