Friday, February 29, 2008

Whose quality?

Inspired by Brer Stanley, our new topic for debate is about quality.  Quality is something we all agree is important and then, by and large, ignore.  People who have read this blog in the past know that the opinion here is that the single most important reform we could make to our system is ongoing evaluation of the quality of programs, regional centers and policies on the basis of outcomes.  Here's the tricky part:  We just debated whether choice is or is not more important than integration.  If it is, there's a challenge to the measurement of quality.  It is very hard to standardize the evaluation of choice because standard measures need to be valid , meaning that the metric must measure what is designed to measure and be counted the same way by different surveyors.  So the challenge will be developing valid metrics to gather statewide while honoring choice.

One model, the one used by HSRI, for instance, I think, is fairly strong on validity but weak on choice.  Even if you evaluate based on whether a client reports being given a choice, if every other metric assumes the state's preferred outcome and rewards for it, the pressure is to treat all people with developmental disabilities as if their most intimate decisions are to be pleasing to the people at the Bateson Building in Sacramento.  

The common alternative model, I think of it as the JN or LQA model, is to have a deeply considerate and subjective evaluation so cumbersome it typically sits on someone's shelf unimplemented.  

A typical Life Quality Assessment was kind of silly because it was so subjective that which day of the week a client was interviewed could alter the entire result.  A more valid survey biases every professional in a client's life toward state policy and away from the person served.

So, the question to you all is: Is it better to employ a highly valid system that might counteract client choice or is it better to use a subjective system which honors choice at the expense of usefulness or is there a better or more balanced solution?

28 comments:

Anonymous said...

It is always easy to count things that are easily countable; but just because something is hard doesn't mean it is not worth investing in figuring out a way to measure it. Quality is job # 1. It is everyone's responsibility to work on quality. What quality means to me (in a personalized service) may or may not be applicable to you or someone else. That doesn't mean it is wrong.
Bottom line Doug- quality when coupled with choice, self determination, inclusion, integration, good support, good planning, etc. etc. etc. leads to goood outcomes for people. In some bizarre way, it is not that difficult really. It is just difficult to do over and over again for every person you stand in front of.
jeff

Doug said...

Jeff, if it's easy to count the easily countable why aren't we up to it? If we don't measure outcomes, how do you know what leads to good ones?

I believe what you believe, but is it really enough for the people we serve that our philosophies are pretty?

Anonymous said...

we should count things if what we are
counting matters; some things are
harder to quantify- that doesn't make
itless important; why we don't do it
now is easy- the results would be piss poor

Doug said...

Yeah, that's what I thought.

paul said...

Me too

Anonymous said...

is it time for a group hug again?

stanley said...

is it time for a group hug again? [anon]

not til we hear from dougs award wining comedian after he has had a few shots of tequlia...and paul has more than a me too.

andand

not til there is some explanation why we just dont just do it...do we have to count anything...don’t we know quality when we see it...I cant tell you what has/has not been counted...but know my daughter has a circle of friends who care for her...andand

know previously at Valley Village there were 2500 pages of check lists, counting, whatever, that was pure bs...but was accepter by RC as proof a she was receiving a quality program

there are p-poor, meaningless, counting results accepted by all too many...submitted to gain some kind of accreditation and to RCs to justiy funding...why is this bs quality accepted.

This probably does not address dougs question: Is it better to employ a highly valid system that might counteract client choice or is it better to use a subjective system which honors choice at the expense of usefulness or is there a better or more balanced solution?

Buttbut

A quick opine...informed choice rules and maybe serendipity will play a part in the discussion in addressing the question.

stanley seigler

Andy said...

I'm busy, Stanley.

Tequila, blogs and comedy must wait. Besides, this topic is unfamiliar to me . . . what do I know about quality?

Well, I do know that 100% Agave is the only way to go.

I hope to pitch in to this discussion, some time next week.

--Andy

paul said...

This blog is too heavy.

Why cant it be like other blogs and discuss serious issues like FC in Iceland, the upcoming retirement party for Elizebeth Hill, the fact the CAR is changing its name, an upcoming Symposium, the ARCA “New Day”, or the Autism film festival, or the blue agave plant!

Geez

Doug said...

Paul, that makes two.

