Developing Tools for Improving Compliance with Child Care Licensing Regulations

State: KS Type: Model Practice Year: 2013

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The target population is adult learners. They are child care providers who care for children in their own homes for children in out of home care. They are licensed through the state of Kansas with the Kansas Department of Health and Environment and are currently doing care in Douglas County. The Lawrence-Douglas County Health Department is a city-county health department. The population in Douglas County is approximately 112,000. Most of this population is in one city. 5.4 percent of this population is under 5 years of age. Child Care providers can care for up to ten or twelve children depending on the children’s ages and depending on the number of adults doing the care. Most of the providers are female and they range from 20 years to 80 years.

In October 2011 a random sampling was taken to see how many home day care providers were cited for paperwork violations. 33 out of 36 providers were cited in their most recent survey. 179 providers were on the active list which is about 1,864 children. A team of two surveyors, the secretary, an intern, and an administrator began to look at this baseline measure to look at developing ways to improve this so immunization records, emergency medical release forms, emergency contact information and other important documents could improve.

The Kansas Legislators were working on new regulations concerning child care licensing and electronic surveys were in the works, so this was a great time to look at improving the method of paperwork. The last of the registered homes had just been transitioned to licensed and that meant everyone would be getting a survey. Many of the homes would not be able to find the required paperwork for children or it would be incomplete at a survey. Each provider had their own method of organization- or lack of it. The surveyors were spending too much time trying to find the paperwork in the piles or in the folders and then spending too much time making the citations.

The objective was to teach providers how to organize and how to fill out the paperwork appropriately. The goal was to cite less than or equal to 20 percent on paperwork violations. The baseline with 33 out of 36 providers was at 91 percent being cited.

Our group met several times and discussed the overall responsibilities of the program, made a list of what makes a great child care facility, made a list of what is included in orientation trainings, and made a list of possible ways to help them organize their paperwork.

It was decided to use a six sided folder that is sturdy and can hold all of the required children’s information in the correct order. We put a sample of what each document should look like when completed and included sample immunization pages and a sample of different immunization names. We also developed a 3 ring binder with divider tabs for providers to hold their required adult information, trainings, pet information, transportation information, licensing book, supervision plan, and other things the surveyor might ask them for. We rolled this out at the same time the new online tablets were going to be used and the same time the new regulations went into effect. Using the new tools started in March 2012.

We changed the orientation training for new providers from two hours to three hours to include the new regulations and to include the new paperwork instructions. We offered three trainings to current providers to train them on the new and amended regulations and to teach them how to use the new children’s files and the three ring binder. We gave them one of each. This was our model group. When we went to do their next survey we documented on an excel spread sheet the number of paperwork violations during the previous survey and during the current survey. As of September 1, 2012 there has been 79 percent improvement from the previous survey. Because of this we decided to have one more training on the new and amended regulations and to give them the new paperwork tools.

Providers were very concerned with the cost at first and with the time of setting it up. They were very pleased after getting all of the children’s files in order. They said they knew what they had and there was no guess work. They were confident and were empowered to run their business like a professional.

