Five-Star Quality Measures & Outcomes

Introduction

In the Five-Star Quality Model^TM there are several key elements that must be clearly understood in order to accurately describe the degree of quality that exists. Accurately (and objectively) describing a human service agency's quality level, provides the necessary understanding of what quality level the organization currently is delivering and thus provides the direction for what must be done to move to the next higher level.

Additionally, we hope to provide further information on the measures that will help the reader to more objectively identify the level of quality by the outcomes evident. There are many ways to accomplish the different levels of quality so it is not possible or necessary to describe every way that these things can be done. It is far more important that we have a clear understanding of what the outcomes are for each level.

At the same time, it is not our intent to come up with a chart that details percentages, logarithms, or can be scientifically proven. Thus, Five-Star QualityTM is a system that is not about "paper compliance" or abstract policies and procedures, but rather something that we will be able to define by "what we see when we see it".

Five-Star Quality: The Concept

The Five-Star Quality Model concept can be described as a continuum of five stages in which two things occur. First, the individual is transformed from client to citizen. Second, programs and initiatives undergo a transformation from being agency developed, led and "owned"; to being led, implemented and "owned" by the community. Each level can be described by a set of key measures and outcomes related to these two ideas. We will outline these later in more detail.

In our model (Fig. 1), quality levels One through Three describe initiatives that deliver experiences to the person that are confined within what we call the "Disability Bubble" - meaning that in these first three stages, programs are developed and operated by agencies for people who have disabilities - effectively both the person and the program are confined within the system and are not members in or of the community. Hence they remain in the protective Disability Bubble.

Between quality levels Three and Four is what can be described as the "Quality Transformation Threshold". This is the key line of demarcation that needs to be described and evaluated. Below this line, programs and initiatives are agency owned and led, and clients remain within the disability system. Above this line, programs begin to be community led and implemented, while clients begin to transform into citizens and to become members in and of the community.

This fundamental distinction between initiatives and the resulting outcomes, and whether they are above or below this Quality Transformation Threshold, is the most crucial idea to understand in terms of defining the quality level of agency or program.

Three-Star Quality is Still Good

Having said that, we want to emphasize that Three-Star Quality is very good - it is the best of what traditional service systems have available. In comparison to much of what we currently see in operation after 60 years of community services - within the Disability Bubble, only Three-Star Quality could be considered great quality.

Most typical accreditation services would consider this level of service to be worthy of their highest evaluation. Three-Star Quality means that an agency has at least crossed the point of no longer seeing that all supports for people with disabilities need to be self-contained - meaning that they understand that not all services and supports must be provided within the walls of the agency, by agency employees or volunteers. Most importantly, it means that the agency helps people enrolled in their services to not just "be" in the community, but helps them truly become participating members of their community.

This frankly contrasts with most Two-Star Quality situations we see that are still incredibly prevalent in human service agencies today. Any type of sheltered employment, group home, or other operation they can be distinguished as self-contained, is clearly Two-Star Quality. These operations may meet all of the licensure requirements, have great health and safety records, hold multiple accreditations, and have community outings on a regular basis, but they are still only a Two-Star Quality program in the Five-Star Quality Model.

From Client-centric Service to Community-centric Support

… the agency becomes a support for building community competency - so that the community can help people who have disabilities become functioning citizens - with the least amount of specialized support from the human services agency as is possible.

This mindset obviously requires a significant transformation of the organization if it is to embrace this clear redefinition of success. Success is no longer measured by the number of employees, the size of the budget, the number of programs it operates, awards, accreditation, or how well it is known in the community.

Quite to the contrary, the organization moves to the background and the community and the people who receive support move to the foreground. The new identification for the person who receives support now becomes that of an employee, member of the (non-disability) community organization, or team-member of the event, or a full citizen participant of the community opportunity, rather than being identified as a "client" of the disability agency.

An Incremental Step to Four-Star Quality

For the immediate future, Four-Star Quality can be defined as when the organization begins a project, such as a supported employment project within a factory, but then turns it over to the management of the factory. The organization then provides support to the various departments of the factory so that they are able to meet the needs of the individual employees with disabilities.

