Section 10. Modifying Policies to Enhance the Quality of Services

Learn how to change policies that ensure the delivery of quality services to the community.

 

• What do we mean by modifying policies to enhance the quality of services?

• Why modify policies to enhance the quality of services?

• Who should work to modify policies to enhance the quality of services?

• When should you try to modify policies to enhance the quality of services?

• How do you modify policies to enhance the quality of services?

Not so long ago, there were no quality standards that all nursing homes had to follow. The federal law that regulates nursing homes and their services dates only to 1987. Before that, in at least some states, there were no requirements for the training of staff, or for medical care for residents.

While many facilities provided a warm and supportive environment, and carefully tended to the needs of residents, others were reminiscent of the horrible images from Dickens novels, where abuse and neglect were common. Relatives and friends of the residents of these latter homes, when they realized what was happening, began to push states and the federal government to change the policies that governed nursing homes. Ultimately, laws were passed that ensured at least a minimum level of respect and care for all residents.

Most services are regulated, in some way, by official or unofficial policies. Sometimes, it is necessary to change those policies to make sure that programs and services are accomplishing what they are supposed to. In this section, we'll discuss some different ways in which policies might be changed, why you'd want to make those changes (and why not, in some cases), who should be involved, when changes might best be proposed, and how to go about making that happen.

What do we mean by modifying policies to enhance the quality of services?

The delivery of services, whether to the public at large or to a target population, are controlled by policies at some level. The makers and users of those polices may be legislators ( in the form of laws and official regulations), federal or state agencies, public or private funders, or the service delivery organizations themselves. How do those policies relate to quality, and what kinds of changes can you make in them to affect the quality of services?

The kinds of policies that we're concerned with here are those that will ensure, to the extent possible, that services are as good as they can be. That means that services accomplish their purposes in meeting the needs of the target population and community, can be used by all who need them, and are cost-effective. Some basic guidelines that will go a long way toward promoting good services include:

• The people offering the services are competent.

• Facilities offering services, or where services are provided, meet basic physical and practice standards.

• Individuals, programs, and facilities follow the ethical rules of their professions, or, if none exist, they employ high ethical standards in their work and in their relationships with other organizations, funders, and the community.

• Programs are aware of and use the best appropriate practices available in delivering services.

• Services are available and accessible those who need them.

• Individuals and programs set and apply appropriate quality standards that both benefit and safeguard those who are affected by the services provided.

• Services are evaluated regularly and modified, when necessary, according to evaluation results in order to best meet the needs of participants and the community.

There are particular ways in which you might want to modify existing policy (or structure new policy) to assure that each of these guidelines is followed. We'll look at each of them individually.

The people offering the services are competent. There is no absolute guarantee that someone will be competent at what she does. That's largely a matter of individual effort, personality, talent for and interest in the work, training, and a number of other factors. What you can do is to control for as many of those factors as possible. If you're doing the actual hiring for a service program or intervention, you may be able to exercise some of that control. Another common way to achieve that control is through requiring professional licensure or certification.

The terms licensure and certification are often used to mean the same thing - an official recognition that the licensed or certified person has met certain requirements that qualify him for work in his chosen field. Where both terms exist in the same profession, licensure is usually the higher level, and means that a licensed individual has more training and experience than one who is certified. For convenience, we'll use "certification" here to refer to both certification and licensure.

Professional certification may be granted by the state, or by a professional association. In some cases, the state develops its own certification standards. In others, the state accepts association certification as its own standard. Lawyers, for instance, in order to practice officially, have to pass a bar exam which is administered not by a government body, but by the state Bar Association.

Some professionals - nurses, electricians, public school teachers, and insurance investigators, for example - must be certified in order to engage in their trade or profession. In other instances - psychotherapy, for one - a professional may be able to practice, but not to call herself by a particular title (psychologist, e.g.), or to gain access to some of the advantages of the certified person (the ability to be paid by a client's insurance). Please see "Examples" for a list of commonly licensed or certified professions.

Many professions and trades offer several different levels of certification and licensure, depending upon the person's education, training in the field, supervision, and experience, and, in some cases, passing an exam. Certificates usually have to be renewed at regular intervals.

