Making Best Practice Typical Practice

Making Best Practice Typical Practice
Support Development Associates April 2017 © Support Development Associates

© Support Development Associates
What would a person centered, best practice system look like? How would we know? © Support Development Associates

We would have a system where
People are supported in having positive control over the life they desire and find satisfying People’s contributions (current, potential, past) to their communities are recognized, valued, and supported People are supported in a web of relationship in their desired communities © Support Development Associates

Where are we now? © Support Development Associates

Moving from Service Life to Community Life
A Good But Paid Life Community Life Service Life ‘Important to’ recognized Focus on connecting, building relationships ‘Important to’ present To and for present Closest people are paid or family Few real connections People are supported to participate in community life, but few connections extend beyond paid support time Important for addressed No organized effort to address important to To and for present Active circle of support Included in community life SDA LLC 2009

There would be informed choice about:
Where the person lives Who they live with What they do with their time (including who to spend it with and employment) What they do with their resources And who provides the services and supports 2015 Support Development Associates, LLC

We would address the challenge of choice
TLC-PCP 2012

Getting there requires more than planning
Person centered planning – by itself Results in Better paper More often than it results in Better Lives © Support Development Associates

It is also more than isolated examples of best practice.
© Support Development Associates

It requires more than training
Exposure Competence Habit Training Coaching © Support Development Associates

You have to be a change target as well as a change agent
© Support Development Associates

What will it take to have a system that moves toward best practice?
Questioning our assumptions Living our, Vision, Mission and Values Creating Alignment & Positive Pressure Seeking what we can do at scale Managing Change & Resistance Leadership that understands and is engaged © Support Development Associates

Assumptions? We all make them – Many are helpful We could not function without them But some hold us back Others hold back the people we support © Support Development Associates

Assumptions about employment
James who was not “work ready” Victor who wanted a job “just like Dad’s” © Support Development Associates

Underneath the single focus on health and safety is an “either/or” assumption not a “both/and” assumption © Support Development Associates

What are our current underlying assumptions?
About the people who use services? About those who are paid to support? About how we support people – How services are organized? What we offer? © Support Development Associates

But you also have to bring assumptions to the foreground Question/challenge assumptions And Leaders don’t just question assumptions Leaders change assumptions © Support Development Associates

Based on the work of Chris Argyris

This is a different way of thinking
Going from “we know best” to “the person knows best” From power over to power with © Support Development Associates

Shifting to a Person Centered System
Moving Away from This ….Towards this Underlying Assumption System is the expert; dependent on the system Person is the expert in their life; enhance capacity of natural support Intake and Eligibility List of deficits; complex; no time frame Capabilities and strengths to build on; transparent and timely Assessment Comprehensive list of needs; system fully responsible Customized list, based only on support identified by the person, their family or loved ones Planning Health and safety is priority; goals identified by professionals; ameliorate problems Interests, comfort and satisfaction equally important to health and safety; outcome for the person Monitoring Verify; emphasis is compliance; establishes a blame culture Accountability for learning and improvement Financial Structure Slots, vacancies, programs funded Resources allocated to the person – move with them Quality Management Assess what’s wrong; comply with minimum Results oriented; shared learning Copyright SDA LLC

Vision, Mission, and Values A composite
People are empowered to live valued and respected lives in their communities in a web of reciprocal relationships Mission Everything we do supports people to live the lives they choose with the people they love in their communities Values Listening Respect Collaboration Innovation Flexibility © Support Development Associates

What are your organization’s Vision, Mission and Values?
Does the vision describe where you want to go, as if you had achieved it? Does the mission describe what your organization does to move toward the vision? Do the values describe everyday behavior? © Support Development Associates

Do you “walk the talk”? Do all of the people who work in your agency know the vision, mission and values? Is what you do, day to day tested against them? © Support Development Associates

One Approach: Person Centered Thinking leads to
Person Centered Practices which lead to Person Centered Organizations which create Person Centered Systems that support Person Directed Lives © Support Development Associates

