The search for the development of organizational and consumer quality in public human services has been a sometimes thing which has created much more smoke than light. A recent review [RESOURCES -1992] of TQM in the service and public sector has indicated the troubling garbled expressions of the expert leadership. If I may cite from that article some unrelated expert opinions:
Berwick and Sterret [judges for the federal government’s Malcolm Baldridge Award for Quality] point out that there is a high variation in service-customer needs. They say that the ‘dynamic, non-linear dimensions’ of services are more difficult to understand and manage. They also point out that in the service sector, individual workers provide more variation in quality and in opportunities for improvement. They write that ‘contact behaviors of staff leave the door open for the old style of looking for CULPRITS [when mistakes are made] rather than focusing on CAUSES [which will point the organization to places where quality can be improved.
There is a difference between being served and feeling served, says [Ron] Zemke Taking into account how a customer feels about an organization’s service can be a more accurate barometer than asking him how he rates the service. Unlike quality control in technical fields of manufacturing, however, creating standards to measure service performance – such as employee behavior and consumer perceptions – can resemble a psychology experiment.
In applying the concepts of TQM to mental health, the two biggest challenges seem to be defining who the customer is and specifying the measurable outcomes.
William George, professor of marketing at Villanova University, did not hesitate: ‘Your customers are your communities’, he said. Not every mental health provider would agree.
Walter Leginski, assistant chief of the Systems Development and Community Support Branch at NIMH, notes that states adopt ‘widely different definitions of who is their customer, leading to equally different ideas about the product that is being provided.
W.C. Enmon, advising the state of Texas on TQM as part of the Xerox Loaned Executive Program notes that when public sector customers of services are devalued by taxpayers, as in the provision of welfare or mental health services, ‘the job of the organization is to negotiate between the needs of all its customers and stakeholders and to find a win-win solution…to find ways of meeting the needs of all.’ This very tension, held by the organization for years, may be the dominant factor that keeps mental health organizations from clearly defining customers and outcomes.
Leginski points out that ‘effectiveness ‘ and ‘outcome’ might be two different things in the provision of mental health services: ‘Effectiveness can be measured from patterns of service utilization…information which most information systems collect. If case management once a week is indicated and the client receives it one in three weeks, you have a measure of effectiveness.’ Outcome measures, Leginski says, are different. Based on a system-wide study of outcome measures, he says, ‘my impression is that not too many states have done routine outcome assessment because their products are not defined.
‘It may be that consumers will have a more homogeneous sense of outcome measures than professionals have had’, he said.
With the exception of the last, we barely have a lucid statement regarding quality. The reader must remember that these are supposedly experts, not people who are rebelling against the implementation of total quality management. Many of these people are being paid to help implement TQM in human services. Yet, each in turn fails to hold firmly on to the concept of quality. Berwick and Sterret, because of the perceived complexity of individualized services turn to managing the process of service delivery and worry about CULPRITS & CAUSES instead of outcomes. Zemke is concerned about how the customer feels about the organization rather than matching outcome to expectations.
After acknowledging the conflicting goals of human services, George comes down on the side of protecting society. Quality for him, therefore, will probably prove to be incarceration of people with mental health problems in large institutions where the public won’t see them. It is hard to see how the general public, led by professional ledgerman to believe that this population is both dangerous and incurable, would come to any other measure of quality. Leginski notes the wide range of definitions caused by lack of rigorous thinking and Enmon feels that there should be negotiation between consumers and providers [ignoring perhaps, that it is the professional experience of such negotiation over the last forty years that has devalued this population]. Imagine Ford Motor Company taking a similar position: “Let’s see, you [the customer] can have a Lincoln or a Ford, lets negotiate!” Leginski then points out that effectiveness and outcome are different because [in mental health at least] effectiveness is measured custodially and outcome isn’t defined.
This is frightening! Fortunately Leginski finally comes to the conclusion that the customer might be able to define quality, which is what total quality management is all about. It really is not that hard. Certainly, one needs to make distinctions between organizational outcomes and client outcomes. The organization needs to focus in on creating a vision [mission or social policy statement] that indicates some overall outcome expectations regarding its performance. It needs to set standards of quality for its performance. It also needs to understand that individual clients will need to create vision statements for themselves, defining in the process, the outcomes by which they will measure quality. While it is likely that each will have compatibility with the organization’s standards, they may not be congruent. The organization may believe in full community membership for all clients, and the client may not value nor desire full community memberships. Organizations that think rigorously will be prepared with an attitude about what then, but they do not change the client’s definition of quality to meet their own.