Despite all the requirements, a certificate doesn't guarantee competence. It does guarantee, however, that the person who holds it has had a certain amount of education, has been exposed to at least some of the important ideas of the field, and - in most cases - has had some supervised experience. Thus, changing policies in order to make certification standards higher, to require certification for practice in a particular field, or to require that those hired to work in a particular intervention or type of intervention be certified, can help to enhance the quality of services.

Facilities offering services, or where services are provided, meet basic physical and practice standards. If a hospital or school is dirty, if it doesn't store food properly, if it doesn't have the proper furniture or equipment to do its job, if its staff treats patients or students with contempt or neglect, or if its finances are poorly managed, it is not only showing a lack of respect for those it's supposed to serve and for its profession, but it also isn't delivering high quality services. People in some circumstances can carefully choose the facility they go to, but others - because of limitations on health insurance, for instance, or the fact that a rural area may have only one hospital that serves a large area - may not have that choice. Once again, licensure or certification (sometimes called accreditation when it applies to facilities or programs) is a way to ensure that a facility - whether a residential one, or one that houses a day care center or outpatient mental health program - meets the minimum standards to be effective at what it's meant to do.

As you might expect, certification for a facility is quite different from that for an individual. It is more often conferred by a state or federal bureau, which usually means that the certification regulations are established by law. In addition, certification often covers several aspects of the functioning of the facility.

• Physical plant. The building or space has to be appropriate for the purpose of the service provided, to be clean and in decent repair, and to follow ADA (Americans with Disabilities Act) regulations. It must have properly functioning heating, cooling, electrical, and other systems, and may also have to provide certain equipment (adjustable hospital beds, child-size toilets, etc.) and/or materials, or be located in a particular area.
• Staffing. The facility may be obligated to hire only certified staff for certain positions, or for all positions. It may have to maintain a minimum staff-to-participant ratio, and to have staff members with particular skills or credentials (R.N., MSW, etc.) available or on call some or all of the time. It may also be required to pay staff members at mandated levels and/or provide stipulated benefits, and to afford or make possible an annual number of paid staff development hours or opportunities for some or all staff.
• Treatment of participants, and attention to their physical, social, and psychological needs. This means providing not only reasonable physical comfort (opportunities for personal cleanliness, freedom from extremes of temperature, etc.), but privacy to the extent possible (depending upon the purpose of the facility and the nature of the program), respectful treatment, positive human contact, productive activity, and access to counseling or psychotherapy if needed.

• Practices and procedures. The organization that runs the facility is expected to use standard and ethical financial and other management practices, and to be audited regularly. It is generally required to have tested emergency and safety procedures, and, in a residential facility, to follow a routine housekeeping and maintenance schedule. It may have to demonstrate that it operates in the best interest of participants, and that it displays openness to requests for information and services from participants and/or those responsible for them. In addition, the organization or facility may have to show that it adheres to professional standards of ethics (see below), and that it has procedures in place to protect confidential information and to prevent ethical abuses.

Modifying policies to establish or change required certification for facilities or for facility staff, or to limit the opportunities of uncertified facilities are ways in which you might improve the quality of services.

Individuals, programs, and facilities follow the ethical rules of their professions, or, if none exist, they employ high ethical standards in their work and in their relationships with other organizations, funders, and the community.

Professional ethical standards cover areas such as confidentiality, abuse of power, and participants' rights. Many professional associations also prescribe ethical standards for facilities - hospitals, nursing homes, schools, pharmacies, homeless shelters, etc. Many organizations develop and follow their own set of ethical standards, either where no professional standards exist, or in addition to those standards.

It is difficult to legislate ethical behavior, but you can advocate for developing new professional ethical standards where none exist, or for adopting or changing those currently accepted. Maintenance of those standards can then be used as a criterion for certification, and violation of them can be used as a criterion for denial of certification or of the right to practice.

Programs are aware of and use the best appropriate practices available in delivering services.

Best practices is, in some ways, a relative term. The best practices for one community may not always be the best practices for another, and sometimes successful approaches are difficult to explain or to duplicate. When a particular method or intervention seems consistently to work better than other approaches to the same issue, however, it may make sense to try to make sure that it becomes at least a part of any program meant to address that issue. You may be able to modify policies to include that criterion among the requirements for any new program, or even to include knowledge of best practices among certification requirements.

