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Continuous Quality Improvement Plan

With the support of our stakeholders and community partners as well as the guidance and technical assistance provided by the Juvenile Justice Reform & Reinvestment and Juvenile Detention Alternatives Initiatives, CYFS has developed and implemented a Continuous Quality Improvement (CQI) process. CYFS’s expectations for continuous improvement apply not only to our contracted providers but to our internal operations as well.

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  I. History and Background

The Milwaukee County DHHS Division of Youth & Family Services is a division of Milwaukee County’s Department of Health and Human Services (DHHS), whose mission is to enhance the quality of life for individuals who need support living healthy, independent and safe lives within our community. By practicing the values of respect, dignity, honesty, integrity, diversity and partnership, the goal is to be recognized as the public model of excellence, leadership and partnership in services driving superior outcomes for our community. Through systematic changes and initiatives, DYFS is committed to elevating and aligning our operational processes.

In 2012, DYFS was awarded the Juvenile Justice Reform and Reinvestment Initiative (JJRRI) demonstration grant; which was a partnership between the Federal Office of Juvenile Justice and Delinquency Prevention (OJJDP), The Center for Juvenile Justice Reform – Georgetown Public Policy Institute, Georgetown University and Vanderbilt University – Peabody Research Institute and Urban Institute. Although the grant is effective through 2016, DYFS is committed to the continuation of the initiative.

The purpose for involvement with this initiative was to provide a framework for our juvenile justice system to effectively assess our structure of programming and service-delivery as it relates to the operational and decision-making processes used with the identified youth. With the technical assistance provided through the grant, DYFS has been able to work toward realignment of its dispositional process, realignment of referrals for services provided to youth, and making considerations for reinvestment of resources based on service effectiveness with the application of the Standardized Program Evaluation Protocol (SPEP) to services in our network.

The SPEP is a “validated, data driven rating scheme for determining how well an existing program matches research evidence for the effectiveness of that particular type of intervention for reducing recidivism of juvenile offenders. The SPEP model is based on analysis of more than 500 studies using meta-analytic techniques that have been conducted by Dr. Mark Lipsey and his colleagues over the last 20 years.” [Standardized Program Evaluation Protocol (SPEP): A User’s Guide, M. Lipsey & G. Chapman, Peabody Research Institute, May 2013.] The SPEP identifies that the effects of juvenile delinquency intervention programs on recidivism are mainly related to four (4) key aspects of an intervention: type of service delivered, quantity (dosage/amount) of service delivered, the quality of the service delivered and the risk level of the juvenile receiving the service.

Operating with these best practices and professional standards, which include ensuring youth are serviced with evidence-informed practices to the extent possible, leads us to an overall better system of service delivery with ongoing quality assurance/quality improvement activities and program development to assure effectiveness.

  II. Statement of Purpose

With the support of the Juvenile Justice Reform and Reinvestment Initiative (JJRRI), Milwaukee County has developed and implemented a continuous improvement process that provides a comprehensive assessment of department programs and community services that are provided to youth that enter its juvenile justice system.

The vision of the performance improvement plan is to enhance the future of all youth involved with DYFS by providing individualized interventions and services through a comprehensive and dynamic service system that meets the youth’s criminogenic needs. Milwaukee County shall be recognized as a state and national model for emulation in its delivery of services to youth involved in the juvenile justice system.

Using a more practical vantage point, the mission of the performance improvement plan is to identify the appropriate risk level of youth in order to match them with the appropriate service at the appropriate time in order to improve outcomes for juvenile justice youth through the continuous development of a systematic and comprehensive approach to quality assurance/quality improvement.

This comprehensive approach aims to evaluate the effectiveness of programs and services rendered to youth in order to reduce the likelihood of any additional delinquent behavior while sustaining the values of engagement with the community, individualizing services, collaborating in care, using evidence-informed practices, as well as operating as a data-driven and cost-efficient system that is sustainable and seeks to change the future of the youth in the world.

  III. Definitions & Terms

Definitions/Glossary (addresses any language within the CQI):

  1. Action Plan (AP): Action plan refers to the excel document that is submitted by providers to DCSD for approval and includes agency profile information as well as identified targeted areas and plan for improvement.
  2. DCSD: Delinquency and Court Services Division is the name of the division within the Department of Health and Human Services that manages juvenile justice in Milwaukee County.
  3. JJ System: juvenile justice system
  4. JJRRI: Juvenile Justice Reform and Reinvestment Initiative
  5. MC3: Milwaukee Co-Occurring Competency Cadre, which was designed to create a community system where the people seeking help engage in meaningful partnerships with the people providing help. (
  6. Meta-analysis: A quantitative statistical analysis of several separate but similar experiments or studies in order to test the pooled data for statistical significance. (
  7. NIATx: An easy-to-use model of process improvement designed specifically for behavioral health organizations. 


