Modeling Act Workers

Questioning Emerging Act ModelsProgram Fidelity Scores

Thesis Title

“Mere Sources of Error”: Workers, Patients and the Reductive Logic of

Rationalized Healthcare (Feb, 2014).-Marnina Norys (PhD)

Rational Technology

• Productive processes for mass production or mass administration.

• Efficiency achieved via standardization (one-size-fits-all-approach).

• Systematic processes (repetitive and mechanistic).

• Processes broken down into component parts (assembly-line style).

• Workers’ inputs precisely defined and rule-bound.

Ursula Franklin

Broken-down rationalized technologies have “spread like an oil slick” through modern society so that it has become “almost sacrilege to question them.”

The oil slick’s

spread into

healthcare

Burdened Systems = calls for greater efficiency

• “The new realties of the healthcare marketplace are forcing healthcare decision makers to implement innovative operational philosophies, techniques and tools that were proven in other industries to enhance the effectiveness of their organization” Yasin et al, 2002, p. 268).

AKA: rationalized managerial techniques developed within mechanistic factory-style productive systems. The authors here point approvingly to the “LEAN” model of production developed by Toyota.

Ethnographic Examples

• Rankin and Campbell’s Managing to Nurse: Inside Canada’s Healthcare Reform.

• Lorna Rhodes’ Emptying Beds: The Work of an Emergency Psychiatric Unit.

• In “The Wal-Marting of American Psychiatry,” Psychiatrist Alastair Donald says many US managed care administrators seem to presume that “the practical treatment of each mental illness can be rationalized and streamlined and made economically efficient.”

One Psychiatric Nurse’s Response

“I don’t know any of these people; I know a name, a diagnosis, I know a med I’m giving them, but other than that I don’t really have a lot of time to learn these people. So I feel that a whole part is gone, and that was actually part of one of the biggest rewards in working here many years ago, was the relationships. I really got to know people, over a long period of time and got to make changes with them; people actually did change.” (Donald, 2001, p 43).

“Moral Distress”

• According to one 1993 study, nurses said “they were concerned with the basic lack of human dignity shown to patients.”

• Nurses used terms such as “nightmare,” “grief”, “heartache”, “miserable”, “painful”, “sad, and “ineffective” to describe their responses to such situations (Holly, 1993, cited in Austin et al, 2003).

• Brodwin’s ACT worker.

Is impersonal/standardized care viewed as immoral? Short answer: No.

Disgruntled patient Jean Dann writes:

“I was shocked that the doctor did not speak to me, either before or after the [surgical] procedure. … During the procedure (I unfortunately was awake) he talked about his daughter's university challenges with no apparent concern or interest for me … I felt like simply a number with no concern, on behalf of the physician, for my well being … I … hope that eventually doctors (I am generalizing) will be educated to realize that they are dealing with people with feelings. We need to be treated with respect.”

“Respect” in moral philosophy

• Respect = respecting another person’s autonomy (her right to make her own reasoned decisions).

• Discussions of autonomy caused today’s shift away from paternalism.

• Kant on sympathy for someone suffering: “this is an insulting kind of beneficence called softheartedness and should not occur at all among human beings.”

• The contemporary philosophical view of the ideal moral relation is pretty cold.

• “Physicians who, far from treating us paternalistically, treat us impersonally and distantly, respecting our autonomy but nothing else” (Callahan, 1984, p. 41).

Respect, meet care

• Many intuitively understand that treating others “like a number” is morally suspect.

• Robin Dillon proposes “Care Respect.” • Respect for autonomy put on equal footing with the

concern to know people as individuals and tailor our relations accordingly.

• Emphasis on “me-ness” adds a little meat to the bare bones of “abstract personhood” required for respect.

• A little radical, because this view makes any assembly line style processes used for human services morally suspect.

How to grasp another’s “Me-ness”

• Loving attention: doing justice to the other (Iris Murdoch)

• Imaginative reconceptualization: actively seeking alternative interpretations (Martha Nussbaum)

• World travelling: understanding multidimensionality (Maria Lugones)

Enter ACT!