Services are available and accessible to those who need them.

This means that the people who need services are eligible to use them; that services are both physically and logistically accessible (handicapped accessibility, near public transportation and/or the majority of the target population, in neighborhoods or areas in which participants feel safe and comfortable, etc.); and that services are affordable to the target population (free or sliding-scale). Some of these criteria - service eligibility, ADA compliance - can be legislated, and others - location, for example - probably cannot. All are subject to funders' policies, however, and to the policies of service delivery organizations themselves.

Individuals and programs set and apply appropriate quality standards that both benefit and safeguard those who are affected by the services provided.

Quality standards, as the term is used here, could refer to air and water quality as applied to the acceptable environmental impact of particular activities or practices. They could refer to the standards acceptable for affordable housing (functional plumbing, no peeling paint, clean and safe apartment hallways, etc.) or school lunches (nutritious, well-balanced, encouraging good eating habits, no "ketchup as a vegetable" substitutions) or medical treatment (most effective treatment available, e.g.).

Quality standards could be built into laws or local bylaws, into agency regulations, into funding requirements, or into the internal policies of agencies and organizations. You might affect any of these by aiming policy change efforts at the appropriate target.

Services are evaluated regularly and modified, when necessary, according to evaluation results in order to best meet the needs of participants and the community.

Many funders require an evaluation component in any proposal, and many service providers conduct an external or internal evaluation of their operations every year. If there's no provision for evaluation and modification in the services you're concerned with, you might work with funders or the organization to chnage policies accordingly.

Why modify policies to enhance the quality of services?

Why should you try to change policies so that only certified people can deliver a particular service, or so that best practices are adopted? We've already said that certification is no guarantee of competence, and that best practices aren't necessarily best in all circumstances.

In fact, there are some very good reasons to try to modify policies...as well as some reasons not to. What's best for you and your community depends upon the circumstances. If services are distinctly unprofessional, certification may not be a cure-all, but it will almost undoubtedly improve the situation. If an intervention simply isn't working, modifying policy in one of the ways described above may not improve the situation, because the problem may lie in assumptions, rather than in training or competency. It's important to understand what modifying these policies can do, and what it can't.

Advantages to modifying policy to enhance the quality of services

It increases the possibility of a minimum level of quality.

While certification doesn't guarantee someone's competence, for instance, it does make it somewhat more probable. It does guarantee that she has had a certain amount of relevant education, training, and experience, and that she can be expected to understand some basic elements of the issue and of the population. Certification of a facility at least guarantees that it conforms to the law, or can be prosecuted and/or forced to if it doesn't. Such minimum guarantees of standards make it less likely that participants will suffer abuse, neglect, or flagrant disrespect, and more likely that services will be effective.

By the same token, adherence to professional ethical standards removes doubt about such issues as confidentiality and sexual relationships between professionals and participants. The use of agreed-upon best practices offers some promise that the approach used can have some effect if it's properly applied. Quality standards ensure that what is being offered is at least not harmful.

It shows seriousness of purpose, and establishes the issue as one that should be treated seriously.

Policy that demands standards of competency and practice makes the statement that the issue is important, and should be addressed by trained and skilled practitioners. If most people wouldn't dream of letting an unlicensed physician perform open heart surgery on their children, they should be equally reluctant to take those children to an untrained day care provider or to allow mental health services to be provided by counselors with no credentials.

It demonstrates respect for the target population.

Again, it makes the statement that the target population is important enough to deserve professional services.

It gives the community confidence that the issue is being handled appropriately.

Most citizens have more trust in an operation they see as professional and capable.

It lends credibility to both the effort and to the organization(s) providing services.

It can increase the chances that an intervention or service will be effective.

By leaving less to chance - removing the need to count solely on intuition to make the right hiring decision, for instance, or instituting criteria by which to judge an organization's methods - modifying policy in this area can remove at least some of the guesswork from health and human service provision.

It addresses what's actually behind most local service delivery.

Almost all service delivery is based on policy, whether formal or informal. By understanding and working to modify that policy, you're often taking the only route that will really improve the quality of services.

You have a moral obligation to the target population, the community, and yourself to try to assure the best possible quality of services to those who need them.

