Quality is performance consequences equal to preferred expectations; all else is rhetoric. But what is the preferred expectation, and who’s expectations should we meet?
“The right act can readily be known once the greatest good has been determined, for it becomes simply that act which enhances the realization of the greatest good, and the immoral act is that mode of behavior which is a deterrent to its realization” [Sahakian & Sahakian, 1993].
Unfortunately, in human services we have many opinions about what the greatest good is, yet we rarely discuss our differences. We employ staff based on the credentials they hold, who may or may not believe that “what’s best for kids” is the same as ours. We have not defined the outcome, except in terse measurable terms that have no relation to out greatest good.
Outcomes for disruptive behavior are clearly measurable – school behavior incidents, detention, suspension and expulsion are up/down 20% over the past three years. For some managers, the goal of reducing disruptive behavior is accomplished through fear, drugs, or incarceration. When closely examined, we may find that those who refuse to comply are no longer in the school because they have been “referred” to a mental health agency that has placed them in a psychiatric hospital, partial hospital or residential program. Or those that “respond favorably to medication” [e.g., meet the ‘dead man’ test – which means the more they act like a dead man, the better they are] are in school and no longer act out. Is this what is “best for kids”?
While it is nice that we have begun to realize that we cannot simply collect custodial data which tracks process and not outcome; outcome data is useless unless we have a clear understand of our mission, purpose, greatest good or summon bonum. Not only does such a discussion help to assure that the greatest good is defined, but it provides a basis for understanding the limitations or constraints upon the process in reaching the outcome. Ending “unemployment” is easy if slavery is acceptable. But is full employment really the goal; or more accurately, is full employment the only dimension of the goal?
Performance management therefore cannot avoid a discussion and consensus on life’s greatest good. ‘What’s good for kids’ must be defined in detail if we are to in fact provide it. Further, ‘what’s good for kid’s’ must be demonstrated and in order to do this, we must discuss how we will know when we have gotten there. Is ‘what’s good for kids’ simply that they be safe, well fed, clothed and housed appropriately? Or is ‘what’s good for kids’ something more?
As we begin to examine this in detail, we may find that ‘what’s good for some kids, is not good for all kids’. We may find that individual self-determination is more important than a broad standard. We may decide that the overall determination is that ‘what’s good for kids’ is that their families have the support and power to determine their own lives.
Whatever we decide, we become aware through a process of collective thinking that “what’s good for kids” is not an easily answered question and that many reasonable people have arrived at different conclusions. The perspective of the individual making the determination is a more powerful influence for ‘what’s good for kids’, then any demonstrable results. Yet most human service managers are perfectly willing to allow reasonable, “good” people to provide services without any real understanding of what they believe is ‘good for kids’.
Kids, need love, structure, discipline, etc., etc. Just what does this mean? Is discipline a noun or a verb? Are we going to discipline kids or teach them discipline? Performance management requires not just the measurement of outcome, but the measurement of outcome against a coherent and consistent standard. And the standard is not a benchmark! Benchmark is a term often used by business to determine the goal of the process. In this sense, a benchmark for human services can only be a ‘perfect’ human being – whatever that means. In a zero defect approach to quality, one seeks to provide services to human beings which will enable them to be perfect. To do any less, is to accept mediocrity. This does not mean that one must provide services until the person with problems in living becomes perfect; rather, that we provide services with the intention and expectation that the person with problems in living will become perfect.
This is the requirement of high positive expectation. If we expect only that the person with problems in living stop the behaviors that are giving them difficulty, that is the most that you will attain; and there is severe question that it is attainable without a higher expectation. Just as “your reach should exceed your grasp”, the expectation must exceed the outcome. Human beings are goal-seeking entities whose goals expand with each attainment. Hope is a pivotal requirement. It has been suggested that hope is etymologically related to hop, and that it started from the notion of ‘jumping to safety’ – one hope’s that they are not “jumping from the frying pan into the fire. One might suggest that you cannot even make a dangerous jump without at least the hope of survival.
Hope, therefore is a substantial motivator in the decision to attempt any new or ‘dangerous’ act. If human service workers are not able to provide hope through their own self-fulfilling beliefs that the person with problems in living is capable of becoming; then what hope can exist.
Thus, the human service manager must not only assure that a summon bonum is defined and articulated, but that it is believed by the people who are providing the help. There are two ways for a performance manager to find out: 1) ask and 2) measure. If you ask staff on a regular basis to comment on their approaches or progress, they will answer in terms that certainly will allow for deduction of attitude demarcates belief. Staff who talk about clients as though they were commodities are less likely to have clients who meet outcome expectations. Any number of clues will surface [s/he can’t, its too much to expect, s/he’s difficult, I can’t control him, etc.] From these clues decisions can be made about the need for remedial responses.
