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Evaluating the Quality of Residential Services for People with Disabilities Using Program Analysis of Service Systems' Implementation of Normalization Goals (PASSING)

Errol Cocks
Director, Centre for Disability Research and Development Edith Cowan University, Australia

AbstractIn 1993, the last group of residents of a large hostel for 41 adults with severe intellectual disabilities and multiple physical disabilities left the hostel to live in ordinary houses in the community. The residents, many of whom had lived in the hostel since its establishment in 1955, were relocated into 13 homes in groups of between two and five people. To address the vulnerability of the residents and safeguard their interests, the agency initiated a Safeguards Project, a major element of which was an external evaluation of each of the 13 homes using an evaluation instrument, Program Analysis of Service Systems' Implementation of Normalization Goals (PASSING) (Wolfensberger & Thomas, 1983).

This paper provides an overview of the service and its changes; a description of the PASSING instrument and its origins; an account of the evaluation process and outcomes; and an analysis of the issues associated with the size of the living unit of residential services and quality of outcomes for people with severe disabilities
.



Introduction

This paper describes a process in which a non-government agency providing residential services for severely disabled adults changed its service provision from a large institution to disperse small homes in the community. The agency developed the "Safeguards Project" to safeguard the residents and service qualities in the new environments which incorporated an external evaluation of the community-based services. The evaluation used an instrument based on Social Role Valorization (SRV) called Program Analysis of Service Systems' Implementation of Normalization Goals (PASSING) (Wolfensberger & Thomas, 1983). The paper provides an overview of SRV theory, a description of PASSING, and the results of the evaluation focusing on one aspect of service qualities, the size of the living units based on the number of people who shared each home.



The Agency, Clients, and Change Process

The agency was established in 1954 by a group of parents of young children with severe and multiple disabilities. The only option for these families who could not care directly for their children was a large mental hospital, which was unacceptable to the parents because of the extremely poor services provided. In 1955 the agency opened a hostel that eventually provided accommodation for 36 young people who remained there into adulthood.

In 1994 when the Safeguards Project began, the average age of the agency clients was 38 years (range 24-61 years), and the average time with the agency was 25 years (range 1-38 years). Clients' impairments included sensory, epilepsy, cerebral palsy, and spastic quadriplegia. One third had limited physical mobility, most requiring facilitative equipment and aids including wheelchairs, hoists, and modified vehicles. Two clients could communicate verbally and seven could sign to a limited extent. Almost all clients required considerable help in daily living activities. All had severe or profound levels of intellectual disability and required high level of supervision.

Elsewhere (Cocks & Stehlik, 1996; Cocks, 1997), the evolution of this agency since 1954 and the relationship of this to broader developments in Western services for people with disabilities were described. The agency began with a focus on custodial care and very low expectations for the clients' developmental potential resulting in almost sole emphasis on the provision of physical care and the denial of developmental and educational experiences considered necessarily for human development and growth. In the late 1960s, the ideology of agency shifted with significant internal and external influences. Expectations increased resulting in the provision of developmental and educational activities for the clients, now young adults. The normalization principle (Nirje, 1969; Wolfensberger, 1972) influenced the agency along with the disability field generally in Western countries. Normalization argued for people with disabilities to be given access to the "Normal" rhythms and routines of life ordinary people took for granted. Implicit here was the vital importance placed on integrated living and a human rights framework. Similarly to many disability organisations across the world, this agency internally reorganised the hostel's physical environment, creating more "homelike" conditions and introducing more opportunities for clients in activities outside the institution.

Finally, it was decided to relocate clients into ordinary housing in the community and close the hostel - a momentous decision considering the enormous commitment to the hostel and the nature of the agency history. With financial support from government, the agency began to establish homes in the community and to relocate its clients in 1987. The first group home was established for six people who needed accommodation but were not clients of the agency, reflecting the early caution of the agency regarding its own clients leaving the hostel. The last group of clients moved in 1993. The relocation took six years although the change process occurred over the entire life of the agency as its ideologies changed. The change process included careful planning underpinned by explicit strategies. It is beyond the scope of this paper to describe these although they have been recounted elsewhere (Cocks, 1997).

In August 1993 when the Safeguards Project was initiated, 41 clients lived in 13 homes in the northeastern suburbs of Perth, Western Australia. The structure of the services included:

1. Three homes, each for two residents;
2. Six homes, each for three residents;
3. Three homes, each for four residents;
4. One home for five residents.

