Point “A” – Potential Clients: Returning our attention to the Helping Triangle – see Figure 1
– let’s start our consideration of Indicators and Interventions with Potential
Clients. They are the target group from which SSI clients come. We can think
about Potential Clients as an element in the SSI eco system. The function of
this element is to provide appropriate clients to receive SSI services. The
element is functioning correctly if it produces a sufficient supply of people who appropriately engage with SSI services.
It is, conversely, not functioning correctly if the supply of people is
insufficient to fully use all available services, if the people who are supplied
are inappropriate, or if those who are appropriate do not successfully use SSI
services.


This simple understanding of
the element’s – Potential Clients – function shows us how to recognize
Indicators exceptions are present. A real-world human services agency situation
would certainly be more sophisticated, but our SSI example suffices here. When
there are exceptions present, we see one or more Indicators. To illustrate, we
determine there are not enough people from the target group requesting services.
– We know this by tracking and analyzing how many people request services. -
This may be because we have not correctly identified the target group, or we
may not have adequately worked with the group to prompt its members to request
services. We know people are usually referred to SSI by someone else, so we may
not be working adequately with people who may refer other people. We start with
the Indicator – insufficient people requesting services – and then develop
possible explanations accounting for the status of the Indicator. We know there
is an exception in the SSI eco system and we proceed to diagnose the cause.
Once we diagnose the cause, we intervene. – Conversely, there may be too many
people requesting services, resulting in waiting lists and long delays for
people needing help. This situation is also an exception needing attention.


To facilitate both the
diagnostic step and the intervention, we meet with Potential Clients and with
people who would likely refer clients, sharing our supporting data with them.
We let them know about our concern, including letting them know we are not
having enough people request services. We enlist their help with understanding
why and with how to correct the exception. We develop additional intervention
strategies, but we start with a clear statement of what the function of the
element is – its purpose. We then determine what the Indicators are showing us
about any exceptions that are present. When an Indicator is present, we
diagnose the cause and develop strategies to intervene. Thinking about another
Indicator assists our understanding here.


It may be there are enough
people requesting services, but a significant number of people requesting
services are not appropriate. We know this by keeping data about who requests
services and whether they are appropriate. We start by revisiting how we
established the target group. Perhaps the target group members are not actually
potential clients. We may be targeting the wrong people. Our work with the
target group may be inadequate or somehow misleading its members about who
should use agency services. We may need to work more with people who refer
other people to clarify who they should and should not refer. As we carefully
diagnose the exception and its cause, we may conclude we should reconfigure the
target group, provide more training for SSI staff members who work with the
target group, develop better literature about SSI and its services for
potential clients and for people who refer clients, or pursue other strategies
to be sure our intervention is actually focused on what is causing the
exception.


From our understanding of the
function of the element, another Indicator might be whether or not clients
successfully use SSI services. We develop ways of tracking this outcome. We
carefully define what we mean by successful and unsuccessful. Once we are clear
about what we mean by those terms, we proceed to diagnose the cause of
unsuccessful use. Let me simply emphasize here we want feedback from clients
who do and do not use services successfully. They are the best source of data
about their behavior. Additionally, we want to know what service Providers
think about the exception and what insight the people who refer clients may
have. There are reasons for the exception. For example, some people using
services may not have adequate resources such as child care or transportation
needed to participate in services. Our task is to find those reasons. Only then
can we responsibly and effectively intervene.


Point “1” – The Initiators: Initiators are concerned about the inability of Potential
Clients to adequately cope and pursue strategies to make sure they receive help
with their difficulties. We understand Initiators as an element in the SSI eco
system, the function of which is for Initiators to take their understanding of
the issues and their proposed solutions to the Authorizers to develop auspices
and authorization for the help Potential Clients need. SSI uses the 0-1 Leadership Connection explained earlier
to track the successful functioning of the element.


·
Is
the Initiators’ understanding of Potential Clients coping difficulties accurate
and complete?


·
Is
their proposed strategy practical and responsive to the issues?


·
Are
they successfully presenting their proposal to the Authorizers?