Anonymous, one at a time is how we roll.

Stan, the problem as I see it is if you don't have a dad to see the quality for you and if no one knows what's working and what isn't. If you were a Service Coordinator, would it help to have some information other than the instinctive sense that XXX runs a terrific vocational program. I know, not funny. I have to remember how to drink.

Andy, we're here when you get around to drinking. We only seem invisible.

Paul, CRA and CAR are changing names. That must be the frontier. OK, get out yer fiddle.

stanley said...

Re: If you were a Service Coordinator, would it help to have some information other than the instinctive sense that XXX runs a terrific vocational program. I know, not funny. I have to remember how to drink. [doug]

Yes funny... andand

Apologies for cliche: “don’t we know quality when we see it”... however seems we have a long way to go before we collect, count and evaluate meaningful data for a Service Coordinator decision making process...

surely we know Broken Homes, cell phone captured abuse, Markys murder... are NOT quality... and how about the indicated in clip from newspaper: "In another investigation that Morrison conducted of group homes for the developmentally disabled, she found that the homes were hiring staff directly from the state welfare program, Cal WORKS, and did not require prior experience in a day facility."

surely our instinctive sense sees lack of quality here...ie, we known it when we dont see it... and how many more NOT quality, instinctive sense, incidents go unreported (covered up)

most current collected data is Potemkin Village stuff (AKA bs)...opine that this opine incorrect most welcome...gawd would love to be proven wrong...could die in peace.

i need to see a highly valid system before addressing dougs question...

stanley seigler

paul said...

I am reluctant to engage. Perhaps because of my lack of of intelligence or experience, but I think it is more likely (at least I hope so) that I believe that life rarely, if ever, lends itself to such a dichotomy.

I realize that you mean to establish a starting point. After all, every discussion must have one, and a question is always a good start. However, it would seem that the more abstract and removed our starting point is from a reality the less pragmatic the academic exercise.

Life is complicated and gray, and does not lend itself to easy answers. An uncomplicated life might be capable of being jammed into either a highly valid system that might counteract client choice or a subjective system which honors choice at the expense of usefulness, but unfortunately life is a round peg and these two are square pegs that may resemble roundness at one moment, and be everything but round the next.

Therefore – surprisingly my answer is a better or more balanced solution

A more challenging exercise might be to identify the borders of our “more balanced solution”. To begin we might exam what is definitely within our cartilage and what is NOT. Then – we can move together until we can no longer distinguish what it is we are discussing. This place will be the indefinable barrier to my answer.

Unfortunately, while perhaps entertaining and with academic value, the exercise may be a waste of our time. That is because our resulting border will likely not lend itself conveniently to a general policy, and will likely be beyond authority to legislate or perhaps even regulate without Draconian measures. It would seem that the inevitable conclusion of this discussion would be that the discussion was in vain.

In addition, if we commence such a discussion I do believe that we would discover that we are repeating the past. Current public policy already recognizes the inability to legislate the nuances.

The Lantern Man speaks simply, and says that consumers are entitled to services and supports that allow him or her to approximate the pattern of everyday
living available to people without disabilities of the same age[PERIOD]. It all grows from there…


Perhaps, if our reality is attended to our discussion would not be in vain. If we find ourselves repeating the discussions of yesterday might that not provide further proof that this discussion is off target, missing our leverage point, or problem?

A little less than ½ of our worshiped value statement deals with our field of gray. The Lantern Man calls them Regional Centers, which are, by the words of the Lantern Man, supposedly condemned to have this very discussion each day and on an individual basis. My choice of the word “condemned” is of course not appropriate, because I do not think our Regional Centers, in the general, have behaved as if they were condemned to do anything.

The somewhat arbitrary treatment of both providers [“don’t we know quality when we see it”... ] and consumers by our system seems to portend that a discussion such as this might be nothing more than mental masturbation, or at least putting the cart before the horse.

We do, expanding on Doug’s words, tend to focus predominately on sounding pretty. Perhaps a discussion as to WHY we spend so much time sounding “pretty” or exert so much energy “standing well in thy neighbors eye”, devising snappy words, and euphemisms would be useful.

Why is this blog the ONLY blog to ask the questions it asks (reminder – I do not get out much)?

