"The American people deserve a government that treats them like customers. Government must be accessible to those it serves and to those who pay its bills.
It must be responsive to [their] concerns.
It must be run efficiently and well with respect for the tax dollars on which it depends.
It must pay its way and live within its means."
-President Bill Clinton, 1995
Americans Expect Quality Services
All Americans rely on services provided by the government-services like mail, social security, public health and safety, medical research, and
transportation. As citizens, we expect good services. As taxpayers, we expect good value. We want our government to work better and cost less.
Government services are working to do just that.
The National Performance Review is the federal government's "reinvention" project, designed to make government work better and cost less. Beginning in 1993, the National Performance Review asked Americans what we expect from government services. Citizens across the country said:
- "Ask us what we want."
- "Don't tell us, 'That's not my department.'"
- "Treat us with courtesy, respect, and enthusiasm."
- "Make it easy."
- "Provide reliable, timely help."
Do the services and supports you provide meet your consumers' expectations? Are they quality services? This booklet introduces some ideas and resources you can use to begin to ensure that they do.
What is Quality?
The "quality revolution" happens when organizations ask their consumers what they want and need-and whether they're satisfied with how their
services are delivered. Agencies use the following basic steps to improve quality and results:
- Understand what consumers want, need, and expect.
- Create service standards that promise how services will be delivered.
- Collect feedback and complaints about services from consumers.
- Use feedback and data to make continuous improvements in service delivery.
- Use benchmarking: Learn to improve processes by comparing them to the best they can find in human services, or in a completely different
Quality management-often called "managing for results"-requires focus, commitment, and work throughout an organization. To get beyond the old
habits of working toward "minimum acceptable" compliance standards, organizations must pay attention to:
- strategic planning
- data, information and analysis
- human resource development
- customer and market focus
- process management
- key performance results
Organizations manage for results to ensure that they accomplish what they were designed to accomplish - because organizations that achieve their
intended results are sustainable. Results can be managed so that the provider is accountable to consumers, families, and funding entities.
Private human service providers, government agencies, and competitive businesses all use the same basic approach to managing for results.
Quality Supports Meet Individual Needs
Almost always, the government support needed by a person with a developmental disability is due only in part to the disability. Individual
needs and wants also depend on personal circumstances such as:
- skills, strengths, personal values, likes, and dislikes
- accessibility and adaptability of home, neighborhood, school, job, recreation and transportation
- availability of "natural" supports-from friends, family, and community sources
- family structure, social networks and relationships, and cultural background
- personal, family, and community resources
Cost is not a good measurement of quality. Costly services are not necessarily quality services. Quality improvements don't necessarily
require more funding. Meeting individual needs-providing just what people need and want-can make services more efficient and effective. In fact,
studies indicate services and supports cost less when they are flexible-when people with developmental disabilities and their families are
empowered to choose and control their own supports.
No matter where people live or where they get their supports, and no matter how long they have used services, Americans who have developmental
disabilities should have an equal right to quality services and supports-including clear, relevant service standards, and reliable, timely help. Merely delivering services in the community doesn't make them quality services. Community services are quality services when they are flexible, reliable, and complete enough to meet an individual's needs. Quality community services will make it possible for Americans with developmental
- to be safe and free from abuse or neglect
- to choose how to spend their free time, and with whom
- to be connected to people who care about them-friends, family, and neighbors
- to access decent health care, including dental care
This means that people may choose many different living situations and many different combinations of services and supports.
The systems we have now were not set up to deliver a broad range of individually-designed services-even if providers are committed to doing so.
There are new management tools and information technology that make individual quality achievable.
Changing the System
Old "standards" defined minimum acceptable services. They were supposed to be the same for everybody. Old service "standards" focused on inputs: how many square feet, how many electrical outlets, etc.
New service standards help ensure that everybody understands how community services and supports are supposed to work. New service standards help organizations focus on delivering services that are "beyond compliance." Instead of focusing on inputs, they are focusing on results or outcomes
that are meaningful to the people who use the supports. New service standards don't come from the federal government- they come from each
organization's interactions with its customers. It takes time to put them together. Right now, systems across the country are working to:
- Clarify principles of self-determination for individuals.
- Identify and publish service standards.
- Support individual choice.
- Listen to what people with developmental disabilities and their
families say they want.
- Be flexible enough to give people what they need when they need it.
- Develop data and information management tools to support this
- Work to integrate all parts of the system.
