PAULA MCELWEE: So we're looking today at a continuation of some of what we said yesterday, but we also want to give you some more tools. We're going to look a little bit at things that are in the RSA checklist related to administration. Some of them are not checklist items. So one of the things, they're on the checklist, but they're not yes/no questions. So one of the things that they will ask you for is all of the documents that describe who you are. And you need to look at all those documents on a regular basis, too. For instance, your bylaws are what you're bound by. They describe often, you know, things about your board structure, whether or not you have committees, how elections happen, whether you're a membership organization or not, and those bylaws contain very good information, so a best practice would be that you're reviewing those at least annually, and that somebody is a pretty good expert on what the bylaws say, the content of the bylaws. Because if you're going to want to change some things in the bylaws, that usually also takes a little more effort. It usually requires a higher quorum based on whatever you say in your bylaws; requires notice before you vote and so on. So any planning that you do about the organizational documents for your corporation need to be looked at from time to time. You need to know what your corporate status is and whether you're meeting your bylaws. Sometimes centers are not meeting their bylaws, so their bylaws require a nine-person, a minimum of nine people on their board of directors, and they only have six. So are they a legally constituted center at that point. Real good question. Because they're not meeting their own bylaws, so of course you need to look at those on a regular basis and make sure that you're meeting your bylaws. You need to look at your IRS Form 990 and the other documentation that goes in. It's possible that your board has never paid any attention to that document, and it has a lot to do with the board. And once in a while we'll run across a center who has forgotten to file it for some reason or another. They're small enough that they're not required to have an audit, so there wasn't an auditor to tell them, and that means you can lose your 501 C 3 status which makes you eligible to be a CIL. Important stuff. So these are important documents for you to review from time to time to make sure you're on target legally. So that form 990 is going to be a real important document, as well as any other supporting documents that go with that. If you have any business licenses, that ought to be a part of this review. So if you are required to have a license in the city where you operate, that needs to be part of things. And any contracts or written agreements related to your businesses and community agencies and governmental contracts and contracts from any source also need to be a part of this review. So as you look at who you are, you look at who you are in the context of your community. Who are you working with. You know. Are you funded by a local foundation. What's their goal, and how does it match yours. And have you made sure that what you asked for from them is something that is in keeping with your mission. So you're looking at all the background information about your organization that is, has to do with your organizational structure. Insurance policies. What coverage is best. If you look at the RSA requirements, there's not a lot actually required in insurance. They require you to have property insurance for the property that you buy with their money, but we all know we need more than that. We need some other kinds of insurance. Do you need directors and officers' insurance. You know, that's worth taking a look at. Do you need liability insurance of other sorts. Do you need coverage on more than just the property. Probably. So you need to make sure that you're looking at that on a regular basis. And if you have it, the original RSA approved application for your Part C funding, we mentioned yesterday that the regional offices held those in the old days, and not all of the regional offices made sure that they got to Washington, D.C. when it was all said and done. So one of the things that we need to look at is, where is that original application. Now, what's happening is that at this point RSA is considering that original application to still be binding on centers, no matter what you've said in your 704 report. And not everybody realizes that. So if you, I'll give you a real good example. There was a center, there is a center that I'm working with that had their review, and they were serving two additional counties more than what their 704 Part C, their Part C grant allowed. Now, two extra counties that were identified as underserved by the SILC, and the state plan was written, and everybody in the state helped divide up these extra counties in a plan, and yet that was not part of their original application. The decision was that they could not use their Part C money to serve those counties; they could only use their Part B money from the State. So knowing what's in your original application tells you a lot about what you can and cannot do. And when it comes to allocating funds, allocating funds to different projects, you need to figure out what that means in your, on the financial side. Question here. Yes. Question here. Yes. AUDIENCE MEMBER: Our original Part C grant shows our service area as serving 16 counties, eight in North Dakota, eight in Minnesota. It was RSA, probably around four years later, that then started making us do two 704 reports and looked at us as two centers. But yet our Part C original grant shows us as one center. PAULA MCELWEE: Yeah. I can't help you with that. AUDIENCE MEMBER: Also, I've always wondered, the SILC is charged with setting up a network of centers in our North Dakota service area. They've designated a quarter of North Dakota as our service area, which includes six more counties than the original eight. RSA says that, you know, we could only serve the original eight. So we used Part B funds and state funds to serve the remaining six. Now, with the latest increases in Part C funding, RSA is saying that we'll each get a COLA, and the SILC is to designate how to disburse the rest of the funds. How can a SILC figure out how to disburse funding and have that ability for Part C funds, but yet when they're charged with setting up a network of centers, not change the boundaries to fit the local demographics and geography. PAULA MCELWEE: You've given a really good example of something that we cannot resolve here, but that as centers, we really need to advocate, I believe, for NCIL and APRIL to take this on and ask the question, can the SPIL, rather than the original application, guide how the centers operate. And I think it's a conversation that needs to begin, but we have not even begun the conversation. It kind of took us all by surprise when this started happening. And I'm not hearing that conversation, anyway. Maybe it's taking place, but I'm not hearing that conversation as a block, as a group, to begin to say, is the SPIL going to have precedence over that original application or not. Interesting conversation that we can't deal with today. All I can tell you is, this is what they're going to be looking for, is your original grant, and they're going to want to know how you're doing that money. Now, there have been a few applied-for and approved modifications to grants through the years, and if you have a modification that