My sarcasm is always based in my frustration, and reality as I see it. Since I have taken a bite from the apple I have noticed that the blue bloods have avoided the open and obvious, and perhaps we do the same right now. This has become even more of a reality as we see more discussion about “estate recovery” regulations, the retirement party of a politician, or a conference with the not so unique mantra, “NO MORE CUTS”

Every discussion involves Sacramento even though the Lantern Man spends only a few words in its regard. Since 1970, slowly but surely, a tornado has grown out of the service system. It now consumes much energy, money, and attention, and it does not serve people with disabilities, rather is serves Quite Handsome and Associates et al.

It seems silly to have this discussion, and successfully build our haystack only to offer it to the tornado. Perhaps discussing our tornado would be more useful.

BUT – the only people in line to have that conversation rely upon what is vouchsafed from the tornado, and ‘others’ – outsiders, are not permitted to engage because we consider them only Muggles. We are our own grandpa.

So – we are condemned to go in circles, and outsiders, because of no opportunity to engage, are left with only one recourse - Reduce spending to keep the leash of the beast short and tight.

Nothing will change until those on the inside take a leap into the dark, slap the warty hand that feeds it and say – NO MORE. That will not happen until there is evidence of a modicum of interest in doing just that.

paul said...

I looked at my post and I though, HOW verbose [delete]

Even so, I think that I should expound upon my meaning of tornado.

The tornado is the cottage industry that is financed by both residual public dollars and private dollars.

It has grown exponentially in the last 10 years. It is a cottage industry of associations, coalitions, networks, junta, and cabals that have the primary purpose of leveraging a small portion of the system for the benefit of each of the respective constituents.

Just as cable news gave birth to the T.V. news personality, the pundit, the talking head – our cottage industry has given birth to the advodiva. It has grown faster than the industrial revolution of yesterday, and now a person can actually make a living being an Advodiva.

Yesterday, the director of a provider was judged by the quality of services, and most of his or her energy was spent towards that end. Today, he or she can be found to be more occupied with making a comment about the latest and greatest judicial defect, legislative bill, or making “pretty” position statement. All are posted on the Internet for all to see and to serve as both badges of honor and modern gang sign.

Anonymous said...

Paul
you have much too much time on your hands- the advodiva would fit mr. doug if he actually didn't spend time with people with disabilities; these are people who tell others that they and they alone remain the sole protector of devalued people--- the professional ED these days, spends their time looking for money, raising money, reducing expenses -- and once in a blue moon -actually passes by a consumer with disabilities they once knew
jeff

stanley said...

paul said... “I am reluctant to engage”... no comment!

Anon said... “the professional ED these days, spends their time looking for money, raising money, reducing expenses... and once in a blue moon... actually passes by a consumer with disabilities they once knew”

Know this doesnt apply to EDs who contribute to dougs blog... but isnt Quality Job #1... at least,

Anon said “Quality is job # 1. It is everyone's responsibility to work on quality.”

No easy answers...when fighting to exist... meet monthly expenses (payroll)... its easy to forget the reason for existing... a quality life for those with special needs.

Perhaps a need exist to reevaluation ED/provider priorities... review/rewrite Professional ED 101.

Still no answer to dougs question: "Is it better to employ a highly valid system that might counteract client choice or is it better to use a subjective system which honors choice at the expense of usefulness or is there a better or more balanced solution?"

Except it's not either/or... a highly valid system that does NOT counteract choice is a more balanced approach... how to achieve... perhaps

start with EDs and board passing...visiting... more (all) consumers once known... ie, "management by walking around" (a catch phrase from another life.)

stanley seigler

Doug said...

Well, Stan, I think we won't get a valid system without trying which is where we are right now. Complaining about rates while making now demands for valid evaluation. Double provider rates and keep accountability as it is and see if anything changes. I'll bet my rate increase it doesn't. My question really is: Do we want to see a valid system of evaluation and accountability? Jeff doesn't, but do the rest of us?

Paul, thanks for the elaborate response. I think we could have a simple valid system for measuring quality from a state policy perspective with little nuance and then providers like Jeff who want to spend three days at a ouija board getting 45 pages of questions to abuse the client with answering can get more subtle without polluting the general information. It's true that people can be subtle but I think the only questions, really, are: do you like where you live? do you find your social life satisfying? do you find what you do meaningful? do you have untreated gangrene?