The Core Concept of Person Centered Thinking
“Important To” “Important For” & “The Balance Between” Provide the framework to help us look and act in a different way © Support Development Associates

It begins with learning how people want to live their life: What’s Important TO
What is important to a person includes what results in feeling satisfied, content, comforted, fulfilled, and happy. Relationships (People to be with) Status and control (valued role) Rituals & routines (cultural and personal) Rhythm or pace of life Things to do and places to go (something to look forward to) Things to have What is important to you also reveals your values, your own principles, these tend to guide your life decisions and to some degree, influence your satisfaction and contentment Copyright SDA LLC

Within that context, Important FOR is addressed
What others see as necessary to help the person Be valued (social rules, laws) Be a contributing member of their community (citizenship) Issues of health Prevention of illness Treatment of illness/medical conditions Promotion of wellness (diet, exercise, sobriety) Issues of safety Environment Well being (physical and emotional) Free from fear (threats, abuse) Copyright SDA LLC

Important To/Important For
For the Person Helps people get more of what is important to them without ignoring important for The connection between “to” and for” is recognized and used Identifying what still needs to be learned Helps people make critical decisions only when the relevant information is present For the Organization Teaches critical thinking Reinforces “think before you act” Helps people feel listened to Supports an active learning culture © SDA LLC 2011

Important To Important For & The Balance Between
Management Skills Relationship Map Routines & Rituals Good Day Bad Day 2-Minute Drill Reputation Communication Donut Important To Important For & The Balance Between Matching Learning Logs Working Not Working PURPOSE: Providing participants with a visual overview of the SKILLS, as you summarize in a few sentences what they have learned. SCRIPT We have asked you to focus upon core skills that an intentional approach to developing positive relationships and keeping the person and those who care most at the center of decision making. We divided the core skills into three categories to help you learn when to use these skills as you work with other people. The 3 categories are- Discovery/Listening- collects important information which leads to understanding the desired balance between important to/for – we practiced these skills today Everyday Learning- organizes the evaluation of everyday situations in order to learn and identify next steps. We covered these yesterday Management- assists in allocation of and support for staff -We practiced developing the donut yesterday –today we learned how to gather information and organize it to create good matches between the people we hire and the people we support. Then we added two facilitation skills (having conversations and GUESS ASK WRITE) that underpin –help to ensure success –when using all of core skills. We learned that all the tools work together. For example when building the person centered description…click to next slide TIPS: The main thing here is to say “We did what we said we’d do” . Don’t try to explain any SKILLS now. In a couple of slides the participants will review their SKILLS Chart and this will help them recall each tool and their own thoughts about their use. Slide is animated. TIME: 1 minute for this slide Discovery/ Listening Skills 4 + 1 ?s Everyday Learning Skills © TLC-PCP TLC-PCP

PERSONALITY CHARACTERISTICS NICE TO HAVE (SHARED INTERESTS)
Supports Needed Skills Required Matching for____________ Pcd pg 7 PERSONALITY CHARACTERISTICS NICE TO HAVE (SHARED INTERESTS) PURPOSE: SCRIPT: TIPS: TIME: 3 Minutes NOTES: © TLC-PCP TLC-PCP

Matching staff with those who use services
For the Person - Because staff find more pleasure in their work they stay longer (more stability) Where there is a good match – People who use services are more likely to have what is important to them New learning about what is important to people is more likely to happen For the Organization - Reduces turnover Makes those who use and provide services feel valued/respected Helps support “real” relationships Decreases likelihood of incidents © SDA LLC 2011

What works/makes sense What doesn’t work/make sense
Working/Not Working What works/makes sense What doesn’t work/make sense Perspective Person’s Perspective Others’ © SDA LLC 2011

Mindful learning: Working/not working
For the person - Results in greater clarity about what needs to stay the same and what needs to change in each person’s life Helps in determining goals/outcomes that help the person move toward a desired life For the organization - Teaches critical thinking Promotes better problem solving Leads to clarity about what needs to change and what needs to stay the same Supports a learning culture © SDA LLC 2011 ELP Learning Communtiy

