Thursday, April 05, 2007

Train Campaign

What is clear to almost everyone I know who is involved in this system is that training follows only good people in importance when it comes to quality of care. What seems to be clear to a lot of people other than me is that large amounts of formal training in a standardized statewide mandate will help a whole lot.

Recently I have been made aware of campaigns or suggestions by The ARC of California, the California Rehab Association and the Consumer Directed Services Network (CDSN, an ideological fellow-traveler with the Service Employees Internation Union (SEIU) all of which have proposed funding access to curricula from The College of Direct Support (CoDS.) One proposals would mandate the training for everyone, one requests funding, and one would implement a pilot project through an Assembly Bill, AB 1427 which offers a rate enhancement for agencies whose employees, among other requirements, complete 200 hours of online training. I can be supportive, generally, of access to the CoDS curricula for staff but am generally dour regarding both the prospect of a statewide mandate and the amount 200 hours.

The most peristaltic reaction I had is to the idea of the mandated training. Anyone who is in the professional or receiving end of client-centered support learns quickly that almost no knowledge is universally applicable. Some small number of techniques for more quickly and usefully establishing communication between staff and clients, such as Essential Lifestyle Planning may be of universal application but almost nothing else is. So one obvious drawback to a statewide curriculum is efficiency. In one-on-one, person-centered support the majority of formal training will be useless between a given staff person and a given receiver of services. Less so, but also, this will be the case in congregate services, however standardized. Spread requirements for training across a system serving over 200,000 individuals and the waste must be in the millions of dollars at least. The current system clearly doesn't want for waste or wasteful suggestions which are both in great supply and substantial demand.

The second concern, related to the first is the general one I carp about regularly. An effective system of delivering value to individuals must allow that individual to define the value. Statewide training mandates are one more large intrusion into the time, funding, and attention of those who offer and receive services driven, devised and defined by strangers.

A final concern, and this one takes in the AB1427 proposal in its current form is the matter of whether formal training not required by the task is good, bad or neutral. They say if you have a hammer in your hand, everything looks like a nail. My concern is that providing tools by training will influence the suggestions staff and managers will make, what problems they see to solve and how they approach those problems. At some point, the standardized curricula may detract from quality of care as easily and often as they help.

Training is important but only helpful when helpful. Standardized curricula can be harmful and are far less likely to be helpful than either informal training or formal training prompted by the needs and situation of the service user.

My suggestion is that more appropriate training is the change worth seeking, measurably better training a laudable goal and more training shady in the typical way.


Anonymous said...

Nice colours!


Doug said...

Thanks, Ariel. I find the colors a nice substitute for grammar, apparently.

paul said...


My cursory impression of AB1427 differs from yours. Although the bill has been revised I will try to refer only the the version for which your post referes.

The 200 hours referenced in AB1427 refers to a “a qualifying training program as set forth in subdivision (i).” This subdivision, subdivision (i), does not mention any “online” requirements or CoDS curricula.

Section 1, subdivision (d) does state that, “The College of Direct Support is a national standard and an example of a values-based training curriculum for consumer-directed services.”

Historically, under normal statutory interpretation, the purpose of the wording is to prevent the department from promulgating regulations that would preclude or not recognize the CoDs curriculum as a potentially part of a training plan developed by an agency. Id est, an agency potentially could include CoDS within its 200 hours of training, but is not required.

You have outlined the dowside and inflexibility of “Statewide training mandates”, and your points are well taken, and I agree with many of your concerns. However, the training plan under AB1427 does not, at this time, preclude an agency from developing a training program that is specialized to the particular service delivery environment. This was not as clear before the April 18th revise after that revise AB1427 said in part:

(j) In order to receive funding from the Quality Improvement Fund, an agency providing training shall be certified by the department to meet the criteria set forth in this subdivision. The Quality Improvement Review Board, established in subdivision (i) , shall evaluate all agency applications for funding and shall recommend to the department certification of the training program proposed by the applicant agency [emphasis added]] . …

Of course an agency must get “department[al] certification of the training program proposed by the applicant agency” and this process involves input from the quality Improvement Review Board. Combined, there can be no guarantee, at this point, as to what kind of training(s) will come out the other end of this gauntlet. So – while I agree, at this point in time, that there is no guarantee that an agency will be able to develop a training program finely tuned to its needs, there is also no reason to assume that an agency will not be able to develop a specialized training curriculum that fits the needs of the consumers served by that agency. The dirt will likely be in the details, the regulations promulgated by the department. This step will likely be as important as the original bill.

I have very much enjoyed reading your posts. If you do not agree with my assessment then I would still love to hear what you would have to say about a public policy that “presumes” what I have presented. That is, Trainings are mandated to received increased funding, but the training curriculum DOES NOT have to be based on any centralized curriculum. Rather, an agency is free to develop training programs that cater to individual needs and individual environments as per approval by the state.


Doug said...

Paul, that's a wonderful review and thank you very much for it. Obviously, this post was written before the revision, and I feel better about the new version as you've described it but with the following concerns:

First, I have trouble with any reform coming before a serious effort to start measuring outcomes. Right now there's no evidence that 200 hours of any kind of training will produce enough extra value for clients to justify a 15% rate increase. In my thinking, an employee only becomes better when (s)he becomes more helpful to the clients. If we had evidence that people with 200 hours of training produced 20% better outcomes for the people they serve, I'd withdraw this complaint but for now not only don't we know that, we have no means to learn it.

Second, the more person-centered the service, the less generalized the training can be. At my agency (~35 employees, 110 clients,) it's hard to think what we could train anyone in for 200 hours that won't be 90% useless for any given one of them. That said, if agencies are free to create and implement their own curricula with DDS approval, it does improve the odds that the training will be more useful. I might add that a larger agency which has staff to create or find a host of training modules and distribute them based on the needs of individuals served might be able to use 200 hours effectively.

Then of course, you have to ask if the legislation might benefit large agencies more than small ones. A legitimate question for an honest debate, but not what the sponsors had in mind.

In case it isn't clear from my post ('twas a long time ago) I do think this legislation is well-intended.

Doug said...

Paul, let me add that the site your name links to is interesting but I'm having some trouble understanding the thrust of the site. I'm interested to know more. If it is problematic to tell that story in public, feel free to email me at dpascover at mac dot com.

Thank you again for taking the time to read the post and write such a thoughtful comment.