System Reinvention and Shifting Accountability

An advantage of persistently pursuing service improvement over a long period of time is that we get to see the progression of slow moving things. Take the notion of accountability in human services for example. Many years ago the provider community held the consumer responsible for his or her own outcomes. If there was no constructive change after an attempted intervention, the person was blamed for being resistant or incapable of change.

With the advent of interventions that have been demonstrated to have clear benefits to consumers, accountability for outcomes shifted to the practitioner. If consumers do not benefit from interventions these days, the practitioner is blamed for being resistant or incapable of change. After all, research has clearly revealed the path to better practices if only the practitioner would use them properly.

What we are witnessing today is a shift toward holding human service systems accountable for the benefits (or lack thereof) at the consumer level. The Institute of Medicine (IOM), Surgeon General of the United States, and the President’s New Freedom Commission on Mental Health repeatedly have pointed to human service systems ill prepared to support the very activities that would help them achieve their mission and goals. This shift also is prodded along by our growing understanding of the science and practice of implementation. It is becoming clear that state and federal systems need to be aligned to support (not hinder) practitioners’ efforts to use evidence-based practices in their interactions with consumers.

Another related part of the slow moving progression in accountability in human services has to do with what is measured. In the days when the consumer was held responsible, exposure to a qualified professional was the key. Exposure to qualified professionals was assessed with measures that tended to focus on academic and professional qualifications of professionals and number and length of sessions. With the shift toward holding practitioners accountable, measures of adherence to evidence-based program protocols (e.g. fidelity) became important. In this view, the protocols are firmly rooted in research demonstrating their benefits, and fidelity tells us all we need to know about consumer outcomes.

With the shift toward holding human service systems accountable, measures have broadened and have begun to focus on consumer outcomes that are related to specific provider organizations and practitioners. Outcome measures themselves are undergoing modification with less emphasis on diagnoses and symptom reduction and greater emphasis on recovery, resilience, and quality of life. The view of “the consumer” also is undergoing change with less emphasis on the individual and greater emphasis on the functional ecology of the individual (e.g. family, friends, neighborhood, community). Statewide evaluation systems in children’s mental health in Hawaii and Michigan point to the amazing value of having reliable and valid data regularly available for decision making at all levels: practitioners, managers of provider organizations, and policy makers and funders. In these states, form follows function. Once the function (consumer outcomes) became known, form began to change (new roles defined to routinize new activities, new bureaucratic systems put in place to support improved results). Knowing their outcomes has helped these states reduce the incidence of highly variable, ineffective, and sometimes harmful interventions and policies (to cite the conclusions of the IOM and Surgeon General, among others) and create whole systems that work better for consumers.

A final aspect of this slow moving progression toward systems accountability reflects a change in problem solving style. For many decades, the predominant style of problem solving in human services was reactive: when something got bad enough, practitioners, organizational managers, or service system policy managers would respond by doing something or the other to try to reduce that source of difficulty. Many states have undergone a seemingly endless series of reorganizations (e.g. centralization, decentralization, and back again) as a result of this reactive style of solving problems (often in response to class action lawsuits).

Along with a greater understanding of the possible benefits of evidence-based practices and programs has come a more proactive and thoughtful style of solving problems. Community needs are matched up with available evidence-based programs with the idea that research-based solutions purposefully can be brought to bear to solve the identified problems. Today, with a growing acknowledgement of service system accountability, we may be on the verge of moving toward a visionary style of solving problems. A visionary style is focused more on goals and desired outcomes and less on specific (perhaps symptomatic) problems. A visionary style helps us see past the current issues that attract our immediate attention into a future of what might be, “if only we....”