• Remarkably different from environments that relied heavily on rational technologies to promote efficiency.

• Unsurprising. Stein, Test and Santos situate the therapeutic relationship as the cornerstone of act and specifically designed the program as a means of tailoring care for clients falling through the cracks.

• More surprising was the extent to which workers enacted and helped illustrate the 3 methods prescribed to get at another person’s “me-ness.”

Loving Attention: The Minutia

• Weekly review re: Greg Wallis (all names pseudonyms)

Trevor: he is ok.Henry [laughing]: That is all you have to say Trevor? Talia: He is far away and the team doesn’t see him much. Trevor: He was really collected when he came in with the chicken pox. Henry: There is a study here. The virus changes the brain.

• During weekly review something, anything, has to be said whether it be that one shaved her dog to look like a llama, or another came back from Miami looking “pretty in pink.” Lends to attentiveness, which makes sense when a big component of the work is monitoring for distinctive signs of decompensation or minute signs of progress.

• ACT’s longitudinal approach contributes to this remarkable attentiveness due to close monitoring of individuals, over extended periods of time.

Imaginative Reconceptualization: The Creative Component

• Team seemed to delight in the unexpected and incongruity.

• “The cleanest hoarder I ever met.” • Maria and her love of beauty services.• Tom actually did know the mayor!• Frank and the elliptical.

Reconceptualising

• Might seem trivial, but sharing these quirks disrupts easy or habitual cataloguing of clients

• Reinforces: these people cannot be pigeonholed. • I saw how keying into small, incongruous details

can persist through time resulting in shifting perceptions of a particular person, disrupt preconceptions while potentially getting closer to that person’s “me-ness,” their individuality.

World Travelling

• Built into the work• “Sexy time!”• By entering into clients’ most intimate spaces,

workers can’t help but be exposed to multiple facets of clients as these manifest in different environments (i.e. office environment vs. home).

• Essential for understanding a person’s uniqueness

Storytelling/narrative medium

• Lends to the sense of clients being “one of ours” i.e. Tom’s eulogy.

• Invites participants to share alternative interpretations, and helping to both challenge, and to have her own presuppositions challenged in the telling.

• Can cultivate caring as shared stories unfold over time.

The Polite Thing to do: Enacting an Ethos of Care-Respect

“Elderly and frail,” parents had requested that someone visit a client in jail who had previously assaulted an ACT worker. The team was likely going to discontinue treating the client.

Otto: it is a polite kind of gesture. In the day when people are breaking up over email. Henry: text him. It’s not you it’s me. Otto: I’ll go. Peter: I think it’s great if Otto goes. I really respect that. It’s a good thing to do. Otto: I want to tell him ‘what you did wasn’t right’ … I think he has had a lot of traumatic loss. His son passed away of cancer. This adds to that. There has been a lot of loss. This is just a polite way of doing things.

More than just “polite”

• Otto’s visit was the morally right thing to do given the client’s particular circumstances.

• “Learning these people,” getting to know a clients’ story, and latching onto his “me-ness” are also intrinsically valuable activities and are as important as respecting his choices.

• This is especially true if we’re talking about people as stigmatized and disenfranchised as mentally ill folks in today’s society.

• Also why advocating for people who are at the intersection of a multiplicity of impersonal and rationalized systems (PGT, public housing, ODSP, ER’s, etc …) is so important and meaningful.

• Clients have as much of a right to be understood and treated as individuals as they do to justice and self-determination.

• Amounts to treatment that is not only smart therapeutically speaking, but ACT work also provides us with an example of a morally superior form of care.

Fidelity

• Emerged in the ACT literature in the 1990’s.• Means fidelity to a program model, not fidelity

to clients.• Dartmouth Assertive Community Treatment

Scale (DACTS) and Tool for Measuring Assertive Community Treatment (TMACT) are two examples.

Fidelity Scales

• Developed to study ACT and compare programs.

• Used to position ACT as EBM.• Was meant to measure a team’s similarity to

the early Madison teams and replicate their successes.

So what’s the big deal?

• If I have nothing to hide, I have nothing to fear, right?

• The problem is not in being monitored now, it’s the potential impact of fidelity scales over time.