was officially requested and approved, then that can change your, you know, can change what you do. So maybe the question is, does there need to be more clarification on a modification process. Do we need to have a modification process, that, as long as it's in keeping with the SPIL, a modification to that grant could be considered. But at this point in time, that isn't happening, and that does probably, that conversation affects more centers than we realize. How many of you feel like your center is affected by this issue, by the issue of the original Part C grant being the grant you're funded by. So maybe five centers in this group. So, you know, it is an issue to more than one, to more than one center around the country, and it is an issue that probably deserves some attention at some, at some level. But between now and then, this is, this is the requirement that you're stuck with. So... And, you know, your mission and your values, your program descriptions, your organizational chart, every document that you have that is part of what describes you should be congruent, should make sense in the big picture of quality. So as you're looking at what is it that you want to be and do, and how do you want to get from here to there, what outcomes do you want, you should be able to look back at program descriptions and say, oh, yeah, that makes sense with what we're, with where we're going. If you go back to program descriptions which haven't been changed for 15 years, and they don't make sense with where you're going, then you need to, you know, reexamine that, make sure that's taken care of. We've got a question here in the middle of the room. AUDIENCE MEMBER: This is Bob from Montana. Before we get too far beyond that, is it to get your original grant given, the fact that apparently we can't find it, is it as simple as contacting RSA and they have a copy. [Laughter]. PAULA MCELWEE: No. And, in fact, when I say get your original grant if you've got it, you need to know what it says, but RSA may very well not have it. And most of us, that original grant, you know, we just, we have policies about how long we keep documents. I was working with a center that I was with in Kansas in 1979, just had their federal review, and they called me, like I carry these things around with me from place to place. And somebody from the State called me and they said, "Well, we're looking for the original grant application. Do you remember how many counties it was?” Well, this center serves a huge geographic area. I don't remember how many counties we did in the first application. I know that there were a couple of times we changed it and had approval to do that, but I don't remember which years we did what or where it ended up, and I've been gone now for a long time. So, but they, actually, nobody had it. Nobody had the information. So in the end, all they could do is trust that the area that they were serving was in keeping with the original application, because neither RSA nor the organization had a copy. So, that's not all bad Maureen want to grab that mic? MAUREEN RYAN: Yeah. I just want to go back and talk about your issue and some of the other issues in the room. We hear this all the time. There is an advocacy committee through NCIL called the Rehab Act committee, and we do capture this kind of information and have regular conversations with RSA. And I think when we see themes like this, this really helps us provide some really focused dialogue with them. So what we need to do is to hear from you when people are having these issues. Otherwise, it's haphazardly coming into our NCIL Rehab Act committee, or what Paula or ILRU hears out on the road, that's the only way we can get it. So I encourage any of you from out there, any of your states, if this is an issue, please let someone at NCIL know so we can put this on the docket. The more we can show that this is happening, the more likely we'll be able to get something to occur. I mean, we meet with RSA folks every time we have a board meeting, and this can rise to the level of our number one thing we need changed. So please let us know or we can't work on it. PAULA MCELWEE: And I think the attention to it has been increasing since the review of RSA by other bodies which require them to have a corrective action plan. So as they had that happen, then they began to pass on to us, the requirements that were placed on them and this has really emerged fairly recently. AUDIENCE MEMBER: The first time I did was 1998. The most recently was three years ago. Three years ago they said they were too far in a process to look at such things so it's not like I haven't attempted but there is always large issues like taking IL out of RSA in order to punish them. PAULA MCELWEE: You know, the whole moving IL issue doesn't affect a lot of this regulatory stuff. It has some other reasons and basis for discussion that could happen in another place but it doesn't change many of these regulations, actually, because the regulations cross over related to how funding has to happen with all nonprofits that are receiving federal money, so if everybody thinks that the regulations are going to go away if we change, that's not the point and that's not what is going to happen. Just so you know. But look at all of the things that might be affected as you do an initiative for quality. So as you look in your own organization for a quality initiative, you need to make sure that everything you do makes sense with the quality initiative that you're gonna come up with, and that includes looking at your administrative policies and procedures, your personnel and volunteer manuals, your fiscal polices and procedures, your financial statements, your reports, your inventory, your audits, everything, has to be congruent with your initiative for quality. So whatever measures you come up with, you need to support them with good information and that may very well come out of some of these other documents, not just out of the database that you keep on consumers. So keep that in mind. Yes. Where. I didn't hear. Okay. Back of the room. AUDIENCE MEMBER: I understand the, what you are saying. My question would be: If there are services or programs that you have, that we have that are not funded by RSA, it's still consistent with our mission, but that's, but the money isn't with it. How much of that information do we share and do we, or do we share any of it. PAULA MCELWEE: During your RSA review. AUDIENCE MEMBER: Right. PAULA MCELWEE: That's a good question. You are not responsible for sharing consumer information if the consumer does not receive any funding from the Title 7, and you may even have some privacy prohibitions for doing that. You will need to look at that with them as you go through. But mostly what you are going to look at is RSA has asked you to do fund development. That's part of the Rehab Act that we can do that. It's not usually allowed actually for, for nonprofits to use federal money to do fund development. We have an exception in the Rehab Act and that exception allows us to do it. So they are going to want to see broad strokes. How have you brought in other money. They also want to know did you bring in that money using their money because if you did, then the same strings are attached. So if you brought in that money using Title 7 funds, then Title 7 Federal Regulations around how you can spend that money apply. It is not discretionary money. I know you don't like that. We are going to deal with it at the fee for, fees for