Afew years ago, the handful of researchers immersed in the topic were lamenting the lack of interest by policy makers in examining nursing home residents’ satisfaction with their care and quality of life. Times have changed. Thanks largely to the federal Nursing Home Quality Initiative, launched in2002, the Centers for Medicare & Medicaid Services (CMS) is now pursuing three initiatives that in one form or another involve measuring resident satisfaction (see “CMS Initiatives,” p. 61). This measurement task is widely viewed as one step toward a larger goal of promoting culture change within nursing homes as a means of enhancing resident care and quality of life.
Having answered the question of whether to measure resident satisfaction with a resounding “Yes,” the question becomes: How do we measure it? With the science of this still in its infancy (but fast approaching the verge of adolescence), the answers are just now emerging. It is becoming increasingly apparent that two distinct approaches are emerging. While these approaches are not necessarily in conflict with each other, they serve different purposes, and without further clarification could seriously confound this new measurement task. In this article, we aim to prevent such confusion and instead promote a deeper understanding of the task at hand through discussion of the whys and hows of resident satisfac-tion measurement.
Inherent in this question is an acknowledgment, now widely accepted by long-term care experts, that residents themselves—not their family members or facility staff or any other proxies—are in the best position to report on this. They are, after all, the ones who are living it.
With that said, the issue is how these reports will be put to use. These days, the most common response is “for quality improvement [QI] purposes.” Resident satisfaction is assessed so that facilities can pinpoint areas in need of improvement and then design and evaluate appropriate interventions. Alternatively, satisfaction data are sometimes used for public accountability purposes. For example, a few states conduct resident satisfaction surveys and report the results online to help consumers choose among facilities.
Purpose is important because it drives the selection of the best methods for measuring resident satisfaction. As Barbara Manard, PhD, points out in a report on nursing home quality indicators (of which resident satisfaction could be one), “the information best suited for internal quality management and improvement is not necessarily the same as that most useful for public accountability… .”1
The table on page 62, a shorthand version of Manard’s work, shows how measurement strategy varies depending on purpose. If a facility’s intent is to improve care and quality of life for residents, then it should collect very specific information at short intervals so that it can determine whether residents are satisfied with new care practices. In contrast, organizations intent on public accountability—often government entities, not individual facilities—will want to collect, at infrequent intervals, global measures from large, reliable samples in order to develop fair and accurate indicators of performance.
Confusion and problems, most notably failed objectives, may result if you mismatch methods and purposes. For example, most state-approved resident satisfaction surveys are designed as public accountability tools. In general, they make poor QI surveys. Increasingly, however, with resident satisfaction measurement now a federal priority, these and other widely available global assessment tools are being recommended for use as QI surveys.
As a case in point, consider the resident satisfaction survey used to generate quality indicators for the Ohio Long-Term Care Consumer Guide (at https://www.ltcohio.org/consumer/index.asp). Although it is designed as a public accountability tool—an independent contractor administers the survey annually to as many as 32,000 nursing home residents across the state—CMS has accepted it as a tool that facilities might use for purposes that include quality improvement.2 A close examination of the survey shows, however, that it is poorly suited to QI tasks.
For example, of the survey’s 48 items, 10, or 21%, are direct satisfaction questions that share a common format: Are you satisfied with (fill in the blank)? Such questions may work well for benchmarking facilities (in any case, they appear regularly in state-approved surveys), but from a QI standpoint, they are arguably worse than useless because of their potential to lead to erroneous conclusions.
In a series of studies, 3-5 the UCLA Borun Center for Gerontological Research has shown that direct satisfaction questions suffer from an “acquiescent response” bias; that is, nursing home residents tend to respond favorably to these questions, despite known problems with the quality of care they are receiving.
Additionally, responses to these questions shed little light on how to correct problems. Does the resident want to get out of bed earlier or later? Does she want to eat in the dining room or her own room? With QI, as with many things in life, the devil is in the details—but the details are largely absent in direct satisfaction questions.
A final problem is that these questions are relatively insensitive to objective improvements in quality of care. In theory, if facilities improve services to better meet residents’ needs and preferences, then satisfaction with care should also increase. Another study found, however, that resident responses to direct satisfaction questions did not change even when the services in question were significantly enhanced and consistent with residents’ reported preferences.5
Considered together, these are serious drawbacks. Based on responses to direct satisfaction questions, facilities might falsely conclude that their services are satisfactory or that new interventions are not working. Either conclusion could scuttle desirable improvement efforts.
Another reason to avoid using public accountability surveys for quality improvement is that the former are typically broad and blunt instruments. Ohio’s resident satisfaction survey, for example, taps into nine separate domains (environment, laundry, meals, etc.). This is fine if the goal is to identify which domain to work on first (After all, what nursing home could tackle them all at once?). And, indeed, Manard’s chart (Table 1.) identifies such needs assessments as an acceptable use for public accountability surveys. But when this assessment is completed, a finer, more focused satisfaction assessment is required to shape and evaluate appropriate improvement interventions.
Measurement for Quality Improvement
Measurement for Public Accountability