Another example could be the dance that was always sponsored by the disability organization and that others in the community were invited to attend. To reach Four- Star Quality status, the agency turns over the dance planning and execution to the local Elks Club and the agency's name now is only identified under the heading "with support from", and thus joining others on the list such as the local radio station that promoted it, the grocery store that provided food and decorations at cost, etc. The agency's role now is to be invisible support as trainers, consultants, greeters, clean-up staff, etc. but not as "obvious staff".

Five-Star Quality Measures and Outcomes

So far we have discussed Five-Star Quality from a conceptual perspective. But just how is one objectively to determine program and agency quality? In other words, what measures and what outcomes can we use to evaluate "what we see when we see it". Fortunately there is a set of key measures and outcomes that one can use as a starting point to provide insight into the quality level of the program or agency we are trying to assess.

We have developed a basic framework of criteria as a starting point for evaluation… However, there are additional general qualitative factors that can be used as measures within the Five-Star Quality framework....

As we have outlined earlier, some of these measures include:

• Program/Initiative Leadership. Who develops or leads the program or initiative? Is it solely the agency or is there community involvement or leadership?
• Program/Initiative Location. Where is the program held? Is it at a sheltered workshop or is it within a community venue?
• Program/Initiative Focus. Who is the program designed for - solely for the person with disabilities, or also the general community? Who can participate - only those served by the agency or does it permit participation by the community and interaction between attendee groups?
• Program/Initiative Responsibility. Is the agency funding, directing and managing the initiative, or is the community in charge? In other words, who is the "owner", who has the final say…

Once these questions are answered, we need to be rigorous in our evaluation of the outcomes they produce for the individual. The overriding issue is how and where we view the person - are they client or citizen? We need to ask ourselves what the result of the initiative is for the person.

• Is the person absent from the community, are they in the community, or are they a participant with the community? (One, Two and Three-Star)
• Is the person a member of the community or are they of the community? (Four and Five- Star)

Quality Levels Illustrated

By using the dance example, we can describe each level of quality and its outcome.

• One-Star: A dance for people with disabilities that is sponsored by the human services/disability organization and held at the sheltered workshop. (The person is "absent from" the community).
• Two-Star: A dance for people with disabilities is held at the local YMCA that is sponsored by the human services/disability organization. People with disabilities are "the audience" even though some people who do not have disabilities may attend. (The person is "in" the community)
• Three-Star: A dance for the general community is held at the local YMCA that is sponsored by the human services/disability organization in partnership with the YMCA and other organizations. People with disabilities from that agency and possibly others are in attendance. (The person is a "participant with" the community).
• Four-Star: A dance for the community is held at the local YMCA and sponsored by the YMCA and other community groups. The human services/disability organization provides "invisible" (i.e., not publicly-recognized) support to the YMCA and the rest of the community to enable people with disabilities to fully participate as anyone else would. People with disabilities from throughout the community are clearly welcomed and may or may not have paid supporters assisting them. (The person is a "member" of their community).
• Five-Star: A dance for the community is held at the local YMCA and sponsored by the YMCA and other community groups. People with disabilities from throughout the community are clearly welcomed and may or may not have paid supporters assisting them.

The human services/disability organization is not obviously a part of the dance planning, coordination, etc., but rather acts as consultants and trainers to the sponsoring organizations to help them have the capacity to support people with disabilities and to fully to participate as anyone else would. The human services/disability agency personnel are "invisible" but remain "on-call" for the sponsoring organizations. (The person is "of" their community - meaning the community has the ability to meet any immediate needs of the individuals who have disabilities).

Final Thoughts

We know that for some agencies it will be a bridge too far. For others it is a chance to move from client-hood to citizenship. We believe that people with disabilities deserve the promise provided by full, Five-Star Quality lives, filled with the richness of experiences as the result of (with apologies to Abraham Lincoln) enlightened programs and collective efforts, of the community, by the community and for the community.

Derrick Dufresne
Mike Mayer
Community Resource Alliance
© 2010, CRA