service training in a little while. AUDIENCE MEMBER; At what point, I can understand initiative but as that program grows and there is no strings, is there a period of time when it's PAULA MCELWEE: We don't have an answer to that question yet. Maybe Richard has an answer now. RICHARD PETTY: We have something of an answer and that is that typically it runs the period of the grant from which that, those funds were, the funds that were used to generate the program income. Now, there is a question about when your grant actually ends, are those three-year cycles simply continuations within the one large grant that you received or not. And that is, I think that's a question that needs to be asked of RSA and it's something that we will ask if it's not asked otherwise, so I think there is an opportunity to have a discussion and a dialogue about what the period of grants are and how that could be interpreted and there is the remote danger that the wrong answer to that question is that it's in perpetuity. And that's not a good answer. PAULA MCELWEE: So what we're saying is the grant, the grant documents for ARRA, for example, your recovery act funds have a time limited period right, so at the end of the five-year period, those funds are over, that project period is finished. So it would seem logical to us, we don't have complete confirmation on this, but it would seem logical to us that if you use that funding to develop a new funding stream, that the program related income would only be restricted for the period of that project, which is five years, and at the end of the five year project, they would no longer be restricted. On the other hand, if you did it with your Part C funds, that is a rolling project period, which the good news about that is it isn't as vulnerable, maybe, as some other funding streams or funding sources. But this relates both to the project description that we were talking about as far as your service area is concerned and to the restrictions around program income. We are a little off topic here so I am going to wrap this up quickly and we can talk during the break or we will have a continual conversation about this, and if we get some good information and can get some solid clarification, we will find a way to make sure you have that information and that clarification, but if it's a grant in perpetuity, then forever and ever your funds that you generate must be spent for the same project and not a different one. Richard. RICHARD PETTY: Just so folks know, there is potentially an out, and I don't think we need to get too far, we're about to wrap this up anyway because we really need to move on, but there is a potential for giving the money back that you used to develop a large project or perhaps something that's going on for a long time. You may at some point, if the worst case scenario does prove to be true, that it's almost in perpetuity, you may want to find a way to give the original money back so that you have, I think that has been allowed in at least in one case and if that's true, again, then there is potential relief there. PAULA MCELWEE: Here is the interesting part. You are wondering where these dilemmas come from that we just put out here on the table. They come from actual reviews. RSA recently reviewed a center that contacted us after the review and asked for clarification on this very issue. They had used $5,000 to have somebody do a business plan with them for a new business, and during the review, RSA said if they used Part C money to do that business plan, then they must spend all of the money raised through that new business for the Part C project with the same restrictions as federal funds. So it came out of an actual review. The example I gave you on the service area came out of an actual review. What we are finding is that we feel like some clarification is necessary on these issues and the centers are beginning to come forward with them. So do new issues happen all the time, even though we have been around the block for a long time. Yeah, they do, because somebody comes along and says it must be interpreted this way and then we begin to kind of take apart the pieces and figure out what are our options and work with the advocacy organizations to resolve them, so up come these issues and they are still not fixed and I can't give you an answer, and, sorry, but here are two emerging issues right now with how we are being reviewed and the information that RSA is working from is different from our prior understanding. So now we need to figure out how we can get the understanding we want. Did you hear the very delicate way that Richard worded how to bring these questions up. See, if you bring up a question before you are fully prepared, you may not get the answer you want. And so we are working on trying to make sure that we get some good, solid review of what the contract language is before we go further with this because we want the answer to come out the way we want it to, so we want to raise this question in the best possible way, right, so as a field, we are still sorting out these emerging issues that come from these reviews. Okay. We are going to go on because we can't solve this today, anyway. I wish we could, I wish we could. So one of the things that RSA will look at and that you need to look at is how your organizational and personnel policies are affected by your quality initiatives. A lot of organizations will have a quality initiative around finding and keeping good staff members. And you may have staff training that will flow out of that. You may have discussions about the benefits that you offer that will flow out of that, discussions around how you figure out your wage structure that will flow out of that. So you need to look at all your personnel issues as a part of your quality of initiative. Does that make sense. You will have to go back and look at those items, what does your training look like, what do your policies say. What are your benefits and pay scales. So any ideas for best practice about how you might do that, organizational and personnel policies. I know I took you out of that more interesting conversation, didn't I. All right. We will come back to it. So staff development and training, and the requirement is for a program of staff development, and a lot of times the center does not have a formalized program. If you are a very small center and you have a very informal way that you approach this, you may want to rethink it because in order to assure that you have the quality you want and the program that you are offering to your staff, you are going to want to formalize what the expectations are. Some of that might be required self-study. Some of it may be things that you do as a group on your staff, but however you look at staff training, it's going to feed into your quality initiative around qualified staff, right. So you're going to be wanting to look at that. A lot of times that is directed on improving the skills of the staff for their specific job and that by its nature is going to be individualized, too, so you are looking back at job descriptions and deciding, okay, for this position, what staff training, program, or plan needs to be in place as part of your initiative. So do you see the layers of a quality initiative emerging here. You have policies and procedures. You've got a staff training program of some sort. You've got job descriptions. You want to have the most qualified staff and you are going to define what that looks like and it's going