Tuesday, September 28, 2004

John O'Brien and the right system design

This post is a week or more late. I received word from my good friend, Julia Mullen, that John O'Brien had recently undergone surgery, and that we all should be thinking of him. I've had a couple of articles he wrote that I wanted to discuss in this space but couldn't find them. After a week of hunting, and this being a weblog (no accountability or expectation of accuracy,) I'm going to write about his work without it in front of me, confident that I won't mislead very many people.

John and his wife, Connie are two of the most important thinkers who analyze, describe and advocate on how society treats people with disabilities and how society can do better. The solutions they describe are both common-sense and radical. Maybe the greatest lesson I've learned from them is the recognition that common-sense is a radical departure in human services. That's how far we have to go.

The article I wanted to write about but can't find talks about redesigning the system so the incentives are aligned with the goals (duh?) All participants are described as agents and are expected to pursue their own self-interest (duh?) It's common sense because that is how the world works everywhere. It's radical, because we design our human service systems on the assumption that people who work for pay should otherwise be altruistic, mortifying their own needs in order to pursue the best interests of those who need help. The belief that direct care workers, boards of directors, executive managers of agencies, regional center staff, etc. should forsake their own interests in order to serve the client is pervasive. But is it realistic or even constructive?

It passes the What Would Jesus Do test, but until He returns, one of the chief sources of inefficiency in our system is how much those of us who participate in it hide what we're really up to. I wonder sometimes how much the state pays annually for camouflage. We create forms and pay people to fill them out which help us appear to follow instructions we all find absurd. We go to meetings with quality assurance folks and they ask us to do things we're too smart to do and then train staff how to imitate bad ideas while doing well. I'll be shocked if, upon arriving in heaven I find out that the State of California and philanthropists spent less than $25 million this year in the developmental disability system to pay the cost of misdirection. I won't be shocked if it's $250M. Then there's the cost involved when people actually take bad suggestions and implement them. There's human cost to that as well.

Our lack of honesty is a lack of efficiency and a deprivation of the aspirations of those we serve. Clients do it, their families too, providers and regional centers and the administration. All of this, in large measure, to appear as though we are pure servants and not self-interested people doing the best we can for ourselves while doing our best for the people we serve.

It's cathartic to admit that I'm fat but still hungry, successful but still ambitious and my hopes for myself drive my work along with those of the clients I serve. Now imagine how much better our system would work if you could eat, buy and aspire more by helping more.

One of John O'Brien's important contributions to our system has been to describe how our system might work better if it were set up to harness the skills and good will of well-intended, self-interested people instead of relying on ascetics.

So, best wishes, Dr. O'Brien, on a full and speedy recovery. Our thoughts and prayers are for your lasting health. Not just for your sake but also for ours.

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