Quality Assurance for Human Flourishing: People over Paperwork...
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Research for Social Change
The Paradox of Control in Human Services
The sad irony in contemporary human services delivery systems, particularly those supporting people who experience intellectual and developmental differences, is that many of the systems designed to ensure quality care undermine the relationships, creativity, and human connection that underpin quality. In many organizations that support people with IDD, staff are spending more time documenting care than providing it. Frontline supervisors are more focused on compliance than on coaching and supporting direct support professionals in building the relational foundation that is central to quality care and skill development. The predominant question in such environments is “Are we doing things right?” The question that should be asked is “Are we doing the right things?”
The default knee-jerk response is that unqualified, unprepared staff, poor management, and insufficient resources are the primary problems. Those factors certainly contribute to environments in which the quality of care is in question. But the root of the problem is a mismatch between the theoretical foundations on which our current quality assurance systems were established and the complex nature of supporting and measuring human flourishing. The traditional quality systems that are in place in many human service delivery systems and organizations were designed for factories, and we are trying to apply them to human beings and human flourishing. This is a dysfunctional mismatch.
People are not Widgets
When examining the compliance frameworks that predominate the field of human services, it is not hard to see scientific management theories and frameworks, developed and popularized by Fredrick Taylor in the 1900’s. The goal of that Taylor-esque style of management was to eliminate variation and individual judgment and decision-making from the workers closest to the product. Moreover, Taylor's managerial framework was optimized for control. Top-down control. If you are making cars, producing steel, or any other kind of widget or inanimate product, that may make sense, though Toyota certainly contributed to the misunderstanding as well. However, when attempting to apply that type of management framework to support human beings, it becomes absurdly contradictory when compared with ideas such as person-centered planning, everyday life, or self-determination.
In many human service delivery systems and human service organizations, the mission becomes the metrics. Good audit scores, good compliance rating, break-even or surplus-producing billing numbers. All of which have their place, but too often it becomes the focus at the expense of the level and type of support that truly embody quality. We need only look to W. Edwards Deming, who spent his career trying to rescue organizations from Taylorism by asserting that the rigidity of top-down scientific management destroys morale, undermines quality, fosters unhealthy competition, and treats workers as replaceable and expendable.
This plays out in our current human service delivery system through Quality reviews that assess whether forms such as training attendance sheets, goal plans, and behavior data sheets are signed, rather than whether lives are improving. We observe the effects of Taylorism in remediation and corrective action plans that emphasize ever-increasing layers of oversight, monitoring, and documentation, and impose consequences for staff, assuming that this will somehow improve the quality of life for the people being supported. Generally speaking, it does not improve the quality of life for people being supported; it leads to a heightened focus on completing paperwork correctly, rather than on providing a higher level of care.
Even Max Weber, whose work on bureaucracy became foundational to organizational theory, assessed the failing of his own work by stating that “once a bureaucratic system is firmly in place, it tends to develop its own logic that is disconnected from human purposes”. The keen insight on the failings of the bureaucracy plays out everyday in human service delivery systems when we hear manager and staff (especially those more directly connected to the people being supported) "I know this doesn't make sense, but it's policy", or managers that cant explain why certain things must be done a certain only that this is the way it must be done.
A Haunting in Human Services
A famous General during the Vietnam War seemed to believe that the only thing that mattered was what could be measured. He was obsessed with quantitative metrics. This obsession and erroneous belief became known as McNamara’s fallacy. The ghost of numbers haunts human service delivery systems when we focus on the easier things to measure rather than the things that are truly important to human flourishing. It is much easier to see how many service notes were entered within a given time frame or how many ISPs were completed on time than to measure genuine growth in a person's quality of life. Timeliness of service note entry doesn’t make a good life. Other ways this ghost of numbers haunts human services include the metrics being divorced from their purpose, like so-called community outings at Walmart or the mall, and checklists and datasheets indicating a staff person sked about the members day but is wholly divorced from asking with genuine curiosity or the formation of a relationship to the degree that people feel genuinely belonging, and unconditional positive regard. The tyranny of metrics comes to mind. We will not even get into the idea of moral injury being inflicted on staff and members when the organization values documentation over staff judgment and opinion, treats them as interchangeable and expendable, or creates such an overwhelming administrative burden that genuine relational work is lost.
The Human Cost
We won't even get into Wendy Deans' concept of moral injury being inflicted on staff and members when the organization values documentation over staff judgment or opinion, treats them as interchangeable and expendable, or creates such an overwhelming administrative burden that genuine relational work is lost. According to Dean, moral injury occurs when the organization and its systems continue to prevent staff from providing support and care that are consistent with the person's values. The primary reason most people enter human services is also the primary reason they burn out—care exhaustion. We do not even take into consideration that burnout is caused not by overwhelming work conditions but from the psychological wound that takes place when people who are trying to provide a level of care they know is required, and the system, the structure, and the priorities of the organization are in complete and utter contradiction to that care.
Systems theorist Russell Ackoff captured this dynamic perfectly: "The righter we do the wrong thing, the wronger we become. When we make a mistake doing the wrong thing and correct it, we become wronger. When we make a mistake doing the right thing and correct it, we become righter. Therefore, it is better to do the right thing wrong than the wrong thing right." Our quality systems have become devastatingly efficient at doing the wrong thing right.
