Capitalism, Freedom and Inclusion

I have been re-reading Milton Friedman's Capitalism And Freedom, may God have mercy on my wretched soul.  Here is a passage I find relevant to the discussions here:  

"The characteristic feature of action through political channels is that it tends to require or enforce substantial conformity.  The great advantage of the market, on the other hand, is that it permits wide diversity."

 Far more elegantly (and probably more glibly) than I have done, Friedman makes the case that I have tried to make (e.g. here and here,) that in asking DDS to provide too many assurances we not only create inefficiencies in the system by encouraging more central planning of the lives of the individuals served, we also undermine the inclusiveness the society we claim the intention to open.  Following Friedman's argument, the more activist we ask DDS to be, the less able our system will become to model the inclusiveness we promote. 

"...a major source of objection to a free economy is precisely that...it gives people what they want instead of what a particular group thinks they ought to want.  Underlying most arguments against the free market is a lack of belief in freedom itself."

Incidentally, openness to diversity includes patience with extreme nerds,  For those interested, the reason I am rereading this book which was written the way Alan Greenspan speaks is an online book club being hosted by Free Exchange, the economics blog sponsored by The Economist newspaper's online entity.  Anyone unlovable and fascinated may wish to participate but please behave and don't tell them I sent you.  My subscription is my only friend besides my dogs, and they're Keynesians.

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?

Further on the topic of choice

On the topic of choice, I have expressed some opinions. I would like to elaborate on a related issue. In weighing the relative merits of choice and integration, I still remain committed to the idea that choice should trump and that neither the State nor Regional Centers, nor agencies have a compelling enough interest to push integration on those who prefer to live and receive services in a segregated system.

That said, after hearing a very compelling speech just yesterday on the topic, I also agree with two embellishments on that position.

The first additional point is that the boundaries of choice as a policy goal may vary in the advocacy of different people, but these distinctions are philosophical not moral. I may disagree with those who believe the state should differently fund integrated and segregated services in order to support the choice of integrated services, but I do so on practical grounds and with no truer compassion or greater honesty than those who take the opposite position. To the extent that state, regional center or agencies believe they have a compelling interest in limiting choice to a more integrated environment, it is appropriate for those entities to better support integrated services than segregated ones.

The second additional point I'll confess is that I agree absolutely with value-based funding as an improvement on the collossally irrational system we have now. I also agree that the supports necessary to sustain people with developmental disabilities in integrated lives are more valuable than those that support the same individual in a segregated setting, given that the former is harder to accomplish. If integrated services were to receive biased funding in their favor on the basis of value rather than cost, I could support such a policy.

OK, satisfied, J? And I posted in November, too.

Apologia

Maybe, Doug Antagonistes. There, that's pretentious. Anyway, Greek really can make a fool look smarter.

I have been informed recently that it is a little confusing trying to guess where I will come down on a given issue, particularly when it comes to new regulations. I thought now would be a good time to restate the first principles of reform as I measure them.

1. Choice Trumps

Most everyone involved in California's Developmental Disability System agrees on three things: That people with disabilities should live lives based on their own choices, that people with developmental disabilities should be fully integrated into their communities and that the health and safety of a served individual should be protected. Even a reprobate like me agrees with all three of these principles.

Not long after becoming a part of this system as an Uncle and as an executive it became clear that on a great day or with an extraordinary client, these three principles work together in perfect harmony. Most of my professional life, however, there are conflicts between two or all of these principles. In extreme situations, like a human locked in a box or someone with frequent seizures and a history of depression wanting to take a handgun hang-gliding, the conflict can be fairly easily resolved. When the distinctions are fine, however, I think we all demonstrate that one of these values is a moral imperative and the other two aesthetic preferences.

In the end, I find that client choice is where I won't give. Integration is important and should be a choice, but what of those people who don't choose integration. If what we call disability is to be seen as many of us would like it seen, as part of the normal diversity of humanity then people who neurological diagnoses are essentially normal and belong to a minority. When other minorities choose to live in communities where they belong to a local majority, this is generally considered ok. It should be with our clients as well. On health and safety, in extreme circumstances intervention is necessary and desireable as it would be with an alcoholic relative or a suicidal friend. However, like in those examples, it is important for the intervenor to establish that the individual, were they fully aware of all factors and able to implement a wise choice on their own, would behave differently. The default has to be in favor of an individual's choice.

