May 18, 2005
Re: SDS
My professional angst regarding the development caught a second wind. I always do share my winds, so here’s the breeze: What if SDSP passes, is implemented and still doesn’t happen. The way this could be so? If the protection features built in create an environment in which the control that clients have over their services actually declined.
Here’s the new data: Regional Center (RC) Service Coordinators (SCs) are intended to review monthly whether potentially very broad language from the clients Individual Program Plan (IPP- I know, I know) to decide whether it was being implemented appropriately. Under the current program, SCs have more frequent interaction, more discretion to intervene and more ways that they are accountable for outcomes. A rational SC who sees SDS as values-neutral would take more control of client services under the new proposal than the current system.
The essential point is that Self-determination will not achieve it’s stated goals unless it transfers authority to clients which simply won’t happen unless responsibility transfers as well. The best and worst professionals in the system regularly circumvent controlling regulations and can be expected to do so in opposition to the purpose of SDS as long as they remain responsible for all the client outcomes. It has to be in everyone’s interest that the client controls services or else we’ll have fake self-determination to go with fake entitlement.
I know this looks ugly in print, but ideally under SDS, the client with their FMS and Service Broker have to have sole responsibility for things that Regional Centers are now accountable for. Examples might include the following:
ÿ Preventing morbidity and mortality,
ÿ Decisions to work or not work and how and where,
ÿ Progress that is or is not made (clients must be allowed a learning curve,) and
ÿ The extent to which the individual participates in the broader community.
This doesn’t mean that clients in SDS should not be counted toward all policy goals, just that RCs shouldn’t get credit or blame for the outcome.
What makes SDS bold, is the trust it places in people with disabilities to serve their own best interests. What makes so many current programs so sucky is the failure to trust the client. Here are a coupl
1. SDS participants should count against a separate performance contract for their Regional Centers. The new draft of the proposal, makes a good start on developing a new one, but doesn’t yet separate from the old one Taken a step further, vis-à-vis an SDS client, RCs should be more responsible for providing control to SDS clients and less responsible for traditional policy outcomes. Appropriate language might state that all the metrics now used for RCs will be reported to and recorded by the Department, but not apply to the RCs performance contact. The SDS outcomes can be used against those from the performance contracts to measure the success of both programs as compared to one another and provide policy guidance into the future.
2. Clarify new roles. Limit what SCs may do to a very simple role that only makes sense if we are empowering clients. Limit service providers’ responsibility for documentation, to clarify that services delivered under SDS are accountable to the client alone (and through the client to the RC for purposes of documentation. Everyone affiliated with an agency remains a mandatory reporter, and obviously, the documentation left must allow for reasonable assurance that services are being rendered. Paperwork requirements that document anything other than services actually rendered should be discontinued where service providers are concerned.
Thursday, May 19, 2005
Monday, May 16, 2005
What's Right about Self-Directed Services
OK, so the Self-Directed Services Program (SDS) proposal has flaws and has been managed imperfectly. Here's why I want SDS to pass anyway, and what I plan to do about it.
Self-Directed services differs from the current system in this way: Those who choose SDS sacrifice a (theoretically) flexible budget spent on restricted resources for a restricted budget which can be spent creatively. This produces a number of efficiencies, such as reducing the principle-agent problem which inflates costs, straightening out lines of accountability, and improved opportunity to find and use resources which lead to lasting changes in the ability of the client to participate fully in society.
In this way, SDS can be expected to lower the cost of quality in support for people with developmental disabilities, improve the harmony between what's needed and what provided while institutionalizing the personal sovereignty sought by the Lanterman Act within it.
Here's my thinking about what to do in seeking SDS as a part of a richer system:
First and foremost, the community needs to take the ownership of SDS. The negativity that many of us feel or have felt toward this proposal seem primarily directed at the parts of the proposal that are not organically SDS. Examples include limitations on client choice, on due process, and on oversight. These elements of the proposal don't arise by necessity from SDS and in fact, diminish SDS and place the success of the program unduly at risk.