Paul and Jeff, Advodivas do 88% of the policy-proposing, don't they?

Stan, my advice to anyone looking for a quality program is what is the ratio of clients per ED and how often is the ED involved in services. Always, always, always go with the program with the uninvolved ED. In fact, let's make that the fifth data point. I remain convinced that any Executive Director who advocates person-centered services and knows all their clients by name, over say, ten clients, is a charlatan control-freak liar.

paul said...

“the advodiva would fit mr. doug if he actually didn't spend time with people with disabilities; these are people who tell others that they and they alone remain the sole protector of devalued people”

Jeff,

I have a different definition of an advodiva.

This is a person that acts primarily to perpetuate his or her status, and perhaps income, over the best interests of people with disabilities to an unreasonable degree.

I will not go into the boring details that are probably needed, but I will state that to be an advodiva by my definition you must be, or have a great desire to be, first and foremost popular amongst your peer group.

So – for Doug to be an Advodiva he would have to first be concerned about his status. I do not know Doug, nor have I rubbed shoulders with all the mucky mucks and panjandrum that probably surround him at conferences. Regardless, when I read Doug’s blog I get the distinct sense that he is not concerned about being popular.

I come to this conclusion because:

1. Doug does NOT argue that funding is our primary problem (see last comment for latest ref.).

This is the mantra of almost everyone else, and I have no doubt that Doug’s position/opinion in this regard has earned him some demerit amongst his colleagues.

2. Doug address issues more tangible and closer to the frontline (RC – accountability – measuring outcomes - provider) rather than behind the line, less tangible, and more esoteric issues (Politicians, legislation, conferences, appointments, lawsuits, MONEY – generally known as SACRAMENTO).

Again, This is contrary to his colleagues and potential groupies

3. Your post provides anecdotal evidence, which makes it clear that Doug opinion’s (actually it would appear Doug himself) is at least not popular with Jeff.

If anything Doug is a contrarian – not the desired quality of a successful advodiva.

As a note, in my book, the fact that someone works with people with disabilities is not dispositive to the title of Advodiva.

Jeff,

I am troubled by your implication that the ED “these days, spends their time looking for money, raising money, reducing.” It was my understanding that the ‘E’ in ED stood for EDUCATION, but then again – I do not have an ED.

What you describe sounds the job of and accountant, MBA, advodiva, or better – a politician. Have EDs gotten themselves pigeonholed into such jobs, or did the modern ED make his or her own bed?

I have found that some EDs try to play JD, alternative PhD, and on occasion MD, but those discussions would bring us back to Advodiva PDQ – IMO.

Doug,

I think that asking whether or not a consumer likes where he or she lives, or his or her social life is a much easier than determining whether or not a consumer actaully DOES like where he or she lives, or his or her social life.

If we simply ask, and take the first answer as reality we bring ouselves back to the old question of opportunity – exposure. That is if a consumer says that they love his or her locked facility where they do noting 24/7 does the job end there?

I do not think so – while we can make the asking of the questions a matter of publilc policy the methodology for finding the genuine answer is more like an art than science and I am uncertain if this is within the capabilities of a legislature to micromanage as you might like.

”Advodivas do 88% of the policy-proposing, don't they?”

Yes – a probably problem #1. If what you imply is correct, and an RC does not distinguish a quality programs from any other program than I agree that no amont of money will present a cure.

I disagree that we can pigeon hole the Regional Centers into becoming useful with more laws. The state has been attempting to do so for some time, and it has been unsuccesful. The list is long…

I simply believe that the quality of the leadership is low, and that most involved make no attempt to set the bar higher in regards to expectation. Because of this we have Regional Center Directors that do not even understand the most basic process like eligibility standards.

I believe that the system can only be fixed from the ground up by employing boards of managers that are there to make it successful for the whole in lieu of being there to do nothing more than watch over his or her child.

If this does not happen the state cannot force a Regional Center to be competent, and IMO it is time to dismantle the whole experiment.

Doug said...