I honor, but often differ on policy matters, with groups which hold health and safety or community integration as their most important policy goal. This frequently puts me at odds with my friends over the closing of Developmental Centers and the appropriateness of congregate services. When I disagree with CAIC or PAI, it's typically on this point.

My policy: When in doubt, choose humility. Because I told you to.

2. Err on the side of under-regulation.

When talking about policy, there is another matter to consider: Statewide laws and regulations can never take into account the idiosyncrasies that make up most of the matter of a human services system. In my own little imagination there is a formula. Since I made a pun of Agonistes above, I get to call this formula, Doug's Law: The formula for Doug's Law holds that 1 divided by (10 to the power of X)+1 is the likelihood of a decision being correct where x is equal to the number of intermediary reporters between the person affected and the person making a decision. So, a decision made by direct care staff has a 50% chance of being correct for the person served. A supervisor making a decision based on the advice of the direct care person has a likelihood between 8-9% of making the right choice. Regional center policies probably provide the right solution around 1 time in a thousand and DDS about 1% as often as a regional center. Executive Directors of agencies would get it right around 1%-.01% of the time if they weren't so pitiably stupid. There is no empirical evidence to support Doug's Law but it sounds right and anecdotal evidence abounds.

The upshot of this is that regulations that sound morally correct are very rarely right in implementation. I lean heavily toward reform which relaxes regulation in favor of accountability for outcomes. Specifically, risk, reward and oversight (verification) should be the guiding principles of the entire body of law by which the state manages this system. I honor but differ with groups that frequently propose or favor regulations which serve to bound decisions made by people who would not recognize the proponents in the criminal line-up which many should be standing in at any given time. As a consequence, I frequently disagree on policy matters with organized labor, most large advocacy groups, and many parents' groups on matters concerning regulation of agencies and regional centers, and I tend to disagree with regional centers on the value of POS policies as guidelines.
My policy: Support insuring outcomes and leaving process to chance. Plan to follow.

3. Put the cart before the horse.

Almost everyone I know agrees that outcomes are all important and almost no policy is ever proposed or implemented that doesn't directly controvert this principle. Every time a "best practice" is mandated, every time a proposal comes forth to prefer one mode of support over another, every time wages are legislated the assumption is that this will help clients live lives that are meaningful to them and yet the 200,000 or so people aren't often asked by policy makers what is meaningful to them or what help is needed.

Separating a person served by our system from the most appropriate support is massively inefficient, because money is spent on something that doesn't help as much as an alternative. No one handy suggests a tool before they know the project and yet some groups annually propose to alter the landscape of available services without ever learning what help is needed by whom for what purpose except anecdotally. People whose primary language is neither English nor Spanish nor spoken are rarely heard from even anecdotally. Once again, the real accomplishment would be to see that every person served makes progress towards life as they would choose it. Given that nothing useful is ever measured in our system, I could not be more certain that it is possible to mandate any service mode now vendored or imagined at any funding level without helping anybody.

Aesthetically, I don't like congregated services. To the (statistically nonexistent) extent that my niece's Uncle Doug will advise her service decisions she will never even look at a site-based day program or a group home. But still, as in item 1, I don't believe any person born with disabilities should suffer further because of my good judgement and moral vision. If the system worked right, and I am right on the unattractiveness of congregant services, most such programs will close and the rest be genuinely needed. While I cannot picture a stranger (or my niece) working in a site-based work activity program and be happy about it, it's actually fairly easy to imagine someone who, for some time, would benefit more from such a program than any other type. Just off the cuff, someone with significant anxiety towards the community at large, no existing work skills, normal fine and course motor control, and treatable behavioral issues might succeed in a WAP setting to prepare for more integrated and more meaningful work, while that same person might fail repeatedly without that preparation.

Some of this inefficiency actually harms clients as opposed to just wasting scarce resources or not helping as much as possible. When process becomes the focus, the goals of the client can be adversely affected as easily as neglected.