Under the U.S. and California constitutions, the part of government meant to belong most directly to the people is the legislature. To this point, DDS has been defining what SDS is to the legislature through proposed trailer bill language. That language is close enough to right that the community needn't write much. I plan to direct my attention to communicating the purpose, importance and optimum design of SDS directly to my legislators and Senator Chesbro. I urge my friends in our community to do the same.
Self-Directed services differs from the current system in this way: Those who choose SDS sacrifice a (theoretically) flexible budget spent on restricted resources for a restricted budget which can be spent creatively. This produces a number of efficiencies, such as reducing the principle-agent problem which inflates costs, straightening out lines of accountability, and improved opportunity to find and use resources which lead to lasting changes in the ability of the client to participate fully in society.
In this way, SDS can be expected to lower the cost of quality in support for people with developmental disabilities, improve the harmony between what's needed and what provided while institutionalizing the personal sovereignty sought by the Lanterman Act within it.
Here's my thinking about what to do in seeking SDS as a part of a richer system:
First and foremost, the community needs to take the ownership of SDS. The negativity that many of us feel or have felt toward this proposal seem primarily directed at the parts of the proposal that are not organically SDS. Examples include limitations on client choice, on due process, and on oversight. These elements of the proposal don't arise by necessity from SDS and in fact, diminish SDS and place the success of the program unduly at risk.
Under the U.S. and California constitutions, the part of government meant to belong most directly to the people is the legislature. To this point, DDS has been defining what SDS is to the legislature through proposed trailer bill language. That language is close enough to right that the community needn't write much. I plan to direct my attention to communicating the purpose, importance and optimum design of SDS directly to my legislators and Senator Chesbro. I urge my friends in our community to do the same.
Monday, May 09, 2005
What's the matter with the Self-Directed Services Program, Part II
A continuation of the second-guessing from the previous post, this series is meant to be commentary on the response to SDS rather than an analysis of the program proposal. Today's scolding: The proper usage of the word "voluntary."
An apparent disconnect between direct policy-makers and the community comes from differences between how the first group uses the term "voluntary" and how the second group hears it. On CDCAN townhall telemeetings, there has been frequent use of the term which seems not to be convincing a lot of the community.
To the direct policymakers, the fact that the program is voluntary means it doesn't have to work for everybody. To the community, there seems to be a sense that "voluntary" means the program needs only to work for the people DDS likes best. The difference was clearest on two recent conference calls when people described the pilot project participants as pioneers and others referred to the same group, essentially, as the anointed. The difference reflects something that I believe I have also detected, that there has been a broad, community-based but group of fierce advocates with strong values that believes itself to own this program and a far broader group with a strong interest in SDS that feels unincluded. The truth is, it is easy for government to find anointed pioneers and hard to find most of the others for whom this program should also be designed.
Nonetheless, this program is emblematic of how the State sees our community, and offers the kind of reform that break the cycle of a system growing more expensive and less successful. The failure of SDS to be implemented will break a lot of hearts, but it's failure to succeed broadly once implemented carries more tragedy. The voluntary nature of SDS justifies the a trade of rigidity (budget formula) for new choices. It remains important that the program be designed as robustly as possible whether it's voluntary or mandatory.
An apparent disconnect between direct policy-makers and the community comes from differences between how the first group uses the term "voluntary" and how the second group hears it. On CDCAN townhall telemeetings, there has been frequent use of the term which seems not to be convincing a lot of the community.
To the direct policymakers, the fact that the program is voluntary means it doesn't have to work for everybody. To the community, there seems to be a sense that "voluntary" means the program needs only to work for the people DDS likes best. The difference was clearest on two recent conference calls when people described the pilot project participants as pioneers and others referred to the same group, essentially, as the anointed. The difference reflects something that I believe I have also detected, that there has been a broad, community-based but group of fierce advocates with strong values that believes itself to own this program and a far broader group with a strong interest in SDS that feels unincluded. The truth is, it is easy for government to find anointed pioneers and hard to find most of the others for whom this program should also be designed.