to affect all of these processes and all of these documents as a result. Because you are layering all of this together as part of your initiative of quality in that area. That includes training on how to serve unserved and underserved populations. However, you've identified that either in your state or in your area, and it is typically also recommended that you have a governing board training and development program. It is fascinating to me that it is not required, but certainly, if you want to have a board that is working with you on these initiatives, they need to have the training to make that happen, so the best practice is certainly going to be a written plan for training that's based on job duties, helps you with retention, and for boards, you're going to want to look at how you can make that happen. One of the things that I've seen happen well with both boards and staff is that every single meeting contains a training component. Might be a brief one. So your board meeting, you might send out your packet ahead of time and they have some reading material, but you might show a ten-minute video on a specific topic that comes off of our website or something else, and when you show that ten-minute video and have a ten-minute discussion, you haven't taken a huge block of your board time, but you show your attention to making sure that your board is capable of doing the things that they need to do. So we just had a really interesting thing happen in Kansas. Kansas brought together all the directors, and they decided together to come up with the training for the board. So they're still working on that. We'll see how it all comes out. But the state association of centers said, let's look at the topics that we think are the most important for boards, and let's come up with from ten to twenty minutes of video around that topic, and some handouts around that topic, and let's roll this out state-wide so that we have a state-wide initiative for quality for board members, which is kind of an exciting concept. Okay. We're going to shift gears here a little bit and talk about some of the ways that we can monitor ourselves or that we can engage other people in monitoring us. Okay. So here's, we can and should monitor ourselves. We should set up for ourselves a mechanism to check ourselves against the regulations that are applied. We suggest the checklist as a way to do that because the checklist gives you those specific regulations in some detail. But the reality is, there are also some other systems that can be done, and we may want to look at creating a team of people to do this, or purchasing that service from other folks to do this. And I want to show you the staff development piece from the California peer system. Now, in the light of full disclosure, let me tell you that it doesn't look like this particular system is going to continue. It was funded by the SILC. Executive directors all got together and decided they were going to do peer review of each other for just the executive director function, that's how they chose to approach it, so it was peer to peer executive director to executive director option for the state of California. And probably ten of the centers got reviewed. Probably, maybe even a few more than that, but at least ten of the centers got reviewed as a part of that. They came up with the standards themselves, so they went through and said, they used the checklist. I think they used some other documents probably too, but they said, what are we going to look for when we come in and we invite in, or invite in a peer to look at what we do. And here's a sample on personnel management from their standards. Now, the document is on the Wiki page and, you know, it's not copyrighted or anything, so people can do whatever they want to do with the information there. But they looked at critical standards, and then other standards that ought to be discussed, and they had these conversations around every topic that they thought was the responsibility of an executive director. So you could almost go through their system and see an executive director's job description in there, you know, each item was something that an executive director would probably do. So here's the sample. The organization operates under a defined structure with clear duties and responsibilities for staff. Then they had a rating system, but the items were written job descriptions for employees, job descriptions define essential duties of each position. There's an organizational chart that describes who supervises who and the structure of the organization, and that's available and shared with stakeholders. The board has approved the organizational chart and approves major changes to job duties. The center provides for staff development and training. Documentation and demonstration may include copies of the job description, and the organizational charts and essential functions are identified. Now, that was just one of the goals under personnel management. You can see how they laid it out and where they were going with this. They said, we want to examine each other. We need somebody else to come in. We are not the best people to review our own situation because we don't see it objectively. So I want to, you know, invite in my peers in the state of California to review the performance that I have as an executive director, and this is all private to me. Now, this is an interesting approach. I was involved a little bit in this. I was real surprised that it went this direction, actually. Because we usually think about accreditation, and if you're familiar with accreditation models, or models of a third party review, usually they're organizational wide. Usually they encompass the entire organization. And they decided in California to narrow that scope as a part of the way that they could support each other in the statewide effort for making sure that good quality happened. I think it was an interesting concept. The only reason it isn't continuing is that, well, first of all, we have a bunch of vacant executive director positions in California, if anybody's interested in knowing more about that, but also because it takes a lot of time for the executive directors to do it. Executive directors are not always the best people to try and find extra time from, and they just, and there was no more payment. The SILC was done with its experiment, and so there was no more funding for it. And maybe it will reemerge. From time to time, the conversation still comes up. The reason I'm showing it to you is that you can do something similar. You have a state association in your state, or if you are a very small state with not very many centers, you can look at something similar to that. You can look at the standards that they've got and apply those just like you do the checklist, so you have a number of different ways you can approach this information if you wish to. I like the interesting twist that it's one position to the same position within an organization, which we could also do with independent living specialists in a state if we wanted to. There could be other applications of the same concept of peer to peer at the professional level within centers. So I thought that was kind of an interesting piece, and I wanted to share that with you. But think about how we can work together to ensure, ensure that, or assure quality in independent living, and this is the kind of thing that can happen best with peer review. We should be used to the concept of peer to peer, right, because