Again, I honor but often differ with people (nearly everyone I like) who would use state or regional center policy to determine broadly which forms of service are available to the community at large.

My policy: Support letting the design and prevalence of supports result from their success meeting the real needs of individuals, even if the result is more of format I don't like and less of what I personally sell. As a matter of policy.

Oh, and happy second anniversary to this blog (last month.)

Why transparency matters

Transparency may be the most underappreciated feature of a strong system. Every day system stakeholders experience the ability of bureaucrats throughout the system to stretch the letter and spirit of existing statute and regulation. Often, those innovations are flexible solutions to situations not foreseen in the development of existing law. Often the experience is of a misrepresented regulation for the purpose of saying no to a flexible or compulsory solution.

The more that DDS, Regional Center and Vendor actions are exposed to sunshine, the more likely flexible solutions will be applauded and inappropriate denials of rights will cost the decision-maker. At every level of the system from the legislature to the quality of breakfast in a group-home, people with disabilities benefit from the various agencies understanding that the quality of their work being widely known and understood.

I offer an additional point, my own theory. I do believe that control must be balanced with the organic process of policy-making. Because most decisions are made in the dark by people alone, each of whom most often prefer to be in control, I expect that the system of support for people with disabilities is massively out of balance on the side of rigidity. An open dialogue can massage that stiffness and restore some of the flexibility the developmental disability system in particular was wisely designed for.

The CDCAN initiative to enable journalism by system stakeholders is so important. The fact that anyone's actions may be the subject of a webcast marks a major change to the milieu in which professionals act regarding disability rights and opportunities. Along with the teleconferences which highlight the micro-effects of macro-policy, CDCAN is the largest part of a systemwide push for greater transparency and through that, greater accountability and better decision-making.

CDCAN is not intended to be, nor should it be the only agency expanding transparency. At the local level support groups, boards of directors, blogs (God help us,) and other networks have the opportunity to make transparent local and even individual policy-making and action.

A note about client and worker confidentiality. The right of the individuals involved in this system impedes transparency but also represents a crucial element of the dignity of the individual. Efforts to increase informal information-sharing and public awareness of what actually happens in the system need to consider the importance of privacy and privacy-protecting law. That said, two principles should be remembered: The freedom of the press is enumerated in the constitution and, therefore, no law or regulation can impede the right of people to seek information regarding public decision-making and to publicize the information obtained is superior to every confidentiality provision on the books. Second, confidentiality is the property of the person the decision regards, not the professionals participating. There is unlikely to be a legal offense where a person wants their story told.

Update: Chris Thompson has left a link to a site he writes with a partner on transparency as a communication tool. Click here to read about why transparency matters.

Choice and Choices, Part II

The process of filtering the client's IPP through vendor codes has two major costs. The most important is to the well-being of the client. This post will explore the less important cost, to the efficiency of the system.

To recap, the process of planning and purchasing support in California's developmental system begins with the client, those the client cares to have input and the service coordinator from the Regional Center, as well as any professional support providers in place to review the clients preferences, their disabilities and to plan for whatever support will mitigate the effects of the disabilities on the individual's aspiration. Good start if done correctly.

The next step is generally to attribute the supports to certain vendor codes based on matching needs with codes, but primarily based on Regional Center POS policies. At this point, the plan becomes centered on the vendors not the clients. The efficiency cost is this: If the POS policies are taken as gospel and they too often are, there can be a gap in resources which can only be bridged by purchasing the wrong support for too much money.

Here's an example off the top of my head but not theoretical. If a Regional Center tries to contain costs by limiting units of service available based on vendor codes, one can imagine (or name) a client whose needs exceed the provisions of the POS policy. If, as often happens, the regional center seeks to maintain those policies rather than make an exception, a client can fail to live in their own home, leading to a group home which leads to a day program which typically requires transportation. The result is, and this happens frequently in this system that when $5000 per year in support doesn't suffice to maintain a client in their own home, plan B costs closer to $40,000 per year while providing the wrong services for the client.