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Lawrence-Douglas County Health Department
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Developing Tools for Improving Compliance with Child Care Licensing Regulations
The target population is adult learners. They are child care providers who care for children in their own homes for children in out of home care. They are licensed through the state of Kansas with the Kansas Department of Health and Environment and are currently doing care in Douglas County. The Lawrence-Douglas County Health Department is a city-county health department. The population in Douglas County is approximately 112,000. Most of this population is in one city. 5.4 percent of this population is under 5 years of age. Child Care providers can care for up to ten or twelve children depending on the children’s ages and depending on the number of adults doing the care. Most of the providers are female and they range from 20 years to 80 years. In October 2011 a random sampling was taken to see how many home day care providers were cited for paperwork violations. 33 out of 36 providers were cited in their most recent survey. 179 providers were on the active list which is about 1,864 children. A team of two surveyors, the secretary, an intern, and an administrator began to look at this baseline measure to look at developing ways to improve this so immunization records, emergency medical release forms, emergency contact information and other important documents could improve. The Kansas Legislators were working on new regulations concerning child care licensing and electronic surveys were in the works, so this was a great time to look at improving the method of paperwork. The last of the registered homes had just been transitioned to licensed and that meant everyone would be getting a survey. Many of the homes would not be able to find the required paperwork for children or it would be incomplete at a survey. Each provider had their own method of organization- or lack of it. The surveyors were spending too much time trying to find the paperwork in the piles or in the folders and then spending too much time making the citations. The objective was to teach providers how to organize and how to fill out the paperwork appropriately. The goal was to cite less than or equal to 20 percent on paperwork violations. The baseline with 33 out of 36 providers was at 91 percent being cited. Our group met several times and discussed the overall responsibilities of the program, made a list of what makes a great child care facility, made a list of what is included in orientation trainings, and made a list of possible ways to help them organize their paperwork. It was decided to use a six sided folder that is sturdy and can hold all of the required children’s information in the correct order. We put a sample of what each document should look like when completed and included sample immunization pages and a sample of different immunization names. We also developed a 3 ring binder with divider tabs for providers to hold their required adult information, trainings, pet information, transportation information, licensing book, supervision plan, and other things the surveyor might ask them for. We rolled this out at the same time the new online tablets were going to be used and the same time the new regulations went into effect. Using the new tools started in March 2012. We changed the orientation training for new providers from two hours to three hours to include the new regulations and to include the new paperwork instructions. We offered three trainings to current providers to train them on the new and amended regulations and to teach them how to use the new children’s files and the three ring binder. We gave them one of each. This was our model group. When we went to do their next survey we documented on an excel spread sheet the number of paperwork violations during the previous survey and during the current survey. As of September 1, 2012 there has been 79 percent improvement from the previous survey. Because of this we decided to have one more training on the new and amended regulations and to give them the new paperwork tools. Providers were very concerned with the cost at first and with the time of setting it up. They were very pleased after getting all of the children’s files in order. They said they knew what they had and there was no guess work. They were confident and were empowered to run their business like a professional.
Responsiveness Describe the public health issue that this practice addresses. The public health issue is that child care home providers were not organizing the required paperwork and the documents were not filled out completely. It is very important for a home provider to know where documents are located and to have all of the information in case of an emergency or illness. When documents are completely filled out she/he will have required information such as emergency contact numbers, addresses, health insurance information, immunization history, and much more. When surveyors arrive at the home they are required to see the emergency medical release form, the medical record, the health assessment, the immunizations, the authorization to transport forms, the authorization to administer medication forms, and any accident or serious injury forms of the children. Other documents surveyors look at are certificates of trainings attended, a copy of the KBI/DCF child abuse registry check form, their health assessment and results of a TB test, discipline policy, supervision plan, driver’s license, declaration page of their vehicle insurance policy, their yearly mechanical safety check, pet vaccinations, well child health information, and crib and playpen information if a child has not transitioned to a mat or cot by the age of 1 year. The surveyors also ask to see their regulation book. There is a place for that in the three ring- binder. It is a requirement of the Kansas Department of Health and Environment to have these documents on file and to have them complete. When surveyors do not see a document or see a document with the information lacking, they are required to cite it as a violation. What process was used to determine the relevancy of the public health issue to the community? The regulations concerning Child Care Licensing are to improve the health and safety of children in out of home care. How does the practice address the issue? This practice addresses the issue because it empowers the provider or licensee to know all of her paperwork is accounted for and complete. Innovation Please list any evidence based strategies used in developing this practice. (Provide links or other materials for support)This practice is new to the field of public health. In the past providers have used their own method of organizing. Some have used file folders, some have used sleeves with plastic, some use paper clips, and some have used zip lock bags. Much of the research and professional literature related to working with adult learners focuses on the non-traditional student in the university or college setting. Information was gleaned from these resources and applied to the problem of both teaching and motivating home day care providers to make changes in their business practices. As described elsewhere compliance with child care regulations around appropriate documentation of up-to-date emergency contact information, health records and the like were routinely found deficient upon routine annual inspection. While health department child care licensing staff provided guidance and interpretation of regulations, strategies specific to encouraging home providers to undertake more effective business practices were not systematically