A concerted, team effort by facility management and staff in long-term care can do what government oversight alone cannot in improving efficiency and resident outcomes.

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he public has significant concerns about the quality in America’s long-term care facilities. That is a statement that was made in the 1960s and, in my experience, continues to be valid in the 21st century. For more than 40 years, the public and public policy makers have fretted over the perceptions of quality, but little has been done to actually improve the outcomes. Certainly, much activity, numerous regulations, and considerable rhetoric has occurred, but the concerns continue. None of the stakeholder groups are satisfied with the outcomes.
       The current system for monitoring quality is the federal Medicaid/Medicare certification system. While it means well, it does not improve or even measure quality. It subjectively determines compliance with federal certification standards, which may or may not have a relationship to improving outcome. Quality improvement (QI) must be done at the bedside and in the facility by direct care staff. While the facility leadership can provide guidance and support, it is only the direct care staff that is able to make process improvements that may lead to better outcomes.
       Should we continue the current pathway, or are we going to get real about improving quality in America’s long-term care facilities? When will the pain of the current inspection system be harsh enough for long-term care profession to take a leadership role to really improve outcomes?
About 13 years ago, an earlier business unit of the Benedictine Health System (BHS) asked that exact question and decided to do something. After considerable introspection and reflection, they retained the services of 3M, a company heavily engaged in the QI process in the manufacturing sector, to assist in the process. Thus began a journey that continues today, as BHS has been using the Malcolm Baldrige Quality Award criteria as its current model.
       The BHS leadership examined several quality assessment systems and settled on the Malcolm Baldrige criteria, as they are highly regarded for service sector evaluations. Also, 3 health systems have been awarded Malcolm Baldrige Quality Awards in the past few years. The Malcolm Baldrige criteria has been used for more than 17 years and follows 7 categories for the evaluation: leadership; strategic planning; focus on patients, other customers, and markets; measurement, analysis, and knowledge management; staff focus; process management; and organizational performance results.

Leadership: What Role Does it Play in Becoming a Quality-Driven Organization?

       While actual QI is done at the bedside with direct care staff, it takes leadership starting at the highest levels of the organization to achieve systematic improvement. Governance leads with encouragement, incentives, and high expectations. The demand for achieving superior outcomes and continuous improvement is a role for governance. It must demand the reporting of agreed-upon metrics and the achievement of superior outcomes.
       Senior leadership contributes to QI by creating a culture and work environment that stimulates innovation, decision making based on knowledge, risk taking, commitment to clients, and a focus on continuous QI. The team must share a vision and values, such as loyalty, humility, outcome-driven activity, and forward thinking. It must allocate time, resources, and focus on the QI process.
       The leadership at the facility level must share all of the attributes of senior leadership and also work to cascade those values to the direct care staff. All must be committed to leading, teaching, and achieving quality outcomes. Direct care staff members are encouraged to become leaders in the quality improvement process. They are allowed to make critical decisions about their work settings and challenged to try new tactics and strategies, without control by management. This risk-taking culture allows for innovation without the consequences of failure.

Strategic Planning: How are the Mission and Vision Aligned Within the Organization?

       It is the obligation of the leadership to create a strategic plan that clearly articulates the purpose (mission) and direction (vision) of the entity. This is the foundation of the ethos of the organization, providing a road map for the future success.
       The strategic planning process includes a brutally frank analysis of the strengths and weaknesses of the organization, typically done using a Strength, Weakness, Opportunity, and Threats (SWOT) analysis.¹ The challenge is to find, develop, and review the internal and external data elements that are critical to the survival and success of the organization.
       External consultants may be able to assist in creating some of this information, and they can also be unbiased in the presentation. However, much of the effort and work product needs to be created by internal experts, including senior leadership.
       The strategic plan needs to be communicated and cascaded through the organization. Each employee needs to understand the plan and, more importantly, how he or she fits into it. This is important so that all participants are aligned and working toward the same goals and objectives.

Zeroing In: Focus on Patients, Other Customers, and Markets

       Since the inception of federal regulations and the inspection system, the process has moved away from the needs and expectations of the resident, patients, and family and toward compliance with the regulations and the judgment of surveyors. Providers have struggled to find the ways and means of engaging the residents and patients into the improvement process while balancing the expectation that they always be in full compliance with federal and state regulations.
       The federal inspection process is a needed element, but the most important assessment is what the resident, patient, and families expect, need, and demand from the organization and the staff. How do you secure that information from them?
       The use of a survey tool is a means of acquiring the information about expectations, but it needs to be combined with focus groups and evaluation of formal and informal complaints. Survey tools are excellent sources of information but lag behind the knowledge curve. As long-term care becomes increasingly short-term care, waiting for an annual questionnaire is less acceptable.
       The data-gathering process needs to change to shorten the time lag. Techniques, such as admission and discharge survey tools, mystery shoppers, the traditional “management by walking around” approach, and asking questions, are all potential data sources.
       An additional organizational effort must be to listen to concerns and complains from internal and external sources. Constructive comments provide a means of focusing on issues and problems very quickly. A quality-driven organization goes to extraordinary efforts to learn of concerns/complaints and resolve them quickly.