The response often made by people defending POS policies by vendor code is that they make exceptions when following the policy will lead to the client's living in a more restrictive setting. Heck, we're required by law. Anyone who works directly with clients knows how rarely this is the case. We go through this process. There is typically a long road into crisis and a longer one back from the brink. Clients in our program have died, ruined their credit or lost their health before the evidence that the POS policies were deficient became clear enough for the exception. The client who died now costs the State nothing. The others now cost the state roughly 6-8 times what the adequate level of support would have cost.

The result is that the system does not behave like a continuous array of supports to be tailored to the client's needs and preferences. It flows like lumpy oatmeal and people get involved in day programs they neither need nor want because the group home they didn't want to live in requires it. This is a costly problem that merits fixing for the sake of the budget if not for the sake of the clients.

Choice and choices, Part I

One of the great interruptions in the quality of lives of people with developmental disabilities, and a barrier to the efficiency of the system is the frequent failure to provide services on a continuous spectrum. The initial concept behind the Individual Program Plans (IPPs) is to assess the needs of the client in order to provide exactly what is needed to mediate the effects of the disability and provide for a meaningful life in the community. It's been widely agreed that the IPP is the central administrative and regulatory event in the provision of services in California's Developmental Disability System.

The IPP is designed to take into account the nuances that every individual brings to their own assistance. The client is expected to be both the central object and leading subject in the development of their own plan. The IPP carries every aspiration that well-meaning people have for useful service and every hope the taxpayers have for an efficient system.

Once the IPP is complete, however, the plan typically loses most of it's meaning as Service Coordinators try to allocate the meaning from the client's plan into vendor codes. Vendor codes represent modes of providing services and allow the delivery system to be regulated according to function. Most Regional Centers, often influenced by their vendor community and to a lesser extent, their clients, typically establish Purchase of Service policies (POS) based on restrictions on who can receive services from which vendor type under what circumstances and to what extent. This system offers efficiencies for the administration of a Regional Center but is just as clearly inefficient for the support of people with disabilities.

The processing of needs into codes might not be fatal where the understanding is, as it is in law, that the POS standards are guidelines for arranging things of lesser status than the POS. Essentially, the deal statute makes with the Regional Centers is: Set up your POS policies and if you can meet the client's needs within them great and if not, you must exempt the client from the policy. That's not the deal typically made between Regional Centers and clients which can often be summarized as I understand that's what you need, let me see what I got. I'll look at the POS policies.

Vendor codes makes sense to me. To assure minimum quality standards, it is necessary to regulate agencies and the vendor codes allow that to be done appropriately for broad categories of modes of service. For example, it is generally inappropriate to have three ILS clients being served by one staffperson at a time whereas at a site based program, the minimum appropriate ratio might be higher than that.

But given that services are placed in broad categories, keeping faith with clients and their IPPs requires that these categories be understood as ranges on a continuum not as separate and distinct modes. Seeking to fulfill a client-centered IPP with vendor-centered service purchasing betrays choice by limiting choices.

Value Stream Management, Summary and Conclusion

The Lean model proposed through Value Stream Management offers moral excellence to the agencies serving people with disabilities. The Lanterman Act promises choice, integration, health and safety as outcomes of three billion dollars in funding to Californians with developmental disabilities. The statutes passed within the Lanterman Act, the regulations produced under the Lanterman Act and the policies and procedures of our agencies, however promise next to nothing.

The assurances that do exist fall into two categories. Caseload ratios, provider qualifications, records responsibilities and board membership standards are all process requirements which partly define costs but have no measured bearing on client outcomes. The outcomes promised and measured, mainly on Individual Program Plans (IPPs) and Individual Service Plans (ISPs) rarely get followed up on. In other words, quality is neither designed into nor inspected into this system.

Every professional working in the system and every client and family benefitting from it does so toward the purpose that people with disabilities live better, more meaningful lives of greater consequence to their communities. The accomplishment of that goal is a moral good. Any waste absorbing resources which would otherwise serve the goal of the system is an ethical taint on those who tolerate it.

Advocates frequently point to poor funding by the state and lack of responsiveness of regional centers and their vendors as the great evils suffered by people with disabilities, but I submit that the most plentiful errors depriving our clients has been the systemwide failure to account for and eliminate waste. Furthermore, as long as this is the case advocating for resources is hampered by our inability to assure lawmakers of what the benefit will be from greater investment, if any.