communicated. Research related to adult learners emphasizes that older learners are practical and problem-centered and seek information that relates or applies directly to their perceived needs. The use of examples and hands-on materials reinforces the ability to learn new practices. Learning is most effective when it is timely and appropriate for their current lives. Another important strategy is the need to show respect for the adult learner by acknowledging and validating what they already know. Best practices associated with adult learners include the integration of new ideas with current knowledge. The development of tools to organize paperwork and documents required by child care regulations followed these best practice strategies. Child care providers understood the problem to be solved (i.e., high numbers of deficiencies) and were open to learning about low-cost, low-tech strategies that could improve compliance. The group trainings provided actual samples, concrete step-by-step instructions and clear description of how each requested document was related to the child care regulations. To increase the probability that the new practices around organizing paperwork would be put in place, health department staff emphasized the benefits to the child care providers. This practice is new to the field of public health?What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review.This practice is different because we gave the providers the tools to use to organize their paperwork. It also gave examples of how to fill out the paperwork in the complete and accurate method. An email was sent to all the counties in the State of Kansas. A variety of responses came back. How does this practice differ from other approaches used to address the public health issue?This practice is in the order of how the new Kansas inspection module is laid out. There is also a cover page that encourages the providers to check their paperwork four times a year. Some counties in Kansas have no tools, some have a sheet of paper that is used to let providers know what is needed, and one has a newsletter type of format to let providers know what is needed. One county said they use a medical record as a sample of how to set up the paperwork. This method is different from the six section classification folder because a Douglas County surveyor can flip through the required paperwork easier and with one hand. One hand is on the electronic tablet while the other hand is easily flipping the pages. This practice also has the six sided tabs that help the providers organize each child's documents in an order so the most current information is on top and a surveyor can see this information without having to look for it.
Primary stakeholdersThe primary stakeholders were Licensed and Group licensed providers who were invited to three initial trainings on how to use the new tools in March and April 2012. They were also given one three ring binder and one sample of a children’s file. 105 providers attended. Child Care Aware and Douglas County Child Development Association attended one of the three initial trainings and were given a sample of each. Child Care Aware and Douglas County Child Development Association are the two professional organizations that support child care providers. Child Care Aware is the Resource and Referral Agency. Douglas County Child Development offers the Child and Adult Care Food Program; both offer trainings and support. Starting in March of 2012 we started training the new providers on the new paperwork tools and gave them each a copy at the required orientation training. Orientation trainings are held once each month. LHD's roleThe Lawrence-Douglas County Health Department first invited employees from Child Care Aware and Douglas County Child Development Association to attend a meeting. The both have a library used by providers and were given a sample of the three ring binder and the children’s file. After the trainings data was kept to see if the paperwork tools improved the citations on paperwork. By the end of August 2012 there was an improvement of 83 percent. The team and the Directors and Coordinators at LDCHD felt it was time to roll out the tools to the providers who had not attended the training. Stakeholders/partnersChild Care Aware and Douglas County Child Development Association helped advertise the trainings and encouraged providers to attend. After the additional training in September of 2012 LDCHD had a meeting with Child Care Aware to train them how to help providers put the folders and files together if they request help. They call this a TA visit and were excited to be a part of helping providers get their business organized.What does the LHD do to foster collaboration with community shareholders?  Child Care Aware and Douglas County Child Development Association are very supportive of these new tools. They both see the need to help providers be organized in their business. The Child Care Aware director said we have “created a fantastic formula!” Communication is through emails, phone calls, and face to face meetings. Lessons learnedA lesson learned from collaboration is everyone wanted to jump from the problem to the solution. Our team worked for several months before we could allow our partners to help providers who had not been trained because we were collecting data to be able to measure the improvement in paperwork being cited. We started with finding a problem. A home provider told the Child Care Licensing Coordinator that the hardest thing for her when she started her business was the paperwork. She said there are so many forms and she did not know how to get them organized. At that point CCLC came back to the office and pulled a sampling and found that 91 percent of the providers were cited for children’s paperwork missing or incomplete at their last survey. The Child Care Licensing team worked through a process of analyzing what the Child Care Licensing program does, what is taught at orientation trainings, developed a Fishbone of what makes for a great child care facility, and decided to launch a method for providers to organize their paperwork. During this time the Child Care Licensing Surveyors also started tracking the time spent on surveys. This included prep time for the survey, travel time, survey time, and follow-up time. Time frame for carrying out tasksKDHE was coming out with new regulations so our goal was to launch the paperwork tools at the same time so training on the new and amended regulations could be taught at the same meeting. This was also about the same time that electronic tablets were going to be used to conduct surveys and the questions would have to be answered in a pattern. It would be difficult to jump around like it was done on the paper survey. The CCL team decided if the paperwork was organized to match the electronic tablet, (CIM), it would make the surveys go smoother. The new and amended regulations were effective February 3, 2012 and we launched the new trainings in March. Succinct outline of basic stepsOur outline was pretty simple. We let the providers know we were going to have trainings and got the word out by email and postal mail. Our local Resource and Referral helped advertise. We made a sample copy of the children’s files and put dividers in the three ring binders with sheets of paper that explained what needs to be put in each section. We had some supplies on hand but had to order more. We set up an excel spread sheet to document the past surveys and the current surveys. We developed a new PowerPoint training on the new regulations and included how to fill out the paperwork and how to organize the new folders. After tracking for just a couple of months we could see huge improvement. At