In fact, the percentage of individual outcome expectations that conflict with the organizational outcome expectations should send a message to the organization that they are out of step with their own definitions of organizational performance. Quality is essentially a measurement against a standard. The problem is whose standard and to what is it applied? TQM says that it is the customer’s standard that counts. You don’t have to manage this way, but then it is not total quality management. Dennis O’Leary [1991] in writing about the attempt of the Joint Commission on Accreditation of Healthcare Organizations states “We sometimes use the term quality in a glib fashion. There are those who would characterize quality as something akin to beauty or pornography which can be appreciated but not easily defined.” He then goes on to define his definition of quality. I have no argument with his definition, but he is not my customer and his definition does not take into account his customer. Like beauty [I am not sure about pornography], quality is in the eye of the beholder. And the beholder to whom I am a servant is the client. Therefore, that client must define truth and quality. I must meet his expectations.
Further, the standards that measure my expectations, those organizational standards must not be standards of performance meaning process, but standards of outcome. Standards of performance are epitomized by the regulatory standards now in place. They define specifically who is to do and what they shall do, without reference to what is expected as outcome. If I develop standards of process, such as those that Berwick, Sterret and Leginski are concerned, I duplicate those regulatory standards regarding means. This does not deny that there need to be certain guidelines about means in public organizations. We have spent a great deal of time reviewing ethics, duties and responsibilities for just this purpose. But the construct that Deming, at least, is trying to help us understand is that the staff are capable of designing the means, providing they are very, very clear on what ends are expected.
This change of focus from means to ends comes at a difficult time for public human service agencies, since they are dealing with another paradigm shift regarding ends. Ends in public human services are shifting from organizational ends to end-user ends, at the same time. The “experts” indicate some confusion with both shifts. Public human service organizations must spend a great deal of time with their boards, staff, clients and stakeholders defining the organizational ends which will support individual ends. The Joint Commission, with such rigorous analysis, might find that the outcome expectation of the organization is to prevent illness and accidents and that this is a total retooling about what business they are in. All of the standards about how they provide services may be inappropriate because what they really should be doing is preventative health care.
I have referred through this document to the classic/quantum physics change because I feel it has the same contextual feel as the classic medical [command and control] transformational model conflict in which human services is centered. Newtonian physics still have a place, but the Schrodinger construct is the operational mode. Medical model human services may still have a place, but not in human services. This is not a pejorative statement; it is a statement of coherence. But just as it took the young Turks of Bohr, Heisengberg, Born and Pauli to carry the construct forward, so too it will take some young Turks to take hold in human services. The old guard does not get it.
“Current ‘quality assurance’ approaches, which are based on collections of hundreds of detailed standards applied uniformly in every setting monitored, are not producing desired results. Clearly the current approach in ‘assuring’ quality lacks efficacy.” “The current approach also lacks reliability. Given the same setting, different monitors cite different deficiencies. Finally the current approach lacks validity. One often cannot distinguish, in quality of life measures, between …[programs]…intended to cause dozens of good outcomes [safety, comfort, freedom from exploitation, opportunities to learn, therapies as needed, good diet, etc.] as written and implemented they may unduly emphasize paperwork, environment, and health and safety issues at the expense of other quality of life measures.”
“…quality is different in different settings …for different people.” [Lakin, Prouty, & Smith – 1993]
Individualized services require individualized quality measures. “Quality is thereby manifested in the achievement of desired outcomes” [Lakin, Prouty & Smith – 1993] [emphasis added]. It is the personalization of services, quality outcome expectations, data collection of formative and summative focus, and the responsiveness to the changes in the client’s expectations as achievements are attained that will contribute to the quality organization. It is the cumulative data of many clients across time that will be the ultimate organizational performance standard. “Our shared goal is to develop processes and concepts useful for reconceptualizing and redesigning services that honor the distinctive contributions of people with disabilities, their family members and friends, service workers, and other community members.” This action learning approach contributes to organizations learning by creating time and space for reflection and creative problem solving” [O’Brian & O’Brian – 1993]. It also helps to set up a learning process in which the learning entity [client or organization] can begin the process of learning over time how to define quality and measure results through experience.