·
Do
the Initiators continue to positively perceive SSI and support its providing
the services?


We ask and answer specific
questions related to the functioning of the element. We look for exceptions,
for Indicators the element is not functioning as expected. Further, we create
measures letting us know the degree of malfunction. Through these tracking
activities, the Leadership Team is alerted to any Indicators of element
malfunction. This enables them to diagnose the cause of the exception and
develop strategies to intervene.


It is also important for the
Leadership Team to support the Initiators as a strategy to reduce the
likelihood of exceptions developing in the element. This is also true for most
other elements in the SSI eco system, but it is especially important with
Initiators. We want them to continue functioning successfully. To support this
goal, we actively pursue opportunities to support and facilitate their success
in areas not necessarily related to their SSI-related function. Along with our
genuine interest in them as people, our more general interest in and support of
their goals and priorities increase the likelihood they will continue to value
their SSI-related activities. Let me simply emphasize here relationships need
to be two-way. Interpersonal reciprocity is more than merely a useful
management strategy. It is the right thing to do.


Point “B” – The Authorizers: First define the function. Authorizers
provide the necessary auspices and authorization for SSI to provide services to
its clients.
Given this understanding of the element’s purpose or function,
we highlight possible exceptions. Exceptions with this element reflect changes
in either provided auspices or provided authorization. It is important to note
increases in auspices or authorization are exceptions just as are decreases.
Both require compensating adjustments within the SSI eco system. For example,
The Potential Client target group may be expanded or contracted. SSI may close
facilities or open additional facilities. The agency’s geographic area may be
changed to include more neighborhoods or fewer. Any change in either auspices
or authorization is an exception within the element. It is an Indicator one or
more exceptions are present and require intervention.


In addition to changes in the
levels of auspices and authorization, Authorizers can and often do change the
terms of auspices and authorization. This is particularly true with public
agencies, but is also true for agencies in the private sector. Resources,
funding, laws, rules, policies, procedures, and definitions may change –
sometimes quite abruptly. Those changes may relate directly to the agency and
its operation or may only indirectly effect operations. Nonetheless, SSI and
its eco system adjust to the changes in order to maintain ongoing auspices and
authorization. Minor to major changes in the Authorization element are simply a
fact of SSI management life. Drift is a constant and ever-present aspect of the
SSI eco system and the Authorization element is not an exception to the
principle.


It is worth a moment’s thought
to reconsider the nature of the SSI eco system. Each element in the eco system
is like a living organism. Imagine, for example, an aquarium populated with a
large variety of living and non-living elements. There are various animals and
plants, along with numerous other objects filling the aquarium environment. As
we watch, the environment constantly changes and reconfigures. The elements in
the environment are also changing, some slowly and others more rapidly. This
complex system is in a state of continuous flux. “Systems are defined as
entities composed of interconnected parts and characterized by complex webs of
relationships. If one part of the system is changed, then other parts are
affected as well because of the interdependence of the parts.” If we do not carefully and conscientiously attend to the system,
it quickly deteriorates. Even with our best effort, though, we occasionally may
need to replace the filter, remove dysfunctional elements and add replacement
elements, and actively manage the system. If we conceptually exchange the
elements in the aquarium for the elements in the SSI eco system, we see, like
the aquarium, the SSI eco system is inherently unstable and quite simply cannot
survive without highly skilled, competent Management. We must actively manage
the ubiquitous exceptions, manage change.


Just as the SSI eco system
continuously changes and requires constant management, each element itself
continuously changes and requires constant management. The Authorizer element
is not an exception to the rule. Auspices and authorization, like the elements
in the aquarium above, are in continuous flux. They are inherently unstable.
The rate and degree of change may generally be subtle and gradual, but change
they do. Further, occasionally the change is extreme and potentially
catastrophic. We can never take either auspices or authorization for granted.
SSI management proactively manages this element instead of simply reacting to
exceptions as they appear. The SSI Leadership Team first attempts to prevent
negative change – the appearance of unfavorable exceptions – and if this cannot
be done, the Team influences the direction and rate of change. This is Preventative Management. We know what
the exceptions in the element are likely to be and thus can anticipate their
occurrence. To the extent we successfully anticipate an exception, we are able
to develop an intervention to prevent or influence its occurrence. We prevent
or at least slow the particular
instance of drift. Better to feed the fish in the aquarium while they are still
healthy instead of waiting until they are dying or already dead.


