What do we know about the quality of social work service? How, where, and why does quality vary? Most important, what do we know about how we might work to improve the quality of care?
For nearly two decades, quality of care has been the focus of sustained attention in health care. Professional organizations, accrediting bodies, government regulating agencies, and researchers have worked to advance conceptual and operational understandings of what constitutes quality of care and to develop markers or indicators to guide quality assessment. A substantial research agenda now focuses on the systematic exploration of variations in care, and quality improvement is vigorously pursued. Serious concerns about quality persist. Indeed quality of care is recognized as ranking among the most pressing issues in current health care policy. The National Academy of Science's Institute of Medicine (2001) recently concluded that "[b]etween the health care we have and the care we could have lies not just a gap, but a chasm."
Quality is no less pressing a concern for social work. We have no reason to believe that social work is immune to quality chasms such as those prevailing in health and mental health care. Quality assurance and quality improvement have been addressed by professional social work organizations for more than 25 years. Social work has addressed issues of quality largely through the "professional model" of quality improvement (Palmer & Adams, 1993), which is through credentialing, education and certification, licensure, and standards for care. The National Association of Social Workers has established standards for practice in several areas, including clinical social work, cultural competence, school social work, and case management. The NASW Code of Ethics (2000) identities competence as a core value and component of the foundation for social work's unique purpose and perspective. Most of these standards are expressed in terms of the knowledge, training, and comportment of individual social workers.
Standards for care have been advanced by other professional organizations. Working with NASW, the Society for Social Work Administrators in Health Care, of the American Hospital Association, pioneered the development of high-risk screens and methods to evaluate patient satisfaction. The current Society for Social Work Leadership in Health Care works to advance its goal "to foster and maintain the best in social work practice" through, in part, the establishment of standards of care for domestic violence, child abuse/neglect, and elder abuse/ neglect. Likewise, such organizations as the Joint Commission on Accreditation of Healthcare Organizations and the Child Welfare League of America have established quality standards, standards of excellence, or standards of "best practice."
The Child Welfare League of America requires agencies to meet standards for quality assurance and offers technical assistance in creating and implementing quality assurance programs. At the local level, many individual agencies work creatively and energetically to establish their own quality improvement indicators, largely of service processes such as timeliness in response to client requests for service.
The "quality agenda" may constitute yet another gap between social work research and practice. Although many professional social work organizations express commitment to advancing standards for quality care, the topic of quality is all but absent in the social work literature. Social work research reflects little if any attention to such issues as how quality is defined, what indicators in extant data bases or service records can appropriately reflect quality, or how and where quality of care varies. The profession would be well served by sustained, concerted research on quality and particularly on the gap between "care that is" and "care that could be. …