Chapter 7 Assessment of Institutions

Historical Background  In the mid-19th and early 20th centuries, parallel events occurred in the United States, Canada, and Great Britain that set the conditions for assessment and quality assurance of institutions. These were led by reformers who were pioneers and early professionals.  Dorothea Dix was a social reformer and social work pioneer who campaigned for the care and safety of the mentally ill.  John Langmuir was a Canadian civil servant who was inspector of prisons, asylums, and public charities and established the idea that inspection/assessment could lead to positive reform.  In Great Britain, the reform movement forced a reconsideration of ineffective practices and the establishment of several committees to oversee the needs of vulnerable populations.  In the early days, assessments were almost always internal and, more often than not, driven by financial concerns.

Historical Background (continued.)  Much of the assessment work of our professional forbearers relied on inspections rather than on ongoing studies of effectiveness.  Clifford Beers was influential in fostering a reassessment of mental hospitals and his advocacy paved the way for a national movement and the establishment of the National Committee for Mental Hygiene.  Julia Lathrop was a social reformer and social worker who documented the deplorable conditions of asylums and helped promote scientific approaches to social problems.  In 1917, the health-care sector was the first to establish formal care standards with the development of a document by the American College of Standards outlining minimum standards for hospitals.  Erving Goffman was a sociologist who revealed the processes and dehumanizing conditions of mental hospitals, prisons, and hospitals. Goffman's revelations coincided with the anti- institutionalization movement and helped reinforce evaluative measures that could be applied to institutions.

 In the 1970s, the deterioration of state mental health institutions led to the acceleration of the deinstitutionalization movement.  Deinstitutionalization involved two elements: the discharge of existing state hospital patients to the community and a decrease in new admissions to the state facilities.  Concepts of "normalization" and "least restrictive environment" were introduced as part of the deinstitutionalization movement and implied having conditions similar to a client’s home environment and the ability of the client to enjoy maximum freedom in daily living and pursuits.  While deinstitutionalization led to the development of some community-based services for clients, it did not achieve the aim of community-based systems of care.  Hospitalized mental patients were moved to communities without adequate community services.  Paralleling the rise of community-based services for deinstitutionalization has been the emergence of consumer-delivered services. The Anti-Institutionalization Movement

Frameworks for Assessing Institutions The expansion of social programs during the 1960s combined with the Government Performance Results Act of 1993 led to the establishment of several accreditation/quality assurance institutions: 1.The Joint Commission on Accreditation of Healthcare Institutions (JCAHO) improves the quality of health care institutions by setting standards and evaluating their performance. 1.The National Committee for Quality Assurance (NCQA) utilizes the the Health Plan Employer Data and Information Set (HEDIS) "report card" mechanism to review and accredit health maintenance institutions of all types. 1.The Association of State Correctional Administration (ASCA) set standards and monitor performance of the nation's prison systems. 1. The Child and Family Services Review assesses state performance in the child welfare sector. 1.The Commission on Accreditation of Rehabilitation Facilities (CARF) is an accrediting body that serves the human services sector and mental health services in particular. 1.The Council on Accreditation (COA) monitors the quality of social and welfare agencies across the country.

Organizational Effectiveness Organizational effectiveness (OE) approaches to the assessment of institutions focus on higher- level indicators that measure overall achievement. Several OE models were developed: 1.The System Resource Model defines effectiveness as the degree to which an organization can preserve its internal integration and adapt to the environment. 2.The Multiple Constituency Model defines effectiveness as the degree to which an organization can satisfy the interests of multiple constituencies or stakeholders. 3.Institutional Theory Model defines effectiveness as the degree to which an organization can conform to expectations about structure and outcomes. 4.The Social Constructionist Model defines effectiveness as a social construction that is evaluated.

 Quality Assurance approaches to the assessment of institutions focus on regulatory processes and program evaluation.  Bellin and Dubler (2001) describe the way in which the quality assurance process naturally encourages continuous assessment because it is committed to using the results to immediately inform the process of care.  The renaming of the quality assurance process to continuous quality improvement (CQI) reflects the recognition that the process is one of continued improvement in the context of error rather than an idealization.  One method of improving quality that is gaining popularity is called benchmarking. Benchmarking is a way to monitor and evaluate health care outcomes by comparing them to best practice indicators identified by leaders in the field.  Recently, there has been an increase in the development of quality indicators to assess quality of care in the health and mental health settings. Quality