Point “2” – The Implementers: The function of this element is to put in place the systems and sub-systems to successfully operate SSI.
Let’s limit focus to only a few of these systems and sub-systems, understanding
the element is typically much more complex for real-world human services
agencies. SSI operates with its auspices and authorization associated with a
primary authorizing entity that has specific restrictions and requirements.
Additionally, SSI has national accreditation and operates under the auspices
and authorization of the accrediting entity. Further, its services are approved
for reimbursement by Medicaid. The requirements and restrictions associated
with each of these entities are both complex and exacting. SSI’s Implementers
do what the Authorizers expect, when they expect it, the way they expect it to
be done. Some of these expectations can be negotiated, but most cannot. The
implementers must put the systems and sub-systems in place and maintain their
functioning as expected by the Authorizers.


With focus on the three
authorizing entities, we identify potential exceptions associated with each. At
a simple level, the primary authorizing entity has rules and guidelines
regulating who SSI serves and what services they are authorizing. The
accrediting entity has rules and guidelines regulating how the services are to
be provided and who is eligible to provide those services. Medicaid has rules
and guidelines regulating which services are reimbursable and to whom they need
to be provided for SSI to receive reimbursement. There are multiple and
potentially conflicting rules and guidelines SSI’s Implementers must follow.
They include for whom SSI provide services, how those services are provided and
by whom, and when and how SSI will receive payment for those services. If we
focus on these rules and guidelines, we see numerous possibilities for
exceptions as the Implementers pursue their activities. There may be exceptions
involving who SSI’s clients are, what services they receive, who provides those
services, and SSI’s being reimbursed for those services.


To understand the possible
exceptions in any eco system element, develop an exceptions map for the element, as illustrated in Figure 8,
substituting the new sub-elements and requirements for those shown in the
Figure. The exceptions map organizes possible exceptions – with appropriate
Indicators – by each component and sub-component in the element. Whether the
map shows the way to success depends on our success with accurately identifying
all possible exceptions and understanding their significance. It also depends
on developing and tracking appropriate Indicators for each exception and
carefully and systematically tracking – measuring – the status of each
Indicator.


Our exceptions map for the
Implementer element in the SSI eco system includes, among many other possible
exceptions, who SSI clients are. We know they come from the target group of
Potential Clients and experience the coping difficulties with which SSI is
authorized to help. People who do not meet these two criteria are not to be
served by SSI. We track the extent to which SSI clients conform to the criteria
because a client’s not conforming is an Indicator an exception is present in
the SSI eco system. Clients also meet the eligibility requirements for Medicaid
reimbursement. Providing services to clients who are not Medicaid eligible is
another potential Indicator that an exception is present in the SSI eco system.
Along with assuring the agency is serving the right clients, SSI also assures
Authorizers no eligible clients have been refused services or otherwise
prevented from receiving services. This is another area for possible
exceptions; and appropriate Indicators are needed and must be tracked.


The exceptions map for the
Implementer element also includes items related to how services are provided
and by whom they are provided. For example, services are to be provided
respectfully and confidentially. They are to be accurately documented and
records of services systematically maintained. All applicable ethics rules are
to be strictly followed. Services are to conform to best practice standards. All SSI services provided are to be
randomly peer reviewed. Service Providers are required to have valid and
current professional licenses or appropriate certifications. The list of
requirements could be extended, but the point is each requirement or
sub-requirement represents the possibility of an exception in the SSI eco
system. We develop and track an Indicator for each. Based on the data from
those tracking activities, we develop management strategies – including
Preventative Management – to intervene with each exception. Our goal is to
minimize the presence or recurrence of exceptions in the SSI eco system.