W. Edwards Deming, the statistician Total Quality Management guru famously argued that quality cannot be inspected into a system, it has to be designed in. At the end of the day, the most compelling moral challenge to the constituents of this system is to build in process which eliminates waste and improves quality. Until that happens, the contrast of client-centered values and labyrinthine process will remain an unfunny irony.

Value Stream Management, Perfection

The fifth and final step in developing a lean system or agency is the pursuit of perfection. Most of the inefficiencies in our system are the cumulative effect of years of making habits out of responses. In a system or agency that has followed the four preceding steps, it is likely that over time, persistent new forms of waste will inevitably develop. The result would likely be a magnificent, transformative improvement eroded over time.

The alternative to this is to continuously address waste through a permanent team. Value Stream Management was pioneered in Japan and two Japanese words are used to describe change in this context. Kairetsu refers to radical change and the expected result of a VSM transformation. Kaizen refers to incremental change. Kaizen teams are a continuous presence bringing representatives from all along the value stream seeking waste, either waste that was not recognized during Kairetsu or new waste that finds its way into the system later. The lean agency commits itself to a permanent war with waste.

The result, in industry, has been a massive reduction in cost at the outset, but also small, incremental reductions in cost forever after. When we talk about cost reductions within this system, the assumption is a reduction in quality. Remember that part of this process is to have the client define quality. Eliminating waste improves quality while reducing costs.

Value Stream Management, Pull Value

Traditional models of enterprise are based on production. The producer is at the center of process which also includes vendors and buyers. From the producer to the buyer, we can think of this as a process of pushing goods and services. The firm designs, generates, markets and sells its wares to an end user. The communication between producers and end users consists primarily of the producer convincing the customer that what is offered is valuable and the feedback from a potential customer who chooses to believe and buy or go elsewhere.

I'll argue that most of California's system operates on the push model. The seminal event in the availability of a service or support comes when an agency creates a service design and presents that to the Regional Center for vendorization. The Regional Center may then offer that service, as designed, to a client. Although some agencies (such as ¡Arriba!) submit minimal service designs with the intent that the actual service provided will be designed by the client, the system model is clearly designed according to the old industrial pattern.

In a lean system, this model reverses. The analysis, process and activity are all designed around the idea of pull. In other words, the end user defines the value. Instead of a series of suppliers beginning with miners and farmers and ending with a consumer, we look to a series of customers leading from the consumer back through the value stream. The macro process would look like this, there is a meeting at which the client describes his or her situation and what they want. The professionals attending that meeting would then be responsible for providing the support indicated to the client which they would seek from either their superior or an outside agency. They are now the customer pulling value from up stream. It's like The Lanterman Act only for real.

Value Stream Management, Make Value Flow

The next important concept in a lean agency is making value flow to the client. Basically, this means the identification and elimination of barriers, delays, redundancies and any other waste. Beginning from the customer's perspective, the parties closest to the client examine all that they do and need in order to create value for the consumer. Are any steps taken unhelpful or counterproductive. If so those steps should be eliminated, unless they are required by compliance. In that case effort should be allocated towards changing the requirement.

The next step repeats the previous one with a new customer. Now, instead of the consumer, the direct care worker (DSP) is the customer and those who provide resources to the DSP evaluate their activities, eliminating any waste of time, treasure, effort or energy along the way to providing the DSP what he or she needs to provide value to the client. As above, some waste will be immediately correctible and some will be in service of robust statute, policy or regulation. Either way, that waste (called Type II waste) is as bad as the correctible (Type I) waste.

To make an agency lean, these step should be followed not only for the entire heirarchy at the agency, but as far back in the Value Stream as can be observed. At each step, the purpose is to eliminate wasted functions. As the process goes on, it will be mapped in terms of tasks, not jobs. At each step, the influences causing Type II waste should be recorded for the purpose of advocacy.

When this process is complete, all the Type I waste should be eliminated and value will flow more quickly and efficiently from the finding source to the client. It should be noted that in this system, real leanness will have to change regional centers and DDS as well as vendored agencies.

Here's an opinion. I suspect this system has an absurd amount of waste and that a ridiculous amount of it is of Type II.

