Designing A Comprehensive Quality Assurance System
for California's Developmental Services:
A Background Paper
What We Were Asked to Do. Through a contract with the
Department of Developmental Services, we were asked to:
Develop a way to look at the outcomes of services used
by people with developmental disabilities and their
families in California;
Figure out a way to fit it into the developmental
service system; and,
To go out and try it out.
What We've Been Doing So Far. Since July, 1993, we've been
busy doing a lot of the background work needed for this
project. During that time, we have:
Asked other states if they look at services for their
quality and if so, how they do it (Potential Conflicts
of Interest in State Department of Developmental
Services' Quality Assurance Efforts: A Survey Summary);
Looked at how different state and federal agencies look
at developmental services in California (A Summary of
Selected Quality Assurance Regulations, Legislation,
and Activities in the California Developmental Services
System Part One: Overview and Part Two: Analysis By
Asked people how they could tell a quality service and
what quality means to them (Looking At Quality
Services: A Survey Summary);
Developed a paper (not a contract requirement) on all
of the ideas we've read about
Services for Californians with Developmental
Disabilities: Some Thoughts);
Met with the Quality Assurance Advisory Group to hear
the thoughts of people with developmental disabilities,
families, advocates, regional centers, area boards,
service providers and other professionals and to bring
their ideas into this work.
What We Think We've Learned. From the work above, we have
Assuring quality services means doing a lot of things
(e.g., technical assistance, education and information
It means looking at some basic things like health and
safety and it also means looking at life quality and
asking people about their quality of life;
Looking at services means looking at the outcomes of
those services for people who use them;
Important outcomes seem to be things like community
participation, friendships, and service satisfaction;
The best way to find out about these outcomes is to ask
people who receive services, observe if you can't ask,
or talk to families and friends if you can't ask or
The best way to make sure that we have quality services
is to get all of the service users involved;
A lack of resources (e.g., time, training, money,
staff) are the big barriers to looking at valued
From our analysis of regulations, standards and activities
we have also learned that:
Quality assurance at this time in California means
looking mostly at things like health and safety. About
79% of all of the standards and regulations we reviewed
are focused on inputs and processes (e.g., health and
safety, staff, individual program planning and rights);
While valued outcomes (e.g., relationships, community
participation, service satisfaction) have been infused
into the Lanterman Act, they have not made their way
Service monitoring is heavily focused on living
arrangements, whether congregate care, group homes or
Federal regulations (and state regulations influenced
by them) are the most wanting in terms of looking at
valued outcomes; and,
There is at best an insignificant focus on quality
enhancement or improving service quality.
Considerations. There have been many elements to consider
in developing a design of a comprehensive system. We have
been sensitive to balancing the requirements of our contract
with what we have learned, recent changes in the Lanterman
Act brought about by Senate Bill 1383 and the terms of the
Coffelt agreement. Those elements have led us to understand
that this system must:
Focus on the individual;
Look at valued outcomes;
Include persons served, families, and community
Rely on a variety of activities;
Facilitate collaboration; and
Emphasize service enhancement as well as sanctions.
The quality assurance that we outlined stresses:
Accountability and Choice. Measures of
self-determination, choice and service satisfaction will
provide the key to looking at successful outcomes for
people with developmental disabilities.
Local Control and State Direction. A locally determined
quality service plan will provide a focus on differing
Does it Make the Grade? That's for others to decide, but we
believe that it:
Implements the 'common threads' of the Coffelt
settlement and Senate Bill 1383 by focusing on the
individual, valued outcomes, the person-centered
planning process, sharing the power through local
control and collaboration;
Incorporates what we've learned from others about using
a variety of activities, asking the individual,
focusing on service enhancement and including persons
served, families, and community members;
Relies on the checks and balances already built into
the Lanterman Act;
Fits into the current developmental services system,
but is based on the future with room to grow; and, most
Meets the best practice criteria quality assurance is
A Context of Change
Changes in Federal Law. The passage of the Americans with
Disabilities Act, revisions to the Individuals with
Disabilities Act and the reauthorization of the
Rehabilitation Act signal a changing federal landscape.
These laws of the land now contain language which mandates
that people with disabilities and their families play a
major role in determining their own service needs.
A Change in State Law. Senate Bill 1383 has created
significant changes in the Lanterman Developmental
Disabilities Services Act. Changes which will move the
developmental system in California towards an individualized
support service model based on choice, community
participation and self-determination.
A Court Mandate. The recent Coffelt settlement provides a
blueprint for implementing these legislative changes. The
two major components of this court directed blueprint are:
1) a major restructuring of the individual program planning
process; and 2) the development of a quality assurance
system which focuses on outcomes for people served. While
outside the scope of this contract, changes in the
individual planning process will dramatically affect the
quality assurance system.
