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.” (Proehl, 2001, p. 64) 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. Lets 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.” (Gortner, Ball, & Nichols, 2006, p. 106) 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 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. Whats more, each SSI staff member can and does function autonomously and relatively independently. He (or she) 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 everyones 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 SSIs 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 agencys 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.” (Unrau, Gabor, & Grinnel, 2001, p. 7) 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 SSIs 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.