Cautions in modifying policy to enhance the quality of services

• It can assure, at best, only a minimum level of quality. Because establishing such things as certification requirements and quality standards is generally the result of compromise, they often represent a lowest common denominator of what's acceptable. Consequently, people and organizations that meet the standards may be no more than adequate at best.
• It may filter out imaginative solutions and people with valuable talents and skills. If minimum requirements for an intervention involve best practices or certification, they may make it impossible for organizations with truly creative ideas and programs or for gifted - but untrained - people to participate. You may lose more than you gain.
• An emphasis on professionalism may alienate the target population or the community. If there have been bad experiences in the past with "professional" interventions, or if the target population or community feels that it's being looked down upon, your service or intervention may start with two strikes against it. It may be viewed as just one more instance of professionals from outside the community thinking they know what community members need or should want better than they themselves do.
• Bureaucratic requirements may present barriers to talented individuals and organizations. Fulfilling the requirements for certification or the need to demonstrate adherence to best practices or quality standards can be made so difficult or expensive by bureaucratic procedures that it's simply not worth the trouble to many people and organizations. They may be lost not only to services in your community, but to health and community development by their inability or unwillingness to negotiate what may be an unnecessary bureaucratic maze.
• Changing policy may not address the problem. As mentioned above, if an intervention simply isn't working, it may have nothing to do with professional or quality standards. Instituting those standards won't solve the problem, whereas further analysis of the issue and the community, or more participation by members of the target population and the community in strategic planning might. A cynical or dishonest organization will find ways to appear to meet standards, and still continue to be cynical and dishonest. It's important to understand the situation before you act. Advocating for changes in policy about standards and requirements is not always the best way to accomplish your goals.

Who should work to modify policies to enhance the quality of services?

The drive to modify policies often starts with an individual or organization close to the issue. That individual or organization may have the knowledge and perspective to see the need for quality asurance, and the experience and expertise to know what kind of quality assurance is called for. In general, however, it's often best if an individual or organization doesn't work alone at changing policies, but finds a varied group of allies.

As has been discussed elsewhere in this chapter, the best answer to any question about who should work for policy change is often a broad-based coalition. If such a body exists, or if you can start one, it can be the ideal group to work on this issue, for several reasons:

• Coalitions represent a broad cross-section of the community, including all those affected by the issues in question, thereby demonstrating broad support for modifying policies.
• The broad representation leads to a variety of perspectives, which can generate a plan that makes sense, rather than one which may have unintended consequences.
• Coalitions have credibility, because they represent all points of view, and include leaders and spokespersons of all segments of the community.
• Coalitions, because they involve all segments of the community, generate plans that everyone can buy into and feel ownership of. In this situation in particular, by including both policy makers and those likely to be subject to policy, you may be able to eliminate defensiveness about either establishing or adhering to standards.

If a coalition isn't possible, alternatives to spearhead the drive to modify policies include:

• An advocacy organization
• Community based organizations that work with the target population and the issue
• A local initiative including members of the target population
• A local branch of a professional association.

When should you try to modify policies to enhance the quality of services?

As with most efforts at policy change, there are times when modifying policies to include standards may be particularly appropriate, and likely to meet with success.

• Before services begin, to ensure best practices and best quality. If you can set appropriate requirements or standards beforehand, you may never have to deal with trying to modify policies later.
• At the beginning of a new service period or funding cycle. A funder, organization, or the field itself can institute new requirements or standards as a new cycle starts, just as they might at the very beginning of a new service.
• When services prove unsatisfactory. When it's clear that services are inadequate, or not achieving their purposes, it's easier to persuade policy makers that change is needed.
• When regular assessment and reporting shows little or no progress on a particular issue. If the community is already involved in regular assessment and reporting as part of meeting the goals of a strategic plan, a no-progress report may act as a red flag that policies need modification.
• When new possibilities or information become available. Some factors that might influence the modification of policies:
  • New studies identify previously unrecognized best practices.
  • New certification procedures or requirements are issued by a professional association, or by the state or federal government.
  • New standards for air or water quality or other areas are released, or new scientific information sheds further light on current standards.
  • The field agrees on a new canon of ethics.
  • New laws or regulations are put in place.
• When public opinion demands it. In the case of nursing homes, for instance, publicized abuses often lead to a public outcry that results in changes in regulations. Policy makers are usually extremely sensitive to strongly-held public opinion.