Nonetheless, this program is emblematic of how the State sees our community, and offers the kind of reform that break the cycle of a system growing more expensive and less successful. The failure of SDS to be implemented will break a lot of hearts, but it's failure to succeed broadly once implemented carries more tragedy. The voluntary nature of SDS justifies the a trade of rigidity (budget formula) for new choices. It remains important that the program be designed as robustly as possible whether it's voluntary or mandatory.
Friday, May 06, 2005
What's the matter with the Self-Directed Services Program
The self-directed services (SDS) proposal been developed simultaneously by the administration and the legislature is encountering resistance bewildering in light of the almost universal wish for SDS. Notwithstanding that I've written about this a couple months ago, I thought millions of people probably would like an update on my thinking, hence this post. Following is my interperetation of the resistance to the current SDS proposals.
First of all, our community is by and large suspicious of anything printed on DDS letterhead. I suspect giving the magnitude of change represented by SDS, some portion of the current concern would manifest. While I have suggested and am about to resuggest that DDS made mistakes in the development of this proposal, a perfect draft would not have met hosannas. I think the response is fair in light of history, but probably not fair to the current proposal.
A second source of worry in the community has to be a fear for the programs which frequently serve clients in the current delivery system and are unlikely to serve clients, regardless of the final language. Many of these programs are barely surviving now and even if SDS only enrolls 5% of California's people with developmental disabilities many agencies are rightly threatened with a change or die crisis. Not only entrenched professionals but people who benefit from those agencies are rightly concerned about SDS.
That said, there are a few almost bewildering elements of the proposal which keep coming up in community fora like the 6 (to-date) CDCAN teleconferences, meetings at Regional Centers and other public events where this topic comes up. Good things to fix, if this proposal is going to find the acclaim many of us expected. These changes are more than political and more than cosmetic, many of us want SDS to succeed, not just pass.
The clearest of these is the foggy funding proposal. Althought the program is voluntary and people are free to leave if they don't like their budgets, it is very hard have faith in a capped budget based on factors that are aren't available. It would be very helpful if DDS would develop and publish their formula, bearing in mind that there is no reasonable formula which won't bring out some of the torches and pitchforks.
To me, the most infuriating source of concern (but far from the most important) is the (softening) language that forbids SDS participants from using congregate (group) programs. This does not infuriate because I advocate for, use or provide these types of services my family and I don't. It infuriates me for these reasons:
1. This program is primarily about choice, and significant choice is being obstructed because of the (noble) values of the DDS and regional center employees and pilot project participants. This program doesn't belong to anyone except ALL people served by this system who think they can provide better for themselves at lower cost than their service coordinator can.
2. The exclusive language makes the overall proposal needlessly more complex than it already is, insuring extra unintended consequences.
3. The exclusion, which is unnatural to the purpose and generates extra risk to participation, also provides a target for those few who don't want SDS to happen. Politically, it just doesn't make sense.
4. It fails to account for the lives many clients lead. There are a significant number of clients who can benefit from SDS who will with considerable risk and, therefore instability. Several ¡Arriba! clients are capable of living well for years in their own homes but periodically encounter challenges that require them to spend short terms under more intensive care or monitoring. These clients could be well-served under SDS simply by not hindering them.
5. Finally, it's unnecessary, dammit. Phil Bonnet, the admired Executive Director of one of the pilot project regional centers recently said that of the 120 or so pilot participants none chose to spend SDS funds on congregate services. SDS is likely to satisfy the thirst for more included lives with no regulatory help. Of course, that's the bad news for those who are concerned for congregate agencies. It'll still be change or die time.
Aaah. I'm a little vented. To be continued. For now, let's just say that publishing a budget formula and deleting all language that exists in order to promote inclusion would improve the proposal itself as well as its reception.
First of all, our community is by and large suspicious of anything printed on DDS letterhead. I suspect giving the magnitude of change represented by SDS, some portion of the current concern would manifest. While I have suggested and am about to resuggest that DDS made mistakes in the development of this proposal, a perfect draft would not have met hosannas. I think the response is fair in light of history, but probably not fair to the current proposal.