  1. NIATx Change Project Template: A form intended to document the detail of a Change Team’s rapid cycle Change Project.
  2. Provider Hub: Centralized location on the DCSD’s website that holds CQI-related information for Milwaukee County providers of DCSD services.
  3. Recidivism: DCSD defines recidivism as youth that have a new petition filed, Deferred Prosecution Agreement (DPA), adjudication in the juvenile court or a judgment of conviction in the adult court system after the initial petition, DPA or court order with the juvenile justice system.  However, across the nation, recidivism has a variety of definitions that include other aspects of contact with the justice system, e.g. any contact or referral for contact with the justice system.
  4. SPEP: Standardized Program Evaluation Protocol - a tool that evaluates the effectiveness of specific service types for youth involved in the juvenile justice system. The SPEP was developed by Dr. Mark Lipsey and colleagues of Peabody Research Institute.
  5. SPEP Basic Score (a.k.a. Full SPEP Score): The BASIC Score is the actual total SPEP score that is found by adding the results from each of the four components of the SPEP tool.  The Basic Score is used to compare a program’s service to the research.
  6. SPEP EPISCenter: Website dedicated to connecting the research, policy and practice aspects of implementation of the SPEP in the state of Pennsylvania. 


  1. SPEP Pop Score: The Program Optimization Percentage, or POP Score, is the percentage of the maximum possible Basic SPEP Score that a program receives.  This POP Score is used to compare programs that have similar services to one another.
  2. Wraparound Milwaukee: Wraparound Milwaukee is a unique type of managed care program operated by the Milwaukee County Behavioral Health Division that is designed to provide comprehensive individualized and cost-effective care to children with complex mental health and emotional needs in the Milwaukee County area. 


  1. YASI: Youth Assessment Screening Instrument is an innovative validated assessment tool that assesses risk for reoffending, needs and protective factors in youth.


  IV. Performance Improvement Model

DCSD is seeking to be involved in continuous improvement activities.  As a part of these activities, we are applying a systematic and comprehensive approach to quality assurance/quality improvement.  The main goals of this approach are to identify the appropriate risk level of youth involved in the Juvenile Justice System in order to match them with the appropriate service, at the appropriate time, in order to improve the outcomes for juvenile justice (JJ) youth. 

In Milwaukee County, the Continuous Quality Improvement (CQI) plan will involve improvement strategies at various levels, to include the county and the provider.  To determine success, three core strategies or approaches will be utilized. 

  • Application of the SPEP resulting in a full SPEP score,
  • Application of the SPEP components in the absence of a full SPEP score, or
  • Application of the NIATx Model. 

With consideration for each provider agencies’ mission and program profile, one of the three core strategies or approaches will be utilized.  A collaborative discussion with the provider and a DCSD representative will be held to determine which approach would best meet the needs of the provider and DCSD.


In order to achieve success with the full SPEP score

Success with the full SPEP score involves application of the SPEP protocol as designed by Dr. Lipsey.  This application entails consideration of 4 main aspects of interventions: type of service delivered, the quality of the service delivered, the quantity (dosage/amount) of service delivered, and the risk level of the juvenile.

  1. The Type of Service delivered by the program involves matching the primary service delivered by the agency with the service type indicated in the SPEP research.  Dr. Lipsey’s research only applies to the services that have historically been used as interventions and have had research conducted on their effectiveness.  Matching the primary service in the program to the service on this prescribed list is how you identify and match the type of service being rendered. 

In addition, the service type refers to whether a supplement to the primary service is identified and utilized by the agency.  The research indicates that supplementing some primary services with specific supporting services (e.g. behavioral contracts as the supplemental service for the primary mentoring service) will increase the effectiveness of that service, particularly as it relates to reducing recidivism in that juvenile.  For additional information on the specific services included in the research, as well as their primary and supplemental service options, refer to SPEP Service Classification Guide (See Appendix A).

  1. The Quality of Service is rated by the SPEP and assigns points for low (5), medium (10) or high (20) ranks based on the following items:

Protocol – The existence and utilization of a program manual or an equivalent written protocol that describes the intended service and the way it is to be delivered and documentation to verify that the manual/protocol is implemented as intended.