Three homes were purpose-built with accessible features; four homes were rented or leased; and six homes were purchased on the open housing market or were joint ventures with the state government housing authority. Each home provided full rostered staffing to enable 24 hour resident support. The three smallest homes used a live-in staffing model with rostered staff.



The Safeguards Project

In 1993, the Safeguards Project was conceived with the following purposes:

1. To safeguard the service quality and positive client outcomes that existed both prior to the change and resulted from the change.
2. To safeguard against complacency that could develop following such a major change.
3. To ensure ongoing focus on improving the service quality and achieving better outcomes for clients.

The Safeguards Project used two main processes, internal and external service evaluations. The internal process involved the agency key stakeholders (family members, staff, board members, and certain external people) in the identification of positive agency characteristics and client outcomes that had been achieved or were desired to be achieved in the future, and also negative characteristics and outcomes that could possibly occur. A total of 43 "themes" were identified using this process, each describing an aspect of the agency or client outcomes that stakeholders saw as important (Cocks, 1997). These were then linked to actions that were, or could be, taken by the agency to "safeguard" each issue. A description of this internal process is beyond the scope of this paper.

The external evaluation consisted of three elements.

1. Fifteen ratings from the evaluation instrument-Program Analysis of Service Systems (PASS)(Wolfensberger & Glem, 1975) dealing with the administration of the agency.
2. A "Model Coherency Analysis" which examined the service "Model" adopted by the agency from the standpoint of how well the service purposes and processes are consistent with clients' needs.
3. A PASSING evaluation. This paper describes only the third element of the external evaluation - the PASSING evaluation. Because PASSING is based on SRV, the theory is briefly described in the next section.

Social Role Valorization (SRV) and PASSING

SRV (Wolfensberger, 1983a, 1992) is a major social theory addressing the phenomenology of social devaluation and the processes by which some groups in all societies and collectivities get accorded low social value. It was developed by Professor Wolf Wolfensberger from Syracuse University as a very substantial development of the normalisation principle (Nirje, 1969; Wolfensberger, 1972), to the extent that SRV constitutes a major social theory in its own right. SRV identifies people with disabilities and other groups (e.g. people with mental illness, the poor, elderly people) as vulnerable to social devaluation. SRV incorporates a description of the likely life experiences of socially devalued people-for example, the physical and social rejection common in the congregation and segregation of devalued people; loss of positive identities, loss of possessions, and loss of ordinary life experiences; ill treatments and brutalities, etc. These are described as "Sounds" and constitute the phenomenology of social devaluation addressed by the theory. SRV theory provides an overarching view of handicap by taking into account limitations resulting both from impairments and disabilities, and the ways in which social values, policies, structures, and institutions foster the low social valuing of various groups. The theory emphasises the social construction of devaluation emerging from "the eye of the beholder" and social dynamics and processes.

SRV integrates various bodies of theoretical and empirical knowledge, both to explain why and how social devaluation occurs, and how strategies and actions can be developed to counter social devaluation. Briefly, SRV theory identifies seven "themes".

1. Low awareness of social realities and dynamics that contributes to social devaluation perpetuates social devaluation. Unconsciousness at individual and collective levels (i.e. groups, organisations, societies) leads to much inadvertent social devaluation and hides many motivations intrinsically harmful to certain groups of people that may benefit other groups or individuals. Consciousness-raising, well-known to various liberation movements, is a key strategy to counter social devaluation.

2. Social role theory highlights the importance of social roles, especially the negative roles imposed as part of the role expectancies of devaluation. For example, people with disabilities are commonly seen as "sick" and as "children" which creates great limitations. Conversely, valued social roles (e.g. learner, family member, citizen, elder) provide a fundamental safeguard against social devaluation.

3. Understanding the nature and consequences of personal and social vulnerability is incorporated in the Conservatism Corollary of SRV which supports a moral stance in relation to addressing devalued people's needs. This requires one best effort, to "send over backwards", to avoid imposing further harm on vulnerable people. This is also called "positive compensation" - the greater the need, the greater should be the response.

4. SRV incorporates key assumptions about human beings and human potential described in the developmental model. Developmental potential is identified as an essential element of human identity. If denied, human dignity and integrity are also denied. The developmental model incorporates a set of methods (pedagogies) that promote human learning.