we should do that a lot with everything we do. Flows naturally from our philosophy to figure out a peer to peer process. Now, the most complete version comes out of Wisconsin, and later this morning you're going to hear more about that from Maureen, but that's an important piece then of the California system, and it's an important piece if you're going to create your own system if you choose to do that. Whatever you look at, but having someone else look at your center, not just you, is an interesting conversation. Now, another, oh, let me back back up. I may be in the wrong place, and if I am, we'll pick this up in a minute, but another peer to peer review that's an interesting concept out there that's not quite fully formed is CARF. Some of you are familiar with CARF and there are all kinds of reactions related to that. It used to stand for Commission on Accreditation of Rehabilitation Facilities. Based in Tucson AZ, a non-profit organization, started in 1966, started getting interested in independent living centers as soon as they rolled out, so in the early '80s, rolled out their first set of standards for independent living centers. And when they rolled out those standards for independent living centers, the independent living movement said absolutely not, we're not going to have anything to do with you, and it pretty much died on the vine. The reason was because it's a peer review process, but there weren't any peer reviewers from independent living who could do the review. And so you ended up with a couple of centers that tried it and were reviewed under those standards, ended up with surveyors who didn't understand independent living, and so it wasn't really a very useful process at that time. I was a CARF surveyor at that time and I surveyed an organization that thought it had independent living and it was nothing at all like independent living, and told them kind of first thing out of the gate that this is not an independent living center; I can't review you under these standards. And they, they were very upset. They couldn't understand why they couldn't be independent living. So there was a lot of confusion in the field. Well, they've just come out with standards again. This was maybe three years ago. Because Michigan and Missouri, anybody here from Michigan or Missouri. Yeah. Michigan and Missouri included that as either a requirement or permissible piece for organizations that have employment programs. And some of our centers for independent living have employment programs that were going to have to be reviewed anyway by CARF, and so they thought, well, we have them coming in here; let's try to do this as well. I wish that I could tell you that there were lots of peers now available to do these reviews. There are some. And there are some people who come from some pretty great centers with a long history who are doing this review. And the standards are available; you can buy them. They're expensive, but you can buy them from CARF. And CARF has always also looked at administrative standards in a pretty thorough way. And so organizations that are CARF accredited tend to be, have the right attention on the financial piece, the board piece, all the administrative pieces that we've looked at a little bit here. So, you know, I have, I'm a little ambivalent, actually, about where CARF may or may not go with this, but if centers decided that they wanted to do it and center directors approached CARF and said, I want to be a CARF surveyor, and I want to, there's not much money in it, by the way, but if you decided you wanted to do it and there was a group of peers who came forward, I think it could be really exciting. At this point there are only a few centers that are accredited. I don't know that it's going to grow much bigger. There was a lot of talk also in Florida around whether or not they were going to do it, and I think they decided against it. I think Michigan is still optional, and I think it's only in Missouri that it's required for the employment programs. So who knows where it'll go next, but it's an international organization with a long history in accreditation, and they really have attempted this time to get actual peers to do the review. However, the peers that do the review only review the independent living program because if they send in a team and they don't have enough people for the administrative person to also be somebody who is from independent living at this point. So at this point in time, it's a half formed thought that it's a true peer review, and I think there's still a need for a lot of involvement if centers decide that they want to do it. And at this point, that has not really emerged in any place else, as far as I know, it's only been in those few situations. But that's also a peer review option that's out there. I'm continuing down the checklist. You can't tell that, but I am. I think I missed a transition slide here somewhere. But, anyway, conflict of interest is another thing that shows up a lot in independent living. You know, I get more questions about conflict of interest than I would ever have thought possible. And I've come to a conclusion that because we're a consumer-run organization, we see potential, some people see potential conflict of interest all over the place and they don't really understand conflict of interest. Conflict of interest has to do, if you're somehow going to benefit personally from something. So if you're going to personally benefit from a decision that you have a partial responsibility to make, well, then that's a conflict of interest. If you're not going to benefit from it, it's not necessarily a conflict. We're a consumer-run organization. Right. So we might have people who have received services who also serve on a board of directors. We may have staff members who receive services who also are now employed by us, and we may have people on the SILC board who will include people for the centers that might benefit from getting grants from the SILC board but I had a question the other day from some who asked me, is it okay for a volunteer from the CIL to serve on the SILC board. Would it be a conflict of interest? Well, they are not going to benefit financially in any way that I can see. I finally said, because they asked me three times and I kept sending answer back, this is the email. I finally said, there is something else going on here, what do you really want to know because. Well it turns out, the something else going on was they didn't feel this was a very effective SILC board member and it was easier to claim conflict of interest and kick her off than it was to deal with the fact the person wasn't a good board member. I think in independent living, sometimes that's what we do with conflict of interest, we pull it out of our pocket when we get to that point where we think, ooh, I don't like this situation. Oh, maybe I can say it's a conflict of interest and get rid of this person. So we do really need to look at conflict of interest, frankly. I am going to come up here and get a drink of water if you don't mind. I am all dried out. So as you look at quality measures and look at conflict of interest as one of the things you actually want to, you want to prevent a conflict of interest because you want to be above board. You want to have some transparency which we will hit in a second and you want to look at this policy that prevents a person from participating in a decision that benefits them or someone very close to them. That is what you