How do you modify policies to enhance the quality of services?

Make sure you understand all existing policy, both formal and unspoken.

You can't change policy until you know what it is, and what its consequences are. Becoming familiar with current policy is therefore the first step.

Decide whether modifying policy is the appropriate course of action.

The next step in the process is to make sure, by examining its advantages and disadvantages, that modifying policy in this way is the route you want to take. If people in the field are at odds over whether certification is necessary, for instance, make sure you've heard both sides before deciding to pursue a policy change. If there are technical issues involved, consult with experts - researchers, service providers, service participants, policy experts. If services are simply not serving their purpose, more may be gained by examining and trying to change the attitudes and methods of providers through education and training than by mandating particular practices or requirements.

Some questions to ask yourself:

• What should the ideal results of service be?
• How will what you're proposing help to bring about those results?
• What are the likely long-term consequences of modifying policy?
• What are the possible unintended consequences of modifying policy?
• What are the likely consequences of not modifying policy?
• What are alternatives to modifying policy?
• How do the possible consequences of those alternatives compare to the consequences of modifying policy?

While good-faith efforts to modify policy in this way generally result in improvements in service, they sometimes generate unforeseen or unintended consequences as well. It's important, to make sure you anticipate - as much as you can - the possible results of your effort before you embark on it.

Determine what kind of policy modification needs to take place.

Once you've made the decision that policies need to be modified, there are three approaches you might take to that end, depending upon where you're starting from, what's already available, and what the services in question are.

• Policy formation. You might start from scratch. That means advocating for policy that will develop and apply certification requirements or a canon of ethics, determine best practices, or define minimum quality standards for the first time, where none have existed before.
• Policy adherence. You might try to change policy to demand adherence to existing certification requirements, ethical or quality standards, or best practices. Perfectly acceptable standards may already exist, but policy may need to be changed to state that they must be met or applied.
• Policy change. You might try to modify policy to change existing certification requirements, ethical or quality standards, or ideas about best practices, if they've proven inadequate or ineffective. Are there existing certification requirements, ethical or quality standards, or best practices that could be adopted to serve the needs of the current situation?

Develop new or revised requirements or standards, if necessary.

Whether you're asking for the development of a whole new set of requirements or standards from scratch, or for the revision of existing ones, there is nothing to be gained simply by working for modifying policies. If you want to be satisfied with the results, you also have to work on modifying policies. Some considerations in developing new or revised requirements or standards:

• Involve the people who are most closely affected: practitioners and anyone else who will be subject to requirements or standards, target populations, those responsible for members of the target population (parents, relatives responsible for elders in nursing homes), and those who will enforce adherence to requirements or standards.

• Establish new requirements and standards that reflect the realities of the current situation, but also look to the future. If they're too narrow or rigid, they may not respond to unforeseen needs and circumstances. If they're too broad, they may have no effect.
• Examine new requirements and standards to make sure that they actually address the problems they're aimed at, and don't create their own problems. Facility certification that results in micromanagement by a state agency, for instance, may generate more problems than it solves. Certification that makes clear the requirements of and restrictions on operation, but allows the facility to work out its own methods of compliance, leaves much more room for adjustment to individual circumstances and needs, and therefore more room for success.
• Create practical and reasonable standards. Individual certification requirements, for instance, can allow for a certain amount of experience to take the place of a certain amount of training or education, or for a variety of combinations of the three, so that the largest number of competent people can be certified. Rather than demanding the immediate removal of toxic materials - asbestos, e.g. - from a facility, a timeline can be instituted, so that whole facilities don't have to shut down for months in order to comply.
• Make sure that the standards include some mechanism for continuation. As with any other change, new certification requirements or quality standards are only useful as long as they make a difference. The need to recertify every year or two - with actual requirements for each recertification (courses, professional development, update of facilities, etc.) - the annual reexamination of quality standards, or the annual reassessment of best practices could serve to ensure that the positive consequences of policy modification will carry forward.

Advocate for your proposed modifications.