Staff Training – The staff who oversee and deliver the services directly to the youth, such as group leaders or therapists, have the licensure and credentials appropriate for providing the service and have also been trained in the particular program or service being delivered.

On-Going Staff Supervision – A procedure is in place to actively monitor adherence to the protocol and other aspects of quality of those providing the service.  A related indicator is staff and management performance evaluations that are based, at least in part, on an assessment of service quality and consistent service implementation.

Organizational Response to Drift – Data is collected to determine the effectiveness of the service provided and used to enhance service delivery.  Procedures or polices are in place and used to take corrective action when significant departures from the service protocol or lapses in quality are identified.

The expectation is that all services delivered by the program will strive toward continuous quality improvement and ongoing refinement of service delivery.  Ultimately, the goal of the SPEP is to reduce recidivism through consistent and high quality service delivery; therefore this component is essential.

  1. The Quantity of Service rendered by the program refers to the amount of that service and is determined based on the total number of contact hours (dosage) and the total number of weeks (duration) that each youth received that service.

The amount of service is a shared responsibility between the juvenile justice system and the service providers.  A closer look at both dosage and duration by DCSD and the service provider may allow for opportunity to positively impact recidivism by adhering to the dosage and duration as recommended by the SPEP for that service type.  For additional information on the target dosages for the services included in the research, refer to SPEP Service Classifications and Dosage Targets (See Appendix B).

  1. The Risk Level of Youth Served refers to the risk score the youth receives as a result of administering the Youth Assessment Screening Instrument (YASI), which is a validated assessment tool used to predict risk and criminogenic needs of youth involved with the JJ system. 

Dr. Lipsey’s research reveals that on average, there are larger positive effects on recidivism with higher risk level youth than with their lower risk counterparts (M. Lipsey, May 2013).  The SPEP progressively assigns points in the risk level area for moderate to high risk level youth based on the assumption that the JJ system should focus its finite resources on the moderate to higher risk youth in order to achieve the greatest positive effect on the community.

Each of these areas are evaluated by the SPEP and points are assigned accordingly in each category.  There is a subsequent set of conditions that accompany the process of evaluation and must be applied as well in order to receive a full SPEP score.

There are several conditions to be met in order to utilize the SPEP tool.  Initially, there must be youth that have cycled through the juvenile justice system and have completed services to score.  Subsequently, a time frame must be set to create the parameters to measure effectiveness.  Once youth that have received a closed service, i.e. that youth ended the service within the specific time frame to be used to define the cohort for scoring, are identified, there must be at least ten (10) youth in the group or cohort during the specified time frame, i.e. ten (10) or more youth actually got the service being evaluated by the SPEP.  Lastly, at least 80% of the identified youth must have had an assessment for risk and needs with a validated risk assessment instrument prior to the youth entering the service, i.e. the YASI must have been completed before the referral was made and the service began. 

This is the evaluation process and subsequent conditions used to determine the full SPEP score.  After application of the evaluation process, with the four components the criteria must also be met.  If both, the evaluation and criteria are not met, the service cannot receive a full SPEP score.

According to the research, the SPEP score can be expressed in two ways, both of which are information for program and system improvement purposes.  The Basic Score compares the target service to all other delinquency intervention services based on evaluation research in terms of that services’ ability to reduce recidivism when the service is optimized in the manner provided by the SPEP.  The Basic Score is meant to be a reference for overall recidivism when comparing this program’s service to other program services.

The Program Optimization Percentage (POP) Score is a percentage score that indicates where the program is compared to its potential effectiveness if optimized to match the characteristics of similar programs found to be effective in research.  The POP Score is meant to be a reference for overall recidivism when comparing this particular program’s service to the most effective program of that type delivering that particular service.  [What is a SPEP Scoreable Service and What are Scoring Options?, G. Chapman, Peabody Research Institute, July 2015].

In summary, the Basic Score is used to compare a program’s service to the research; while the POP Score is used to compare programs that have similar services to one another.  In the event that a full SPEP score cannot be achieved, the remaining approaches can be applied.


In order to achieve success with components of the SPEP

Success with components of the SPEP involves a process of evaluating the programs and services using elements of the SPEP tool.  In the absence of a full SPEP score, the areas involving service alignment, quality of service, quantity of service and risk level can still be considered for continuous improvement.