Changing the Way We Plan Services
Based on Excerpts from Supporting People with Severe
Reputations in the Community by Michael Smull and Susan
Burke Harrison (Baltimore, Maryland, 1992).
Starting With The Individual - Listening To The Individual.
Most human service systems develop programs and put people
into them. [Senate Bill 1383 requires] a system that starts
with individuals and builds services around them. [To do
this] people need to be provided with settings where their
essential lifestyle choices are met. If this can be done,
the lives of people with disabilities will improve
dramatically and the problems of the service system will be
significantly reduced. People who are getting what they are
"asking for" clearly have a better quality of life then
those who do not.
Shifting Our Investments. The process of supporting people
in lifestyles of their own choosing requires that we shift
our "investments" in service development. We typically spend
relatively little time in individual planning and more time
in locating or developing a program. This [shift] requires that we spend more time in planning. It
will also require extra time in helping providers develop
services around individuals and in developing a flexible
array of supports.
[Person Centered]. The first part of this process focuses
on the individual. Any planning that begins with the
individual rather than the program is referred to as "person
centered planning". [This method of] planning helps people
discover their choices and then helps them to have those
choices honored. There is no bias for or against a type of
service or a predetermination of the number of people who
should live together. It is focused on individuals and what
Honoring Choice. In the current system of service, complete
control over all essential choices is in the hands of the
professionals. The outcome of this planning process is to
rebalance the locus of control. The service system must
continue to assure reasonable protection of the individual
[when needed], while supporting substantial freedom. People
who cannot articulate where they would wish to live or who
they wish to live with can tell us of their preferences
through their behavior. Those who tell us what they think we
want to hear can learn to put forward their own wishes. We
will need to assist these individuals to discover what their
informed choices are. They will need encouragement and
careful exposure to relevant life experiences. We have found
that as people gain power over their lives, they often need
less control or protection.
Neither the process nor the outcome eliminates the need for
skilled professionals. People will still need support for
their behavioral, psychiatric, and medical needs. People
will still want to learn new skills and will need good
teachers. We are not discarding all of our professional
skills, we are simply putting them in their proper position.
Our skills should be used to help people in achieving the
lifestyles of their own choosing. They should not determine
The greatest challenge in supporting people with
disabilities is finding the balance for each individual. A
Freedom of choice and the safety and health of the
Personal liberty and the expectations of society to
conform to social norms, and
Encouraging individuals while avoiding coercion.
Because the balance achieved needs to take into account the
circumstances, the core values, and the complexities of each
individual, [like an individual program plan] it is
different for each individual.
Changing the Way We Look At Services
Excerpts from a speech on the Coffelt Decision and
Quality Assurance presented by Bill Allen to the Area IV
Board on Developmental Disabilities, January, 1994.
Our Current Service System. For better or for worse, for
richer or for poorer, we have developed over the last 25
years, a managed care system of services for people with
developmental disabilities and their families in California.
A system that seeks to provide clean, safe, healthy and
stimulating living, education and working places for people
24 hours a day. A system which does not, however, provide a
lot of choice or option for people who must use it.
A Brief History of Quality Assurance. Now, if you want to
improve those places you can always establish some standards
and write some procedures, go out and look at those places,
ask some questions and then (depending on what you find out)
request or demand some changes which will probably make them
cleaner, safer, more healthy and stimulating. This, in the
broadest possible sense, is what we've referred to as
Thirty years ago, if we asked questions at all they might
have been Do people have a place to live? Do people have
three meals a day? Twenty years ago, those questions became
a little more refined like Do people get bathed on a
frequent enough basis to avoid unhealthy skin conditions?
Ten years ago, those questions got even more specific around
something we started calling active treatment like Are
people assessed by a standardized functional assessment?
Are treatment plans based on those assessments?
So, over time, we're getting better at asking questions and
we've probably made things a little better for people using
those services each time. Now, we're all quite excited
about a new set of questions. These are questions like Do
you have enough friends? Do you get to see them enough?
Did you get to choose which clean, safe, healthy environment
you want to live in and with whom?
Some New Questions. These 'new' questions will certainly
help move things along. In fact, these questions have
already been developed or are being developed and can be
readily adapted or adopted. However, changing the questions
doesn't change much of anything at all unless all you want
is a better managed care system. It will help us look more
at how services affect individuals, that can only be good.
