Blog

In the middle of a great week writing this post.  Monday I was honored to give the Keynote Address at the International Association of Employee Assistance Professionals in Education Conference in Scottsdale Arizona.  It was one of those great conferences where I learned as much as I taught. Now I’m in Santa Fe conducting a HIV Medical Case Management Certification for some amazing folks at Southwest CARE Center. Good to be in the Southwest with great and passionate people!

Great conversations on the last quality post!  I encourage everyone to check out the comment sections from the last post.  To review last week’s post, we started with Sid Kemp’s definition of quality “The opposite of quality is error, and quality management is the effort to bring error under control and reduce error to acceptable levels.”  In this post I want to rethink error in our work and therefore question how we approach quality in the helping professions. 

We utilize many of the processes that were developed by our peers in the business world to improve “quality” in our organizations. While there is value in processes such as Plan, Do, Check, Act, our struggle to measure the work of helping traumatized individuals is that we have not fully defined what error we are trying to correct.  As so often is the case, I have to start by admitting that my wife is right!

If you have not met Sarah, I somehow convinced one of the most amazing and beautiful people I’ve ever met to share her life with me.  Sarah teaches first grade and we have had an ongoing argument about pay for performance in the teaching professions.  I have always argued that paying teachers based on their students’ academic growth was a fair way to reward the best teachers (Sarah being one of the best I’ve ever seen) and to remove poor teachers.  In my thinking, you could utilized quantitative data (standardize tests) to determine the quality of teaching being delivered to the kids in our community.

Then I started to research and think about quality in the helping professions and Kemp’s definition of quality and the role of error.  In the human services (and let’s include education here as well) we utilize the improvement process developed in Six Sigma, Total Quality Management and other approaches designed to reduce error.  But what is this “error” we are trying to eliminate? And even more important what error do we have control over?

In manufacturing, where the quality movement was created, they have near total control over error.  The error occurs as a result of their own processes.  In other word, the manufacturing process creates the error and quality improvement attempts to identify and fix the process in order to eliminate the error.  The key word here is “control.”

What control do we have of the processes we are trying to measure?   Certainly we have control of some errors like doing harm and traumatizing clients.  However, when it comes to Sarah educating first graders, an HIV Case Manager trying to increase medical adherence or a therapist trying to help a client overcome a personality disorder, we have limited control over the factors we are trying to improve and measure.  Learning, healing and well-being are dependent on so many factors how much “control” do we really have and where do the errors occur?

The root of Sarah’s argument is that there is so much that happens outside the classroom, which affects student performance, that it is nearly impossible to measure the teacher’s work.  How do you measure what the teacher, therapist, case manager is doing and what is due to past trauma, housing instability, substance abuse, attachment or  social economic or mental health factors?  I would like to propose that quality in the helping professions is really working with errors that occur in the community and not something we have “control” over.

The error we are attempting to “control” happens in the community, outside of our actual work.  After rethinking quality I have come to the conclusion that we work to correct error that occurs in society.  Child abuse, HIV, domestic violence, homelessness, hunger, war, etc. is a failure of aspects of our community.  We have the capacity and knowledge to prevent these events from ever occurring.  We have enough food to feed the world, we can talk through our problems instead of abusing or bombing each other and many diseases could all but be eliminated with easy and cheap behavioral changes.  I’m attaching a slide from a recent quality training that states the rate of some errors in our society.

The errors in society come through our doors every day.  Please do not hear that I am saying our clients are the errors, instead I’m saying that these errors have happen to them.  Our clients seek our services because they have been traumatized, impacted by generational poverty or have not had the resources or opportunities to create sustainability for themselves and their families.  Instead of controlling processes that cause error, most of us work to help our clients overcome the errors that have happened in their lives. 

In our professions we work to correct errors that already happen. My wife has little control over the parenting her kids receive, the kids’ past educational experience, developmental and learning issues, the culture of the school in which she works and whether a first grader had a bad morning before taking the test.  To hold her accountable for all these variables is insane and isolating the variables we could measure her performance on is nearly impossible. 

I learned this lesson early in my career, then obviously forgot it!  My first job was working with gang members from Indianapolis.  At the time Indianapolis had the highest murder rate in the country due to the Chicago based gangs fighting for control over the crack trade.   I considered myself a good therapist at the time but my teens did not do well after leaving our juvenile justice facility.  When I thought about what I was trying to do I realized that my failure was due less to my skills, than to the fact that we sent these kids right back to the neighborhoods that were the killing fields of the gang war.  Leaving the gang likely meant their friends would kill them, and would do nothing to decrease the threat from the rival gang.  Staying affiliated to the gang at least gave them some protection in numbers. 

They were safe in our facility, the moment they went home they were in danger and returning to the gang was the only logical decision and one I would have made if I had been in their place.  I was supposed to help them live a life free of crime, yet a life of crime was basically their only chance for survival.  Needless to say my outcomes (future criminal activity) were not great!

So one of my favorite things about quality is challenging assumptions.  In my example it was assumed that putting kids in locked facilities would prevent future criminal behavior.  The reality was that their survival was dependent on continuing criminal behavior.  The money that paid my salary would have been better utilized in improving the neighborhoods and stopping the crack war.  At this point I want to turn it over to you in our community.  If you look at the errors as happening outside our organizations what does that say about what we are trying to measure? 

I can’t wait to hear your thoughts!