  1. With regard to the Type of Service delivered by the program, consideration for addition of the identified primary and/or supplemental services can be made – given that the research indicates that supplementing some primary services with specified supporting services enhances their effectiveness.
  2. With regard to the Quality of Service areas (i.e. Protocol, Staff Training, On-Going Staff Supervision and Organizational Response to Drift), each area has components that can be considered for agency implementation.  The expectation is that the program will strive toward continuous quality improvement and ongoing refinement of service delivery; therefore enhancing elements in the quality area will contribute to that.
  3. With regard to the Quantity of Service or dosage, the program can consider modifications to programming to meet, or get closer to, the targeted dosage and duration specified for that particular service being delivered. For additional information on the specific services included in the research, their primary and supplemental service options and target dosages, refer to SPEP Service Classifications and Dosage Targets (See Appendix B).
  4. With regard to the Risk Level of Youth Served, programs can consider making modifications to their internal processes to incorporate and use the overall YASI risk level of youth referred into their programming.  (e.g. although programs cannot control whether a YASI is complete prior to the referral, programs can make efforts to ensure low/moderate risk youth are not mixed with moderate/high risk youth or that the risk scores are incorporated into the intake and case/treatment planning process).


In order to achieve success with application of the NIATx Model

The acronym NIATx originally stood for Network for the Improvement of Addiction Treatment when it was founded in 2003; however it has evolved and expanded to fields other than addiction treatment, including behavioral healthcare settings and other human services organizations.  For this reason, NIATx is no longer an acronym but simply, NIATx.

The NIATx model is a research-based improvement process that is part of University of Wisconsin-Madison’s Center for Health Enhancement Systems Studies (CHESS).  The NIATx model incorporates four major aims or goals, five principles, promising practices and use of its learning collaborative to inform the change and continuous improvement process. 

The model produces its baseline via an evaluation designed as the “agency walk-through” and builds to include flow-charting to create a visual of the change project, nominal group technique to brainstorm ideas and application of the Plan, Do, Study, Act (PDSA) cycle to test the effectiveness of the changes made. 

The NIATx model has been incorporated throughout the Performance Improvement Plan (PIP) for Milwaukee County with concepts embedded in the various techniques and formats of the Performance Improvement Model.  For all providers, whether the evaluation is based on the full SPEP score, components of the SPEP or the NIATx model, NIATx techniques will be used to carry-out the change process and associated activities.

For additional information and specific instruction on the NIATx model, refer to Appendices C - E: The NIATx Model, NIATx Walk-through and the NIATx Change Project Form.

  V. Measuring Performance Improvement

A primary goal of DCSD is to identify the appropriate risk level of youth entering the juvenile justice system in order to match them with the appropriate service at the appropriate time via a systematic and comprehensive approach for continuous improvement.  In doing so, DCSD has defined success at various levels to clearly illustrate the emphasis of this performance improvement process and the collaboration needed between providers and the juvenile justice system.  

DCSD will utilize the first year of the cycle to establish baselines.  In subsequent years, the initial benchmarks will be used to determine targeted goals for the below indicators. 

The parameters of success have been defined and will be measured at the various levels in the following manner:

  1. DCSD Goals: DCSD’s completion of YASI assessments and use of YASI risk scores to inform decision-making and meeting overall SPEP requirements, including action planning to achieve one or more of the following identified objectives:
  • Services that meet all SPEP criteria will be evaluated and scored annually.
  • DCSD service providers will develop and implement an annual collaborative action plan.
  • YASI assessments will be completed accurately and timely within the policy guidelines for assessment.
  • YASI re-assessments will be completed accurately and timely within the policy guidelines for reassessment.
  • Youth referred to services will be appropriately matched to services in alignment and accordance with the youth’s identified risk level.
  • Agency  Goals Agencies will implement program changes and action planning to achieve one or more of the following identified objectives:
  • DCSD service providers will develop and implement an annual collaborative action plan.
  • The percentage of referred youth starting services will increase.
  • Service and/or program completion rates will increase.
  • An increase in the overall SPEP score [SPEP Components: A. Quality Measure Component, B. Service Type Supplement, C. Dosage & 4) Risk].
  • An increase in the Quality Measure (QM) indicators of the SPEP [QM Components: A. Protocol, B. Staff Training C.  On-Going Staff Supervision, & D.  Organizational Response to Drift].
  • An addition of a supplemental service to the primary service type (if applicable).
  • Any internal program change designed to meet the specified target dosage amounts for a specific service (i.e. Changes must occur in practice (forms and documentation) and procedure (protocols) and must have supporting implementation documentation). 
  • Any internal program change to incorporate YASI risk scores in operations (i.e. Changes must occur in practice (forms and documentation) and procedure (protocols) and must have supporting implementation documentation). 
  • Youth Goals: Youth will achieve the identified objective as a determination of success:
  • For youth with a moderate or high YASI risk level, the level will be maintained or reduced.

