|
Home
| Projects
| Publications
|
Training
| What's
New |
Some Features of a Good Quality Community ServiceA Discussion Paper For A Colloquium
on NOT FOR DISTRIBUTION Prepared By: Michael J. Kendrick PhD December 2004 © December 2004 Lex Frieden Publications Staff: Sharon Finney, Marisa Demaya, and Darrell Jones This paper was developed under Grant No. 18-P-91554/6-01 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS). The contents do not necessarily represent the official position of CMS and no endorsement should be inferred. This paper is a draft for discussion purposes at the January 11-13, 2004 colloquium, “Unlocking the Code of Effective Systems Change,” and may not be reproduced or quoted in its present form ILRU is a program of The Institute for Rehabilitation and Research (TIRR), a nationally recognized, freestanding rehabilitation facility for persons with physical disabilities. TIRR is a part of TIRR Systems, which is a not-for-profit corporation dedicated to providing a continuum of services to individuals with disabilities. *The Community Living Exchange Collaborative is a program in collaboration
with Rutgers Center for State Health Policy TABLE OF CONTENTS INTRODUCTION It is not as easy as some might think to identify what is meant
by a word as common as “quality”. In an historical sense,
the term quality is equated with the finest of human achievements,
and so a synonym for it would be excellence. Since we have not had
formal home and community-based service systems for people who experience
a disability or chronic illness for more than several generations,
we lack extensive experience in this specific genre of service that
might make this task easier. In fact, we see no comparable systems
of highly formalized services documented in any prior civilizations
including western societies. Most of these points of agreement cluster around several overarching themes. These global themes are that the service should: · Meet the actual needs of the individuals served. While the essence of these overarching quality themes is non-controversial, there is disagreement on how these simply stated points ought to be specifically interpreted. There is much to disagree with on particulars and there is no way that such disagreements can be reconciled without resolving the underlying problem of differing philosophical starting points. Quality is usually linked to human well-being and this is, by definition, a deeply values-laden question since it is based upon what people may believe “the good life” is. Invariably, any selection of criteria of a good service may be divisive since people’s underlying beliefs may vary. While the task of defining quality is challenging, it is a necessary undertaking. Resolving the question makes it possible to avoid paralysis and focus energies on achieving quality rather than setting its direction. However, we can proceed towards realization of a vision of the good life even when there is just provisional agreement on shared directions on quality. What follows in this paper is a proposed set of features of a good and therefore high quality human service. The features have been selected for their harmony with mainstream thinking on the question of quality. The discussion does not provide a comprehensive list but rather seeks to identify the fundamental core of what good community services require. Key Components Of A Good Community Service The Service Is Embedded In And Governed By The Community Most people consider an authentic community service to be part
of a community rather than be located and governed from other communities
or even states. Consequently, community services are most often
local or regional and the communities that sustain them, and in
which they work, oversee them. Services that are controlled by parties
that are remote from a given community and that are not accountable
to that community may certainly be services that operate in the
community, but are not generally considered to be of the community.
So, one can see that there may be a difference between community
owned and directed services, and services available in the community. If a service does not cultivate values that are respectful and
nourishing of the worth and potential of the individuals and families
they support it should come as no surprise that the service loses
worth. Values competency and authenticity is a key foundational
qualification for doing the right thing by way of quality service.
This applies to both individuals and groups since both express values
in what they do and fail to do. Mere declaration that one has good
values is a largely empty exercise as the proof of what values actually
exist is written in the life experience of each and every service
user. The relatively recent history of social services in western societies
shows clearly that services can often be the agent for the removal
of people from their communities to relatively segregated locations.
This can result in permanent lives of exclusion from community.
So a good community service is one that does not separate people
from their natural communities. Separation deprives people of their
participation and citizenship benefits in the name of service, treatment
or protection. If belonging to community is not considered important
as both a value and a practice then either coercive or voluntary
segregation are likely outcomes. Though we do not do it often enough, we can require that a service
adapt itself to meet the unique needs of the individuals it serves
in a better way and we can demand that the actual model of supports
grows out of and is built around the person being supported. Much
of the work in person-centered approaches draws on this principle.
These kinds of considerations are matters of degree in terms of
implementation though there is little quarrel with the direction
of personalized services. If a service cannot be properly adapted
to the individual, there is a real risk that the individual user
will have to adjust to ill suited services that intrude on his autonomy.
