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1. Introduction
Some years ago, when I started
to work with a computer for the first time (as a sort of improved typewriter),
I had the greatest difficulty in understanding why I had to ‘click' my
mouse on the ‘start' icon when I really wanted to turn the machine off.
I found it utterly illogical ! Why should one press on ‘start' when one
actually wanted to ‘stop' ?
My experience appears to
have been shared by many others. The computer has its own form of logic.
Every once in a while this logic appears to be in direct conflict with
the way we contemplate things. One might conclude that the difficulties
encountered while learning to work with computers (and software) are to
a certain extent the direct consequence of these differences in the logic
being maintained.
This workshop is about experiences
acquired in the setting up and implementation of an automated client monitoring
system within a number of revalidation centres. It goes without saying,
we too have been confronted with the problems I just mentioned. Furthermore,
it seems that association and working with a client monitoring system can
produce both predictable and unforeseen consequences. This is true for
the way work has to be organised and for the staff as well as for the clients
themselves. The goal of this chat, therefore, is to present a sketch of
the evolution, the goals, and the practical consequences of a client monitoring
system. Attention is also drawn to the interactions between the client
monitoring system and the actual activities of the revalidation. 2. Revalidation
for the visually handicapped in the Netherlands: its development and the
current state of affairs
In order to understand the
factors which were taken into consideration, at the time policy was being
determined for the establishment of a client monitoring system, it is important
to sketch briefly how revalidation works for the visually handicapped in
the Netherlands.
In the past, around the
age of six years, the visually handicapped (originally for the blind only,
but since the 1950's also for the visually impaired) were placed in large
institutions where a total package of services were offered (including
accommodation, care, education and revalidation). This total package was
financed by the government. Around their twentieth birthday the visually
handicapped were discharged from the institution where they had been staying
either to return to their original homes, go to another institute, or (in
some cases) they might undertake their own care. The greatest part of the
revalidation took place within the walls of the institute. This situation
has changed drastically in recent years as a consequence of appeals from
parents, influence from pressure groups, urgings from the government and
last but not least; advice from the professionals working within the revalidation
system.
At the present time (1997)
revalidation takes place in small regional facilities which are spread
throughout the entire country. In principle, children having a visual handicap
remain living at home and attend ‘ordinary schools'. The ordinary schools
are provided with special support by teams of specialised teaching staff
from the regional facilities. Only in special cases are the children sent
to specialised schools for the blind and/or the visually impaired. Both
care and education continues to be financed by the government. (The situation
surrounding education is being treated in another segment of this workshop).
Revalidation (such as mobility,
training of ‘remaining vision', skills in the area of ADL and self-care)
usually takes place under the auspices of one of the regional facilities.
Children and adults visit the regional facility a number of times each
week in order to participate in various forms of revalidation. If necessary,
the clients are visited at their own homes by specialists from the regional
facilities. The contacts between the regional facilities and the visually
handicapped are of short duration: the client has a specific need the regional
facility provides an answer to this need after which the client only returns
if and when a new need arises.
These changes in revalidation
are not simply a question of organisation; a major shift has taken place
in contemplating the problem as a whole. The current situation reflects
the point of view of a ‘normalisation principle', which reflects the acceptance
of the importance of integration within society. It also includes the adjustment
of situations and facilities within general society so that the visually
handicapped can study, live and work as part of that same society. Revalidation
facilities and schools therefore offer the specialised assistance which
is not readily available in the regular public care and education system.
All assistance has to be tailored to the needs of the individual client,
which means:
Care must be close at hand
. Care must meet the specific
requirements of the client
. Care must fit within the
available budget
Care should be given at
the time it is needed.
A broad variety of short
term revalidation, training and preventative activities has evolved. Added
to this is a growing number of parents who are directly involved in the
care of their visually handicapped children. Last but not least, client
organisations are becoming more and more involved in the establishment
of the revalidation.
Visio, the organisation
for which I work, has established seven regional facilities throughout
the Netherlands from which specialised revalidation services are offered.