Paul, thanks. I don't feel unpopular with Jeff but I appreciate your putting my position so well. I agree that it is easier to ask people if they are happy than to determine if they are happy. I've thought a better way of determining whether the choices of the client are being served successfully is to ask not "are you happy?" but "what do you want" and then determine more objectively after an interval first if the client wants the same thing the next time you ask and whether that person has moved objectively closer to the desired outcome since the last assessment.

paul said...

“I've thought a better way of determining whether the choices of the client are being served successfully is to ask not "are you happy?" but "what do you want" and then determine more objectively after an interval first if the client wants the same thing the next time you ask and whether that person has moved objectively closer to the desired outcome since the last assessment.”

Doug,

I can see how your approach might prove fruitful, and I am sure that other approaches might be as able to separate the wheat from the chaff.

I see your approach, and any other approach re: outcomes, as tactical rather than strategic, and I believe that our current system was designed to place the tactical amongst the Regional Centers and providers and the strategic in the Act itself. This is why I question whether any system of outcomes/accountability can be implemented in a systemic manner when the very nature, the chasis, of the system was to place those systems at the local level.

The Regional Centers were to sieze the moment, and they have blatantly failed to do so. Over the years the state has impossed and implemented numerous legislative interventions that could be best be described as micro-managing a system that was designed NOT to be micromanaged. It is like using paper to fix plastic, and metal to fix stone.

The last example is likely the budget act of 1998 (AB2780) I think, that implemented the DSP training [AB896 could be sited as an attempt]. It took the state to act upon poor staff quality, and it took the federal government to force the state to do so. Much of the micro-management legislation I reference deals with issues that have always been within the control and authority of the Regional Centers. The RC always had the ability to act, correct, change, adapt and improve but most have simply failed to do so. As a result, when things got bad enough, the state “mandated” it.

How does your system, any system, of accountability/outcomes differ from all the micromanagement of the past? Does not your point/isse just supply one more data point of proof that our system of 21 Regional Centers is a failed experiment?

Doug said...

Paul, the purposes of outcome measurement are twofold and might answer your concerns: one is to improve strategic thinking by the state. You might have noticed in policy discussions, making the system work better is never the topic. How advocates think strangers ought to live is the only topic. I would like to believe that if we had data concerning what works maybe we could replace 10% of the surplus data we receive as to what scolds like Jeff think people they've never met ought to want.

Second, part of why quality never prospers in this system in my opinion is that nearly all the information available to most of those served is the subjective opinion of a service coordinator who has never even heard of the overwhelming majority of options, has no resource to justify instinct with and experiences quality much differently from the client. If outcomes data were available, intrepid clients could learn about their choices from accessible sources other than the SC who might in any case be much smarter if he or she chose to be.

Andy said...

Whose Quality? Perfectly titled, Doug . . . implying that quality is in the eye of the bewilderer ----or is it? And should it be? Doesn’t it depend on the product, or in our case, the service? Wouldn’t a better, more perfect title be, “What’s Quality?”

Or is this suggested heading too pedestrian? . . . too flat and shallow? . . . a crude and clunky counterpoint to the poetry of the original . . . void of the inherent abstraction and the endless possibilities it offers the reader.

If we consider the subject, though, does it benefit more from your flighty, cosmic lyricism or my look-you-straight-in-the-eye, roll-up-your-sleeves, and get-those-calloused-hands-dirty approach?

In short, is “Whose Quality?” of greater quality than “What’s Quality?”

I don’t understand why we would talk of only one tool, or system, to evaluate a whole life. Certain services appear very easily measured by outcomes.

Let’s say that Paul gets money for his wonderful, nonprofit supported employment program called, “Paul’s Occupational Support and Employment Resource Services, Inc.” Do we really need a CARF survey to find out how P.O.S.E.R.S. Inc. is doing? What’s the average length of time it takes for someone to get a job through POSERS? How many POSER people got jobs last year? How many lost jobs? What’s the average length retention? What’s the average wage? What’s the average cost per placement?

After looking at those numbers, we could justifiably ask why the hell are we paying Paul so much money for accomplishing so little? And Paul would wave his three-year CARF accreditation in our faces, join a lobbying network of providers, and respond that he’d surely accomplish more if we paid him more.

Granted, supported employment is an easy one . . . low hanging fruit, as the TQM boys used to say. At one time, long ago, I think ILS may have also been a service with obvious and easily measured outcomes.