Measurement, Analysis, and Knowledge Management: Putting it to Use

       Many quality and management gurus agree that if it cannot be measured, it cannot be improved. They also believe that human nature will focus our efforts on those things that get reported.
The role of senior leadership is to identify the critical factors that truly represent the elements that separate an average organization from a great one. They include data elements that measured as both leading and lagging indicators.
       Data elements need to meet the following conditions:
• Can it be consistently measured?
• Can comparable measures be found from outside your organization?
• Are the elements relevant?
• Do your stakeholders agree that these are important?
       There is a tendency to collect large amounts of data as a means of covering all options. While the belief is that “more is better,” if the goal is to define and focus on problems, the opposite happens—focus is not achieved and confusion reigns. The challenge for leadership is to find those vital few data elements that are critical to the success of the organization.
       Once the critical elements are determined and the data received, the information needs to be used for decision-making. There is a pitfall of attempting to explain away the results (eg, statements like, “The survey team arrived and therefore everyone was in turmoil,” or, “We had union problems so the employees were upset.”) Results—good or bad—need to be used to make decisions and manage by fact, not by supposition or by guessing.

Staff Focus: Are Staff members Part of the Process or the Problem?

       The essential players in QI are direct care staff members. They are closest to understanding the problem or barriers to improving outcomes, and they are actually able improve outcomes. However, they need motivation, tools, and resources in order to achieve better outcomes.
       Quality improvement must become a part of the culture and the expectations of each other, not another burden imposed by management. It must be a part of the fabric of the organization and individual. The vision to constantly improve must be fanatical.
       The role of management is to eliminate the barriers that prevent direct care staff members from their roles in improving outcomes. Communication, education, knowledge, understanding of expectations, and resources need to be readily available.
       The expectation of accountability needs to be communicated through the organization. This starts at governance, goes through to direct care staff, and then moves back up the line. Direct care staff members need to hold management accountable, the same way management holds them accountable, with improved outcomes for the customer/patient/resident being the final goal.

Process Management: Is the System Integrated Throughout the Organization?

       There have been mountains of books written on the QI process. The classic quality gurus, such as Juran and Deming, have been followed by many others, including Buckingham and Collins. All of their theories and processes have individual elements and merits. The choice of a system is important but somewhat academic. The critical decision is to pick a QI system or technique that fits the culture of the organization and relentlessly work the improvement process.
       The organization develops a common system and common language, which then create an environment for the individual and organization to succeed. If the individuals cannot communicate on the same level, the improvement process will not be sustained.

Organizational Performance Results: Is the Improvement Process Demonstrating Superior Results?

       By the time the organization has gotten to this point in the improvement process, it should be actually demonstrating improvement. If it is not generating significant improvement, it must go back to the starting point and examine each element. If the organization has exceeded significant improvement, it did not set the goals high enough.
       The quality-driven organization wants to be measured against the best of the very best, not slightly above average. Achieving scores in the 90th percentile, as measured against peers, is an excellent starting point for quality-driven organizations.

Conclusion

       The challenges facing long-term care and its quest for quality recognition is really no different than the challenges facing the other sectors of the healthcare delivery system. As reported by the Institute of Medicine, acute care faces similar quality issues and negative outcomes.² The difference between acute and long-term care appears to be a desire on the part of providers, public-policy makers, and payers to work together on a common vision to make systemic changes.
       Across the nation, hundred and perhaps thousands of long-term care organizations are trying new care-delivery systems that are focusing on the expectations of their communities. Pioneer Network, the Eden Alternative, and the Greenhouse Project are among the groups trying to change how care is provided. This is occurring not with government mandates and new regulations but with organizations trying to create a better outcome for their customers. This is a growing, grassroots effort that needs to be encouraged and nurtured.
       Some in long-term care believe that consistently superior outcomes cannot be achieved by using a systematic QI process in long-term care facilities. Further, they believe that additional regulations, oversight, and sanctions are the only means of improving care outcomes. We disagree.
       We have seen remarkable improvements in results in numerous long-term care operations that have adopted QI processes. We believe that the pathway to achieve superior outcomes is to:
• Use a systematic quality improvement process
• Forge a relentless quest by leadership to achieve superior results
• Create a commitment of all staff to meet and then exceed the expectations of residents, patients, and their families.