Excerpts from

Quality Assurance
as a Tool for Change

Bradley, V.J. and Kimmich, M. (1994). Quality Assurance as a Tool for Change in Creating Individual Supports for People with Developmental Disabilities. Baltimore, MD: Brookes Publishing.

Realigning Quality Assurance Outcomes

Quality assurance in the deinstitutionalization phase of service development not only focused on numerical measures of client progress but also emphasized the need for professional assessments of quality, including peer review and accreditation. This notion of professionally defined outcomes comes into direct conflict with a basic premise of the new supports paradigm, that is, that people with disabilities and their families should be participants in decisions about their futures and about the supports that will be required to realize their futures. In bringing quality assurance into line with these emerging participatory values, customer satisfaction should be a key ingredient in any comprehensive monitoring approach.

Learning and Enhancement

A further change in quality assurance that will foster the supports paradigm is the rejection of top-down, centralized, and heavily controlled monitoring and enforcement mechanisms. If it is assumed that the supports paradigm requires a creative and individualized approach to each person's possibilities, then such a system is best served by an open process of assessment in which learning and sharing information are priorities (Taylor, Bogdan, & Racino, 1991). In this environment, the application of uniform standards and punitive sanctions can only constrain the development of the collaborative relationships necessary to mobilize supports and to empower and support front-line staff. As noted by Holburn (1992):

The natural reciprocity inherent in effective managing and teaching has been replaced by routine rule-based deficiency evaluations with ensuing corrective action to ameliorate the rule violations.... Despite our complex process of assessment, team meetings, plan development, monitoring and program documentation, very little new learning takes place.

To retrieve this reciprocity and learning, the oversight process should be restructured to provide constructive feedback that enhances performance.

Renewed Interest In the Role of Staff

A legitimate area of examination that has been missing in most quality assurance systems has been the critical role that staff can play in facilitating the person's participation in his or her social, community, and/or work environment. When the aim of services was to teach and train, the skills required by staff could be more easily delineated. The role of facilitator and guide (as well as teacher in some instances) requires a different set of skills and sensitivities. A unitary focus on outcomes will provide a needed attention to the effectiveness of interventions but will not illuminate the variables in the interactions between staff and individual that contribute to or detract from such outcomes. If quality assurance is to serve an enhancement function, such an up close examination of what works and what does not work will be crucial to the dissemination of best practices.

Five Aspects of the New Quality Assurance

The traditional assumptions underlying current rule-bound quality assurance systems-the anti-institutional framework, reliance on professional judgments of client progress, centralized monitoring and enforcement, and strictly defined staff skills-need to be transformed to create systems that will nurture and support the view of quality as individualized, dynamic, and process-sensitive. A new foundation is needed for quality assurance activities, one that translates the reformulated assumptions into operational guidelines. Following are the five aspects of this new foundation: 1. The underlying philosophy of quality assurance must embrace enhancement as a complement to quality control elements.

2. The focus of quality assurance must move beyond process and input concerns to outcomes for individuals.

3. The role of the consumer and family must be central in the design, implementation, and ongoing maintenance of quality.

4. The vision of quality must be revisited at regular intervals rather than remaining static.

5. Quality assurance monitors should be given the discretion to respond to organizations and staff in a supportive and teaching role rather than a policing role.

Community Resource Teams

A rural model for the empowerment of communities

Blake, E.M., Prouty, R.W., & Lakin, K.C. (1995) Reinventing Quality. University of Minnesota: Institute on Community Integration.

The formulation of Community Resource Teams (CRTs) meaningfully involves consumers, parents, and advocates in designing, implementing, and assuring quality of supports. These teams act as community hubs to produce community owned supports responsive to unique rural needs.

CRTs grew out of a group of parents from the rural town of Dillingham, with the desires to get services in their community. Formerly, those with disabilities had go to metropolitan areas to receive services.
Concerned people such as parents, teachers and Alaskan Native leaders now compose CRTs. These teams act as advisory councils to Hope Cottages, Inc., a nonprofit private provider of services to people with developmental disabilities. They also solicit local support, act as connections to their communities and advocates, address problems, and provide for networking and informal education about the service system. CRTs are instrumental in accessing state funding for respite care, case management, and family support.

Robin Ynacay-Nye, Director, Supported Family Living Services for Hope Cottages, says it is important for those working with such teams to remember that team members must be taken seriously and need tangible, results-oriented projects in order to stay focused.

New Hampshire Self Determination Project

Blake, E.M., Prouty, R.W., & Lakin, K.C. (1995) Reinventing Quality. University of Minnesota: Institute on Community Integration.

The New Hampshire Self Determination Project is a three-year demonstration project with the goals of (1) increasing the quality of life for consumers participating in the project and (2) decreasing per capita spending for services. Through the project, personal networks are to replace professionally dominated service teams in assisting consumers. The role of the case manager will be transformed to a personal agent who serves as a catalyst to help the consumer realize and define a positive future. The project has three major parts: (1) each consumer will be given the opportunity to control planning for their needs with the assistance only of those people they choose; (2) each consumer will be given a budget of Medicaid and state money, which
they may spend on residential, employment, and personal needs as they, and those persons they choose to assist them, determine; and (3) services for the consumer will be purchased through a variety of brokering methods, and each consumer will be free to purchase any services through separate contracts. A premise of the project is that linking self-determination with individual consumer budgets will result in lower costs and more satisfactory outcomes for consumers. Early data suggest some per capita savings and enhanced quality of life for consumers.