(CAUTIION: Tangent Ahead!)

However, for quite a while in many parts of the state, its been used for any service you can’t, for a number of reasons, otherwise get. Because ILS rates are relatively decent, you’ll find it used for respite---because respite rates are relatively horrendous, it can be very hard getting a provider who can provide any kind of reliability or continuity. You can find ILS used for Social Recreation Services because a number of regional centers won’t pay for social rec. . . . “We aren’t spending our precious and limited POS funds to pay for people to have a good time”---a sadly funny position to take when they quite readily pay for services that make people miserable. ILS is used for job development, day programming, in home support services, counseling, etc. I’m surprised it’s not used for camp.

Stanley starts a wonderful nonprofit ILS agency called “Stanley’s Helpful and Responsive Independent Living and Leisure, Inc.” He started the program when he found he could get one of those sweet, dollar-a-year, nonprofit leases on an old Boy Scout camp in the mountains. Thanks to Stan’s “entrepreneurial spirit” you can now send your 42-year-old kid to Camp SHRILL for a week each year. He’ll learn to paddle a canoe and make a leather belt . . . independent living skills for the 19th century.

If ILS had remained as it was intended, I think it too could have provided us with easily discernable and measurable outcomes. Let’s say that Andy runs a wonderful nonprofit ILS agency. It’s old-school ILS, designed to actually provide the training people need to live on their own and it’s called, “Andy’s Rehabilitation Resources In Becoming Autonomous, Inc.” The desired outcomes for ARRIBA’s clients are pretty obvious and its quality indicators easy to identify and measure----length of time, average level of follow-along support needed, etc.

A student of California’s emerging social, political and cultural trends, Andy (not his real name) denies that choosing the name “ARRIBA” for the organization is pandering to the state’s growing Latino demographic. The fact that it’s the first listing under disability services in the Spanish Language Yellow Pages is just a lucky coincidence . . . and the full-page ad on the following page is not as expensive as people think. His eyes have become very sensitive to fluorescent lighting, hence the sombrero he wears for intakes.)

Okay, okay, no more lame acronyms . . . So on one hand we have services (or at least one service) with obvious purposes and outcomes, making it rather easy to define and measure quality “with a highly valid system.” On the other hand, we have a bunch of services created with an original intent long forgotten or abandoned.

What now is the purpose of a sheltered workshop or day program? Originally the workshop was meant to train people for real jobs. Day programs were supposed to train people for less restrictive (i.e. fewer staff) day programs and then on to workshops. (With the creation of supported employment and supported living, I think we finally realized how weird it was to create a service, stick people in it, and then explain that their purpose there is to try get out)

I know that the main purpose of these programs has become simply a place to send people each day, just to get them out of the house. If their actual purpose is of dubious value, how can we identify a valued outcome to measure? Meaningful activities? By almost anyone’s standards (except the spin doctors running these glacial treadmills) such is not occurring in these programs.

Recognizing the meaningless is easy . . . defining meaningful is another story. For the advocrats, a job, absolutely any job, is meaningful for people with disabilities. Jobs that they, and nearly everyone else, would find empty of thought, status and meaning, somehow become a spiritually infused higher calling when foisted on people with disabilities. Chasing a taco wrapper across the windswept parking lot of a strip mall in Fontana, may put a little change in your pocket, but let’s not overstate its value. Look, I’m not saying we shouldn’t be helping people work, we most definitely should, but let’s leave the significance of the work up to the individual doing it.

And then, there’s residential services . . .

Decent shelter, food and clothing . . . ready access to adequate healthcare . . . can we agree to these basic outcomes? Beyond them, I think I’m with Jeff . . . and our objective, validated system of quality review must become more individualized, subjective and subtle.

There’s much more to write but I will post this fragment now (gasp! It’s just a “fragment”?) before Doug changes the topic.

(For those of you who suspect that the only reason for this post was to find a way to conjure up an image of Doug in a big sombrero . . . I must plead the fifth. For those who have met D., I can only apologize for the disorientation of such an image . . . at once comic and horrific)

--Andy

stanley said...