Because DCSD places great value on the qualitative aspects of performance improvement, provider investment will also be measured as a part of the continuous improvement process.  In conjunction with the items outlined above, DCSD will also measure the level of effort, commitment and engagement demonstrated by the organization as a means of determining success.  Specifically, the agencies will be measured using criteria such as if the mandatory information sessions or trainings were attended, the required levels of participation were represented in the change process, providers sought out and/or participated in support efforts, etc.  To preview the tool for use, please refer to the attached: Provider Investment Measurement Tool (See Appendix F).

  VI. The Cycle, Time frames, & Protocols

This section will outline the activities and expectations for all involved parties in this continuous improvement process. DCSD will formally present the information and clearly outline future expectations and evaluation results will then be disseminated. Both providers and DCSD staff will be provided with an annual collaborative opportunity for guided development of the action plan. Continuous support will also be provided to supplement the change process outlined in the action plan before revisiting the elements and repeating the cycle. A more detail outlined is as follows:

General Timing Considerations: 1 Year Annual Review Cycle: The initial 4 month time frame for education and training and the subsequent 8 month time frame for performance improvements.

  1. Introduction Email This will be sent to all providers announcing the “Kick-off” of the Performance Improvement Model and season.  This email will contain information regarding the required informational meeting date and purpose, registration instructions and corresponding training dates as well as a brief overview of expectations.


(2 week time frame)

  1. Disseminate SPEP Scores via analysis reports (or general feedback via feedback reports in the absence of a full SPEP score) via email, including Basic and Pop scores.  Providers will have an opportunity to submit questions in advance of the information session to follow.


Refer to Appendix G to review the Provider Feedback Report/SPEP Review and Recommendations Template used as the Analysis Reports that provide feedback.


(2 week time frame)

  1. Information Session hosted by DYFS to provide information and engage providers.  Provider Ambassador Representative to co-facilitate.  [Mandatory]
    1. Required Participants: Each agency will be required to have representation from 3 levels within their organization to participate in this information session.  These levels are outlined in the NIATx model and include:

i.An Executive (to remove any project barriers)

ii.A Change Leader (to lead and coordinate the change team)

iii.A Change Team Representative (to carry out the tasks of the change project).

  1. The content of the information session will include an overview of the continuous improvement process and various aspects associated with this, including but not limited to:

i.general expectations for providers and DYFS staff,

ii.addressing any provider questions re: dissemination of the reports,

iii.provide a training on how to read and understand SPEP scores,

iv.discussion on the impact of this process on organization profits and population of youth served,

v.a brief discussion/presentation of a completed change project,

vi.contract implications (e.g. termination of contracts or not renewing existing contracts) for refusal to participate or failing to demonstrate change, and

vii.addressing any outstanding needs (i.e. training registration, scheduling site visit dates, action plan submissions, general due dates, etc.)


 (30 day time frame)

  1. NIATx Change Academy Training will be hosted at DYFS by DYFS and a Provider Ambassador Representative in conjunction with NIATx representatives to guide the process of developing and implementing a change project within your organization.  [Mandatory Initially/ Optional After]
    1. Develop Train The Trainer (TTT) Team (DYFS staff & Provider Ambassador)
    2. Identify other needed components for TTT, i.e. additional training needed
    3. TTT Team to provide subsequent Change Academy Trainings


(30 day time frame)

  1. Submission of the Action Plan (AP) to DYFS via email for approval.  Following the NIATx Change Academy Training, providers will be required to submit their completed action plan that identifies their goal and other parameters around the improvement process. 

A.AP’s will be completed and submitted electronically via email

B.AP’s will include goals for the provider as well as DYFS

Refer to Action Plan Template (Appendix H) to preview the Action Plan Template.


(30 day time frame for submission & DYFS email approval)

6.Provider Performance Improvement Time Frame is the time frame that providers have to implement and test changes within their organization using the action plan and NIATx Project Change Form developed during the Change Academy Training as the framework.


(8 month time frame)

7.DYFS Performance Improvement Time Frame runs parallel to the provider’s performance improvement time frame. DYFS will work to implement and test changes in addition to conducting data analysis via quality assurance on provider data entry as well as scoring to inform the next performance improvement cycle.


