Measuring Quality in Long Term Care

Over the years there has been a great deal of concern about the quality of residential care. Frequently there are stories in the media about poor care, neglect and abuse. I have been told that complaints about this peak in January after Christmas visits from relatives. Many concerns were expressed during the Labour/Greens/Grey Power consultation in 2010 , which concluded “Our older people deserve better.” [1]

But what do we mean by quality and how do we measure it? This question is part of some research I am associated with at the moment, so I was keen to go along and hear an address on the subject by Professor Vincent Mor, from Brown University School of Public Health, in the USA, who was in Wellington in February. Professor Mor is working on a long-term project –  “Shaping Long Term Care in America”. His research focus is the quality of nursing home care and the factors which influence quality and outcomes for frail and chronically ill people.

If funders of health care are demanding greater accountability from the providers then there has to be agreement on what concepts of quality are important to measure and how measurement will take place. What concepts? Who should be measured? When and where? And who is going to take action on the findings? What if there are differences in what “quality” means?

This is not going to be a simple process.

Indicators of themselves are not quality, no more than a finger in the air is the wind – it only indicates that there is a wind and which way it is coming from. In order to identify indicators, clinicians are likely to focus on medical care and treatable symptoms. Regulators are likely to focus on whether certification standards are being met and proscribed care processes are being carried out. Families of care home residents are likely to focus on staff behavior and responsiveness and whether residents appear comfortable. And the older people themselves will be concerned with individual perceptions of their lives and their “home”.

As Mor points out – “Quality is multi-dimensional.” Are these perceptions of quality equally important? How can you compare measures to control symptoms against falls prevention, keeping people “dry” or avoiding depression? This is an almost impossible question to answer and we have no perfect tools to measure quality. But it does not mean that we should not try, nor that we should give one perception priority over others.

When older people and their families are selecting a rest home they want to know which will provide the “best” care in their terms. The regulators will focus their energies on facilities which do not meet the legal standards and have to be pulled up. Funders are looking for efficiency and the best value for their investment. Can there be a “best” to satisfy all? Does quality ultimately depend on individual perceptions? A rest home may have a superbly welcoming and friendly atmosphere but the medication regimes may not be 100% by the book and their fridges may not always produce the required temperatures. So residential care facilities may have high levels of quality on one dimension but fall short on others. Combining measures to create a single composite rating, like a star rating for a hotel, will necessarily be crude and some of the stakeholders may be misled by it.

Professor Mor – full of questions – also asked “Who is Accountable for Performance on Quality Measures?” We have not found a way to completely prevent or slow functional decline in extreme old age. Rest home managers can be held accountable for the actions of their staff, but what about the actions of physicians who they do not control? Do families have some responsibility for care and wellbeing even when their relatives are in residential care?

In his research, Professor Mor found considerable variation in residential care services in the USA, which could not be attributed to clinical factors or patient preferences. He called for more work to identify quality indicators as a means of promoting discussion about quality improvement in residential care. If these can be agreed on, recognising the different dimensions involved, this would increase confidence among the various groups of stakeholders. He is in favour of public reporting and even consumer ratings – as in hotels and restaurants. This would help consumers in choosing residential facilities. Informed consumers would seek care from better ranked providers. It would then stimulate providers to ensure and enhance their reputation and attractiveness. And poor performing providers may have more difficulty retaining quality staff.

In New Zealand we have a well-developed process of auditing for rest homes and audit reports are published in full on the Ministry of Health web site. I would very much like to hear if people use these report and, if so, how useful they find them, in the light of Professor Mor’s comments.


[1] Labour/Green Party, Grey Power (2010) A Report into Aged Care: What does the future hold for older New Zealanders.

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