Services must respond to the needs and preference of the individuals
who will use them. Service models based on false understandings
of who people really are will result in services that are a misfit
for the individual and may even be harmful. Since understanding
people correctly, even oneself, is not at all easy or straightforward,
great care must be taken to ensure that we really understand the
needs and identity of individuals. Mechanistic or overly standardized
techniques of needs assessment may encourage the very mindlessness
that undermines the goal of a clear and respectful understanding
of individuals. Though a substantial number of people in roles of authority in
today’s service systems presently lack any firsthand experience
with developing and supporting either self-directed services or
services that are collectively managed by service users, the popularity
of these approaches continues to grow because they are perceived
to be highly beneficial to individuals and families. It is a part
of people’s nature to want to captain their own ship. We now
much better understand how these self-directed and user-managed
approaches can be reconciled with conventionally managed services.
Thus, it is increasingly considered odd when these empowering options
are not pursued more vigorously as a routine aspect of service operation. It is one thing to understand needs correctly; it is quite another to be able to assist directly or indirectly in meeting them. It is a further challenge to go from meeting needs minimally to meeting them more fully, and to go from meeting superficial needs to engaging and meeting more fundamental and important needs. Yet it is precisely these accomplishments that will allow us to claim that a service has been significantly beneficial in meeting the needs of service users. These steps will progress incrementally since getting it right in terms of what will actually meet needs will evolve as we gain more experience. This is one challenge to the limited capacities of most people and organizations that provide service--moving the evolution forward to excellence. The Service Uses Methods That Are Consistent With What Best Suits The Person And Her Needs The meeting of needs requires not only that what is needed is available
but it also requires the use of methods and processes that deliver
what is needed in a useful and sensitive way. The service must be
able to ensure a good fit between methods, needs and program content
and be able to alter this pattern if the methods prove not to be
useful. The difficulty increases the more the service accommodates
the wide range of individuality and uniqueness among users. The defining assumptions at the core of service models must be
consistent not only with what people actually need but also with
accepted theory about what works. Since so much is unknown or unresolved
at the level of theory, this is no easy task. Often, service models
are adopted with little appreciation for their theoretical foundation
or the evidence for and against these theories. This leaves them
vulnerable to rigidity and inflexibility being unable to change
practices adaptively and evolve as better theory becomes evident.
All service models are based on some theory or assumption. The advantage
of understanding the underlying theory is that it can be appraised
consciously rather than followed uncritically. The term “right relationship”, borrowed from Buddhism
and adapted to the modern human service context, essentially suggests
that human beings ought to be treated, both interactively and structurally,
in an ethical and respectful manner. Our contemporary service agencies
and systems often lose track of their ethical bottom lines and they
can become insensitive to the many ways in which their attitudes
and behaviors impact the people they support. We can correct this
failing by defining what a “right relationship” is and
resolving to pursue it until the relationship is repaired. The ability to take full advantage of community life is contingent
on whether an individual has access to valued social roles. Much
of this will be deeply influenced by how people are perceived and
how others will, or will not, afford them valued social roles. A
service can markedly assist an individual by supporting him to be
seen in a positive way and to help him acquire valued social roles
within community life. To leave people stigmatized, socially devalued
and bereft of positive and life roles is to fail to meet their need
for respect and status commonly available to other citizens. Good
community-based services offer a model that promotes positive roles
and interactions based on a positive image of the person. People and their needs, wishes and life circumstances are dynamic;
as people experience new dreams, goals and circumstances they may
need a new array of services and supports to meet their needs. A
good community service is not one that prides itself on the careful
definition and rigidity of its service models and practices, but
rather is one that is able to respond in flexible and creative ways
as life changes for individuals. Services that rely too heavily
on across-the-board, standardized and non-negotiable service options
will clearly be unable to respond in the ways that meet people’s
needs. The idea of having a life that is deeply satisfying often means
that people’s interests are freed and supported in ways that
produce growth and development. When people feel trapped, stuck,
in a rut, or as if they are failing it is often a sign that what
they really need in order to grow and develop is not present. Many
individuals with disabilities are at risk of being more or less
marginalized even within community life because what would enliven
them and bring them more satisfaction in their lives is not available
in a way that is acceptable to them. Getting the conditions right
for moving past these realities is a significant but essential quality
challenge. The presumption that whatever a person needs will have to be provided through paid, formal supports offered by agencies and professionals is profoundly misleading, and may serve to deny the person rich possibilities for meeting many of her needs through informal means. Often, the quality of informal supports is quite high and integral to a comprehensive package of supports. Formal supports may still be crucial to a person’s well being. The community service that creatively identifies the precise blend of informal and formal supports that the person desires and needs adds benefits to that person’s life that professionalized options cannot achieve. The Service Selects And Nurtures The Right People In Service Roles It is impossible for any service to be able to offer quality supports
if it does not first have in its ranks the people who possess the
right qualities and competencies to be able to assure that this
quality is present. Quality is a human contribution and people cannot
give what they do not have. On the other hand, people with the latent
capacities can acquire and master many of the competencies and qualities
that are needed in service. Services that carefully define, select
and support the right people to make the best contribution they
can will be most successful. It all comes down to people and getting
the “right” ones in the proper place and then providing
continuing supports to them. A service can be very well administered and yet be profoundly
misguided in its models and practices so that its outcomes are actually
harmful to people. This failure rests partially in the presumption
that management equals leadership and partially in the incompetence
of service leadership to deliver on a people-centered service agenda.