4 + 1 Questions (focus on learning and act on it)
What have we tried? What have we learned? What are we pleased about? What are we concerned about? And then, what should we try/do based on what we have learned? © SDA LLC 2011

Mindful learning: 4 plus 1 questions
For the person - Provides a record of those things that have been tried and their efficacy Those who support are less likely to continue to do those things that are not working in support Figuring out better ways to support people are likely to happen faster For the organization - Everyone has a voice and feels listened to Collective learning/knowledge is gathered efficiently More effective use of meeting time Facilitates effective problem solving Mt. Rogers in VA is primarily MH – use recovery format – their billing office uses 4 +1 to meet with directors of programs as they discuss billing procedures, documentation, etc. © SDA LLC 2011 ELP Learning Communtiy

Key Roles Trainers – Do formal teaching Support coaches Provide feedback Coaches – Train by demonstrating Take the skill from competence to habit Leaders – listen and act on the learning © Support Development Associates

Levels of Change Level 1 Level 2 Level 3
Any change that results in a positive difference in the lives of people who use services or in your own work life. Level 1 PURPOSE: To help the participants understand how change happens at different levels and how it trickles down. SCRIPT Discontent leads to change and it is helpful to think about change as happening at several levels. Level one, you don’t need any permission to implement. Changes in such things as routines, rituals, approach. These are changes that can be made immediately. Level two changes require approval from management. It is a change in practice, policy, or structure. The need for Level two changes is best identified by having a structured way for the shared learning of direct support level go to the organizations leadership. Level three changes can be thought of as “systemic” changes. A change in state law or regulation is an example of a level three change. TIPS: If you have primarily direct support staff in your training, you do not need to spend a lot of time on level three changes. Simply refer to them as state or federal rules. TIME: 3 minutes NOTES: Any changes an organization makes to it’s practices, structure or rules that result in positive differences in the lives of people. Level 2 Any change in practice, structure and rules made at the system level. These changes have an effect on many organizations, and therefore many peoples’ lives. Level 3 2015 Support Development Associates, LLC and The Learning Community for Person Centered Practices TLC-PCP

SDA LLC 2009

Change agent becoming change target
Person Centered Thinking & Coaches Commitment from Leadership Plus Quality Management Skills Interest from Org & System Leadership Exposure Structured Ways of Listening to Coaches Competence Creating a Learning Cycle Habit “Difficult” Level 2 & 3 changes Level 1 changes “Easy” Level 2 & 3 Changes Changes in structure Changes inside Current Efforts Changes in Practice

How do we go from where we are to where we want to be? You have to create a new “path of least resistance” You can’t just change the destination Most of us do what we already know Moving off the old path requires pressure that is greater than the resistance You have to make it easier to do the new and harder to do the old © Support Development Associates

External Pressure The external pressure that we typically respond to the most are the “4 whats” What is funded What is authorized/approved What is required and inspected What is measured These four “whats” are established by the system managers --- While there are many external pressures the strongest are typically the “3 whats” © Support Development Associates

We also respond to “internal pressures”
Values, assumptions, and attitudes Structures & practices Skills Organizational culture The most typical internal pressures are… © Support Development Associates

transforming • mediating • buffering • structures & processes •
External Pressures Licensing& accreditation Funding rules & amounts transforming • mediating • buffering • structures & processes • Culture of Support Community Expectations Wage & hour rules Where you are building a culture of support and EP hasn’t changed you create The way we have coped with external pressures is to mediate or buffer them - it sucks a lot of time and energy from leadership. You spend all your time mediating and buffering the amount of energy you have is limited. All those EP easy way to think about is 3 Whats (typically the strongest) Workforce issues, wages & demographics Family expectations O S H A

Transformational change
Requires a persistent, coherent set of pressures that all push (or pull) in the direction of the desired change But change without wreckage also requires that – Those who feel the pressure see a way to move in the desired direction Movement is consistently supported For True transformation, we need to recognize the pressures that are positive (the pushes) as well as those that are not so positive (the pulling back) © Support Development Associates