Point “C” – The Agency: As we saw when the Helping Triangle was first introduced, the
agency is at point “C” and is the location in the Helping Triangle
where services are provided. We went on to see the agency can be understood as
a circle, with the Primary Function of SSI located in the center of the circle.
The Primary function includes assessment, family counseling, and case management
services. Around the Primary Function are various Secondary Functions
supporting the Primary Function. Let’s revisit a few of SSI’s Secondary
Functions to better understand strategies for developing exceptions maps. We
also discuss strategies for creating Indicators for exceptions we identify and
consider the range of possible interventions.


Executive Services: The function of Executive Services is to manage the internal SSI eco system in accord with the restrictions and
requirements of associated authorizing entities with the outcome being agency
clients cope more successfully with the needs, problems, and vulnerabilities
prompting them to use SSI services. As discussed earlier, a few of the
sub-elements within this element are Implementing the Policies of the SSI
Board, delegating functions and sub-functions to other areas of SSI, developing
an effective organizational configuration, and overseeing all SSI duties and
responsibilities. The SSI eco system as a whole and the agency in particular
would be, in principle, self-managing were it not for drift and the resulting
exceptions. One goal of Executive Services is to come as close to this ideal as
possible. Keep this perspective in mind as we consider some of the possible
exceptions in the sub-elements of the Executive Services element.


There are numerous, potential
exceptions associated with each sub-element. It sometimes seems there is no end
to how many ways things can go wrong. An exceptions map for this element is
extensive. Many exceptions are possible when implementing the Policies of the
SSI Board. Each policy is a declarative statement saying what the Board expects
to be done or expects to happen. For example, SSI services shall be provided at times and in locations convenient for
SSI clients.
The times and hours of operation are periodically reviewed,
since what is convenient for clients today may not be the same next year, the
Boards intent may change as Board members change, or other factors may affect
the implementation of this policy, e.g.,
it may become too costly to maintain certain hours or locations. The
implementation of this and all other Board policies involves the potential for
exceptions. We require an Indicator for each potential exception, track it, and
intervene appropriately, as necessary.


Delegating functions and
sub-functions to other areas of SSI is similarly replete with potential
exceptions. Consequently, developing an exceptions map for this activity is
particularly difficult. The central issue is whether or not the function is operating
successfully after it is delegated. For this reason, developing an effective
way of assessing performance and outcomes before delegating the responsibility
is essential. We have to be able to tell whether or not the job is getting done
and whether it is getting done correctly. If the delegated element is
functioning ideally, how do we tell? To the extent we understand what ideal
functioning is, we can identify deviations from the ideal. Those deviations
each represent an exception. This focuses on what is going wrong and not on
what is going right. The point is going right is the minimal acceptable
outcome. At SSI, doing the right things
right is not exceptional; it is expected
.


Developing an effective
organizational configuration similarly holds possibilities for exceptions.
Additionally, it is not a one-time activity. Any time there is a change in any
element within the SSI eco system, the system has to either spontaneously
adjust or be intentionally adjusted to accommodate the change. Periodically,
changes require rearrangement of the system elements, reallocation of
resources, redistribution of duties and responsibilities, redefinition of
secondary functions and sub-functions, and other configuration changes. At
times, we immediately know one or more of these management interventions is
needed. We simply see SSI cannot function successfully with the elements and
resources configured as they are, given the current circumstances and
requirements. At other times, we become aware the SSI eco system or some aspect
of it is not functioning as expected. At those times, close attention and
extreme care are needed. It can be very tempting to precipitously reorganize,
reassign, reconfigure, redistribute, or otherwise just do something. The
problem is whatever we do has expanding effects throughout the SSI eco system.
Further, it violates the first rule of SSI management intervention. Diagnose and then intervene.