[2:19 PM: paul say] I have a different definition of an advodiva...etc

gawd I hate to agree with paul...but almost nodded my hear off...til the last comment: dismantle the whole experiment (Atlas Shrugs)...what would replace the Lanterman Act...the state (DDS) can force RCs to be competent...they just don’t.

rather than dismantle

KISS, enforce the LAW. 1. Determine needs. 2. RC find cost effective, positive outcome producing, programs that meet needs (eliminate Potemkin Village programs). 3. state adequately funds programs (or tell those w/ special need we don’t give a damn)

DDS demand accountability for 1, 2, 3...weel maybe they cant demand accountability for the State's priority of cheap plates for Hummer owners over quality programs...but

then its up to society to vote for legislators who care about quality lives for those w/ special needs...but

they can demand RCs submit true cost and in turn submit these to the legislature...of course providers have to submit true cost to RCs.

caveat: as doug say...double rates w/o accountability is meaningless.

Guess there was another paul opine that didn't get a nod...[paul said] rather than behind the line, less tangible, and more esoteric issues (Politicians, legislation, conferences, appointments, lawsuits, MONEY – generally known as SACRAMENTO).

that pogo-etal (all stakeholders) have not called the frontliners on their bs...eg, responsible for gaming the system...is a fact..., however:

SACRAMENTO is not less tangible than the frontline...they are paid politicians and appointees who swear to up hold the law...not to mention they actively seek these jobs...

BTW perhaps the most egregious frontliners who have let the Lanterman dream become a bureaucratic nightmare are parent board (RC and provider) members who acquiesce (suck up) in hopes of better treatment for their child...the greater good gets the nasty end of the stick...

in this regard...

paul say: I believe that the system can only be fixed from the ground up by employing boards of managers that are there to make it successful for the whole in lieu of being there to do nothing more than watch over his or her child

Again apologies for not addressing dougs question...but maybe in a round about way quality is touched on...

stanley seigler

Doug said...

Andy, I think of course you can't use metrics to judge a life, but you can do pretty well to judge a publicly-funded support. I think work, home, health and friends are good measures of whether Andy's Sea-Side Wellness and Independence Program Enterprise is effective. My sense of the whole vendor code thing you refer to is we ought to do away with vendor codes entirely and just have the regional centers buy support.

Stan, as you can see I have a long-suffering patience for off-topic comments. I agree with you, as well, that agreeing with Andy makes me wonder about what's in the food-chain. I know where he gets his ideas and as far as I know I haven't been exposed to it since I was a teenager.

Stephanie said...

Sorry if I am too late to the party but i was napping. Doug, i think the question you posed presented a false dichotomy. LQA was never intended to be a measure of quality. If you want measurement of quality by definition you will need tools that are valid and reliable. Valid and reliable measurement tools does not, by definition, mean choice is tossed out the window or ignored or twisted or what have you. Perhaps the question is WHEN and for WHAT should statistically valid measurement of quality be applied.

Doug said...

Stephanie, I agree, actually. I didn't mean to present a dichotomy at all but to talk about how we can get to some level of accessible information about what actually helps.

stanley said...

well now that the topic has changed...I now have some comments on quality...better late than whatever.

[doug say] LQA model, is to have a deeply considerate and subjective evaluation so cumbersome it typically sits on someone's shelf unimplemented.

So much depends on the individuals involved in the LQA...the interviewer, provider supervisor, and the RC counselor...sad typically it sits...little follow up...why was “the LQA was never intended to be a measure of quality”...seems like it should be...especially if there is a follow up to determine if wants were/are being met.

[doug say] It's true that people can be subtle but I think the only questions, really, are: do you like where you live? do you find your social life satisfying? do you find what you do meaningful? do you have untreated gangrene?

and

[doug say] I've thought a better way of determining whether the choices of the client are being served successfully is to ask not "are you happy?" but "what do you want" and then determine more objectively after an interval first if the client wants the same thing the next time you ask and whether that person has moved objectively closer to the desired outcome since the last assessment.

Soo at “Stanley’s Helpful and Responsive Independent Living and Leisure, Inc (SHRILL): The quality evaluation would include...

Dougs questions: do you like where you live? do you find your social life satisfying? do you find what you do meaningful? do you have untreated gangrene/? are you happy? and (not but) what do you want?...would also add, have wants expressed in LQA been implemented? and have IPP goals been/being met?...