A second source of worry in the community has to be a fear for the programs which frequently serve clients in the current delivery system and are unlikely to serve clients, regardless of the final language. Many of these programs are barely surviving now and even if SDS only enrolls 5% of California's people with developmental disabilities many agencies are rightly threatened with a change or die crisis. Not only entrenched professionals but people who benefit from those agencies are rightly concerned about SDS.
That said, there are a few almost bewildering elements of the proposal which keep coming up in community fora like the 6 (to-date) CDCAN teleconferences, meetings at Regional Centers and other public events where this topic comes up. Good things to fix, if this proposal is going to find the acclaim many of us expected. These changes are more than political and more than cosmetic, many of us want SDS to succeed, not just pass.
The clearest of these is the foggy funding proposal. Althought the program is voluntary and people are free to leave if they don't like their budgets, it is very hard have faith in a capped budget based on factors that are aren't available. It would be very helpful if DDS would develop and publish their formula, bearing in mind that there is no reasonable formula which won't bring out some of the torches and pitchforks.
To me, the most infuriating source of concern (but far from the most important) is the (softening) language that forbids SDS participants from using congregate (group) programs. This does not infuriate because I advocate for, use or provide these types of services my family and I don't. It infuriates me for these reasons:
1. This program is primarily about choice, and significant choice is being obstructed because of the (noble) values of the DDS and regional center employees and pilot project participants. This program doesn't belong to anyone except ALL people served by this system who think they can provide better for themselves at lower cost than their service coordinator can.
2. The exclusive language makes the overall proposal needlessly more complex than it already is, insuring extra unintended consequences.
3. The exclusion, which is unnatural to the purpose and generates extra risk to participation, also provides a target for those few who don't want SDS to happen. Politically, it just doesn't make sense.
4. It fails to account for the lives many clients lead. There are a significant number of clients who can benefit from SDS who will with considerable risk and, therefore instability. Several ¡Arriba! clients are capable of living well for years in their own homes but periodically encounter challenges that require them to spend short terms under more intensive care or monitoring. These clients could be well-served under SDS simply by not hindering them.
5. Finally, it's unnecessary, dammit. Phil Bonnet, the admired Executive Director of one of the pilot project regional centers recently said that of the 120 or so pilot participants none chose to spend SDS funds on congregate services. SDS is likely to satisfy the thirst for more included lives with no regulatory help. Of course, that's the bad news for those who are concerned for congregate agencies. It'll still be change or die time.
Aaah. I'm a little vented. To be continued. For now, let's just say that publishing a budget formula and deleting all language that exists in order to promote inclusion would improve the proposal itself as well as its reception.
Saturday, April 23, 2005
Anonymous, I hardly knew ye
In my previous post, an anonymous friend left a comment with three questions that seemed relevant to the blog in general. In my ongoing effort to provide maximum service to all of my reader(s), I thought I would respond in a new post.
1. What if the agreements, reached in the beginning, change or evolve as movement is made toward the goal?
This is an excellent question regarding Earned Value Analysis. Because clients are free to change goals at any time, many objectives become obsolete before they can be accomplished. There are methods for dealing with this that shouldn't damage the basic right of clients to change their minds. One offhand example is that most methods of counting Earned Value give partial credit for partial success, so that if an objective agreed upon and funded with a 6-month time horizon is changed after two months, and the objective were 1/3 complete as planned, then the agency would still be evaluated well (6/6=2/2=1.) If a funding mechanism were attached, compensation for the 2 months would be equal to the portion the agency expected to earn in the same time. Please, anonymous or other reader, feel free to ask for more clarification if I haven't answered the question.
2. Do you tend to lean more toward Weber or Durkheim in your analysis of institutions?
Do what now? You may be confusing "opinionated" with "informed." If you read more weblogs about politics and government, the distinction should sharpen nicely. (Shrug)
3. What should anchor decisions about the appropriate level of intrusiveness by public authorities in a self-determined service model?