Visio is active in the north, the west, and south-west of the Netherlands.
Furthermore, a number of special schools, as well as ‘living and work communities'
for the mentally handicapped having visual problems, are part of Visio.
In total Visio has a staff of about 700; of which 200 being attached to
the regional facilities. Between them, these regional facilities serve
more than 3,500 clients in the age group 0 to 100.
The services rendered from
the regional facilities are diverse. We provide:
_ Research & diagnostics;
research into the visual functioning of the individual client, and the
actual potential of what can/might be done with the remaining vision. Research
into the method whereby visual stimulation is employed, where no physiological
explanation exists for the problems experienced when ‘looking'. Research
into the progress being made by children at school, especially to determine
whether they are getting behind as a consequence of their visual limitations.
Research into effective reading aids and/or adaptations for computers.
In other words, we do research with the specific goal of attempting to
understand the specific problems being faced by individual clients. On
the basis of this research, and in consultation with the client, the optimum
help is indicated. _ revalidation, treatment, accompaniment; the (help)
requirements of the client are answered in a number of ways. Short term
training, for example in the use of reading aids, guidance in the learning
of a new hobby, and the improvement of house-keeping skills. Slightly lengthier
revalidation in response to questions in such areas as mobility or visual
training. Assisting parents with questions associated with upbringing.
Activities with children specifically to stimulate the use of their remaining
vision, the strengthening of their self-reliance and assisting contacts
with other children having similar handicaps. Last but not least, there
are the discussion groups for parents, the aged, and for (seeing) partners
of visually handicapped.
_ information and advice;
information for professionals concerning how to associate optimally with
the visually handicapped, information for public groups, and specific advice
concerning practical matters such as the furnishing and lighting of homes
and offices. Furthermore, we offer information opportunities where anybody
may drop in without appointment; there are showrooms with the latest in
available aids, games which have been modified for the visually handicapped
and extensive information in the form of folders and brochures.
_ consultation and the stimulation
of exchanges in expertise; the sharing of expertise takes place with colleagues
from the regular health care; on top of which consultation opportunities
are offered to institutions and persons who work professionally with the
visually handicapped and who wish advice concerning the best forms of assistance
and help for their clients. For a number of years we have been working
with an (adapted) model of the ICIDH. With the assistance of this model
we strive on a professional level to provide substance to the revalidation
of the visually handicapped. It is our opinion that interdisciplinary co-operation
is an absolute necessity. The complexity of visual perception is so vast
no single discipline incorporates sufficient knowledge. The bundling and
focusing of specialisms upon the specific needs of an individual is therefore
essential. In employing this model we strive to use an interdisciplinary
language which can be understood by every professional involved in revalidation.
With the assistance of ICIDH a classification system is used whereby the
problems of the client can be analysed while simultaneously this same classification
system is used for the indexing of research and treatment.
The increase in the number
of professionals involved with revalidation as well as the increase in
the number of revalidation activities has surpassed the potentials of the
former revalidation organisation. We had become too rigid and bureaucratic
to respond optimally to the needs of rendering modern care. The earlier
mentioned changes within revalidation required prompt and effective practical
responses. The organisations had to become flexible, efficient and capable
of meeting the needs for information promptly. Within Visio we came to
the conclusion that flexible care and revalidation programmes (meeting
the requirements of the individual clients) would only be possible if the
organisation of the care/revalidation was harmonious. To put it in another
perspective, the evolution within the practice of care and revalidation
has led to changes in the organization.
Within Visio, during the
past two years we have developed and implemented an information (collection
and processing) programme which provides both the management and the staff
with the information they require to fulfil their work. With the assistance
of the programme all relevant decisions concerning care/revalidation of
a specific client are recorded; this same programme makes it easier to
prepare planning and appointments, as well as the necessary registration.
All in all this programme contributes substantially to guarding the objective
quality of the care as well as the development of meaningful care policy.
I shall now go into the specifics of the programme and how it works.
A minor word of caution
in advance: I am neither a computer systems manager nor an expert in automisation.