(8 month time frame)

8.Individual Provider Site Visits (SV) will be conducted annually following the submission of the AP to discuss any associated agency changes and/or needs, including any factors beyond provider control that affect change.  The SV schedule will be determined by level of provider need; whereas the SV’s will be prioritized with the providers that require more immediate support being scheduled first.  At the SV, the following will occur:

  1. Discussion regarding the AP and any continuous improvement activities
  2. Finalize a plan for interim:

i.Technical assistance (TA) with a DYFS representative and

ii.Coaching calls with a NIATx representative


9.Ongoing interim TA and general support will be provided as needed to all providers through the cycle. Please refer to Continuous Quality Improvement Cycle (Appendix I).

  VII. Education, Training, Support, & Communication

In order to support the CQI process, there are specific actions that must take place in order to sustain the plan and yield successful results. The CQI plan must be effectively communicated to all necessary parties in addition to ensuring the availability of ongoing education, training and support to those involved. These sustainability components are outlined below:

Education, Training and Support

  1. Introductory informational email
  2. Informational session to introduce, review and gain additional understanding of the CQI process [Mandatory]
  3. NIATx Change Academy Training [Mandatory initially/optional thereafter]

A.Formal academy sessions will be offered annually for new providers

B.Booster sessions

i.Informal support/sessions will be available year-round for providers as needed

ii.Train the Trainer (TTT) team of DYFS staff and ambassadors will facilitate

  1. Resources will be available on the DYFS Website. A “provider hub” on the website will centralize archived tutorials and resources that support the CQI process (e.g.: “How to read SPEP scores”, informational sessions, links to additional resources, etc.)

  2. DYFS technical assistance (TA) calls and NIATx coaching calls

  3. Provider Meetings bi-monthly to address any needs and share information [Mandatory]

  4. Providers’ presentation of change projects at provider meetings and information sessions


Communication Plan

Situation Analysis

DYFS’s development and implementation of a continuous quality improvement process

Development of a communication plan to support the presentation and sustainment of the CQI plan


-To ensure consistency in messaging of pertinent information, related news and updates

-To engage stakeholders

-To provide general education and training to stakeholders

-To implement a sustainable CQI plan

Key Messages

-Enhance the future of youth

-Education, partnership and transparency


-Cost-Efficient CQI

-Evidence-Informed Practices

-Individualized Engagement


Primary: Community service providers and DYFS staff

Secondary: Other stakeholders and the general public


A. Website: Create provider link to store all archived CQI and provider related information;

B. Webpage links; C. Tutorials: 1. Understanding SPEP Scores, 2. What is a SPEPable service, etc.;

D. Bi-Monthly Provider Forum Meetings; E. Email Blasts, Newsletters, Power Points, Best Practices Standards, etc.; F. Graphs of CQI progress.

  VIII. Provider Ambassador Program

The Milwaukee County Division of Youth & Family Services’s Provider Ambassador Program was designed and implemented in 2015 to build on the existing relationships with providers in Milwaukee County and DYFS representatives. At the time of implementation, ambassadors were identified through a collaborative process with DYFS, Wraparound Milwaukee and JJRRI representatives. As the program evolves, other provider agencies will be acknowledged for their continuous improvement activities and can be recognized as ambassadors as a result.

The foundation for the work being done in the community lies in the collaboration between the public system of service delivery with the greater community and its resources as the key to increasing public safety and reaching better outcomes for youth involved in the juvenile justice system of Milwaukee County.

There are numerous benefits associated with developing and utilizing the Ambassador Program. The most important is the development and ability to sustain a dynamic JJ system. Ambassadors will demonstrate a commitment to the performance improvement process and serve as mentors to other providers in need of support as well as demonstrate change with their own agency action planning.

This format provides the ability to support the informal collaborations amongst providers and use it to inform JJ practices. In doing so, the ambassadors can also communicate the message with other providers regarding the importance of the actual program change versus focusing on a change in the numerical SPEP score. Also, ambassadors are able to facilitate the presentation of change projects at provider meetings and encourage the enthusiastic participation of providers to sustain the investments made into the community.

The model anticipates that providers will contribute to DYFS’s development of a performance improvement model and participate in workgroups. Additionally, the goals include sustaining a positive relationship with DYFS and continuing to advocate for the needs of the youth we serve, the providers, the community and DYFS. Ambassadors will especially be responsible for demonstrating a commitment to their own agency’s action plan and change projects, but will also be expected to mentor other providers on their change projects.