We would expect that those who don’t believe in the people they serve will attain fewer positive outcomes; but we may be wrong. Performance management is based on learning. All human services are based on a thesis, which should be followed by an antithesis, which should lead to a synthesis, which is then contested. Only as we respond to data can we learn.
Eight key questions have been developed in regard to outcome management. The first seven by Reginald Carter and the eighth by Positive OutcomesTM. They are reported as follows as written in the Positive Outcomes TM Training Manual:
- How many clients are you serving?
When does a client become a client? Duplicated or unduplicated count?
- Who are they?
Basic demographics such as age, sex, income, disability level, race and ethnicity.
- What services do you give them?
Services are intervention strategies. There can be multiple services. Need to determine which client received which service resulting in an outcome.
- What does it cost?
This varies. It could be your budget, your program cost, need to sort out hidden administrative costs. Most costs are for personnel.
- What does it cost per service delivered?
This is the best measure of efficiency. Divide the total cost by the number of services delivered. This measures services delivered whether or not the intervention is a success.
- What happens to the client as a result of the service?
This is the expected client outcome. Also the most difficult and important dimension of management.
- What does it cost per outcome?
This is the bottom line and measures the program effectiveness. The cost of a successful outcome. Divide the cost by the number of outcomes.Source: Reginald Carter. The Accountable Agency: Sage Human Services Guide 34, 1983
- What is the return on investment?
This compares the cost of programs and services for a client with the benefit to the community when the client is less in need or no longer dependent on social services.
This is a training process in which the trainers may have decided to not overwhelm the participants with too much information and therefore criticism of what is missing may be somewhat unfair. Nonetheless, there is no indication of standards, zero based defects or of clients defining quality: e.g., outcome expectations. In addition, it is interesting to note that the trainers added the eighth question. While it is true that all of us shape materials to make it our own, the nature of the question seems to clarify the intent of the training. The training is not in increase the quality of outcomes, which is what performance management should be about. It is rather oriented towards convincing funding sources that you are giving them a return on investment and therefore should continue to be funded. The return on investment is benefit to the community – in short, it is the double focus of human services: protection of society and/or improvement of people’s performance. Are we really talking about what is best for kids?
If we assume that we help all of our clients achieve perfection as defined by their own standards and our own, and there is no benefit to the community or the costs exceed the benefit – do we stop what we are doing? What is your life’s greatest good?
Continuing our review of the key questions, I wonder whether there is not an initial question before you determine your share of the market, and that is what is the universe of people with problems in living of the type you serve? How many children with problems in living exist within your potential clientele? If you are defined by geographic area – how many children between proper ages exist at any given moment and of these, how many have been identified as delinquent, mentally “ill”, dependent or otherwise labeled as having problems with significant parts of living? If the second is delineated as a percentage of the first – 03%, how many of the 03% do you serve?
This is important because you want to impact on the social problems, not just individual clients. A social benefit that is not mentioned in the training manual is that if you are able to help clients achieve a level of social competence which is above present functioning, they will impact on other people who could become clients. Thus even though you serve only 50% of the 03% with problems in living, you should be able to have an impact on more than 01.5% over time. It is also critical to ask the sub-question listed in number one – When does a person become labeled as having problems in living. Human services operate responsively since there is no money for prevention. However, by becoming clear about the thresholds for official entry into the humans service system, you may be able to identify behavioral difficulties that lead up to this threshold. Here is where we separate human services from business. Human Service mangers have no need to reduce their percentage of the market, they want to reduce the market! If we could reduce the 03% of children who have problems in living, we are, in fact, reducing the need for our services. Critical question – is this you mission?
If this is you mission, the data you accumulate over time may be used to change public policy rather than to justify what you do. What you do may in fact, be unjustifiable in regard to the greater good. If you are consciously aware that what you are doing can be compared to applying a bandaid after the wound is created; but have the capacity to avoid the wound – how do you justify bandaids? A real shift in human services would be to enhance the capacity of the community to nurture its children rather than to remedy the mistakes. You may want to review Regenerating Community by McKnight in this regard.
However, it is important that you know who your clients are in number and type. Disability level is another clue to our constant interest in problems rather than solutions. Would we not be better identifying the ability level? Further, while it is of major importance that we relate to the culture or group thought/behavior of our clients, what is the necessity for documenting race and ethnicity. Does this mean that we apply our stereotypes of their race and ethnicity to them. Does the fact that a person is Irish Catholic indicate somehow that they have certain cultural habits? Or is it better to actively listen to what they tell you about values, family and clan behaviors and respond effectively. Is this not politically correct. Or are we required by governments to document that this or that group has a higher level of problems in living and if that is so, should we comply? How does this help our client? If we savage them sufficiently I suppose that we could stereotype them as “people with severe problems in living” and perhaps make them a protected group and through that process assure that they will always be victims. There is no problem with collecting data on any aspect of the clients providing you can justify that there is a benefit derived from the process. Have you considered the benefit/cost of such collection and dispersal of personal data?