are looking at. You are not looking at the fact that they might have an opinion about something because they are associated with, in fact, we feel like that is important, right? It is part of the consumer control, the people who come on our board have an opinion about how independent living ought to be operated and that's a good thing, so keep that in mind. We want to be above reproach in administrative things that we do. Now, transparency has come up a couple of times in, just a second. Transparency has come up a couple of times and we want to be sure that we are transparent in that process, so we want to not only meet the requirements around conflict of interest but also be transparent and above reproach. So usually one of the things you do with conflict of interest policies, say, you have to tell people if there is any potential conflict so that it's transparent, so everybody knows exactly why you have a connection to the item being discussed and once you have that connection described, you can seek, then, to not just meet the requirements around conflict of interest but be totally transparent in the discussion in the power that the board has and the hiring of the staff and those other situations that you may find. Do you have a question back there. AUDIENCE MEMBER: Yes, from the board perspective, I am on a board of another agency but can it come up in the bylaws or the policy or past history, should they define what is a conflict of interest. PAULA MCELWEE: We think that's the best practice, that you and you are required to, RSA will require you to have a policy around conflict of interest. We feel like you can put that in your code of ethics or you can put that in some of your other written material that may not actually be in the bylaws. It may end up being in a policy, in a procedure, or in a code of ethics. A lot of times with codes of ethics, you can look online and find ethical codes of conduct from all different kinds of areas and can get great ideas for that. But a lot of times that's a signed document. You use it when you orient a new board member. You describe to them what is the, a potential conflict of interest and what are the other ethical expectations that you have for board members and they sign that and that goes in the same file that has their application. You can drop it in that file and that begins to resolve some of that issue. Yes, Maureen. AUDIENCE MEMBER: Do you also suggest that that's addressed for all of the decision making staff, also, not just board. PAULA MCELWEE: Yes, in fact, I suggest with a conflict of interest policy and procedure or with the, with the written code of conduct, that everybody ought to review that, not just board but also staff. Not just decision making staff because in the, you know, fair description of what is transparency, every staff member ought to know that that conflict of interest policy is in place. Now, with very small organizations and very small towns, you will often find some kind of iffy staffing situations, where somebody hires a relative. People marry each other. All kinds of things happen in a work setting, right. You need to be prepared to deal with that in a way that makes sure that that person does not have a situation that's unfair in any way happening from your conflict of interest policy so you are probably also going to want to look at staffing there and whether or not it's okay for people to be married and on the same staff or it's okay to supervise my brother because I thought he would be a great IT person at my center. Whatever it is. So you need to look at those conflicts of interest. Sometimes we are a very small world. And it is not always in our best interest to hire from within our very small world. And my father is a very wise man and he has all kinds of interesting sayings, but one of his things that he reminds you of in this kind of situation is, well, of course, it's not a problem to hire that person until it's a problem. [LAUGHTER]And it's true, isn't it. As long as everybody is getting along, it's not an issue, but as soon as something goes wrong, it is a bigger issue than it would have been had that relationship not been in place, so. Richard. RICHARD PETTY: The same holds true for staff relationships with individuals that are served by the center. And in a movement, well we are a movement... and where we often have a different kind of relationship with the people who receive services. We may be doing civil disobedience with the folks who are, who are part of the center's constituents, the people who are being served by the center. We have some, we have some important decisions to make because even though all of those things that I just said are true, and we, we typically, because we are a movement, been looser about that than some other fields, we can't ignore the fact that there is a power dynamic, or the fact that we, like it or not, intended or not, are in a situation of power and authority in terms of guiding and providing assistance. We are, in many ways, like teachers. We are, in many ways, like counselors, and in some cases, we actually have people on our staffs who are absolutely bound because of their professional role, but even without that professional role, we have some very important decisions to make and they are not easy decisions but they are decisions that need to be thought through and we do need to have policies about that so that there is a very clear understanding of what is okay and what is not okay. So I would just encourage all of us to spend that time and to be thoughtful. The answers may not be the same as they would be for another organization that's more traditional, but we still need to spend the time doing it. PAULA MCELWEE: We do. To be thoughtful doesn't necessarily mean that we will, as you said, all end up with the same policy. You will find some organizations that will have a very strict policy, absolutely no hiring of, you know, immediate family, absolutely no, you know, if people are, a couple become a couple in the workplace, they can't supervise each other, you know, those are the most common things that we will see. But we also see exceptions all over the place because we are a very small community and we know each other well and to some extent, those relationships tend to kind of bubble up within that community, so it becomes one of those issues. Being above reproach throughout all of your quality initiatives is going to be an important aspect, though. How will the community perceive this is also part of what we have to talk about. How the community perceives things informs us about the expectation within that, that community wherein we live. And so some very small towns, it happens in every business because there are only so many families and they are all cousins anyway, and I know we've all seen those very small situations, where it's almost family run. Almost feels like a family business so step back and ask, but how does the rest of the world perceive this, because it will help give you another compass to consider as you look at being above reproach but seek not only to meet the requirements around conflict of interest but also to be transparent and let me tell you something. Secretive centers, secretive centers are harmful to the reputation of all of us and I have seen some and because I do technical assistance and some of the centers I work with are in some pretty tough situations or sometimes somebody will call me and they are heading down a road that is a tough situation, and I