Ambassadors can host and/or facilitate gatherings for providers and co-facilitate various informational sessions and trainings held by DYFS. Wraparound Milwaukee and DYFS co-facilitate bi-monthly meetings for all providers in their networks. This venue is used as a means of gathering and sharing needed information regarding providers, the community and DYFS.


Provider Ambassador (PA) Program Overview


  1. General PA Outcomes

    1. Improve youth outcomes

    2. Build community relationships

    3. Develop a dynamic system of collaboration


  1. General Expectations for Provider Ambassadors

    1. Contribution to DYFS workgroup process/ Provide feedback as needed

    2. Sustain a positive relationship with DYFS

    3. Advocate for youth, providers, the community and DYFS needs

    4. Co-facilitate provider meetings/ Facilitate Q & A portion of the meeting

    5. Present change projects at provider meetings

    6. Co-facilitate the information sessions and change academy trainings with DYFS

    7. Participate in additional training as needed for Train the Trainer (TTT)

    8. Standardized Program Evaluation (SPEP) Champions

i.Demonstrate a commitment to the PA agency’s action plan

ii.Mentor other providers with action planning


  1. General Expectations for DYFS to Sustain the Ambassador Program

    1. Commit to seeking input from the community providers

    2. PA trainings and opportunities to ensure consistency in communication

    3. Advocate for providers and champion the PA program message

    4. Hold training for all providers to formally gain information

    5. Host meetings/sessions for all providers to gain information and consultation

    6. Recruit new PA through recognition of participation, investment and continuous quality improvements


  IX. Key Messages

There are several key messages important to this CQI plan, as follows:


  • The purpose of the CQI process is to enhance the future of the youth that are involved in the juvenile justice system.

  • Significant value is placed on the collaboration between the community providers and the staff of the juvenile justice system (DYFS) required for successful CQI efforts.

  • There is greater value placed on the qualitative assessment and providers’ effort versus the production of numerical SPEP scores.

  • The enthusiasm and investment of the participants is of great importance.

  • Education, partnership and transparency are the keys to sustainment and success of CQI.

  • Ongoing opportunities for training and development are necessary for both providers and DYFS staff.

  • With the indicators of success, providers can strive to meet each standard or can choose one or more for improvement in one cycle through a collaborative discussion with DYFS staff.

  • This CQI Plan will be reviewed annually.

  • The CQI process will impact contracts with providers.

  • Services offered to youth involved with DYFS will be based on engagement with the youth and family and individualized planning in order to offer evidence-informed practices to drive change.

  • It is only through the continued efforts of ongoing improvements that focus on quality that will create a cost-effective, data-driven juvenile justice system that does not operate from anecdotal information and is sustainable over time.

  X. Appendices
  Archive of Training and Informational Sessions

Policies & Procedures

Quick Forms

Policy and Procedure Acknowledgement Form (For Staff)

Policy and Procedure Acknowledgement Form (For Providers)