The first responsibility of the manager of public human services is to help his/her organization decide who the customer is going to be. “In the service system as it has existed to date, the customer primarily has been the government agency that certifies, operates or funds the service system. Providers have had to satisfy the regulators, not the people they serve.” “When agencies write mission statements and policy documents, it is not uncommon to see …documents espouse lofty ideals such as ‘empowerment’, ‘individual choice’, and ‘inclusion’, and remain virtually silent about these political and self-interest forces that in reality shape much of the decision making” [Sundram – 1993]. If clients are not the customers, this should be made clear to the public and potential clients alike. Sundram goes on to ask the pertinent [or impertinent according to your point of view] questions of “a) how can people be empowered unless they have effective control over the money being spent on their support, and can choose to spend it differently; b) how do we truly make the person with a disability the customer whose expectations must be met as an essential component of quality; and c) how does the current provider-driven system, with its need for predictable budgets and revenues, accommodate to a world where the negotiations will occur not with a single state official for “beds” and “slots”, but with dozens of consumers with their own ideas of what they want and are willing to pay for? [Emphasis added]”
If the customer is the client, the client must be placed in a position to have his preferences [outcome expectations] respected. The free market accomplishes this through a vote with feet and fee. Sundram echoes this author when he says “…it is clear to me that one cannot redesign quality assurance without redesigning the service system as well. Thus the task must start with ensuring that the service system itself is built on a firm foundation that promotes quality. Quality begins with explicitly and honestly articulating the values that under gird the system, and maintaining simple, clear and consistent expectations for performance.” Philip Crosby, in his book, ‘Quality is Free: The Art of making Quality Certain’ tells us that quality is conformance to requirement: it is precisely measurable. To paraphrase Democritus, Quality is performance consequences equal to preferred expectation; all else is rhetoric. There is no mystery here! There is decision-making and measurement. Managers must 1) decide who the customer is; 2) allow the customer to make his/her requirements clear; 3) develop each customer’s specifications for outcome in a manner in which both they and the organization’s staff are clear as to what is to be done, what is expected, and how performance will be measured; 4) perform [act] in a manner which will support the outcome expectations that have been defined; and, 5) measure the performance consequences against preferred expectations.
There are debatable areas that will need rigorous analysis. Who is the client is not simply a decision between the community and the customer. We will refer in the last segment of this article to the child/family as a single unit. It should be clear to anyone that children and their families do not always think as a single unit. But two things need to be recognized: 1) that until the child reaches age 14 for mental health, age 18 under most circumstances, and after twenty-one for some severely disabled children the parent is the decision-maker, and 2) that if the child does not consent, the service in his/her regard will be unwarranted, since without the child’s sanction, they will probably sabotage the process. Therefore, even in setting quality outcomes, the helper will need to help the child and adult family members negotiate a win/win agreement. Failing this, who is the customer?
Another area for rigorous thinking is the development of process regulations. If what the customer wants is inconvenient or requires doing something in unfamiliar ways, it is incumbent upon the helper to create the means [capacity] to meet those expectations. This cannot happen if the organization has developed such stringent process standards that the helper is unable to comply. In fact, such regulation often results in such statements as -”It’s against policy” and “I just work here”. Child/family customers of human services will tell you that they have heard those statements before.
Deregulation of process is as much a requirement as standardization of expectation. The helper must have freedom to decide the how, while always conforming to the values and expectations of the customer and the organization. If the customer’s choices are to be real, they must be empowered to affect the provider system, be able to ask for unique and varied services and be able to define expected outcome.
It is nice to find that at least one “expert” has been able to fathom the quality paradigm and provide positive guidance for designing a quality assurance system. Clarence Sundram, suggests that once the customer is defined and the value base is established, the manager [local public administrator] should:
- Establish a careful process for deciding whom to entrust with the welfare of vulnerable people.
- Instill curiosity about how well the values, plans and policies are actually being implemented.
- Inculcate a passion for the truth and willingness to hear it, and give license to all, especially consumers, to speak it.
- Emphasize spending time listening to and seeing the real conditions of people’s lives through their eyes rather than on examining provider processes alone.
- Teach and spread success by calling attention to the places where you find it, and take prompt and effective corrective or enforcement action against deficient performance.
- Rediscover common sense, and focus on improving the quality of service rather than extracting plans for improvement.
Public human service administrators must define the perfect world. Extract through partialization and prioritization, the activities that need to be done and the outcomes expected. Develop the strategies and tactics to carry out these activities. Collect data on the outcomes formatively, summatively, and cumulatively. Think rigorously. Evaluate. Talk about values. Improve. These principles hold equally for organizations and individuals.