It may provide greater choices within the service system as
we know it and that sounds good! However, it will likely do
It will not transform a system of managed care into a system
of individualized supports. It will not lead to a full
implementation of the revised Lanterman Act or the Coffelt
lawsuit. It will not make cars into airplanes. That's not
bad, that's not good- it just is!
Something Different. If we intend to create a system of
individualized supports, we will need to do something
different about the way we look at those support services.
On an individual level, we'll need to spend time with people
and their friends and family to figure out what makes a good
life for someone, what do good quality services mean to that
individual and how will we know when we see it. At the
service agency level, providers will need to collaborate
with everyone they serve (people with developmental
disabilities, families, referral and funding sources) to
figure out whether or not people are satisfied with their
services and how they provide them. Finally, if people in a
given regional center area want to enhance their local
service system, they will need to collaborate on finding
answers to questions like What's the best way to find out
what kinds of services we need? and How will we know when
those services are good?
Achieving A Balance in the
Design of a Quality Assurance System
The ideal quality assurance system would , as suggested
above, reinforce the development of individualized supports
and discourage managed care approaches to service delivery.
However, the realities of political and economic forces will
likely dictate balances:
Accountability and Choice. Measures of
self-determination and choice will provide the key to
looking at successful outcomes for people with
developmental disabilities. However, funding sources
(whether local, state or federal) typically require
more traditional methods of accountability when
purchasing or brokering services with public moneys.
Local Control and State Direction. The regional center
system was developed to ensure the development of
services which reflect the needs of local communities.
Recent changes in the Lanterman Act reiterate the
importance of local control through outreach efforts,
generic resource development and performance contracts.
However, it also encourages the responsibility of the
Department of Developmental Services to provide
leadership for these 21 local constituencies through
policy, training and technical assistance.
Critical Elements of a
Policy Direction from the Department of Developmental
Services (DDS) and the State Council on Developmental
Disabilities (SCDD). It's critical that these state
agencies act in unison to provide leadership in the
implementation of a comprehensive, statewide system. As it
has with performance contracts, the Department (in
conjunction with the Council) should direct a collaborative
effort between Regional Centers and Area Boards in the
development of a local Quality Service Plan. In fact, this
plan should be incorporated into the contract.
Quality Service Plans. In order to adhere to the mandates
of Senate Bill 1383, local plans should include the
Documentation of how the plan was developed through
community involvement and public meetings.
Methods for including people with developmental
disabilities, their families, advocates, services
providers and community members in all quality
Goals and objectives for enhancing local service
A commitment to collecting information on valued
outcomes for use by the Department and Council in an
annual statewide report.
An annual report of activities and progress on
service quality goals and objectives.
Development of a Life Quality Review. The Department should
add information elements to the Client Development and
Evaluation report (CDER) regarding life quality (e.g.,
friendships, community life, health). In addition to a set
of commonly asked questions, there must be an opportunity
for adding individualized questions as well. None of these
questions should be considered a part of the CDER assessment
and they should not be linked to service rates. The
procedures for completing this component of the CDER should
be flexible enough to include persons (or families when
appropriate) completing their own reviews. This review will
need to meet the test of the courts as a central element of
the Coffelt settlement. It will also create a statewide
database which can be used in a general way to drive
resource development, training and technical assistance.
Individual Program Planning. Senate Bill 1383 revisions to
the Lanterman Act as well as the Coffelt settlement requires
that service planning be completed in a way that will
encourage choice, self-determination, and community
membership. The IPP document must also include an
individualized quality assurance plan. That is, in
collaboration with the person, family and others, a way to
determine whether the plan has been successful through
agreed upon outcomes.
Self and Parent Peer Advocacy. While current performance
contracts include a major goal area of Self Determination
Supports, they should be amended to include more specific
language regarding the development of and access to
self-advocacy and parent peer support groups.
Revisions to Title XVII. Choice and self-determination in
planning for services and selecting service options are not
currently supported in Title XVII. A major realignment of
these regulations must be completed . In regards to
shifting the focus of service quality from the state to
local agencies, Title XVII should be amended to include
service quality in the program evaluation component of
required program descriptions. In addition, these
regulation should require regional centers to develop
performance contracts with all vendored services which
stipulate incentives for service quality as well as criteria
Revisions to Title XXII. As with Title XVII, a major
realignment of these regulations must be also be completed
in order to reflect changing service values. Title XXII
should continue to provide a method of sanctioning licensed
services when necessary.
State Level Coordination. An interagency coordinating
committee of major licensing entities (Departments of
Developmental, Social and Health Services) should be
convened for the purpose of reviewing and eliminating
regulations which conflict with changes in the Lanterman
GO BACK TO THE ASA MAIN MENU.