Policy # Policy Title Effective Date
001 Milwaukee County Accountability Program (MCAP) 07/01/2018
002 Alternative Sanctions Program 07/15/2013
003 Level II Monitoring Program (w/Optional Use of GPS) 01/01/2017
004 Passes for Youth in Out of Home Placements 01/01/2018
005 Physical Appearance 01/01/2018
006 Mileage Reimbursement 09/01/2021
007 Complaint and Grievance Process 01/01/2018
008 Duties and Responsibilities of Human Service Workers – Juvenile Justice 01/01/2018
009 DYFS Supervisor Responsibilities 01/01/2018
010 Critical Incident Reporting 08/15/2022 
011 Mandatory Reporting 01/01/2018
012 Case Noting 03/01/2018
013 Device Usage 01/01/2018
014 Youth Contact Standards 03/01/2018
015 Ethics and Boundaries 11/01/2019
016 Case Assignment Process 03/01/2018
017 Cultural Competency/Diversity 01/01/2018
018 Family Intervention Support & Services FISS Cases 08/01/2018
019 Youth Assessment and Screening Instrument (YASI) 01/01/2018
020 Attendance and Reliability 04/01/2019
021 Rapid Urinalysis Screens 01/01/2018
022 Aggression Replacement Training (ART) 08/01/2018
023 Provider Referral and Authorization Process Policy 01/01/2018
024 Case Planning Policy 01/01/2018
025 Court Reporting Policy 09/1/2020
026 Missing Youth 01/01/2018
027 Milwaukee County DYFS Custody Intake Policy 11/01/2019
028 Milwaukee County DYFS Order-In Intake Process Policy 06/01/2019
029 Detention Overcrowding Policy 01/01/2018
030 Global Appraisal of Individual Needs Assessment Policy 08/01/2018
031 Court Capias Abatement 08/01/2019
032 Employee Arrest, Citation and/or DCF Notification Requirements 01/01/2018
033 Youth Advocate Program Pilot Project Protocol  03/01/2020
Policy # Policy Title Effective Date
034 Service Authorization Request (SAR) 08/01/2018
035 Provider Documentation and Billing Process 08/01/2018
036 DYFS Emergency Plan 08/01/2019
037 Limited English Proficiency (LEP) Policies & Procedures 01/01/2021
038 Case Transfer Process 03/01/2018
039 Central Staffing Process Policy - Out of Home Care 04/01/2019
040 Shelter Care Operations 09/01/2018
042 Effective Response Grid Policy 12/01/2016
043 DYFS Weapons Policy 01/01/2018
044 DYFS Corrective Action Policy 01/01/2018
045 Out of County Youth Transfer Process 01/01/2018
046 DYFS and Wraparound Milwaukee Referral & Teaming Process 08/01/2018
047 Intensive Monitoring Program (IMP) 01/01/2017
048 Change of Placement Process 06/01/2019
049 Case Closure 03/01/2018
050 Provider Roles and Responsibilities Policy 08/01/2018
051 Provider CQI Responsibilities Policy 08/01/2018
052 Group Home Policy - Out of Home Care 04/01/2018
053 YASI Policy Addendum: Scoring Aftercare Youth 04/01/2018
054 Human Service Worker - Youth Advocate Duties & Responsibilities While Youth are in the Institution 04/01/2018
055 Office of Juvenile Offender Review (OJOR) & Joint Planning & Review Committee (JPRC) 08/15/2018
056 DOC Facility Visitation & Security Policy 08/15/2018
057 Human Service Worker - Youth Advocate Duties & Responsibilities While Youth are in Aftercare 08/15/2018
058 Field Home Assessment Responsibilities while Youth are in Aftercare 04/01/2018
059 Interstate and IntraCounty Process Policy  07/01/2020
060 Targeted Monitoring Program - Intentive Monitoring Program (IMP) Aftercare Policy 08/15/2018
061 Out of Home Care -- Safety Assessment Process 01/01/2018
062 Mentoring Policy 04/01/2018
063 Aftercare Youth: Violations, Holds & Hearing Processes 01/01/2021
064 DYFS Formal Incident Review Process 04/01/2019
065 Bakari Center Residential Care Center 08/01/2019
066 Transportation Policy  04/01/2020
067 DYFS LGBTQ Youth in Placement  04/01/2020
069 Aftercare Youth Policy: Conduct and Revocation Process  01/01/2021
070 Capias Procedure Policy  11/1/2020

DYFS Protocols

Protocol # Protocol Title Effective Date
003 Shelter Care Transportation Protocol 09/01/2018
004 Provider Mandatory Meeting Reimbursement Protocol 03/01/2020
009 Out of Home Placement Notification Protocol  11/01/2019
011 DYFS Travel Meal Reimbursement Protocol 12/13/2019


DHHS Policies 

Policy # Policy Title Effective Date
010 DHHS Critical Incident Policy  12/20/2021 
CI Form  DHHS Critical Incident Form  08/15/2022 




Trainings & Guides

Additional Provider Resources

Suggestion/Complaint Form

Do you have a suggestion to improve the services offered by Milwaukee County DHHS Children, Youth & Family Services (CYFS) or want to make a complaint regarding services you received from CYFS, please let us know.


Please complete the form and submit it.  The form will go to CYFS's Quality Assurance Department for follow-up.


Your Association with CYFS (Check one):


II(A) Formal (4): It is the policy of the Children, Youth & Family Services (CYFS) that when the complaint outcome results in a decision adverse to a youth or family, the youth and/or his/her authorized representative will be advised of their right to submit a verbal or written Grievance to the CYFS Quality Assurance Department.  A written grievance may be submitted in any form.


1220 W. Vliet St.

Suite 301

Milwaukee, Wisconsin 53205

Our Vision

Together, creating healthy communities.

Our Mission

Empowering safe, healthy, meaningful lives.

Our Values

Partnership, Respect, Integrity, 

Diversity, Excellence

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