Quality is not easy. The "system" must have integrated services -from Medicaid and Social Security, to public education, vocational rehabilitation, housing, transportation, and aging. And, the "system" must be integrated through all levels of government-from Congress and federal agencies, to state legislatures and state agencies, counties or regional boards, communities and local providers. Specific examples of a wide range of quality projects include the following:
- The Oregon Developmental Disabilities Council published "A Foundation
for Quality Assurance of Community Services" in 1997. This booklet lays out
principles for an evolving system of quality assurance and foresees getting
all parts of the system to work together. It integrates programs that serve
people with developmental disabilities with Oregon's statewide "Benchmarks"
- The Council on Quality and Leadership in Supports for People with
Developmental Disabilities publishes numerous guides on outcome-based
performance measures, including new measures published in the Fall of 1997.
The booklets explain outcome measures that focus on whether a person's
services and supports are achieving what the person and their family
want-from early intervention to residential services. The Council's
publications explain how to listen better to people who have developmental
- The Monadnock Self-Determination Project in New Hampshire reported data
on the outcomes achieved when family and friends help a person manage their
own support budget. In the project, the money is turned over to the team.
Initial data show that almost all outcomes are much better-and none are
worse-and costs are 12-15 percent lower than when the government managed
- The Robert Wood Johnson Foundation's Self-Determination Initiative
published "An Affirmation of Community: A Revolution of Vision and Goals."
It clarifies the new goals of community supports, and lays out principles
for systemic action.
- The Human Services Research Institute is working with the National
Association of State Directors of Developmental Disabilities Services to
track and evaluate the development of state quality assurance systems
across the country. These studies will provide benchmarks to improve
- Many states will share the monitoring reports and program evaluations
completed by independent and university consultants. These reports explain
innovative methods used to convey the philosophy of individual supports to
providers and recipients. They also include descriptions of practical
problems being encountered in particular states.
- Performance contracting is beginning to provide data on what is working
and how well it is working in states as well as incentives to improve
- Minnesota's Developmental Disabilites Council published "Minnesotans
Speak Out," a collection of focus group findings concerning perceptions of
- Missouri's Developmental Disabilities Council is compiling a "report
card" containing data on customer evaluations of services and providers.
- Across the country, person-centered planning is helping service systems
recognize the highly individual needs of people with developmental
disabilities, and it is helping people and their families recognize their
own strengths and choices.
Helping Systems Listen to Consumers
These new tools and approaches are useful, and system integration is important. But the real work of a quality organization is much simpler:
Listen to your consumers and families.
Some parts of the system are working to improve how they listen to the individual people who use their services. For example, in early 1997 the Administration on Developmental Disabilities sponsored Family Forums in Florida, Tennessee, and Washington state to listen to parents and family members of people who have developmental disabilities. It was not an easy process. Family members often came to the meetings deeply divided by their histories and beliefs that people get better supports either in institutions or in the community. During the Forums, family members listened to each other and discovered they had a lot of common concerns-no matter where the person they love lived-and they were tired of fighting with each other over issues they could not resolve. Families decided to agree where they could agree, and try to move forward from there. Instead of arguing, people who had seen themselves as "enemies" found themselves ready to work together and respect each other's opinions so that:
- Each person's needs would be met.
- Systems would demonstrate equity.
- Family input would be included in an individual's decision-making process.
- Systems would be driven by the needs and wants of the individuals and families who use the services and supports.
- Litigation would be avoided as much as possible by strengthening alternative dispute resolution approaches such as mediation.
- Consumers and government agencies would both work with providers to help solve problems before they became crises.
Participants made it clear that they had not seen any service standards for community services yet, but that they expected them soon-and not just
Medicaid standards of what should be available, but provider standards describing how services would be delivered. For example, how many hours or days will it take to return a phone call, or to get an answer to a question, or to get a dental appointment.
The Family Forums were a successful way to listen to consumers. State developmental disabilities councils or state departments of human services for people with developmental disabilities might sponsor similar efforts to improve the information and data-gathering processes. In addition "stakeholder" organizations like People First, Self Advocates Becoming Empowered, The Arc/US, United Cerebral Palsy Association, Parent Training and Information Centers, the Voice of the Retarded, family-to-family groups, and family support councils are likely to be interested in helping providers improve the quality of community services.
In addition, individual leaders such as Partners in Policymaking graduates are likely to want to help. To improve your listening skills, consider
- one-to-one meetings between providers and consumers-get to know people (Don't forget to make participation possible by
providing transportation and childcare if possible.)
