Excerpted from chapter 2 of Quality Performance in Human Services: Leadership, Values, and Vision, edited by James F. Gardner, Ph.D., M.A.S., & Sylvia Nudler, M.A.S.

Copyright © 1999 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

The evolution in services and supports for people with disabilities has provided a framework for the discussion of the quality of those services and supports. The movement from large residential settings to community-based systems of support redefined quality and exposed areas of both agreement and disagreement among families, providers, professionals, and public officials. The national debates on such terms as deinstitutionalization, normalization, behavior management, and least restrictive environment have revealed wide differences in values and definitions of quality.

Since the early 1990s, however, a consensus has been emerging. The consensus finds expression in the use of the term support to describe a new type of service relationship. Supported employment, supported living, and family support are designed to offer support to individuals and families to address their own priorities. Another expression of this consensus is the emergence of person-centered planning models that are challenging the older and more established forms of habilitation planning. Finally, there is an increasing recognition that formal systems will not be able to provide the full range of services and supports needed by people with disabilities. Some blending of both formal and informal support networks will emerge as cost containment continues to gain momentum.

But, this consensus does rest on the recognition that quality begins with a definition that is person centered. Managing for quality requires that the priorities of people with disabilities directly shape the design of the services and supports that they receive. Although learning from and listening to the person with the disability is the prerequisite for services of quality, there are many management strategies for successful implementation.

A Matter of Definitions

The definitions of good and quality and the suggestions for examining quality have been the center of the world's religions and philosophies for several thousand years. More recently, advent of the industrial revolution and mass machine production in the late 18th century thrust the question of definition of quality from the study of religion and philosophy to that of industrial engineering, operations research, and statistical quality control.

Quality in Services

In a review of the definitions of quality, Reeves and Bednar concluded that "the concept has had multiple and often muddled definitions and has been used to describe a wide variety of phenomena" (1994, p. 419). Quality has been defined as excellence, as value, as conformance to specifications, and as meeting and exceeding customers' expectations. In the mid-1990s, quality was most frequently defined as conformance with specifications. Since the 1950s, however, the service economy in the United States and Western Europe has expanded. In 1900, only three out of ten workers were employed in the service economy. By 1990, that figure had grown to almost eight out of ten workers. In the late 1990s, the most frequent definition of quality is that of meeting and exceeding customers' expectations (Reeves & Bednar, 1994).

Albrecht (1992) argued that quality in the 21st century will begin with the consumer not with the products, services, or work processes that create them. Organizational systems, policies, and procedures are guides for serving consumers not ends in themselves. In the customer-value paradigm, "the primary focus of measurement is on outcomes" (p. 41). Zeithaml, Parasuraman, and Berry (1990) also stressed the role of the customer in evaluating service quality. They wrote, "Only customers judge quality; all other judgments are essentially irrelevant" (p. 16).

Quality in Services for People with Disabilities

In the provision of services and supports for people with disabilities, quality is most frequently defined in the context of quality assurance. As Bradley (1990) noted, the purpose of quality assurance is to enhance systems as well as to ensure conformance with specifications. This is consistent with the definitions of quality assurance in the Malcolm Baldrige National Quality Award categories. Quality Assurance of Products and Services measures the extent to which the organization's systems are effective in maintaining quality control of all operations. Quality Assurance Results focus on the degree of the organization's success in improving quality, as determined by quantitative measures. These Baldrige Award categories clearly indicate that quality assurance is more than discovering and eliminating defects.

Quality assurance has generally been associated with the necessity of maintaining an agreed-on level of quality in public and private services to people with disabilities. Quality assurance systems require the development of standards, periodic reviews based on the standards, and feedback and control functions based on the review. Quality assurance mechanisms provide assurance to the community that standards will be maintained, provide evidence for state compliance with federal requirements, and provide feedback to providers of services. Unfortunately, quality assurance in disability services is generally associated with inspections and surveys that measure compliance with organizational processes, funding requirements, and federal and state regulations (Bradley, 1990).

The negative connotation of quality assurance, in part, resulted in the popularity of the term quality enhancement to describe quality improvement efforts that were not grounded in compliance inspections. The positive, proactive approach of the quality enhancement efforts were also influenced by the total quality management (TQM) literature of the 1980s and 1990s. Deming's admonition to "cease dependence on mass inspections [and] to improve constantly and forever the system of production and management" (1986, pp. 23-24) symbolized the difference between traditional quality assurance approaches and the emerging quality enhancement models.