Questions/evaluation would be at least every six months and reviewed by an ED or supervisior (in a sombrero) who knows client...and is not responsible for (good friends with) more than 10 clients...

Would leave it up to andy to give the evaluation a name...a Shriller might do.

Would also discuss Shrillers with andy, doug, jeff, paul on a routine basis.

stanley seigler

Andy said...

Doug . . . of course you “have a long-suffering patience for off-topic comments.” More than anyone, you realize that without it you might soon be cast back into the tumult and clamor you once generated with topics and postings such as, “Apologia,” “Diamonds and Dirt Are Forever,” and the like. The Blogger geeks at Google must have been beside themselves when, shortly after posting “An Illustrious and Heuristic New Year To Us All,” their overwhelmed servers started crashing like drunken pigeons---“It’s Y2K! . . . eight years late!"

Honestly, I do appreciate your patience (though “long-suffering” is a bit of a stretch). And I agree that asking questions like, “Are you happy?” . . . “Do you have enough friends?” and such, may have nothing to do with service quality . . . or, at times, it may have everything to do with service quality.

Several years ago, we took over an SLS arrangement from another agency for a rather crotchety guy in his sixties who would remind you of Humphrey Bogart in the African Queen. In the two previous years (the start of his sls) he’d had a half-dozen 22-year-old, slacker staff housemates. His house was a mess. What little food was around was growing legs and beginning to walk upright. His SSI was completely screwed up and his rent was past due. At 6 pm, the first shift of our first day, one of our best, experienced staffers knocked on his door. Our staff person introduced himself and, without saying a word, Bogie kicked him right between the legs . . . thus answering the question, “Are you happy?” . . . with personlized punctuation.

After a few months, all of the problems we found were worked out. He’s had several of the same staff, who are much closer to his age, for years now . . . and for years he was pretty happy with things. About three years ago, he said he wanted a dog. His landlord wouldn’t allow it and (I hate to admit it) we fed Bogie a bunch of b.s. about why a dog wasn’t a good idea (he’s got good, stable, affordable housing; it’s hard enough finding a decent rental in Santa Cruz, a pet makes it almost impossible; we’ll get you on as a volunteer at the SPCA, blah, blah, blah).

In truth, we didn’t want the work or the hassle of moving. Bogie didn’t kick anybody or get himself kicked out of his house . . .but you could tell, something was missing for him . . . we had broken a subtle trust we’d built with him. When this finally dawned on us, we got him a new place and he got his dog. He walks his dog everywhere, everyday.

What do you want? At first it was safe, clean and secure housing, stable finances, and stable, older staff. Later, it was all that, and a dog. Our services were good, then bad, and then good again.

If we provide good services, it is only because we recognize, and will admit to providing bad services. (By the way, I can't think of one time when our crap services had any correlation to our rate) If providers don’t know what quality is, and I’m certain that many don’t, than---by any and all means----regional center service coordinators must! That’s what happened to Bogart. He got a new service coordinator who pushed him to change agencies . . .

This assumes, of course, that there’s a decent agency out there, still willing to take referrals. It’s not always the case that “Andy’s Sea-Side Wellness and Independence Program Enterprise” is ready to swoop in and clean up after “Doug’s Upward Mobility Program.”

More on the regional center later . . .

---Andy

Doug said...

Stanley, it is a little funny me that the "Life Quality Assessment" we abbreviate as LQA was never intended to be a measurement of quality, although I am inclined to agree with Stephanie in that it doesn't seem but for the name ever to have been intended for that purpose. I do kind of think we need a simple, measurable and valid test for judging regional centers, policies and programs but your folks with the sombreros can help evaluate quality more broadly for process improvements, etc. Feel free to continue this thread, too. New posts are less about changing the subject than getting a certain party or parties not to give me a ration of trouble for not having posted in a month.

Andy, that trust is everything, isn't it? We learn either to be direct and honest or to run piss-poor programs that can't handle all the referrals we get. My sense of what you are talking about is there are two levels of evaluating how we are doing at being useful. The first, which as I've said I think should be direct and simple is what specific outcomes are we generating and the second, which can be broader tells us a broader more person-centered story with more wisdom behind it.