*****Second section

I received Spam as soon as I initially posted this. I don't like spam but haven't taken precautions against it because one option eliminates anonymous posting (although it allows a person to take a name not their own) and the other includes a verifier which could be hard for people with disabilities. How would you, dear readers feel about a requirement that you identify yourselves (as anyone or anything) in order to make a comment?

Value Stream Management, Identify the Value Stream

Apologies for my neglect of this site, now, where were we?

Once value is specified in terms of what the client wants, the next step in developing a lean system or organization is to identify the value stream. This refers to the sequence of actions that bring resources forward toward the end client. It includes everything the agency does, but also everything their suppliers do. In California's system, for example, the process of becoming lean would start with what the client needs and look at how the direct support staff provide for that. The next step would be to look at the both the program design and the supervisor and how each provide the needed resources for the direct support person to serve the customer.

Value Streams when looked at honestly are extraordinarily complex and long, and rarely confined within a single agency in manufacturing. Certainly not in this system. This does not mean by itself that they are wasteful or inefficient. The economist, Milton Friedman once used a cover photo on one of his books depicting himself holding a pencil. The point of the photo was the pencil which contained rubber from Indonesia, metal mined in Central America, wood from canada and graphite from somewhere else (it's been awhile since I read Friedman) and were assembled and sold in the United States for a dime apiece.

A rough example of a value stream might be as follows: A male Supported Living client is hungry so a staffperson cooks for him using food purchased by another staffperson with money delivered by a Supervisor. Those funds may have been given to the Supervisor by an agency comptroller who cashed a check with funds for several clients received from the regional center as the fiduciary for Social Security. On another branch of the Value Stream, the employee cooking was following a person-centered Individualized Service Plan (ISP) which authorized cooking and described any parameters to the meal. That ISP may have been reviewed by a supervisor and must have been also reviewed by a regional center employee, signed off on by a Program Manager and funded. Both the funds and the terms of approving the ISP were delivered to the regional center from DDS based on allocations and controlling statutes set forth by the California legislature. If the client was eligible for the Medicaid waiver, a second branch of the allocation and regulation process travels through the federal government.

There are three things that I believe can safely be said about the process above:
1) That it is an oversimplification of the value stream leading to a single client eating a single meal,
2) That it probably repeats tens of thousands of times per day in California, maybe a half-million times per year.
3) That it probably doesn't go smoothly every time at every step. Even 99% success reflects a lot of defects in a tiny portion of the overall community-based system.

Taken together, if the assertions above are true, there exists extraordinary potential for both improving the satisfaction of clients and reducing the cost of the system. Just in the preparation of meals. Just in Supported Living clients.

Note: Because demons have prevented me from updating this site regularly, I am adding a feed to the links. People interested in this site who have browsers with RSS capability can bookmark the link marked "Pay attention!" to be notified of updates.

Value Stream Management, Specify Value

The first step in Lean Thinking is to specify value: What will our whole process from the legislative appropriation through the client create, and what that should cost. At this step, original and comprehensive thinking are crucial. For example, in our system, we often treat the service provided as the outcome. I suspect that we think this way, because in our system, the service is, in fact, the last compensated part of the process. Sometimes assigning a value to the service doesn't seem like such a good idea in case someone compares the cost, but this is why we try to fix stuff.

I would suggest that in the system design, value is creatively and well described. We say that the system exists so that people with developmental disabilities can choose and experience lives similar to their non-disabled peers as fully integrated members of their community. To this we add health, safety and dignity at least in interactions with the participants in the system. This isn't very specific, but it is humane, measurable, creative and comprehensive. The current specification in statute of what that should cost is "whatever it takes" which may be unsettling to many taxpayers and politicians but it won't be me pushing for a hard number. It may be useful, however, that if Lean Thinking settles in that some rationale for costs may actually be useful in providing better lives to clients.

So we have three pieces of our value specification:
1. The outcome of the system is that people with developmental disabilities will live in a manner of their own choosing a life equivalent to that of a non-disabled peer as an integrated member of their community.
2. The client's experience of the system will be dignified, attentive and safe.
3. It will cost whatever necessary to meet the first two value propositions and no more.