As the director of the institute I have for the past few years been the
project leader for the development of the client monitoring system. As
a consequence I know very little about the information side of the system
which has evolved. I trust this lack of technical knowledge will be more
than compensated by focusing upon the organisational and substantive implications
of our system.
3. Specifications and structure
The client monitoring system
has been developed because we wanted to be able to organise more flexible
revalidation programmes. The former administrative system was in danger
of ‘gridlock' especially because of the increasing numbers of clients requiring
care. To achieve the basic goals a number of specifications and related
requirements had to be formulated. The most important of these were:
_ the system had to be easy
to use, also for people having little experience with computers.
_ the system had to be quick
_ it was essential that
interaction should be facilitated between those concerned with a given
client within the system
_ the system should be set
up in such a way that an up-to-date summary of information is always available
concerning any given client
_ rules of privacy must
be maintained
_ control of the administrative
support related to the revalidation should be easy and accurate
_ the system should contain
sufficient information concerning the number of clients, types of requests
for assistance, and the nature of the revalidation, so that policy makers
have the data they require.
_ the system should support
the methodological work methods of the professionals
The client monitoring system
is built up in modules. This means that the system exists out of a number
of loose parts, each of which is a complete unit. These independent units,
where necessary, are connected with each other. The great advantage of
a modular construction is that during the development of the system one
can work in parallel. It goes without saying the cohesion of the system
as a whole has had to be maintained a point which has been given a great
deal of attention during its development. The system is built up from six
modules;
1) The heart of the system
is formed around an automated client system whereby the client is followed
from the first contact until such time as the contact is terminated. This
central module is called VIS Base. Within VIS Base all decisions concerning
research and treatment are recorded, complete with relevant information
about the client such as name, date of birth, address, medical data, details
concerning request for aid, name of doctor(s) etc. In this way VIS Base
becomes an electronic dossier for each client. The information in this
module is can also be called up through other parts of the programme. Dependent
upon the intended use, the data is made anonymous.
2) The module LDIS guards
the logistical progress of the client. In this module are found the norm
times for waiting between the first contact and first examination, and
the waiting time between examination and revalidation; furthermore, this
module records the norms for the times when a client should be given attention
in staff meetings. In addition the norms are recorded of the time it takes
to register a question (often via the telephone) and the time actual information
is made available. With the help of this module it is possible to maintain
control of the objective quality of aid. The system also warns us when
we run the risk of exceeding the norms in our contacts with a client.
3) The module IP (interactive
planning) lends support to the making of appointments with clients. Each
of our facilities has an average of about 150 contacts per week with clients;
the contacts being planned partly at the facility and partly at the home
of the client. The system provides a central planning between staff and
clients even in those cases where a staff member is temporarily not available.
In this way the appointments are ‘client-friendly' and flexible. Simultaneously,
this module records the number and sort of contacts being made each week
and month by a specific member of staff. Information of this nature is
necessary for justifying the expenses to the government.
4) Staff (both researchers
and those responsible for treatment) employ the OBE Module (OBE = ‘Onderzoek-
en behandelepisode' = roughly translated ‘research and treatment') for
the preparation of minutes of a discussion and/or a report. A part of a
report (the conclusions and recommendations for further revalidation) are
automatically added to the electronic dossier of the client. Each discipline
has a standardised model for preparing a report conclusions and findings
are coded, which makes them suitable for providing information about the
scope and nature of the revalidation provided.
5) The module PRO (protocols),
provides descriptive outlines of how various revalidation activities (or
treatments) should be carried out. VIS-PRO incorporates all treatments
(including the various steps and the related supporting materials) associated
with a given discipline. The instructions include a build-up of the revalidation,
the way in which training is given, and the most suitable materials. This
module is for new staff members who must still master their various professions,
as well as for staff members who wish to acquire knowledge about an unknown
product.