What services do you give them and what is the impact of that service is a critical issue in performance management and often difficult to attain. The description of services is often incoherent. Thus people who provide living arrangements describe the services as providing living arrangements and people who provide partial hospital services describe providing partial hospital services. Anyone who has visited two or more of these services is well aware that each service entity [residential day, partial hospital hour, or case mangement contact] has distinctly different characteristics depending upon who is providing it and the external context of where it is provided. Thus, without a specification of the function behaviors of staff in regard to clients, there is little definition of services. For example: an hour of counseling can be oriented towards approximately 476 different therapies [there may be more or fewer, it has been a while since I looked]. Further, each person providing the therapy uses their own individualized style – many claim to be eclectic in their approach, meaning I will do what please me at any given time and if forced to justify it I will respond “I only want to do what is best for kids”.
As a manager, you have a responsibility to seek standardization of staff performance. This is of course contrary to conventional wisdom in that we expect individualized services. However, the individualization is based upon the goals and preferences of the client and the standardization is on the delivery of the service. At the same time, one does not want to standard the process as in command and control management. A dilemma arises. How do we standardize without controlling process through command and control. We do so through standardization of staff belief systems, and we standardize these belief systems through the angst of a philosophical consensus on summon bonum. And as performance managers we are constantly on the look out for incoherence by what staff say and how they act. And we address these exceptions, without controlling the aggregate. When a staff person refers to resistance and compliance we know we have a need to intervene. And if you believe that people can hide their real beliefs, read Bernard J. Barr – A Cognitive Theory of Consciousness.
When measuring results of interventions, it is important to look at trends and not just aggregate counts. Continuous quality improvement is a process of always moving towards quality expectations. As we move, we will find that it gets harder for two reasons: first, the quality standards are raised. As we achieve, we expect more, and therefore the bar is raised. Second, we cannot ever reach perfection. As in cutting a line in half, sequentially having the remainder, we never get to nothing. We always have half a line. So too with quality. We can get ever closer, but we cannot attain perfection. Perfection is infinite.
Developing costs is another interesting dilemma. There are at least three levels of cost to the delivery of services. First, there is the direct cost, which would include the direct service staff and their peripherals [occupancy, travel, etc.]. Second, is the program administration, which would include the supervision and direction of the program, and third, is the administrative overhead. Each public relations cost contributes to the cost of the delivery of services. Allocation of each of these costs has considerable leeway, but should be standardized. There are often other marginal costs such as the cost of the space in the home or school where we provide services, the cost of natural support volunteers who attend planning and review meetings, etc., but these are sophisticated cost analysis which may not be important.
It is not clear, however, that these cost per service delivered represent the best measure of efficiency. Unless we compare these costs to all other forms of service over time, we may find that we are not inexpensive. More importantly perhaps, if we find we are the lower cost, we may find that we are not inexpensive or efficient but cheap. The difference in the two terms is, of course, connected with the quality of the service, in this case as measured by impact. If we were to spend more money per hour than any other service, but had a quicker and more long lasting impact our program would be expensive, but efficient.
Thus efficiency is connected to effectiveness because what happens as the result of the services, comparison to what happens in competing services, and the substantive nature of the impact are important criteria in determining the actual cost of the service as opposed to the price of the service to the funding source and taxpayers. The impact of a service cannot be construed without elements of substantive impact on quality of life over time. My service may be very helpful in the immediate, but provide no inoculation or immunity to future circumstance. If this is so, we can expect a fair amount of recidivism since life is full of little traumas. Thus, if we feed the client fish we may reduce or eliminate hunger for now; but if we teach him to fish, we may eliminate hunger for good [or at least until the fish run out]. Without such inoculation can we really call a service efficient?
Return on investment is likewise influenced by the ability of the client to learn a competence that will enable him to cope more successfully and appropriately with the problems in living that are sure to occur throughout life. Too often human service managers look at short-term outcomes and ignore long term outcomes. This discussion is not to suggest that the Positive Outcomes training is wrong, merely that it is not sufficient. Any training that brings to consciousness an additional dimension of thought about what we are doing here is valuable. However, analysis of what we find demands a rigorous and zero based review, not unlike that done in cognitive restructuring.