My answer would be fraud, abuse and illegality should be actively watched for and trigger intervention when identified. Other than that, self-determination should mean what it says. By public authorities, I would include government entities, government entities that assemble boards and start carrying airs of private agencies, and any mandatory reporters in proximity to the self-determined use of state funds. Self-determination is a massive re-balancing of individual sovereignty against professionalism and shouldn't be sought or entered into by any party that doesn't accept that.
I expect self-directed services to be less gratifying to it's sponsors and the professional class of social servants, messier and less predictable. Professionalism has brought a level of order and advanced philosophy to this system which has value and cost attached. Scandals and catastrophes will be more frequent, but less pervasive than in the current system where many feel there is only one scandal and one catastrophe which are inclusive.
1. What if the agreements, reached in the beginning, change or evolve as movement is made toward the goal?
This is an excellent question regarding Earned Value Analysis. Because clients are free to change goals at any time, many objectives become obsolete before they can be accomplished. There are methods for dealing with this that shouldn't damage the basic right of clients to change their minds. One offhand example is that most methods of counting Earned Value give partial credit for partial success, so that if an objective agreed upon and funded with a 6-month time horizon is changed after two months, and the objective were 1/3 complete as planned, then the agency would still be evaluated well (6/6=2/2=1.) If a funding mechanism were attached, compensation for the 2 months would be equal to the portion the agency expected to earn in the same time. Please, anonymous or other reader, feel free to ask for more clarification if I haven't answered the question.
2. Do you tend to lean more toward Weber or Durkheim in your analysis of institutions?
Do what now? You may be confusing "opinionated" with "informed." If you read more weblogs about politics and government, the distinction should sharpen nicely. (Shrug)
3. What should anchor decisions about the appropriate level of intrusiveness by public authorities in a self-determined service model?
My answer would be fraud, abuse and illegality should be actively watched for and trigger intervention when identified. Other than that, self-determination should mean what it says. By public authorities, I would include government entities, government entities that assemble boards and start carrying airs of private agencies, and any mandatory reporters in proximity to the self-determined use of state funds. Self-determination is a massive re-balancing of individual sovereignty against professionalism and shouldn't be sought or entered into by any party that doesn't accept that.
I expect self-directed services to be less gratifying to it's sponsors and the professional class of social servants, messier and less predictable. Professionalism has brought a level of order and advanced philosophy to this system which has value and cost attached. Scandals and catastrophes will be more frequent, but less pervasive than in the current system where many feel there is only one scandal and one catastrophe which are inclusive.
Monday, April 11, 2005
Earned Value Analysis, Part II
OK, maybe I can make an early wrap-up of this wonkery. There are many important ways that Earned Value Analysis can be used to measure how work is going, providing, where necessary daily feedback to a client, a service provider, a regional center or the state.
One of these compares Earned Value (EV, the extent to which progress has been made against a goal) to something called Planned Value, the extent to which progress should have been made by the same point. Remember that Earned Value can be broken down into single steps, or even discrete portions of single steps. The ratio produced by dividing Earned Value by Planned Value allows an individual client to measure the success of their program, providing advice to the client or the service provider as to how successful their supports have been to any given point in time. For regional centers and the state, this ratio aggregated provides a comparable measure for external evaluation of a program or vendor. A high individual or aggregated ratio (in comparison) demonstrates that a program has been effective in assisting a client with their purpose.
Another important metric (EAC) compares EV with Actual Costs (AC, it means what it says.) This is a measure of efficiency which provides feedback to the agency as to whether it's service plan is being implemented effectively. This provides a useful metric for a service provider to identify supports which may have problems in effectiveness. Individual support plans which have an unusually low ratio of EV over AC are likely to have problems which have not been identified. For example an employee whose work typically has an unusually low EAC is a good candidate for additional training or discipline. Another example, an individual support which produces an especially low EAC vis-a-vis others in the same program with the same staff would be a good support for review as to whether there are unnoticed factors adversely affecting performance, such as the learning style of the client or environmental factors.
