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.

An announcement

Square Girl has generously agreed to write for this site. It's a big upgrade. Square Girl is a provider of Applied Behavioral Analysis to children with autism and a dedicated learner from them. Her blog, Girl Squared offers both the humility and cheerfulness that I simply can't provide you. Her analysis is very humane and compassionate and I can finally look forward to reading this blog myself. As a direct care provider, Square Girl has been recently confronted with how systemic dysfunction further challenges the children and families she supports. I recommend her site for wit and wisdom about her direct care service and look forward to the same regarding her perceptions of California's developmental disability system.

Part II of Choice and Choices will be up about the time I get off my dead butt and write it.

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.

My (advocacy) New Year Resolutions

Resolved, in 2006 I will:

1. Not lift one finger if the only motivation is to save the (present) system;

2. Be open-minded and constructively engaged in any system-reform proposals.

3. Continue to study, implement and support the development of more efficient and client-centered service delivery;

4. Be even crankier than last year except toward clients and ¡Arriba! employees. I want to break the record.

5. Assist CDCAN in the development of it's statewide network.

6. By the end of the year not be an officer of any board or committee, except the Pomona Valleys Foundation.

7. Kick an innocent child. Insult someone important. (By January 31)

About Comments

In order to prevent disruption of the comments on this site by spammers and taggers, I am disallowing anonymous commentary. N.B. This does not require someone to expose their actual identity. If you wish to comment on this site without disclosing who you are, you can establish a free account by registering with blogger. These accounts do not require anymore information than an email account which can be blocked from view in the "Edit my profile" section of your new blogger account. I apologize for any inconvience.

OK, I got a bunch of spam on this very comment so now there is a verifier requirement. I think it may be difficult for people with certain disabilities to use, so if you wish to comment and have trouble, there is an email address connected to my profile and I will be happy to post comments even if I disagree with them. No profanity, though, please.

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.