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January 1, 2005
by Paul R. Willging, PhD, editors
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It's time to take the politics out of nursing home quality

The quality of care in America's nursing homes has, beyond a doubt, become the most contentious issue in contemporary long-term care. The issue has polarized the political process; it has created an environment at cross-purposes with the very goal of enhancing quality and threatened the underpinnings of an entire industry. Clearly, something is wrong here.

How has our discourse regarding shared aspirations for improved long-term care quality descended to this level? While not inclined to place blame, which can only exacerbate the controversy, I can't help but look to attitudes expressed by each of the parties involved: providers, government, consumer advocates, and the press. None can be ignored as we search for ways to overcome this problem. And if we're serious about resolving it, none of these groups can avoid reconsidering its basic position.

Let's start with the industry. Providers, for their part, must accept the reality of the quality problem. They must openly admit to the presence of poor providers among them and accept responsibility for working to eradicate their practices and, if necessary, the poor performers themselves. Few in the industry are unaware of the “bad apples” and their identities—and equally few are willing to admit this publicly.

Unfortunately, until recently, those who were willing to go on record usually accompanied their recognition of problem facilities with the age-old shibboleth of “inadequate reimbursement—an excuse unlikely to garner respect from an already skeptical public.

There is, though, some evidence of progress here. I refer here not to the current emphasis on “Quality First,” a campaign pushed by the industry's major trade associations. Nothing is really new about “Quality First” except some repackaged programs. I recall, during my tenure as president of the American Health Care Association (AHCA), launching a similar project, also within the context of quality management. Materials were produced; sound bites were developed; and the media were engaged. And I doubt whether we changed any more minds about the industry's intentions than will the current initiative.

The public is looking not for words, but for action. Not for form, but for substance. And some of that substance is, fortunately, now visible. I was impressed, for example, when another past president of AHCA, Charles H. Roadman II, PhD, CNA, addressed the age-old issue of inadequate staffing—first, by admitting to it and, second, by recognizing that solutions would result only from cooperating with those who had previously been seen mostly as antagonists. In announcing the formation of and AHCA's participation in a National Commission on Nursing Workforce for Long Term Care (whose memberships includes the likes of AARP and the Service Employees International Union), he and AHCA's elected leadership showed themselves ready—for the first time in a long time—to accept the reality of, in Dr. Roadman's words, “a chronic workforce shortage that threatens care quality.” That may not sound like much—just acceptance of an issue that had long been apparent to many—but to me, it was one of the defining moments in AHCA's history and, hopefully, in Washington's perception of the industry itself.

Along with AHCA's lessening inclination to confront rather than collaborate appeared an increasing willingness to admit to the presence of some bad actors in the provider community. However, accepting the reality of “poor performance” and being able to define it in a fashion understandable by all are two separate issues. Here is where government comes in. It must play a much different role than it has become accustomed to. If the provider community chooses, after years of official silence, to take on the responsibility of working to rid itself of bad apples, it must have some assurance that the definition of “poor care” is analytically based, understood, and accepted by all.

This issue—the issue of quality definition and measurement—is critical to the entire debate. Absent some common understanding as to how we measure quality, or the lack of it, how can we expect to join forces to improve quality and, moreover, fund that improvement? Avedis Donabedian, in his seminal work on quality assessment, posited three measures of quality: structure (the resources available to provide care), process (adherence to procedures), and outcomes (the results achieved by the patient). Our system of measurement is, unfortunately, still oriented primarily toward structure and process and less toward outcomes.

That approach has two major disadvantages, as has been pointed out eloquently by Rosalie and Robert Kane in a publication coauthored with Dick Ladd, The Heart of Long-Term Care. They write: “(1) The majority of the regulations are based not on empirical evidence of what activities are associated with better outcomes but on professional judgments, which quickly approach dogma. (2) Strict statements about what should be done for whom become rapidly restrictive at a time when long-term care dearly needs innovation and creativity. Especially because so little has been proven about how to deliver the best care (and there is every likelihood that more than one way is available to achieve this end), it is premature to ossify the process.”