forget until I hear from them exactly how bad this can get but if I have a board member, I have had this happen. If you've got a board member who is going around and having secretive conversations, this is a red flag. It is a huge red flag for your center. There is no good outcome to that because they are being secretive, they are spreading a rumor whether they intend to or not because everybody they talk to thinks what is going on over there that he is going around and doing this. Or she is going around and doing this, right. There is no good outcome because they are probably seeking evidence to get rid of somebody. My experience has been, it's a power play. They want the power, however they want it and sometimes the executive director is not letting them get involved in day-to-day stuff or attempting to block that and they don't like it and then they come. Secretive board members, another example I can give you is around conflict of interest, in fact, or around purchasing, which kind of overlaps. I worked with a center where the board president was an architect and they were going to do a building project and the board president solicited comments from people he knew to say that it would not be a conflict of interest if they just picked him. Well, actually it would be a conflict of interest if they just picked him. And so the, in that case, the executive director just kept pushing back and said we have to get bids, we have to get bids, that's our policy. Remember this was discussed at the last RSA review. We have to get bids and finally was able to come through all of that but any time a board member says, oh, no, we don't need to do that, that's not transparent. It is another approach trying to come and the backdoor and get what they want with the power they would like to see so it's interesting. You have a comment. AUDIENCE MEMBER: Yeah, one quick question. Conflicts of interest and the code of ethics, I see two different dynamics. Do you see it that way or do they blend. PAULA MCELWEE: I see conflicts of interest as one aspect of your code of ethics. So avoiding conflict of interest would be one ethical point in that code of ethics but there would be others, yes. And we have some samples, again, on our website for you, looking at those, but the best practices that both staff and board receive training in the codes of ethics that you come up with and they sign those off and they agree to those. Confidentiality is one of the points in the administrative standards in the, on the checklist. And they ask that you developed and implemented policies and procedures to safeguard the confidentiality of all personal information, including photographs, publicity releases, lists of names, and that you protect both current and stored personal information about the people that you serve, so you need to have some very tight attention to this. This also includes electronic information. So you might remember a certain laptop that was lost by a certain VA employee, right, who put all of that VA access and information at risk a few years ago, whenever that was. You know, you want to make sure your electronic information is also protected if it has any personal information. A lot of times centers will just say, no, you can't take that laptop off site. You know, or everything has to be password protected and you have to go through these steps to make it happen. But you need to have policies and procedures and make some decisions around that. Now, we're mentioning several items that are important for you to do that may or may not be in your overall outcome objectives, but may still be worth measuring as part of looking at your quality. So do you know what people are doing with confidentiality. Has anybody done a confidential sweep of your, you know, of your organization on a given day. Are there any files laying out on people's desks when they went for coffee. Are people, are consumers coming in and out of your building without an escort and kind of wandering around anywhere they want because they want to go back and get coffee in the break room and they want to visit with this person and that person. And, oh, what's on the desk. What's on the screen. What's on the computer screen. So those are things to look at. Yes. Question or comment back here. AUDIENCE MEMBER: Well, we actually have, had went on to implementing some HIPAA rules because we do interpreting services, and with a lot of those contracts, we have to follow HIPAA anyway. So we went ahead and just made it center-wide. And when we had our RSA review, they asked us why we had included HIPAA, because it was in our policy manual. Because we had to have it in one section, it just seemed easy to go ahead and follow the procedure through the whole center. So we're actually doing HIPAA. PAULA MCELWEE: Yeah. And as you get involved, if you haven't will, as you get involved in transitions from nursing homes, you're going to find yourself in the middle of that conversation anyway, if you're working with waivers or Medicaid dollars in any way. So you just as well have that conversation now. All right. You do also want to inform people about your confidentiality so that they know what your practices are. And we see often in the reports that this also extends to meeting spaces that are private, so that people can have private conversations, and that's probably the toughest one for a lot of us to figure out how to accomplish, because we don't have a lot of, a lot of times we're in open spaces, and cubicle kind of spaces, and don't have a lot of conference room space. So where is your private conversation if the person wants to have a private conversation. So that's an interesting one that needs to be looked at. And then the policies and procedures are written, and the staff are trained to implement them applies to everything. But how do you go back and make sure that your policies are being followed. You need to figure out your own process for that as a part of your quality process. Just because you say it should be so does not mean it is so. And an external review sometimes helps you see things that you otherwise might not notice because it's there every day, but your own internal review should cover anything here that you think is important. You ought to be making sure that it actually occurs. And that's a part of your quality initiative as you go through things. There's a prohibition on lobbying that falls into this same section of the RSA checklist, and we aren't going to go into lobbying today because that could take the whole day. But there are a couple of things you have to have policies and procedures, and you also have a few other, besides policies and procedures, there's an annual certificate of lobbying that you have to do. The form is there in that section, but did you know you have to have a signed, dated copy of that form on file. You don't have to send it to anybody, you just have to have it on file and be able to produce it if requested, so ... But, anyway, you get the idea. There are a lot of different administrative standards that apply to us that are found in that RSA checklist that could lend themselves to outcome measures if they rise to the level where you want to measure them. If they don't rise to the level where you want to measure them, then you still may want to look at them because they're important for you to make sure you've maintained. So they may be a progress or a process rather than an outcome that you look at. Let me see if this link is live. Yay! VIDEO: Okay. How to choose. I wish I could tell you, choose number 1, 7, and 14, but that's not going to work, is it. Well, you can try. It might work. What I'm going to suggest is a tip. You've got to juggle three things at once, and this is just the reality of what you've got to do. You have to juggle three things at once. The first one is, what outcomes capture the most meaningful benefits of your program. That is really the essence of what you're about. If someone were to say to you, what are you trying to achieve, what's like the first thing you would say. So you want to keep that ball in the air. That's obviously really important; right. But you also need to balance ... You need to juggle another ball. And that one is, what outcomes would be most helpful to improve the effectiveness of your program. To improve the effectiveness. So look at your outcomes and say, okay, which ones would really help me improve, if I knew how I was doing on that. That's another ball to keep up in the air. Now, there's a third ball to keep up in the air, too. As you can see, it's how can you best communicate the value of your program. What outcomes best communicate. What ones speak most to the outside audiences that are going to be caring. And that's important, too. Let's face it, it's a real world, and, yes, I want you to focus on improving the effectiveness of your program, but also, we all know that we do have to keep trying to tell a good story about what we're doing, because we're going to be doing better and better all the time. So we've got to have that ball in the air. So you've got to juggle these three things. Capture the most meaningful benefits of your program, what would be most helpful to improve the effectiveness, and how can you best communicate. The problem is, those don't always come together. You know. It doesn't always converge on the same outcomes. So this is where the judgment call comes into it. PAULA MCELWEE: Okay. Now, you see where we're going. This is all good information to help you know what a quality program looks like, but at the end of the day, you can't measure all of them. At the end of the day, you have to make some choices about what works best for you. And notice, I thought that slide would stay up there. I'm going to go back there and get it. Turn him off. At the end of the day, what matters most to your program. What is the most meaningful thing. What would be some of the most meaningful things that you do as centers. What are some ideas on that. Most meaningful thing you do. AUDIENCE MEMBER: Overcoming barriers in the community. PAULA MCELWEE: Overcoming community barriers. AUDIENCE MEMBER: Provide information and resources. PAULA MCELWEE: Providing information and resources. What are some other really important things that you do as centers. AUDIENCE MEMBER: Advocacy for systems change. PAULA MCELWEE: Advocacy for systems change. So you're going to decide what do you most want to measure. Yeah. AUDIENCE MEMBER: Jack. Ensure that you are implementing your services using the independent living philosophy, the five tenets of it, and continue to review that, the staff, and interactions in the PAULA MCELWEE: Yeah. Never lose vision, the vision of that philosophy. Right. So those are all really meaningful things to us. Now, that doesn't necessarily mean that they're where you have a need to improve. Maybe you're doing them really well and you want to sustain them, but you also need to look at, what's the most helpful thing to improve, to improve the effectiveness, however you're defining effectiveness and quality, in your quality initiative, and how can we communicate the value. And you're going to see some really good examples for communicating the value of services from Anne and Maureen as we go through the process, but how do we communicate the value of services. There are also some centers that have done some interesting return on investment studies. I know the SILC in Texas is working on that right now as well, so the value and how you communicate it, you know, can come out of some of the things that you're measuring. Okay. Just a couple more slides. I'm not even going to go back. So the next question I have for you is, how are you going to use these things that you are learning. Tools get rusty if they're left in the tool box. Ideas are useless unless they are used. So if we don't do something with this stuff that we're going through, it's been an interesting exercise, be well and prosper. You know, I don't know what to say. But if you really decide that you want to focus in on some of these items and measure how you're doing the rewards that you will reap will be tremendous because you're going to know where you're going, you'll be able to measure how you got there, when you get there, and you'll be able to communicate that to your stakeholders in a way that puts your center at a distinct advantage. Now, any questions about this part of the presentation. Yes. AUDIENCE MEMBER: I just want to reflect back on what you were saying about the SILC in Texas working on the return on investment models. Is that something that the rest of us would be able to see. PAULA MCELWEE: I don't know. We'd have to ask the SILC in Tex. What I do know is that I have one from the center in Fresno and he's made that available. If you drop me an e-mail, I'll be glad to send you a copy. It's only meaningful, though, all you can see, when you look at someone else's return in investment, all you can see is what a return on investment document looks like. It will not apply to you; you have to do your own. But it's one of the ways that you can measure some of your outcomes. Other questions or comments. AUDIENCE MEMBER: Well, in regards to working on return on investment that the SILC is doing, there is discussion on what are you actually going to count as a return. PAULA MCELWEE: Uh-huh. AUDIENCE MEMBER: Some people just want to say it's cost per service per consumer, but you have return on your effect on community. John and I are involved like with the University of Kansas on capacity building project that we could do, and every action that we do is put on that project so that it'll show the outcome, how many people it affected, and that's the kind of stuff that you want to have a return on investment, but it's not going to be in a monetary way. PAULA MCELWEE: It's not just cash. Yeah. It's not just cash. Huge things happen because of what we do if we're doing it well. And we do need to find ways to measure that and communicate that because it will position your center differently once you've done this. We see a lot of centers who just kind of plot along and they do not ever break out of that mold of being a small center in a small town, doing a few services, you know, getting by. But if you want to position yourself to grow and to really facilitate change in your community, you need to examine the things that are important to you in your community and find a way to communicate the outcomes related to those facts. It's really essential that you do that. Yes. AUDIENCE MEMBER: I totally agree, and one of the things that, it's important to have policies and procedures in place, but if you put something down that you're not going to do, you're screwed. PAULA MCELWEE: Yeah. Exactly. AUDIENCE MEMBER: And having that balance of having those policies and procedures without restraining yourself to making a change and difference within your community. I think, it is a balancing act. PAULA MCELWEE: And that means it's time for a break.