Of all of the trends, the push for quality and outcomes management is the most real for social programs. What is important to recognize is that the changes have just started. First, we need a bit of historical context from the business world.

The main change agent for quality improvement efforts has been the Total Quality Management (TQM) movement. Starting mainly in the mid-1970's, many companies (primarily from Japan) made major competitive gains by providing high quality products at a low cost. TQM techniques helped enable this shift by providing a systematic way to simultaneously improve both quality and efficiency. It is beyond the scope of this article to describe the methods used in TQM; the important point here is that by the early 1990's, almost half of all medium to large-sized businesses had some type of formal quality management program in place. Further, these programs were producing major results when properly implemented. Globe Metallurgical claims they receive a 40 to 1 return on their investments in internal improvements. Companies like Hewlett-Packard and Xerox have also achieved demonstrable successes. The Saturn division of General Motors was created from the ground up with TQM principles in mind and quickly became the top-performing division of GM.

As TQM became more entrenched, three significant things happened. First, quality became a consumer expectation and therefore a "given" in competition. Companies that could not match the quality of their competitors quickly lost business, and many ultimately disappeared. Second, the focus on quality naturally led to a focus on the end outcomes being achieved for consumers. Measurement of outcomes became common in many industries, such as the push in health care to prove positive health gains and high rates of patient / health plan member satisfaction. Third, quality and outcomes became the basis for payment for many products and services.

The human services sector has dabbled in TQM, mostly in public agencies. The problem is that governments, private foundations, and businesses alike are now beginning to hold social programs accountable to the same standards of quality and client outcomes that are expected of commercial ventures - without allowing human services the time to learn quality management practices! What the business world spent the 1980's learning about quality management in order to survive in the 1990's, human service organizations are being literally forced to learn overnight. The end result is an attempt to skip TQM and go straight to outcomes, to somehow demonstrate outcomes without gaining the skills needed to systematically optimize the production process that leads to the outcomes.

The central points to emphasize here for human service administrators to ponder are:

• The ability to prove quality and client outcomes will soon become a given in human services, just as it has in many industries. Funding sources will demand this information and will refuse to support programs that cannot deliver it.

• As soon as quality and outcomes data becomes commonplace, there will be a push to performance-based contracting whereby human services are paid for results, not efforts. Here, we should heed the radical transformation of health care that has occurred under the onslaught of managed care. Health care providers who have always been paid on a per-person basis suddenly had to learn how to manage under capitated arrangements where they received a fixed amount of money to handle all of the health care needs for a group of people. Under the recently enacted federal welfare reform legislation, the shift of funding of welfare programs from a per-capita entitlement to a block grant approach may be a precursor to bringing managed care concepts into many types of public welfare programs.

• In order to deliver the level of results demanded by funders and the community, human service programs must learn how to systematically manage quality and outcomes. Dr. Lawrence Martin pinpointed the issues when he identified six central elements to practicing TQM in human services:

  1. quality as the primary organizational goal,

  2. customers define quality,

  3. variation in processes must be understood and reduced,

  4. change is continuous,

  5. commitment of top management is essential, and

  6. contractors and collaborators must be included in the quality management efforts.

  Trying to get an organization to achieve a high level of client outcomes without addressing these management issues is much like trying to race a car without bothering to put in an engine.

• Tremendous benefits can await those who make the journey. Philip Crosby, one of the leaders of the TQM movement, estimates that for-profit service companies lose about 35% of their operating budgets in doing things over that were done wrong the first time, either doing the wrong things or doing the right things wrong. If the situation is comparable in the human services sector, the potential exists to do a lot more good for a lot more people by eliminating these inefficiencies.