By contrast, it is quite possible for service leaders to bring the
organization and service practices back to a people-centered mission
and priorities. The role of values-based leadership is to mobilize
people not only to be effective, but more importantly to be effective
at the right things, in the right way, and for the right reasons. Modern community services and the technocratic systems they are
part of are presently embedded in and awash in bureaucracy of all
kinds. Often, bureaucracy can be of a helpful and enabling kind,
but this is not always the case. The degree of toxicity of bureaucracy
can vary and so it is important to ensure that service users experience
as little of bureaucracy as is actually needed and that they are
spared having to deal with the forms of bureaucracy that are most
onerous and punishing for them. This requires that services creatively
attend to their responsibilities to other parts of the system and
relieve service users of contact with bureaucracy that is not crucial
to their well-being. Part of everyday living is to manage our lives such that our vulnerabilities are properly understood and supported in suitable and beneficial ways. Whether these vulnerabilities are our health, relationships, livelihood, reputation, employment, security, or dreams, we build support systems that minimize these vulnerabilities. It may be harmful to impose on people across the board safeguards for vulnerabilities that they do not have; yet such practices are commonplace in overly prescriptive services and systems. This is often due to the absence of a more targeted and individualized approach to safeguards that provides a strong role for the person concerned. Intentional and personalized safeguards can be crafted and put into place that address only those matters that are important to the person. Targeted safeguards help to create environments in which we can do much better in supporting people to live well in the face of the many vulnerabilities of life. The Service Is Well Administered The belief that administration should trump all other considerations
in service is very misguided as it profoundly confuses ends and
means. Administration should be seen as a support function that
is intended to assist with achieving the key purposes of services.
Thus, a well-administered service not only pleases administrators,
but also achieves its aims. A well-administered mistake clearly
exposes the fallacy of letting administrative preference and expedience
dominate other concerns. Good community services need to be very
well administered, as their functionality, dependability and consistency
may be deeply influenced by administration errors or administrative
incapacity to properly recognize the mission of the service. At
the same time, a service that is well administered can deliver on
many more of its promises, and its credibility and integrity will
rest on what it can actually deliver. The term “cost beneficial” refers to the balance existing between costs and benefits, and the better the balance, the more economic the service. Put in other words, the value for money is either impressive or not. However, the only way this balance can be evaluated is to be clear about what “benefit” refers to, as cost alone is meaningless until it is linked to what these costs have yielded in terms of actual benefit to service users. This assessment of consumer benefit in turn will revolve around whether the services genuinely meet people’s needs at a reasonable cost. An expensive service may fail to yield much consumer benefit and a very inexpensive service might be powerfully effective. Expenditure levels ought not to be equated with quality outcomes. In fact, spending too much can interfere with quality, if the spending is on the wrong things. A service is likely to be comparatively more cost-beneficial if it provides the right and needed things and uses resources effectively to ensure these are provided. We have selected some characteristics of a good community service
to generate discussion about what features are both fundamental
to quality in service and also contribute to quality. The subject
is actually much more complex than a short paper such as this can
properly present, but there is value in having a summary of the
more overarching features of a good quality community service. All
services vote with their feet in any case. The value of trying to
name what is crucial in quality, particularly in an overt form,
helps clarify for ourselves and others what it is that we most believe
will assist with quality. Badcock, C.R., The Problem Of Altruism, Basil Blackwell, 1986 |
The Technical Assistance Partnership is sponsored by the Centers for Medicare and Medicaid Services to provide technical assistance to Real Choice Systems Change Grantees. The complete ILRU Web site was developed with support from grants from the Department of Education. However, its contents and the opinions expressed do not necessarily represent the policy of the Department of Education, and no endorsement by the Department should be assumed. ILRU is a program of TIRR (The Institute for Rehabilitation and Research), a nationally recognized medical rehabilitation facility for persons with disabilities.
| Home | Projects | Publications | Training | What's New |
©2005 ILRU Program, All rights reserved
ILRU
2323 S. Shepherd, Suite 1000
Houston, Texas 77019
713.520.0232 (Voice/TTY) 713.520.5785 (Fax)
ilru@ilru.org
Last Modified: 11-8-04