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The role of active treatment has been recognized as vital to the habilitation of persons with mental retardation; however, evaluating the provision of active treatment has been difficult. This study describes the development of the Active Treatment Client Rights checklist (ATCR), which was designed to facilitate the assessment, monitoring, and implementation of readily observable client active treatment services. This investigation provides an explanation of item content, initial reliability data (Phase I), and the results of implementation of the ATCR over a 2-year period in an ICF/MR facility with 29 living units serving nearly 500 clients (Phase II). The ATCR is highly reliable, valid, and useful in enhancing staff provision of active treatment. The most sensitive indicator of active treatment was shown to be related to frequency of functional interactions between clients and staff.

Contrasts between the rhetoric of quality assurance and the realities of poor quality in today's ICFs/MR were explored. Comparative studies have shown that ICFs/MR provide the poorest quality of life for persons with mental retardation. The ICF/MR operational model was described here as paper-oriented, failure-based, and insensitive to the effects of its own practices. Recommendations, including the establishment of local control, a less-direct relation between funding and rule compliance, and alternate forms of program evaluation and monitoring, were made.

Licensing and certification of ICFs/MR can adversely affect individuals, distort the allocation of (and waste) scarce resources, and encourage community residences to become small institutions. At a home in Northern California, used as a case study, recent interest in active treatment has emphasized good paper rather than good service or quality lives. Several recommendations were offered to encourage responsive services in line with progressive values and the wants and needs of individuals with developmental disabilities.

Regulations and voluntary standards within the context of organizational design and mission as well as leadership in management for quality were discussed. Rules and regulations are closely associated with the structure and mission of the organization. Altering them may require fundamental redesign of organizational structure and purpose. Likewise, alterations in organizational design can change the need for rules and regulations. In addition, standards do not automatically yield quality. Rather, they define expected levels of performance from individuals, programs, and the organization. The senior management of organizations is responsible for exercising the leadership in managing for quality.