That looks pretty specific to me, although we can debate how often those propositions are really carried out. I would contend that everywhere in this system that we are not conscientiously specifying value the implied value specification is this:
1. The outcome of the system is that people receive services of their choosing.
2. The client's experience with the system will comply with Regional Center policies and state regulations.
3. Costs will be in line with those incurred by other clients deemed similar.

So, I would say the system is relatively successful in specifying value but wholly unsuccessful in remembering or communicating the specification.

Value Stream Management, Introduction

This series of posts will propose a new concept of leanness from the one used currently in our system and outline a roadmap for getting there. This introduction will contrast the proposed definition to the one typically used and lay out the parts of the lean roadmap, which will make up the next five posts in this series.

The idea of leanness in a chronically underfunded system usually refers to underperformance. When we talk about how lean our agencies have become, we usually refer to things we feel we should be doing or be doing more of. My friends who run agencies might point out regulations they no longer comply with, a reduction in Quality Assurance activities, services that our clients need or want that they no longer offer, etc. The failure to perform key tasks is a predictable outcome of frozen rates and growing mandates, but it's better described with the word erosion than leanness.

I remember an old joke about the guy who lost 20 pounds of ugly fat when he was decapitated. That's a good metaphor for our concept of leanness. The usage in Lean Thinking refers to the elimination of waste. Waste can be found at three levels,
1. Activities and costs that do not actually generate value for our clients,
2. Activities and costs that could generate the same amount of value with less investment if done differently, and
3. Activities and costs for which there are substitutes that generate equal or greater value for clients with less investment.

I think most agencies serving California's people with developmental disabilities are about as eroded as they can be. I would argue that none, including the one I run, are as lean as they should be. Growing leaner is a process of increasingly and consistently directing dollars and energy into creating value for the people we serve.

So, the roadmap outlined by Womack and Jones follows the following process.

Part I: Specify Value, defining what needs are served;
Part II: Identify the Value Stream, recognize the contributors to the generation of the value specified;
Part III: Make the Value Stream flow, this step represents a radical reimagining of how work is best done with a focus on seeking and eliminating waste;
Part IV: Pull, which is a corporate analogy of person-centered support; and
Part V: Perfection, which institutionalizes a permanent and continuous process of improving steps I-IV.

So the next five posts in this planned nine-part series will look at each of the parts of Lean Thinking in the context of California's system of service and support for people with developmental disabilities.

New series of posts-Value Stream Management

Thanks to everyone who wished this site a happy birthday or blogiversary or whatever it was. The next series of posts, probably nine in all will discuss the benefits of Value Stream Management as a paradigm for reform of this system. The series will roughly follow James P. Womack and Daniel T. Jones' book Lean Thinking.

There are a few reasons that Value Stream Management (VSM) is an attractive model. The first is that the concept of "Let the customer pull value" is essentially a business-world equivalent of person-centered thinking. The second is that the paradigm defines efficiency in a way that I find much more engaging than the normal way that we discuss the idea in this field. Those of you who have known me for awhile know how pessimistic I am that our system will ever be fully funded to operate under the current structure. The real hope for a better system falls to redesign and reimagination. A third reason is that VSM promotes honesty and transparency regarding the possibility of doing things better.

A Disclosure: I am currently working with partners to develop an instrument for applying the concepts of Value Stream Management to our system. While I certainly honor objectivity, I should admit that I both have already made up my mind as to VSM's value and hope to profit from its application.

Self-Directed Services: My endorsement

I support self-directed services (SDS) because in concept, SDS programs empower people with disabilities by removing some control from service providers (including both Regional Centers and direct service-providers,) because an effective SDS program lowers the cost of quality in services and supports by involving the person best able to control costs in the negotiation for price, and because without SDS the integration and sovereignty sought by the DDS system for people with disabilities are largely absent from its workings.

The current proposal adopted by the legislature's budget conference committee certainly will implement the initials SDS and may well lead to the actual manifestation of its meaning. The ban on using SDS while a client lives in a congregated facility or uses a day program certainly limits both the choice of clients and the benefit to the system and the state. The failure to specify the role of service coordination staff in SDS, which may or may not occur in writing the regulations, leaves up in the air how much actual control will pass to people with disabilities and, therefore, whether or not this new program meets its goals or produces significant benefits.