5. Imagery is central to the creation of social devaluation. Low social value is invariably associated with negative images attached to vulnerable people. A powerful dynamic occurs through juxtaposition of negative images with devalued people, and the juxtaposition of devalued people with one another. Juxtaposition, meaning placing something near to something else in terms of time or distance, encourages the transfer of negative images and stereotypes across groups. Conversely, because high social value is associated with positive languages and images, juxtaposing people vulnerable to social devaluation with positive images will counter social devaluation. SRV theory provides detailed analysis of the use of imagery in social devaluation.

6. Imitation and modelling of behaviour is a powerful, natural way human beings learn and develop. SRV emphasises the dynamics of imitation and modelling and how this influences the according of social value. One important aspect here is an analysis of the imitative models human services provide their clients through various grouping practices. These often result in harmful processes of congregation and segregation of vulnerable people.

7. Finally, SRV theory incorporates the importance of personal social integration and valued participation in the community as a major strategy to counter social devaluation.

The according and protection of valued social roles for people are the desired outcomes in SRV. To achieve this, two key strategies are suggested for people who are vulnerable to social devaluation, or are socially devalued. The first is to enhance their competencies. Social value is usually accorded, within any culture, to people who are perceived to be competent and skilled. The second strategy is to enhance the social image of people and to avoid their association with imagery that is negative. These two strategies have major implications for how human services operate.

SRV theory focuses on the role played by formal human services in social devaluation. The theory identifies crucial aspects of the structuring and functioning of human services that can inflict wounding and thus contribute to social devaluation, or, conversely, ways in which human services can avoid inflicting more harm and reduce existing social devaluation. PASSING is an instrument for the evaluation of human services constructed according to SRV theory, designed to be used both as a means of teaching SRV theory in considerable depth in training workshops in which actual services are assessed, and also for formal service evaluations.

The diagram below describes the four key elements of human service structures and their relationships to the two SRV strategies of enhancement of competencies and images. PASSING is structured according to this schema and the diagram indicates the distribution of the 42 individual ratings across the categories.

Table 1: The Structure of PASSING and its Relationship with SRV Theory (Wolfensberger & Thomas, 1983, p.5)
- 1 PROGRAM ELEMENTS RELATED PRIMARILY TO CLIENT SOCIAL IMAGE ENHANCEMENT 2 PROGRAM ELEMENTS RELATED PRIMARILY TO CLIENT COMPETENCY ENHANCEMENT
01 PHYSICAL SETTING OF SERVICE 11 RATINGS 6 RATINGS
02 SERVICE-STRUCTURED GROUPINGS & RELATIONSHIPS AMONG PEOPLE 7 RATINGS 6 RATINGS
03 SERVICE-STRUCTURED ACTIVITIES & OTHER USE OF TIME 3 RATINGS 3 RATINGS
04 MISCELLANEOUS OTHER SERVICE LANGUAGE, SYMBOLS & IMAGES 6 RATINGS NO RATINGS - NOT APPLICABLE

The 42 ratings and their weighted scores combine in different numbers and combinations to provide 15 scale scores.

Methodologies for the implementation of PASSING are fully described (Wolfensberger, 1983b). Small teams of evaluators gather information on services and service users, using well-established methods, over a period of time. During the conciliation phase of an evaluation, a team of evaluators assigns one of five levels of achievement of the service for each of the 42 ratings.

A number of studies (Dansereau et al, 1990; Flynn, 1996) subjected PASSING to factor analysis, generating a small number of factors and generally supporting the validity of the structure of the PASSING instrument. Other statistical properties of PASSING indicate high levels of internal consistency and interrater reliability, and predictive and discriminative validity (Flynn, 1980; 1994).

This brief account of SRV theory and PASSING indicates its relevance to the purpose of evaluating this agency, particularly in the context of major agency change.



The External Evaluation

The PASSING evaluation of the 13 homes was carried out by four teams, each with four experienced team members. Three teams were allocated three homes each and the fourth team was allocated four homes. Homes were distributed between teams with each team evaluating at least one two-or three-person home, and at least one four- or five-person home. The evaluation took six days and involved analysing agency documentation, interviewing key persons including family members of residents, site visits, and a conciliation process when rating scores were assigned. The evaluation was immediately followed by a two-day model coherency workshop involving all team members and key agency staff. An initial feedback session to those staff members then occurred.



The Quality of Services

The amount of information generated from this extensive evaluation process was considerable and it is beyond the scope of this paper to provide a complete account. Here, the total PASSING scores for all 13 homes and a comparison with other PASSING data in the literature are provided. In addition, some of the differences between the 13 homes were considered because this provided important information on aspects of service quality. The scale scores were derived from summing the scores from the appropriate ratings comprising each scale. Scale scores represented a percentage (i.e. 50.3 percent) of the total score that was possible (i.e. 100 percent). These percentages are reported below.