Resistance If you are not getting resistance you are not getting real change. Real change creates resistance Understanding resistance and addressing what you learn is central to managing it © Support Development Associates

Ask Where does the resistance come from? How much is the past? How much is the present? How is it being sustained? Recognize that there is group resistance as well as individual © Support Development Associates

Group resistance Conversations create a constructed reality – When a group of like minded people talk to each other they create their own reality We see it in politics We see it in cliques We see it in resisting change © Support Development Associates

PCT to PC System Reinventing Qualiyty Conference 2010
It Goes Beyond Person Centered Planning… Person Centered Thinking Person Centered Planning Person Centered Practices Person Centered Organizations Person Centered Systems Ask people what comes to mind when you say person centered planning --- many people will say “individualized, focused on the person, their wants, etc.” what you are looking for is someone who will say “time consuming, only for a few” etc. If no one says it, then just ask --- does everyone in your system have a person centered plan? Why not? Explain that what you will talk about for the rest of this session is based in the idea that person centered thinking is the center post – it is the anchor, the piece that is core to all other parts. SDA October 2010 © Support Development Associates Support Development Associates LLC

What changes do we see in each level?
PCT to PC System Reinventing Qualiyty Conference 2010 What changes do we see in each level? Changes in language Changes in one person’s life Changes in our tools and documents Changes in our processes and our structure Changes in system structure and external relationships Starting with language, what changes begin to happen? I spend several minutes talking about language --- why it is important that it change: Language is how we activate our values --- what we say and how we describe people reveals how we value them. I use some hard examples --- “it’s really not okay to refer to people as clients, or worse, as head bangers or biters.” Use Herb Lovett’s work on labels creating a way to hold people at arm’s length – and dehumanize so that I can do things “to you, not with you.” I’m not a bad person when I hold you down, b/c you aren’t a person, you’re a client. Language changes thinking, thinking changes language, both change our behaviors. Which comes first the chicken or the egg, doesn’t really matter, it just needs to change. Then, talk about tools and documents – daily logs, quarterly reports, goal progress, etc. Needs to align with our thinking – when it doesn’t people get confused; changes in documents requires changes in process/structure; etc. © Support Development Associates Support Development Associates LLC

A system requires 7 parts – working together
Vision, mission, and values that are routinely used Effective ways to learn the outcomes that each person wants Effective use of the skills needed for implementation Alignment of external and internal pressures to support the 1st 3 © Support Development Associates

Requirements for a person centered system - continued
5. Advocacy – external and internal - for the vision and alignment. Including what does and does not get public funding 6. A quality management system that measures effectiveness and identifies areas for improvement 7. Leaders that understand all of the above and engage in sustained and consistent actions for their implementation © Support Development Associates

Leaders who create change that sticks
Avoid the traps, they… Don’t just use coercion to get compliance Don’t just bury the inevitable resistance– they anticipate and embrace it Don’t fall into the trap of elite – Dividing the world into those who get it and those who don’t- they go further by creating collaborative partnerships while still maintaining their authority Don’t get caught up in blame – they change the culture to one of learning Leaders have to pay attention to the details. And we have to do this in a way that accounts for turnover. We tend to do things piecemeal – in silos. Need to make opportunities for dialogue. Ask what the impact will be against the vision. But we are moving very fast and it feels that we don’t have the time. Example of people who have to be out of their home from 9 am to 3 pm. We have remnants of the old medical model based in regulation Coercion – shift toward minimum compliance – it is devolving the system to that minimum is good enough Really good leaders recognize that complying just gets you in the game Expect resistance, embrace resistance – use resistance as a diagnostic – when you understand that resistance in coming form a concern about lack of competence then the response is TA Elite - helping build collaborative partnerships – but expect people to get on board – a responsibility to get people up to speed by working together Blame – how can we learn together – an understanding it is almost always the process that breaks down or is old and needs to be revised – how do we trust each other

Making Best Practice Typical Practice

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