The second rule of SSI
intervention is intervention should
always have the minimum consequence
. We never do more than needs done and
intervene in a way resulting in the least change consistent with expected
functional requirements. This rule especially applies to configuration changes
in the SSI eco system. Reconfiguration is a bad idea without a clear sense of
both the potential benefits and the potential problems the action may cause.
This is particularly true since reorganization and reassignment frequently
accomplish little more than moving the problem or issue elsewhere in the eco
system. “Reorganization often is seen as largely cosmetic and negative,
sometimes improving organizational operations but perhaps more often serving
political or ideological ends or portraying policy makers and leaders as
innovative and administrators as curing intractable problems.” Suppose we have a large, complex aquarium
that is mostly functioning fine. We would not start changing this and that just
because we notice a problem with one element. Rather, we would make only the
minimum change required to correct the problem and one potentially affecting
the rest of the eco system as little as possible. The SSI eco system requires
the same level of thoughtful attention when considering any change to the
configuration of the system itself.


Three factors require caution when
intentionally introducing any change into the eco system such as new
configurations, new procedures, new programs, or modified requirements or
expectations. The first is size and
is analogous to introducing a rock into an aquarium. If it is simply dropped
into the eco system, it NAME=”ehsm_OLE_LINK191″>NAME=”ehsm_OLE_LINK190″>precipitates a significant
disruption; and the larger the rock, the greater the disruption. The point is
to always introduce change as gently and as thoughtfully as possible, given its
potential to permanently damage the ecosystem itself. The second caution
applies to the number of changes
being introduced. The more changes occurring concurrently, the greater the
disruption to the eco system. The third caution relates to speed. The more rapidly any intentional change is introduced, the
greater the associated disruption. All intentional change within the eco system
destabilizes the system to some extent and threatens its operating integrity.
Intentionally introducing change is necessary to assure continuing
effectiveness and responsiveness but must always be managed with careful
attention to the disruption and disorganization it inevitably causes and with
thoughtful consideration given to the size, number, and speed of change both
over time and at specific points along the way.


Overseeing all SSI duties and
responsibilities should not be interpreted to mean anyone understands or knows
about every activity within SSI. Duties and responsibilities are assigned to
specific staff members who are substantially qualified to successfully do what
needs done. What’s more, each SSI staff member can and does function
autonomously and relatively independently. He accomplishes what is
expected, as expected. He does the right things right, the first time, on time,
every time. We trust him to do the job. We focus on outcomes and exceptions.
Our tracking systems let us know if the expected outcomes are being achieved
and if there are any exceptions signaling the need for management intervention.
We do not closely supervise and regularly check up on individual staff members.
Rather, we know what outcomes he is expected to produce. The tracking system
for his area of responsibility is designed to alert us to exceptions or
deviations from what is expected.


Administrative Services: The function of this element is to arrange for and manage all
aspects of SSI daily operations not specifically assigned to other services
elements.
This means Administrative Services includes a wide range of
duties, responsibilities, and activities that may or may not have any clear
relationship to each other. This element of the SSI eco system is very complex
and critical to successful SSI operations. Even what may appear to be minor
exceptions can cause significant problems and issues throughout the agency.


Creating Indicators letting us
know when exceptions are present in the Administrative Services element is
challenging. This is because of the complexity and the sheer number of
sub-elements present. Also, the types of sub-elements vary significantly. Even
a cursory inventory lets us see the sub-elements are very dissimilar. A
computer network is much different from receptionist services. Appropriate
furniture is quite different from scheduling systems. Janitorial services have
little relationship to vehicle maintenance. Even so, we have to know when there
are exceptions in any of the sub-elements. Accordingly, we create and track
related Indicators for the exceptions. Whenever possible, we want regular,
reliable data to signal the presence of exceptions. For some exceptions and
especially for exceptions in many Administrative Services sub-elements, we also
need responsible observers. They are SSI staff members who report
exceptions they observe. This may result when a staff member is asked to report
any problems or exceptions they notice in a specific area or sub-element. More
generally, all SSI staff members are responsible to report any exceptions they
observe in any area of the agency. Assuring the SSI eco system functions
successfully is everyone’s job. It is never acceptable for a staff member to
observe any exception and assume someone else will report it. To co-opt a term
from child welfare, all SSI staff members are mandated reporters with
respect to observed exceptions in the SSI eco system.