One of these compares Earned Value (EV, the extent to which progress has been made against a goal) to something called Planned Value, the extent to which progress should have been made by the same point. Remember that Earned Value can be broken down into single steps, or even discrete portions of single steps. The ratio produced by dividing Earned Value by Planned Value allows an individual client to measure the success of their program, providing advice to the client or the service provider as to how successful their supports have been to any given point in time. For regional centers and the state, this ratio aggregated provides a comparable measure for external evaluation of a program or vendor. A high individual or aggregated ratio (in comparison) demonstrates that a program has been effective in assisting a client with their purpose.
Another important metric (EAC) compares EV with Actual Costs (AC, it means what it says.) This is a measure of efficiency which provides feedback to the agency as to whether it's service plan is being implemented effectively. This provides a useful metric for a service provider to identify supports which may have problems in effectiveness. Individual support plans which have an unusually low ratio of EV over AC are likely to have problems which have not been identified. For example an employee whose work typically has an unusually low EAC is a good candidate for additional training or discipline. Another example, an individual support which produces an especially low EAC vis-a-vis others in the same program with the same staff would be a good support for review as to whether there are unnoticed factors adversely affecting performance, such as the learning style of the client or environmental factors.
Sunday, March 20, 2005
Earned Value Analysis, Introduction
First, thanks to Dr. Strully for holding me accountable to something I don't get paid for. This post is dedicated to your carping.
In my previous post, lo those many weeks ago, I promised to write later about specific methods of better accounting for value created through our agencies. In this series of posts, I'll introduce an accountability discipline that I believe could be adapted successfully to improve our system. WARNING, this and the next few posts are for major wonks only.
Earned Value Analysis (EVA) is a discipline developed by project managers. In EVA, the value of a goal (deliverable) is agreed upon, a date set for completion, and, often, a standard for quality. When accomplishment of that goal requires that several objectives be met on the way, similar standards are set for each component process, with the sum of the parts equal to the whole budget.
Along the way, other related metrics (which I'll introduce in later posts) can be used to determine whether the methods employed to reach the goal are working so that there is feedback detailing how the plan is going and where the problems, if any, may lie. Between projects (Service Plans,) vigilant recording of how satisfactorily goals were reached leads to both the refinement of methods for predicting value, planning for unpredictability and identifying methods, policies and agencies which are notably (in)effective at helping individuals involved. Furthermore, because the values of projects are agreed to in advance, it offers a more flexible, client-centered alternative to accountability than a system predicated on tallying aggregated client outcomes. In short, EVA can be developed into a learning model of accountability that more effectively employs resources to help people with disabilities live according to their preferences, participate more fully in their communities and remain healthy.
More thorough and boring details will be provided in the next few posts.
And thanks again, Jeff. I needed a kick.
In my previous post, lo those many weeks ago, I promised to write later about specific methods of better accounting for value created through our agencies. In this series of posts, I'll introduce an accountability discipline that I believe could be adapted successfully to improve our system. WARNING, this and the next few posts are for major wonks only.
Earned Value Analysis (EVA) is a discipline developed by project managers. In EVA, the value of a goal (deliverable) is agreed upon, a date set for completion, and, often, a standard for quality. When accomplishment of that goal requires that several objectives be met on the way, similar standards are set for each component process, with the sum of the parts equal to the whole budget.
Along the way, other related metrics (which I'll introduce in later posts) can be used to determine whether the methods employed to reach the goal are working so that there is feedback detailing how the plan is going and where the problems, if any, may lie. Between projects (Service Plans,) vigilant recording of how satisfactorily goals were reached leads to both the refinement of methods for predicting value, planning for unpredictability and identifying methods, policies and agencies which are notably (in)effective at helping individuals involved. Furthermore, because the values of projects are agreed to in advance, it offers a more flexible, client-centered alternative to accountability than a system predicated on tallying aggregated client outcomes. In short, EVA can be developed into a learning model of accountability that more effectively employs resources to help people with disabilities live according to their preferences, participate more fully in their communities and remain healthy.
More thorough and boring details will be provided in the next few posts.
And thanks again, Jeff. I needed a kick.
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