that point we decided to have a fourth training. All but about 33 providers attended one of the trainings. We decided to put together a DVD on how to put the tools together and we gave samples to those who wanted them for a cost. They were told they could come to the office to pick up the set and the surveyors took one set with them on surveys if a provider asked to purchase them. Lessons learned One lesson we learned is providers still need to be accountable. We learned if she/he does not sit down and put the paperwork together they will most likely have violations on their next survey. We also learned that even though we have always stressed the need to have the paperwork and to have it accurate and complete, adult learners have a better improvement if they have a sample in their hands. Cost of implementationThe children’s files were about $1.27 a piece and we purchased one for each home provider. We gave a three ring binder to each provider and they were $3.52 each. Total cost was $796.29 which included the dividers. We also had 4 trainings and 2 surveyors at each meeting. Our secretary and an intern put the sample books together. Several hours were spent on making copies and putting the tools together. The provider cost for additional children's files were about $5.00 a piece.
Our goal was to decrease the number of violations cited on a NOSF, (Notice of Survey Findings). Performance measures used to evaluate the practice were number of child care facilities receiving citations on a NOSF. We looked at the number of citations during their last survey and after the training. We also looked at the number of citations during the last survey and the providers who did not attend the training and the number of citations at their current survey. Our second objective was to decrease the time spent on surveys. When providers used the new tools they had fewer violations which resulted in a shorter survey. Objective 1:The first objective was to decrease the number of violations cited on a survey. Data included the providers name, the date of the last survey, the type of paperwork violation cited, the current date of survey, and the types of paperwork violations cited. Both surveyors entered the data at the time of the current survey when returning from a survey. The secretary built the worksheet to work from. The Child Care Licensing team met regularly, to discuss the numbers as they were coming in to see the percentages. The first table was designed to see the improvement of those who attended the training. Our Health Department director suggested having a table to show the difference with those who did not attend the training. Evaluation results were incredible. We learned it takes a long time to implement a plan, do, study, act process and to finally get to the act stage. It took about eight months to get to the point of handing out the new training tools. The first attachment shows what is required to put the children's files and the three-ring binder together. Providers were excited to get new tools in their hands but many were also upset about the cost they would have to occur in purchasing the children’s six sided folders. After putting them together they were very excited to know they had all of their required paperwork in the files and where they needed to be. They knew they were all filled out because they had double checked. They were even more excited when a surveyor came to their home and they were able to spend more time with their children and had no violations or fewer violations when they used the new system. The following are comments from current providers about the new paperwork tools: “I like the new children’s files because I know if I have everything I need,” “It helped me to figure out what was missing,” “I like it. There was no guessing what I needed. It was just all right there. All things are in order. I was able to get rid of the things that I no longer needed,” “I like it! It helps me to know what I have. It helps with KQRIS too.”As of this writing the providers who came to the training and were using the new tools had improved their citations by 70.2%. Among the group of 35 who have had a current survey, 15 had 0 violations after the training. Several of those who had citations have not used the new organizational tools yet. In the group who did not come to a training and had a current survey, their citations improved by 14.3%. It is very evident to us the new tools have improved the paperwork violations being cited. It is also important to note that the environmental violations were also decreased with the homes who had used the new paperwork system. Because it was so successful we were very anxious to train the remaining providers the new system and get the samples out to them. We had a final training the end of September 2012 to train those who were not in the pilot group trainings in March and April 2012. The second attachment shows how the excell spread sheet was set up to track the number of violations at a current survey and at a previous survey. Each violation cited shows a 1. This could have been for 1 or more children for each cite. Objective 2:When child care providers used the new tools the time spent on annual inspections was less. Among providers who received training on the organization tools and had an inspection using the new electronic system, the total survey times were reduced by 42 minutes compared with providers who did not receive the training and were inspected using the old paper format. This is a 20% reduction in time spent. The survey time alone was reduced by 30%. The preparation time and follow-up were reduced by 40% and 50% respectively.
Stakeholder CommitmentWe have observed that the providers have a commitment and a desire to use the new paperwork tools once they get it set up. They see the benefits of having everything in the children's files and the three ring binder. Those who have had a recent survey have seen they have fewer violations cited on the Notice of Survey Findings and they like that. Because there are fewer violations cited, we believe the children in out of home care are safer. Orientation is required as part of the new KDHE regulations before a child care provider can submit an application. We plan to continue to train the new providers how to organize and fill out the paperwork and get them started on the right foot before they start. This will assure that no homes are missed in the process and all homes are organizing their paperwork in the same order. SustainabilityWe have used six-tab file folders that make it easy to update children's files with new information. The updated information such as immunizations and emergency medical treatment forms can be placed on top of each separate section and the surveyor can see this information without having to dig through a pile of papers that have been stuck in the child's file. There is a place for everything making it easier for the provider to file quickly and keep important information easily accessible. There are four lines on the children's front page for the provider to check quarterly to make sure they have all of the forms and they are up to date. Because the folders are constructed from sturdy material the folders can be reused when children leave the child care facility. Another way of helping the provider keep up with this method of filing the children's paperwork was the development of a YouTube instructional video to reinforce what they have been taught in our training. A second YouTube instructional video has been developed for the licensee/staff required information. The videos were completed at the end of October 2012 and will be available at www.ldchealth.org.
 
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