6) With the assistance of
Module MI (Management Information) general management information can be
generated which will assist in evaluating the care being given as well
as developing new policy. Via this module it is possible to acquire a picture
pf how many clients are being cared for, the nature of their needs and
the type of revalidation being provided. It is also possible to cross-connect
the information.
The modular structure of
the system has also influenced the manner by which the system itself has
evolved. Let us now take a look at how it works in practice.
The system in practice: the
consequences of working with an automated client monitoring system.
It would cost too much time
to go into all the details surrounding the ins and outs of the development
of our system. As with so many projects, in which software is developed,
this system cost 100% more than budgeted. Furthermore, development and
technical implementation took three times longer than expected. Those of
you who have had experience in the development of new software will doubtless
recognise these phenomena. Our system has in fact only been operational
since May of this year. Improvements are being added daily. We expect that
by the end of this year, or early next year, new versions of the client
monitoring system will be ready. Under the circumstances it would be premature
at this stage to claim that we have a full picture of all the implications
related to the use of this system. Nevertheless, a number of the implications
are known. I shall name a few.
During the development of
our system it soon became evident that the diversity of requests for assistance,
the various disciplines which would be involved in answering these requests,
not to mention the large number of different types of revalidation activities,
together would contribute to the complexity of the client monitoring system.
The modular structure of the system made it possible to test itself step-by-step
in practice even during its evolution. Some parts of the system were tested
no less than four times before it became clear precisely how they should
function.
The tests carried out during
development of the system were made by the staffs of the various institutions
within our umbrella organisation. It soon became evident that introduction
of the system would only be possible if the existing administrative routines
and procedures were adapted. This was hardly a surprise one of the original
motivations for undertaking the development of a client monitoring system
had been the observation that the existing organisation associated with
care was no longer able to meet the changing requirements of client care.
The surprise came with the realisation that not only administrative procedures
would have to be adjusted but the entire approach to care had to be reconsidered.
The consequent compartmentalising according to ICIDH led to the discovery
that the recording of reliable information about a given client, as well
as the requests for care and the products which are offered to the client
would only be possible on the condition that the client situation could
be reported accurately in more or less standardised terms. Further to this
I would like to refer to the article of J. Crews and R. Long in Journal
of Visual Impairment & Blindness of March/April 1997. The authors draw
attention to the fact that measurements conducted during examinations (during
revalidation of blind and visually handicapped) are especially complex
because standards (ie: models) are seldom integrated into the organisational-structures
of the institutes. This article confirmed our own findings. The system
we have now developed offers the possibility for recording test measurements
more methodologically. The coming years are going to provide us with a
lot of work ! The new client monitoring system has consequences for three
parties:
_ administrative staffs
_ staffs responsible for
revalidation, research and advice
_ clients using the services
of an institute
For administrative staffs
the new system introduced remarkable changes. They work differently, carry
out different tasks, and have been given other responsibilities concerning
the maintenance of information. These changes include:
_ Reduction in traditional
office clerk activities such as filing, copying and/or destruction of archives.
There is now a central dossier in which all relevant information from each
discipline is recorded. This dossier is partly maintained in the traditional
‘hard-copy' manner (on paper and filed), but the most up-to-date and complete
information concerning each client is now found in the client monitoring
system. One might call this an electronic dossier. Many of the traditional
activities, such as copying a report from a dossier, looking for a missing
report etc, are no longer necessary. In practice this has required considerable
adjustment, especially because less and less was to be found on paper and
more and more in the memory of the computer. In the beginning there was
a tendency to regularly print out the electronic dossier in full in order
to acquire a complete picture. With time this tendency diminishes.
_ More contact with the
client. Appointments with clients are now supported by the new system and
are centrally planned. Agenda planning is not yet functioning optimally.
However, it does illuminate the responsibilities of the administrative
staff. Unlike in the past, administrative staff now have much closer and
more frequent contact with the clients. Involvement of administrative staff
in the revalidation process is a natural consequence.
_ Advantages for the support
services. Supporting services (such as housekeeping staff) can now find
out quickly, via the central administration, exactly how many people can
be expected.
