Quality is as Quality Does

Soon after announcing about my plans to write a book on quality improvement in long-term care, I received an email from LTCI Lead Analyst Patti Zoromski with some interesting food for thought on the topic of “What sets up high quality in long-term care facilities?” I’d like to quote from Patti’s email because I agree completely with the well-earned wisdom she shares:

“…In case you need additional questions/issues to ponder, here are a few from my Pandora’s Box (keeping in mind that my most recent experience is in working in facilities which have been seriously challenged for one reason or another):

•  …there is never time to “do it right” but there is always time to “do it over”
• Accountability – I believe staff have a right to and a need to know their corporation’s (up to date) policies and procedures and need their feet perhaps “held to the fire” (no pun intended)
• Not all staff are self directed – many need supervision, not because they are “bad” people but because they do not know how to manage their time
• Speaking of supervision: people are not instinctively born to supervise, great nurses may turn out to be good supervisors; however, they need mentoring
• Until we get out of the “in-service” mode (which is really just a “reminder” and not anywhere close to being an actual in-service) we will continue to reap poor outcomes to action plans
• Do we help staff reach their highest potential or do we allow them to slip into mediocrity?
• Do we see residents, particularly those who are long term residents, as beyond help – have we come to accept they will have UTIs, that they will have behaviors, etc. and therefore “stop trying” because we are so pressed for time elsewhere?"

Doing it right vs. doing it over.
Patti’s insight brings to mind how enforcement has been carried out over decades in long-term care, the industry has been trained to “do it immediately” and this does not always translate into “doing it right.” We have a pretty engrained habit of jumping to solutions without analyzing the conditions that are keeping problems in place. As I have said many times before, we just set ourselves up to “do it over” (over and over again) by allowing ourselves to fall into this trap.

Supervision is key at every level.
I believe that effective supervision supports people in knowing their responsibility and accountability for excellence in care and service. Nurses are not trained to supervise in nursing school and most find themselves willing but not prepared to do the right thing. I have trained many charge nurses and directors on how to supervise people. My supervisory training hits right at the heart of issues in supervision in long-term care, which is a unique setting. In addition, I advocate periodic “check ins” with nurses to provide ongoing support to them in their pivotal role.

The biggest barrier the nurses perceive to holding staff accountable is the same one their supervisors feel, which is that if they have to let someone go they will work short of staff and face great difficulty finding the right person to fill the opening. This leaves the entire facility in a weakened position. In a sense, this inaction “holds us hostage” to poor performance; and is an important mindset to change.

Change comes from learning, not training.
Patti correctly notes that long-term care organizations need to “get out of in-service mode.” (Ah…the tyranny of the in-service as the sole solution to every problem.)

I believe that while ongoing in-service training and periodic training on issues that arise is essential, training in the absence of accountability only leads to more training: it generally does not change behavior.

Let’s face it, if many of life’s challenges were knowledge problems that training could solve, we would all be thin, drive only the safest cars, and live our perfect values.
None of us can say that because we know something, we do it. But the fact is, if we don’t know it, we can’t do it. So knowledge is the basis of behavior change, but learning (actually changing our behavior) is quite a different challenge that has more to do with what happens after training. I think we need more learning to go with our tremendous knowledge in long-term care.

Both residents and staff can be seen as people with potential, or not. I see that often the two flow together—how we perceive staff as having hope and potential matches whether we see residents as being “beyond help” and stop trying. Most long-term care organizations I have worked with are willing and open to develop their staff, although they don’t always know what is needed to do so. But the fact that the intention is in the right place gives me faith that they are also seeing residents as able recipients of care and service. This has been my experience in general.

Thank you, Patti, for sharing such valuable insight from your “Pandora’s Box.” Your views from the frontlines of long-term care enrich all of our professional experiences.

What’s in your Pandora’s Box?
I encourage you to click “comments” at the end of to posting and share your valuable insights.

CMS' Five-Star Rating System Fails Facilities, Residents, and the Public

Intended to be much like the one used for restaurants’ health ratings, the Centers for Medicare & Medicaid Services’ (CMS) Five-Star Rating System was designed to be posted conspicuously in the front window of a nursing home for all to see.  The facility's rating of 1 to 5 stars is intended to give consumers the ability to compare nursing homes in order to make discerning judgments about resident care. Recently published research findings that compared the Five-Star Quality Rating scores of nursing homes to the actual satisfaction level of residents and family members suggest that there is little correlation between customer satisfaction ratings and facility five-star ratings from CMS.

This is quite a problem because facilities will soon be required to post their ratings -- and yet apparently the ratings do not predict how satisfied consumers will be with the care they will receive nor whether residents of that facility are inclined to refer their friends and family.

According to Holleran, the national research firm specializing in the not-for-profit senior living sector that conducted the study, this lack of relationship with customer satisfaction is shown in several areas of satisfaction. “One such example is the fact that those nursing homes rated as a 1-star facility (the lowest according to CMS’ standards) overall had a higher willingness, on average, to select the facility again than all other facilities.”

Essentially, what is being said here is that once the ratings of CMS are posted in facilities, some of those most preferred by customers will be the lowest rated.

Turning people away from the places preferred by their peers is a striking failure for a rating system. These ratings will influence customer perceptions of care and potentially do harm to some of the facilities that residents consider to be the best for their comfort and care.  This gap must be understood and closed before consumers should rely on these ratings in their decision making.