Vol I , No3 March 1994

On January 1, the Massachusetts Department of Mental Retardation(DMR) implemented QUEST (Quality Enhancement Survey Tool), a system that"is designed to provide everyone -- individuals, family providers, DMR staff, and other interested citizens -- with clear, consumer-centered outcomes that define the quality of supports expected by the Department, outcomes articulated in the DMR mission statement." QUEST is designed to focus "on what occurs for the individual as being the most important measure of quality."QUEST is intended to answer the question:"What is the impact of supports and services on the quality of life of people with mental retardation?"

Editors' Note: With the shift of public service delivery systems from a treatment services orientation to offering person-centered supports to promote community inclusion and self-determination, states are re-examining the premises of their quality assurance systems. As a result, a growing number of states are restructuring their approaches to quality assurance. Three themes are emerging:(a) the realignment of quality assurance system to reflect new agency and system mission statements and goals;(b) the shift from process to outcome measures organized around quality of life principles;and, (c) a growing stress on collaborative quality enhancement strategies. In this issue we report on new policies and systems that are being implemented in Massachusetts and Vermont.These initiatives have common themes (although there also are differences in the apporaches that each state has adopted).

DMR's pre-existing quality assurance activities focused nearly exclusively on health, safety, individual rights, and evaluating treatment programs; "little attention [was paid]...to whether the [treatment] objectives were relevant to the lives of individuals and little focus [was given to]...aspects of quality of life such as satisfaction with ser vices." In contrast, QUEST is based on evaluating quality "based on the consumers' satisfaction with the quality of their supports and the outcomes in the lives of people we serve."

QUEST is the product of more than two years of intensive work by DMR officials, provider agency representatives, consumers and family members to revamp Massachusetts' quality assurance/enhancement systems so that they fully reflect the guiding principles that are part of DMR's Mission Statement, including consumer choice, empowering individuals and their families,and recognizing that "services providing meaningful benefits to individuals require a commitment to ongoing monitoring and evolutionary change."

The QUEST survey tool has two parts. Part ?T contains the Individual Service Quality Review. It explores six quality of life areas in-depth: (a) rights and dignity; (b) individual control; (c) community membership; (d) relationships; (e) personal growth and accomplishments; and, (f) personal well-being. Each of these areas, in turn, is broken down into more discrete outcomes that are defined by more specific, observable measures. The tool is designed to gather information from the person who is receiving sup- ports, support workers, and others who know the individuals observation and, where necessary, record reviews also are used. The tool specifically flags areas that are critical to the "person's dignity, health and safety and usually relate to the Department's regulations in such areas as investigation, medication, restraints [,and] human rights." Poor performance in these vital areas can result in marking down an agency's overall performance rating and also trigger corrective actions.

Part II of the tool is composed of quality measures geared to assessing the overall performance of the provider organization. The areas addressed in Part II include: (a) the organization's commitment to ongoing planning and evolutionary change; (b) how well the staff are supported in providing high quality services; and, (c) how well the organization safeguards the rights, dignity and personal well-being of the individuals it supports.

A team headed by a DMR Office of Quality Enhancement staff person conducts the QUEST survey. Other team members may include additional DMR staff, citizen volunteers and other human services professionals. As the team applies QUEST, it develops an overall numerical rating of the agency. This numerical score assists both DMR and the provider agency in tracking performance from period to period. The QUEST team furnishes feedback to provider agencies concerning both individual results and organizational performance.

Survey results also determine the certification status of the agency. High performing agencies are certified for a period of two years; agencies with acceptable but not exemplary performance levels are certified for one year. Where problems are uncovered, an agency may be certified "with conditions". In such cases, the problems must be corrected within an acceptable time frame. Poorly performing agencies lose certification or must agree to complete a time-limited plan of correction. These various types of certifications enable DMR to focus its quality enhancement resources on agencies that are performing poorly or marginally. Such agencies are subject to more frequent reviews and more intensive follow-up to ensure that problems are corrected. High performing agencies are subject to less frequent and less intensive surveys.

A computerized tracking system has been developed to support QUEST. This system will enable DMR officials to gather systemwide performance information and, hence, provide information to key stakeholders concerning how well DMR-funded or provided services are meeting the overall aims set out in the Department's Mission Statement. QUEST also permits DMR officials to spotlight agencies that have particularly high performance as well as identify areas where technical assistance and other support is needed. In addition, QUEST results furnish DMR regional offices with information upon which to base ongoing monitoring activities and arrange regional provider training programs.

With the implementation of QUEST, DMR has eliminated its pre-existing "multiple, uncoordinated systems of monitoring in favor of one, unified tool and process applied to all individuals across all settings where services are provided." DMR officials point out that the strengths of QUEST lie in its adherence to the Department's Mission Statement as well as its focus on outcomes and quality enhancement. The system is fully described in a Survey and Certification Procedures Manual and the QUEST tool itself. FMI: Mary Cerreto, Ph.D., Office of Quality Enhancement, Department of Mental Retardation, 160 North Washington St., Boston, MA 02114 (tel 617/727-5608).

"We are moving from a system that has historically emphasized' processes' to a system that evaluates quality based on the consumers' satisfaction with the quality of their supports and the outcomes in the lives of people we serve."

The Community Services Reporter is supported in part by grants from the Administration on Developmental Disabilities to the Institute on Community Integration/UAP, University of Minnesota to maintain a National Residential Services Information System (No. 90DD0342/01) and the University Affiliated Program at the University of Illinois at Chicago to analyze national expenditure trends (No. HHS90DD347-01). The opinions expressed are those of the authors and do not necessarity reflect the views of the Administration on Developmental Disabilities.
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The Reporter's goal is to provide up-to-date information on efforts around the country to improve the delivery and management of community services and supports for people with developmental disabilities. We always are interested in learning about new developments at the state and local levels. Please forward any materials about such developments and how additional information can be obtained to : Gary Smith, Director of Special Projects, NASDDDS, 6893 S. Miller Street, Littleton, CO 80127.