_ The need for co-operation
and consensus. More people are now involved with the administrative side
of client care. More than before, this means it is now essential that all
personnel co-operate with each other. Furthermore, since it is now obviously
in everyone's best interest, staff members must seek each other's opinions
as to how certain administrative procedures should be maintained. This
new sense of shared responsibility is having a positive effect.
For staff members directly
involved in revalidation and research the client monitoring system has
a direct influence upon methods of reporting and retrieving essential information,
as well as the methodological aspects of their work. The consequences are
less for the organisation of the work but much more for the contents. Specifically:
_ Reporting is standardised. The preparing of reports is now carried out
according to a specified model incorporating fixed groupings of information
and codes. The structuring of these reports has led to fundamental discussions
between the various disciplines as to what and how reports should be made.
I have already told you of the discussion concerning the measuring of results.
_ Information is immediately
available. The existence of an electronic dossier has resulted in the staff
being able to have direct access to relevant information. In practice,
working with the electronic dossiers has to be learned and requires practice.
Information one used in the past to get from a colleague is now acquired
from the dossier. This may be very efficient, however the personal contact
with a colleague is sometimes missed. In the future, client discussions
will be more focused upon interdisciplinary issues and less upon the exchanges
of current information.
_ Style of leadership. The
guarding of agreements related to a specific client is greatly facilitated
by the client monitoring system. It is now almost impossible for a client
to become lost in the system. A consequence of this function of the client
monitoring system is that executive staff now play more of a coaching role
and are less directly concerned with direct (‘hands-on') control.
_ Development of methodology.
The putting together of a description of work procedures, aids and materials
per revalidation product (in VISPRO) implies that within a discipline agreement
exists as to how a specific product should be used. In putting VISPRO together,
numerous discussions have been (and continue to be) held about methodology
and professional content. Through this interdisciplinary process a method
of description has evolved which makes it possible to record both the quality
and the norms for quality which should be maintained by the professional.
_ The development of policy.
The information which can be generated from the client monitoring system
can cover many aspects of the work being conducted in a revalidation institute.
This information can be extremely useful in developing effective short
and middle range policy. However, in all fairness, since the system has
only been operational since May of this year we have too little practical
experience to speak with certainty of real applicability.
The introduction of the client
monitoring system has also brought changes for the clients. One might bundle
these changes under the title; ‘client friendlyness'. Examples include:
_ The client now knows much
sooner when he/she will be called up for participation in revalidation.
_ The client can now make
or alter an appointment, even if the staff member in question is not present
at the moment.
_ With a view towards protecting
the privacy of the client only specific authorised personnel have access
to certain information.
From what I have told you so far it should be clear that the introduction of a client monitoring system brings far-ranging consequences. We have only just started on what will certainly be a long road. Before ending this presentation I would like to formulate a few recommendations recommendations which apply to ourselves in particular but may be important for you too.
5. Recommendations
_ Think before doing ! This
applies to both the setting up of the undertaking and to the incorporation
of further improvements. With the limited experience we now have with our
system I would dare to say it is impossible to think too much ! In particular,
thought should be invested in such questions as: which problems do we wish
to solve, what results do we want, and what are the standards and norms
to be applied to a solution.
_ Combine organisational
change with the other changes these are two sides of the same medal. Quality
improvements in revalidation (including standards, result measurements
etc) cannot be seen as separate from the organisation of revalidation in
our facilities, schools and institutions.
_ Learn from other sectors.
It goes without saying, revalidation of the blind and the visually impaired
is a unique specialism with its own problems. This does not mean, however,
that we cannot learn from our colleagues in health care, in education,
and in other organisations for the handicapped. There is an ocean of experience
out there waiting to be tapped. The problems we have had to face in meeting
the changes in client requirements are not unique. A lot of headaches and
heartaches may be spared.
_ Make a system which can
also be used by the blind and the visually impaired. As a sector we have
a responsibility for setting an example. This is especially so in the matter
of integration. Integration is not served if we produce a system where
our own clients cannot feel welcome.