Reduced Hospital Use

• “The effect size of reduction in number of days hospitalized was used as a measure of program impact. This criterion is appropriate in that it is central to the mission of ACT programs” (McGrew et al, 1994 p. 674).

• Reduction in hospital use was the primary outcome used to develop scales and select for quantifiable items.

• Cited regularly as the most notable outcome of ACT in the literature.

Problem with Fidelity Scales

• The ACT model could come to be shaped so that those aspects of ACT most closely correlated to lower rates of hospital use are codified and emerge as central defining features of the model.

• But, reduced hospital use does not necessarily equate with better lives for patients (i.e. bedbug ridden group homes) or lessen workers’ moral distress.

• May fail to capture valuable aspects of ACT work that can’t be quantified.

• The issue is not what is on the scale, but what is left out.

Dartmouth Assertive Community Treatment Scale (DACTS)

• Mostly measures the composition of a team

What is missing from DACTS?

• The therapeutic relationship as the centrepiece of ACT.

• Trusting relationships over coercive treatment.• Personal traits in workers (Stein and Santos, 1996) :

“patience, empathy, optimism, persuasiveness, pragmatism, flexibility, good judgement and “street smarts.””

• “High level of commitment to clients and their families to ameliorating their problems.”

• “Close team spirit”

Tool for Measuring Assertive Community Treatment (TMACT)

• Goes beyond composition and structure to also measure processes (interactions, procedures).

• Teams using EBPs get higher scores• Team meeting is assessed for “quality,” not

just quantity.

TMACT and the team meeting

• Should consist of:

“The review of all consumers each day, documentation of relevant clinical information, and development of a daily schedule that is driven by the consumer’s treatment plan, emerging needs (e.g., crises, or medical appointments) and proactive contacts to divert future crises. Also assessed is a mechanism to determine whether scheduled contacts were completed” (2011, p. 20).

What’s missing?

• Team spirit and the building of supportive relationships among workers.

• Demonstrated care and concern for clients.• Humour!• The sharing of small insignificant stories that

may solidify the sense of a client being “one of ours.”

• Active discernment of clients’ “me-ness.”

My main worry

• That the fidelity scale’s way become the way to do things so that everything else becomes irrelevant, or come to be viewed as an inappropriate use of precious time.

• Michael Power argues, “systems-based audits can easily become a kind of ritual, concerned with process rather than substance, and governed by a ‘compliance mentality’ which draws organisations away from their primary purpose” (Power, 1994, p. 16).

• i.e. training kids to do well on standardized tests instead of really educating them because this gets measured and rewarded by funders.

Streamlining ACT?

• The creators of TMACT note, ACT is among the most costly community health programs but “questions remain regarding exactly which features and what dose are most critical to desired outcomes” (2011, p. 26).

• According to the authors TMACT can potentially provide, “more specific feedback to guide ongoing performance improvement efforts” (p. 27).

Performance Improvements?

• “Performance improvements” likely means minimizing expenses while maximizing gains, aka: streamlining the program to eliminate “wasteful” activities.

• If equated strictly with reduced hospital use, what could get cut in a bid to streamline ACT?

• Input from frontline workers is essential for these kinds of decisions.

Should we care in Ontario?

• DACTS and TMACT primarily used for research, or by US funders to assess programs.

• DACTS scores routinely reported in the literature on ACT.• Recent studies conducted assessing Ontario teams using

DACTS and Randall et al (2012) have pointed to a need to monitor teams “more aggressively.” They propose using The Ontario ACT Program Fidelity Tool™, a 33-point fidelity scale similar to DACTS they’ve developed.

• So, a more concerted push to start monitoring ACT using fidelity scales could be in the pipeline.

In sum

• The ACT workers I observed appeared to have a great deal of compassion for clients, and have a lot to teach us about the provision of highly personalized care.

• The moral value of the work far exceeds the economic utility gained by keeping clients out of hospital.

• ACT is much more than a tool to reduce inpatient expenditures, and these further values need to be articulated and promoted so as to remain an intrinsic part of the ACT model as it crystallizes over time.