- focus groups (always have these and other meetings in accessible locations)
- consumer surveys: mail, phone, or interview (make sure they are accessible)
- suggestion boxes and feedback forms
- easy-to-read newsletter articles, or forms asking for consumer input
- consumer Advisory Councils that have necessary supports and access to consumer satisfaction data
- "report cards" of how consumers rate programs
- a written and publicized grievance procedure which provides high-level organizational responsibility for consumer complaints
- toll-free numbers for complaints and suggestions
- supports to help people with developmental disabilities give feedback
- performance evaluations of staff based on how well they get input from consumers-even if the feedback is negative
Your consumers may need supports in order to provide the input you seek. Below are examples of supports consumers might request:
- focus groups
- phone or mail surveys
- consumer or family training for staff about their needs and wants
- consumer advisory, support, or advocacy groups
- letters from consumers and families to keep you aware of their needs an ongoing basis
- phone calls or meetings with consumers and their families
- quality improvement projects in your state, region, county or provider association
- a grievance procedure where consumers can register dissatisfaction with the quality of a service you provide
Another resource that's available in most states is a state quality council, which provides low-cost advice and support to a broad range of organizations-including governmental agencies. Any business librarian will be able to help you find your state's council. Many books have been published on reinventing government and the National Performance Review. Check one of the web sites on the Results Act, Managing for Results, or the National Performance Review. These are linked through the National Performance Review site at www.npr.gov.
Putting It All Together
Part of the problem of getting quality services in the community has always been that people with developmental disabilities and their families must
use different systems to get services and supports. Generally, people with developmental disabilities and their families have to figure out how to coordinate the services they need. Usually, it is very difficult. Sometimes, it is impossible.
The responsibility for system integration should belong to the system, not the consumers. In order to deliver quality community services, community providers, county or regional offices, state agencies, and federal agencies need to work together as partners. Blaming each other's rules or performance for failing to deliver or coordinate services accomplishes nothing for people with developmental disabilities or their families. All parties need to find ways to cooperate. They need to find ways to change regulations and red tape that get in the way. You will find many partners eager to help you be a part of the common-sense quality revolution that is
changing the face of government services.
Developmental Disabilities Act Programs
The Developmental Disabilities Act was implemented more than 25 years ago to ensure that the civil and human rights of Americans with developmental disabilities would be protected, and that they and their families would have access to, and be involved in the design of appropriate services.
The Developmental Disabilities Act authorizes three programs in every state: a Developmental Disabilities Council, a University Affiliated Program, and a Protection and Advocacy Agency.
Those programs do not provide or fund statewide services to people with developmental disabilities, but they check on whether those services are meeting people's needs. They are probably good sources of information in your state.
All three programs look for ways to build proactive partnerships with people with developmental disabilities, their families and communities, and with the providers who serve them.
If you would like to work with families, advocates, policymakers, funders, regulators, self-advocates, and other people with disabilities to improve service quality, you may wish to call one of the Developmental Disabilities Act programs in your state. These national organizations can direct you to them:
Administration on Developmental Disabilities (ADD), in the Administration on Children and Families, U.S. Department of Health and Human Services:
(202) 690-6590 (voice)
Web site: http://www.acf.dhhs.gov
American Association of University Affiliated Programs (AAUAP):
(301) 588-8252 (voice)
(301) 588-3319 (TDD)
Web site: http://www.AAUAP.org
Consortium for Developmental Disabilities Councils (CDDC):
Web site: http://www.cddc.com
National Association of Developmental Disabilities Councils (NADDC):
Web site: http://www.igc.apc.org/NADDC
National Association of Protection and Advocacy Systems (NAPAS):
(202) 408-9514 (voice)
(202) 408-9521 (TDD)
Web site: http://www.protectionandadvocacy.com
Do You Provide Quality Services?
Check if your organization is consistently collecting data and making improvements in areas that are important to consumers, such as:
_____ 1) Do consumers think they are treated with courtesy, respect, and enthusiasm?
_____ 2) Do consumers say they are asked what they want?
_____ 3) Do consumers feel your services are reliable?
_____ 4) Do you measure how well your organization performs against benchmarks for timeliness and reliability?
_____ 5) Do you regularly ask consumers whether their supports are working for them?
_____ 6) Do you track how consumers' needs are changing?
_____ 7) Do you measure whether consumers think information is easy to understand?
_____ 8) Are staff members trained and empowered to make processes easy for your consumers?
_____ 9) Are staff members cross-trained and empowered to solve emerging problems in other "departments?"_____ 10) Do consumers say you have an easy-to-use complaint system?
_____ 11) Do you help potential consumers find out whether they are eligible for services?
_____ 12) Do consumers say it's easy to change their services or providers?
_____ 13) Do consumers feel they have input into how they get their services?
_____ 14) Can consumers turn down services they don't value?
_____ 15) Do you publish your own service standards (beyond legal compliance requirements)?
_____ 16) Do you provide performance data to help consumers compare services?
_____ 17) Do you use alternative dispute resolution- such as mediation-instead of litigation?
_____ 18) Do you publish who consumers and families should call if they suspect abuse or neglect?
_____ 19) Do you share responsibility with partners-i.e., other organizations in the system-to effect system change?
_____ 20) Do you measure key performance results?
"Yes" answers to these general questions indicate your organization is committed to improving quality. The number of "yes" answers to questions like these should increase over time as your quality focus improves.
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