Fears as to whether the regulations being developed will follow the normal process of public input have placed many erstwhile supporters of SDS into a skeptical state.

All of that said, this proposal is the most promising reform to come this close to implementation. So, I endorse the SDS proposal with the anticipation that legislative and regulatory corrections will be needed to implement SDS itself.

Individualized and Systemwide

I recently attended a small conference featuring Michael Smull on providing services using client-centered thinking (Thanks ELARC, SGPRC and Yvette.) Brer Michael made the point that the client-centered thinking that happens in our system largely occurs in spite of the design of the overall system. If we want the client-centered results we all say we want (at least in public) it's necessary to recognize how many ways our system is designed to prevent that from happening.

You can see it in so many practices, regulations, habits and behaviors. I was recently at an ILS conference at which a Quality Assurance specialist stated that everything's client-centered at his regional center, but that QA is really between the agency and the regional center.

The problem is, after the system was designed to maximize individualism, 30 years ago, traditional bureaucracy has been reasserting itself. That's not always a bad thing, but if unchallenged it certainly promotes standardization which is the opposite of individualization. In 2004 and from my broadening chair, it's not clear how much ours is even a community-based system. Regional Centers are so heavily regulated and so lightly monitored that it can be hard to tell sometimes whether innovation, creative problem-solving or the impact of local culture are more or less prevalent than in a state-run system. Several Regional Centers are in open warfare against client-centered alternatives to site-based standardized services.

My curmudgeonly opinion is that a rigorous, client-centered plan means exactly nothing when so many greater forces call for standardized thinking once the plan's been written. At an intuitive level, client-centered thinking may be the opposite of systemic thinking but I suspect the two depend on each other. Incremental solutions seem analogous to client-centered ones, but I suspect there is little that can be done at the client's, agency's or regional center's level that isn't undone by the standardized framework of the system.

Three great values that sometimes go great together

During the ILS Coalition conference, a consultant to the state legislature talked about the conflict between emphasizing choice and emphasizing safety. It's a real comfort to see someone get this and I wanted to write a little about the values in our system and how they interact.

I think there are three main moral values written into state law regarding support for people with developmental disabilities. These three values are unanimously supported (at least in public but I think with general sincerity as well) throughout our community. These are:
1. People with developmental disabilities should live lives and pursue goals of their own choosing,
2. People with developmental disabilities should be as safe, as healthy and as well as possible, and
3. People with developmental disabilities should be integrated into the community as substantially as every other member.

These three values sometimes align with one another perfectly. Other times, these two or more of these values conflict or compete. A cliche we use is "People should be free to choose, but you don't let them jump in front of a moving bus." The problem with the metaphor is that it's a metaphor. What is the threshold for free to choose. When is someone jumping in front of a bus (other than when they're jumping in front of a bus.) I know people who work in this field who think eating poorly calls for aggressive intervention. Do you or do you not help someone with a seizure disorder join a hang-gliding club?

Integration is often even trickier. During an intake I once suggested to a new, young client that we could help her join a church choir because she was religious, isolated and liked music. Her answer, and I've heard it more than this once was "No. I don't like normal people, they're mean to me." This is a real conflict. Those of us who care acutely for people with disabilities want to live in a society where cerebral palsy, cognitive challenges, and other disabilities are traits not stigmas, like green eyes or a really bizaare sense of humor. Still, we can't promise people with disabilities that if they participate in the greater community that they won't be insulted, victimized or alientated. If we're honest, we can almost promise that they will be. We no longer question people with other minority identities who prefer the company of those they feel most like.

When we talk about these conflicts, someone always suggests a solution (a church choir where the music director has a child with disabilities.) I believe the solution is besides the point. In working with challenged people we've chosen conflict. The separate character of our system's participants is largely defined by balancing conflicts among our values. Some programs are, when the conflicts grow acute, highly risk-averse others are ultimately zealous about client choice while some purr about integration. The presence of different solutions to the same challenge among available supports is part of the genius of this system and as long as people with disabilities can find support that reflects there own values, our system works.