No amount of work on developing requirements and standards will help if you can't get those requirements or standards adopted. That means convincing policy makers, and often the public as well, that doing what you propose is a good idea.

• Explain why new standards are needed, or why existing standards should become policy. Use research, fact sheets , statistics, testimony from recipients of services, etc., to present compelling reasons for change to policy makers and the public.
• Keep the issue before the public, using the media and key communicators in the community. The more people are informed and concerned about the issue, the more likely policy makers are to act.
• Mobilize your support. Use your contacts with policy makers, members of the media, key community members , and supporters among affected and concerned professionals to keep up pressure for change.

• Offer to help. Present your plan, and offer to convene or participate in a coalition or committee to work on the issue, with your plan as a starting point.

Even after policies are changed, continue to monitor and evaluate the situation indefinitely.

As with any health and community development work, policy modification demands maintenance. When a reform becomes routine, people can forget that there's a reason to pay attention to it, and it can cease to be effective. You have to continue to pay attention, so that if enforcement becomes lax, or the requirements start to slip, someone will notice and remind everyone of why those requirements were changed in the first place. You have to continue to evaluate the new or changed policies for effectiveness, and to make sure they take the changing needs of the community into account. Once you start the process of policy change, you have to stay with it for the long haul.

In Summary

To ensure the quality of services, you have to ensure that the individuals, organizations, and facilities delivering the services are competent and appropriate to the task; offer a certain level of comfort, dignity, and humane treatment to participants; behave ethically toward participants, funders, one another, and the community; are aware of and use best practices where appropriate; and apply quality standards that benefit and safeguard service participants and the community.

Although there is no absolute guarantee of individual competency, for instance, or that a best practice for a particular community will be the best practice for others, there are some policies that can control, to the extent possible, for some factors that influence the quality of services:

• Required licensure or certification for individuals and/or facilities.
• Mandated adherence to a professional canon of ethics, or to a general set of ethical standards.
• An obligation on the part of individuals, facilities, and organizations to be aware of current thinking about best practices in the field, and to employ those practices when appropriate.
• The availability and accessibility of services to those who need them.
• The inclusion of quality standards in local laws or bylaws, agency regulations, funders' considerations, etc.
• The evaluation and modification of policies as needed to meet the needs of the target population and the community.

Some advantages to modifying policies in these directions include assuring a minimum level of quality; showing seriousness of purpose, and establishing the issue as one that should be treated seriously; demonstrating respect for the target population; giving the community confidence that the issue is being handled appropriately; lending credibility to both the effort and to the organization(s) providing services; increasing the chances that an intervention or service will be effective; and addressing the underlying foundation of service quality - the policies that control it.

Among the objections to this type of policy modification are that it may assure at best only a minimum level of quality; it may filter out imaginative solutions and people with valuable talents and skills; an emphasis on professionalism may alienate the target population or the community; bureaucratic requirements may present barriers to talented individuals and organizations; and changing policy may not actually address the problem. Modifying policies to reflect these possibilities is not always the best course of action. It's important to understand and analyze your situation to determine what's right for your community, and to build in flexibility if you do modify policies.

In general, a broad-based coalition is the ideal group to originate and advocate for policy modification. If the formation of such a group is impossible, reasonable alternatives are an advocacy organization, community based organizations that work with the target population and the issue, a local initiative including members of the target population, or a local branch of a professional association.

Some particularly good times to try to modify policies are before services begin; at the beginning of a new service period or funding cycle; when services prove inadequate; when a regular assessment and reporting process shows little or no progress; when new information or events create a logical opening for policy modification; or when public opinion demands change.

Actually modifying policy takes several steps:

• Learn about the existing policies, both explicit and unspoken.
• Decide whether modifying policy is the appropriate course of action for your situation.
• Determine which of the policy modification choices you're aiming for: the development of a certification requirements, or ethical or quality standards where none have previously existed; changes to current requirements or standards; or the mandated adoption of current requirements or standards.
• Develop new or revised requirements or standards as a proposal or starting point.
• Advocate for your proposal.
• Continue to monitor and evaluate the situation so that changes and effectiveness are maintained.

If you are successful in modifying policy to institute changes, you can have a profound effect on the quality of services available in your community.