Systems Thinking versus Machine Thinking
When you look at quality assurance through the lens of systems thinking, it's much easier to understand why legacy bureaucratic quality assurance processes are inadequate. The reasons include, but are not limited to, legacy bureaucratic QA processes that rely on linear thinking in nonlinear systems. The legacy QA process also optimizes the parts, only to destroy the whole. You can never understand the whole by breaking down and examining the parts independently. Moreover, bureaucratic QA processes view resistance and workarounds as non-compliance rather than as valuable feedback and data. When staff develop elaborate workarounds in documentation systems, this is not necessarily, or even exclusively, evidence of non-compliance or negligence; it is, in fact, data indicating dysfunctional systems. The work of Donella Meadows speaks volumes in this area. Legacy bureaucratic QA systems tend to make low-leverage changes that consume substantial energy with minimal impact on the issue at hand. High-leverage system interventions are obscured by bureaucracy.
The Better Way
The work of Donella Meadows also informs us here. Meadows reminds us that Change occurs at the level of paradigm, how we think. Peter Senge calls them Mental models. What if we reject Weber and Taylor and their emphasis on control and standardization outright, and instead embrace Mary Parker Follett, the organization theorist and systems thinker who was decades ahead of her time, and begin to view quality assurance systems through the lens of "power-with" rather than "power-over"? What if the core question shifted from "did staff comply with procedures?" to "are people flourishing, and how do we know?" What if we focused on doing the right things instead of doing things right?
If we adopted that way of thinking, if our paradigm shifted to incorporate or focus on those elements, we would be engaged in "gentleship," a leadership and quality philosophy grounded in trust, growth, and shared purpose. Gentleship represents a radical departure from suspicion, control, compliance, and rigidity that undergird our current quality assurance and compliance processes. The term gentleship in this context is an intentional fusion of gentleness, leadership, and craftsmanship. Gentleness can be defined as a caring and respectful stance toward staff at all levels and toward the individuals being supported by the organization. Leadership in this sense takes the form of the servant leadership model, which emphasizes active listening, empathy, and stewardship. Finally, craftsmanship recognizes that the profession of caregiving requires skill, judgment, relationship-building, continuous learning, and growth.
Gentleship-based Quality Assurance:
Quality assurance (QA) grounded in a gentleship framework is characterized by core components such as trust, judgment, and purpose over process, among others. A QA process within a gentleship framework recognizes that a system that communicates trust in its staff's capabilities and judgment will elevate their performance. It also acknowledges that people want to do good work; when they have appropriate support and feel trusted, they will do so.
The quality assurance and compliance process implemented through a gentleship framework also prioritizes Purpose over process and learning over punishment. The focus shifts from following a set of specific steps to achieving the identified purpose. In a QA process driven through the gentleship framework, views mistakes through a lens of understanding and learning rather than fault-finding.
The North Star: Human Flourishing
A quality assurance framework for human service delivery systems, and for supporting individuals in living good lives, should be organized around human flourishing. Martha Nussbaum's work on ethics and human development and Anthony McCrovitz’s work on the Quality-of-Life model inform the discussion and help the QA process begin to ask: what are people able to do and become?
A quality review and assessment process organized around the capabilities and elements suggested by Nussbaum and McCrovitz, such as bodily integrity, sense imagination and thought, and affiliation, would look radically different from current compliance audits and assessments. There is value in ensuring appropriate signatures are on the ISP, and that service notes are entered within 7 days, and in holding team meetings at the required time and location; however, what is fundamentally more important for human flourishing is whether the person is maintaining genuine relationships with people outside of their paid staff. Are they making choices about significant aspects of their lives with a system of support from others as needed? Do they have opportunities to develop and use their capabilities? Do they have socially valued roles in their community?
The indicators associated with a quality of life or human flourishing are indeed more complex to measure, but the difficulty of measurement doesn't diminish their importance. In the words of Benjamin Franklin, "Not everything that counts can be counted, and not everything that can be counted counts."
The Path Forward...
Transforming the quality assurance process from compliance to flourishing is a heavy lift. It is a paradigm shift. Moving from an authoritarian, rigid process that has been primarily focused on quantitative metrics to determine the quality of human service delivery to one that leans more heavily toward metrics that identify human flourishing requires a new way of thinking, a new way of being. It will require Regulatory reform. Leadership courage. Workforce development. Technology in service of purpose. Inclusive Research and evaluation using qualitative and quantitative methods, and the voice and power for those supported.
Quality Assurance Mechanisms Worthy of Human Beings...
We must acknowledge that reimbursement structures, funding, and resource allocations are not the primary causes of the current crisis in human services, which is typically characterized by workforce shortages, mediocre outcomes, family frustration, and practitioner burnout. Those conditions are outcomes of a purpose-means mismatch. We have taken the most profoundly human work, supporting people to live good lives of dignity and worth, and subjected it to management approaches, organizational structures, and processes born during the industrial revolution and designed for widget manufacturing.
As human service delivery systems evolve and expand, we must decide whether to remain tied to failing systems grounded in distrust and control, or to adopt systems that are better suited to human flourishing. As the direct support workforce crisis continues unabated and technological change accelerates, with socially assistive robotics being adapted across a wide array of care environments, should we continue to rely on a machine age system that treats workers as potential problems to monitor rather than as skilled practitioners? Should we continue to measure the low-hanging fruit, settling for what’s easy, or are we willing to make the paradigm shift and adjust our mental models to understand what matters?
Russell Ackoff wrote that "the only thing managers need to learn is how to learn." It seems the same can be applied to quality assurance systems. We should rely less on elaborate monitoring systems and create genuine learning systems. Learning systems that honor the complexity of human beings, the craft of caregiving, the true purpose of human services: supporting human beings in their quest to have lives of dignity, meaning, connection, and growth.
People who experience intellectual and developmental differences, their families, and the paid and unpaid supporters who support them all deserve support systems designed for human flourishing, not bureaucratic compliance. Through a different paradigm, organizational structures, leadership models, and quality assurance systems can be developed that honor everyone.
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