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been replaced by routine rule-based deficiency evaluations with ensuing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:
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.
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