Overall Performance

Figure 1 shows the mean scores for the 13 homes for the three principal PASSING scales. The agency gained 50.3 percent of the maximum possible score for social image enhancement, 35.7 percent for competency enhancement, and 43.2 percent of the total maximum possible score.

Figure 1. Mean Socres for Image, Competency, and Total Scales for the 13 Homes.
Figure 1. Mean Socres for Image, Competency, and Total Scales for the 13 Homes.


At this point it is clear that the agency performed relatively better on image-related than competency-related ratings. The author and colleagues involved in service evaluations and implementation issues associated with normalization and SRV have noted that many services have occurred to address image issues. On the other hand, particularly for people with severe impairments, competency-related issues present considerable challenges and require concentrated effort and expertise over a long period of time. The short-term outcomes of deinstitutionalisation efforts are possibly more likely to be reflected in positive image outcomes than significant competency outcomes.



Comparative Performance

To compare the performance of the agency with other services, comparisons were made with other sets of PASSING data. Generally, the agency performed at least as well as, and usually better than, other agencies. In this paper, only one indicative comparison is provided. Flynn et al (1991) reported a meta-study of PASSING evaluations on 213 human service programs of different types in the USA and Canada. Figure 2 provides a comparison between the results of those 213 evaluations and the 13 homes on the five PASSING Program scales.

Figure 2 Comparisons Between 213 Services (Flynn et al, 1991) and 13 Homes
Figure 2 Comparisons Between 213 Services (Flynn et al, 1991) and 13 Homes


The agency performed better than the average of the 213 services on all five scales. More pertinent and complex comparisons have been made with other data sets, focussing on services of similar type (i.e. residential) and similar size, but are not reported here.



Differences in Scores Between the 13 Homes

Considerable differences occurred between the scores attained within the group of 13 homes. This is potentially very significant as it may provide indications of the sources of differences in quality. For example total PASSING scores ranged from one home scoring 70.6 percent, a very positive result from an ideal evaluation instrument, and 26.4 percent. Overall, there was greater variation between the homes on competency than on image scales.

To explore between-homes differences, comparisons were made between the various homes grouped according to size. Figure 3 shows mean scores for the three major scales for the homes divided into three groups - three homes each with two residents, six homes each with three residents, and four homes with four or five residents.

Figure 3 Mean Scores for Image, Competency, and Total Scales by Resident Grouping Size for 13 homes
Figure 3 Mean Scores for Image, Competency, and Total Scales by Resident Grouping Size for 13 homes

On every scale comparison, performance improved as the size of homes in terms of numbers of residents decreased. Statistical analyses (multiple analyses of variance) and tests of significance (post hoc Tukey multiple comparisons) revealed that the only statistically significant differences were between the two-person homes, and the other two home groupings. In a statistical sense, although the direction of improved quality performance was uniformly related to decreased size of residence, these differences only became significant when the size of residence decreased to two.



Conclusion

SRV theory and the PASSING evaluation instrument together provide a very useful theoretical framework and operational methodology for the analysis of the quality of human services. At a time of significant change in service structures and processes, such an analysis is especially important. This paper described a major project designed to safeguard service qualities and outcomes for a group of people with severe disabilities who experienced a major change in service provisions. Some results were reported for one component of that project, an external PASSING evaluation of each of the 13 homes established as part of the service change. A significant finding from the evaluation was the importance of small size in achieving relatively better service qualities. This finding was important because each of the 13 homes was relatively small in size, yet homes in which 2 persons lived were of significantly better quality on the PASSING evaluation than homes with three, four, or five residents.

The literature on the relationship between size of residence and quality suggests that size is not a sufficient condition in itself and other variables must also be considered including staffing characteristics and patterns, and service processes such as supports for residents' development. PASSING takes these into account. A more extensive paper providing more detailed analysis on these issues and this evaluation is being prepared for publication by the author.



References

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Wolfensberger, W. (1983b). Guidelines for evaluators during a PASS, PASSING, or similar assessment of human service quality. Downsview: National Institute on Mental Retardation.

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ASIA & PACIFIC JOUNAL ON DISABILITY

Vol. 1, No. 2, March 1998

Published by the Asia and Pacific Regional Committee of Rehabilitation International (RI) and the Regional NGO Network (RNN)