The Quality Dilemma: A Continuing Challenge for LTC Leaders

by Diane L. Dixon, EdD

The recent release of quality data from the nation's approximately 17,000 nursing homes by the Centers for Medicare and Medicaid Services puts the spotlight on long-term care's "Quality Dilemma." In essence, the dilemma raises two key questions:

1) What is the best way to measure quality in nursing homes?
2) What are the most effective quality criteria that will help consumers to make informed decisions about nursing homes?

The Nursing Home Quality Initiative is attempting to answer these questions by publicizing a report card that compares nursing homes using quantitative clinical data that is currently collected in the Minimum Data Set and surveys (see www.medicare.gov). The intent is for consumers to use this information to make more informed decisions about nursing home selection.

However, these data raise other critical questions:

1) Are the data sufficient for determining quality?
2) Are the data accurate, since all nursing homes are not equal in terms of the type of care they specialize in and how they operate?

In essence, do these quality indicators tell the whole story?

Perspectives from the Field

Debra Sims, Chief Clinical Consultant for Transition Health Services, which has headquarters in Flower Mound, TX, says that the quality measures do not tell the whole story because they are published without any accompanying analysis. Transition Health Services manages nursing homes in Texas, Louisiana, and Arkansas.

Ms. Sims pointed out that there is diversity in acuity and type of residents among nursing homes. The CMS report card as it is does not encompass this important fact. Variances may occur for a variety of reasons. For example, a patient coming from a hospital to a nursing home with 14 or 15 pressure ulcers will affect the percentage for that facility. Also, sicker residents with higher potential of decline because of their medical condition may not be able to feed themselves and do other basic daily life functions during their first few weeks in the facility. Consumers will not know this information simply by looking at the statistics.

On the other hand, Ms. Sims suggests that facility leaders can take a positive approach and use the comparative data as an analysis tool for their facilities. Through inquiry and reflection, leaders and staff should ask--Why are we different? What do we need to change? Thus, the data can be used for performance-improvement processes.

Adam Kane, Director of Public Policy for Mid-Atlantic LifeSpan, a company that represents more than 300 senior care provider organizations in Maryland and the District of Columbia, said that the company has raised questions about the quality indicators. Maryland was one of the six pilot states that helped establish the CMS quality report cards. The quality measures do not include data on quality of life, level of staff, training of staff, or turnover, said Mr. Kane, adding that stakeholders working on the Maryland Report Card plan to include satisfaction elements--such as quality-of-life benchmarks--that are more likely to be of interest to consumers.

Steve Shields, Executive Director at Meadowlark Hills in Manhattan, KS, observed that he is looking at the CMS Quality Indicators as a positive first step that may lead to measuring factors that are really important. Quality goes deeper than pressure sores, he said. Measuring "small things that are large in life"--that is, quality-of-life indicators--would expand the definition of quality in a nursing home.

Mr. Shields cited, as an example, asking one of his residents "if you could do anything you want to do, what would it be?" The resident said she had to think about it. When he asked her the next day for an answer, she said she had thought of little else, but the question was too large. So, he restated it and asked, "If you could do anything you wanted to do for five minutes, what would it be?" She responded, "I would like to drink a cup of Earl Grey tea in a special china cup and watch the sun come up." He bought her the tea and china cup and that is what she did.

How can a quality-of-life moment such as this be measured? Yet, the example really demonstrates how huge the quality-of-life issue is in a nursing home.

Quality-of-Life Study

A CMS-funded study on measurement, indicators, and improvement of quality of life in nursing homes is underway nationally, under the direction of Rosalie A. Kane, PhD, a Professor in the School of Public Health at the University of Minnesota in Minneapolis. Dr. Kane said that the purpose of the study--which began in 1998 and is scheduled to end in 2003--is to develop and test measures that could be based directly on what nursing home residents say about their lives. The quality-of-life measures include comfort, sense of security, relationships, enjoyment, functional competence, meaningful activity, spiritual well being, dignity, autonomy, individuality, and privacy. These quality-of-life measures are needed in addition to the clinical measures, according to Dr. Kane.

Resolving the Quality Dilemma

The key to resolving the quality dilemma is a "both/and" approach to evaluating the nursing home experience as a whole. It is evident that a resident's quality of life plays a significant role in determining facility effectiveness. Resident and family satisfaction are the center of quality. If only clinical measures are taken into account, we only have part of the picture. A balance between quantitative and qualitative variables would work to create a positive living environment in which residents receive quality care.

Selecting the best methods to determine how variables individually and collectively should be measured is an ongoing challenge. But it is also an opportunity to continuously pursue quality-improvement processes. The both/and balance not only rests with measurement, but also with figuring out the best ways to help consumers understand the measures so that they can make good decisions as well as give valuable input to leaders and staff.

A recent GAO Report states that "public reporting of quality indicators has merit, but national implementation is premature" (also see "National Nursing Home Quality Data Release Generally Applauded" in the January 2003 issue of Caring, p. 29). The report raised questions about the appropriateness of the quality indicators used for public reporting and suggest that consumers may be confused by the quality data. Thus, stakeholders in this endeavor still have some work to do. While studies and dialogues continue in the national arena, long-term care delivery organizations at the local level are contributing to this effort by developing their own methods for measuring quality.

Internal Accountability is Key

Using the consumer market as a way to improve quality is one approach, but internal accountability is what really drives quality outcomes. For example, the Jewish Home and Hospital Lifecare Systems developed a quality-of-care monthly report card more than a year ago to monitor quality outcomes and share best practices with the Board of Trustees and staff, said Rita Morgan, Administrator of the Sarah Neuman Center for Healthcare and Rehabilitation in Westchester, NY, which is part of the Jewish Home and Hospital system.

In addition to the report card, the organization created performance-improvement and health care committees that meet quarterly to analyze quality of care and monitor ways to continually improve their practices. Facility staff also seek and receive input from their residents and families in both long-term and short-stay units through satisfaction surveys. Further, residents serve on the performance-improvement and health care committees to ensure that their input is heard and valued. "They are quite vocal and eager to let us know how we can enhance care and quality of life," Ms. Morgan affirmed.

This excellent example demonstrates an important point--namely, that leadership and quality go hand in hand. Leaders create the quality vision, embed the values, empower staff to embrace quality, involve residents in shaping quality of life, develop measurement methods that everybody can understand, and use them to hold themselves accountable for continuous improvement. Hence, the quest for quality becomes an organizational cultural norm.

Reflection

The controversy surrounding the national release of the CMS Quality Report Card has many lessons for us. What can we learn from this experience? How can we take what we learn and use it to help shape a better quality-measurement system? How can we work together to make that happen?

Real dialogue among stakeholders is critical in pursuing answers to these vital questions.

Dr. Dixon is a consultant, writer, and lecturer specializing in leadership development, change management, strategy development, and team building. She is also a member of Caring's Editorial Board.

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