Fiscal Services: The function of Fiscal Services is to track, manage, and
report on all fiscal aspects of SSI operations.
As with other elements, we
create Indicators to let us know when exceptions are present. For Fiscal
Services, most exceptions are difficult to spot. This is primarily true because
of the type of specialized expertise required to determine whether or not there
are problems or issues. Fortunately, most human services Managers know when
they do not know. This level of self-knowledge is essential for successful
human services agency management. They can easily tell when people are
complaining about not getting paid, when reported revenues or expenses are not
as expected, or when funders are not paying or are notifying SSI they are not
getting correct or complete information. If there are fiscal exceptions not
reported by outside people or entities, most Managers do not have the expertise
needed to tell. For this reason, regular, thorough audits are critical for
SSI’s continuing success. Additionally, they must be conducted by qualified
people who are in a clear position to be objective both when conducting the
audits and when reporting on them. If the auditors do identify exceptions,
along with explaining the exceptions and their causes, they provide
recommendations about how to prevent any future occurrences of the exceptions.


Let me simply make this point.
Fiscal Services is not the only SSI element or set of activities requiring
specialized expertise to track and manage. Further, skilled human services
agency Managers are never reluctant to acknowledge limited knowledge or
expertise and to access external consultants and subject matter experts to
supplement and expand their expertise, e.g.,
computer network issues, statistical analysis needs, and so on. SSI management
must know what the ideal functioning of each staff member and agency element or
sub-element is. Based on this ideal, all possible exceptions need to be
carefully and consistently tracked. For any human services agency, this
requires the responsible use of outside experts and other knowledge resources.
It is simply not possible to sustain an agency’s success without them.


Point “3” – The Providers: This point on the Helping Triangle represents the SSI
professional staff who provide assessment, counseling, and case management
services to SSI clients. We are interested in exceptions to what we understand
to be best practice. Think about what is usually referred to as quality
assurance or quality improvement. Our issue here is services delivery is not
consistently at an ideal or optimal level. “Quality improvement means that
we continually monitor and adjust, when necessary, our practices and programs
in order to enhance client service delivery.” The
strategy is to adjust the level of practice to reduce or eliminate the
exceptions so practice more nearly conforms with the ideal. To identify
exceptions in any area of the SSI eco system, we first determine how that
aspect of the eco system should function. What would we see if it were
functioning ideally? Based on this understanding, we create strategies and
tracking systems to alert us to any exceptions to ideal functioning.


Within this element, our
exceptions map includes multiple areas of interest. For example, we understand
the procedures and processes used to conduct assessments conforming to SSI’s
standards for the activity. The assessments are only conducted by staff members
who are substantially qualified to conduct the assessments. Additionally, staff
members conducting assessments are provided competent clinical or practice
supervision, appropriate equipment and supplies, adequate facilities, and an
environment conducive to those activities. Further, there are clear procedures
and protocols staff members follow for the assessments. They also follow SSI
requirements for records and reporting. There are clear practice standards and
procedures for this sub-element. The same holds for family counseling and case
management. Each practice area has its standards and procedures SSI staff
members follow.


Exceptions in this element
occur whenever there is a variance or deviation from applicable SSI standards
or procedures. Identifying and tracking any exceptions involves multiple
strategies. Extensive data is entered into the client records, documenting
activities and outcomes. This data is accessed for tracking purposes. Staff
members providing SSI services discuss their activities and progress with their
clinical or practice Supervisors. This process enables the Supervisors to pick
up on and correct many exceptions related to the work of individual
practitioners. Case records are peer reviewed for clinical or practice
appropriateness and completeness as well as to make sure all required information
is in the record. Beyond these internal steps, case records are periodically
reviewed by outside experts on the same basis as used for the internal peer
review. When exceptions are identified, corrective action strategies are
implemented to reduce the likelihood of recurrence. These may include
activities such as more intense clinical or practice supervision, remedial or
additional training, revision or clarification of procedures or protocols,
along with guidance and instruction. Quality improvement is the outcome of
these interventions.