Seasoned senior care providers agree: Nothing gets at the real day-to-day quality of a residence like a site visit. But site visits aren’t what they used to be—or at least they shouldn’t be—for providers that really want to get to the core of how effectively a community is delivering quality care, and what needs improving. In this day and age of ready competition as well as a tough economy, a provider’s edge in the marketplace hinges a great deal on the company’s reputation for quality and the reality behind it.
“What I’m seeing is an increasingly savvy consumer who is looking for markers of quality. Yes, customer satisfaction, but also for what you, as an assisted living community, are doing to help reduce negative outcomes,” says Sharon Roth Maguire, MS, GNP, vice president of clinical services for Milwaukee-based Brookdale Senior Living.
Assisted and senior living experts agree: There’s more to fulfilling the “quality” promise than meeting state or company’s standards, or even exceeding them. Quality, in the subjective sense of the word, is also about perceptions.
“The hardest thing is the subjective pieces, which is so much of it,” says Gregg Colon, vice president of quality and resident care for Sunrise Senior Living, based in McLean, Virginia. “In a task-based approach, it’s easy to say, ‘This was done,’ or, ‘This was not done,’ but people don’t come to us just for the tasks.”
Experts and veteran providers agree: Strategic, results-driven site visits go far beyond the “done’s” and “not done’s.” Rather, they are an important opportunity to get the whole picture, the “feel” of a community, and observe how caregivers are effectively delivering quality care—or not.
One Step Back
Of course, it’s important to have a corporate philosophy and culture that emphasize quality as being of foremost importance. But the best mission will fail unless the right people are carrying it out.
“You’ll never be able to inspect it all. Quality starts with hiring and training,” Colon says. When interviewing a prospective hire or reviewing an employee’s performance during a site visit, Colon recommends following the “dinner rule”: Could you see yourself (or residents, for that matter) enjoying dinner with this person?
If that sounds like an inexact science, it is. The point of the exercise is to trust your own instincts about your employees’ instincts, and surround residents with “people who know quality when they see it,” Colon explains.
In the ongoing pursuit of quality, Sunrise also emphasizes the importance of training employees to become familiar with residents’ interests and past lives, and treating them as the individuals they are.
“No person should be looked at as an accumulation of diagnoses and care needs,” Colon adds. “If we don’t know the resident at that level, we can’t serve them.”
Executives, too, need to personify quality assurance. When visiting communities, Connie Arden, RN, a regional risk manager at Tampa, Florida-based Horizon Bay Senior Communities, believes it is important for executives to demonstrate their expectations about quality through their own actions. If Arden comes across a problem or oversight at the community, for example, “I’ll fix the problem myself,” she says. “I fix it, I model my actions, and then train and retrain as necessary.”
Transcending the “Check Up”
How do community-level associates greet the notion of the next site visit by the corporation’s peer reviewers? If the answer is mostly synonymous with “fear and dread,” then the review team may not be headed for a constructive experience.
“We have state surveyors. An easy mistake to fall into is to mirror that process for your own program,” Colon explains. In other words, if you treat internal reviews as an “auditing” process, they can easily become too punitive. “If you take that approach, you won’t get the best results. People will hate the process.”
Experts say the goal in any mock survey, announced or unannounced, should transcend “checking up” to make sure the community passes state standards or even the company’s. The focus also should be on the opportunity to train, gather great ideas, and support the employees.
“View it as a meaningful process where you can enhance services to residents,” says Budgie Amparo, RN, MSN, senior vice president of quality and risk management for Seattle-based Emeritus Senior Living.
Sunrise casts its “quality service review” process as an extension of the training experience, full of teachable moments and the opportunity to raise company standards even higher. For that reason, the visits by a multidisciplinary team often include outside experts and last for days.
In addition to ensuring that operations are up to snuff, the goal is to learn from what works well, and change practices accordingly. “Once we see progress, what can we do to raise the bar another notch?” Colon suggests.
Colon and others also advise stepping off the corporate bandwagon to ensure the company’s perception about a community’s performance matches reality. “Another pitfall is to think that what you design is the right thing. You’ve got to be willing to ask your residents and families” for feedback, Colon says. For example, when Sunrise solicited feedback about the company’s extensive communications, they learned that families appreciated all the information, but they also wanted more one-on-one interaction with staff with specific updates about their loved ones.
Sunrise reviewers sit down with individual residents, family members, and team members to ask how well their programs are working and ask for ideas. Horizon Bay’s Arden sits down with caregivers, residents, and family members but also makes a point of talking with housekeepers and wait staff, who often pick up on the deterioration of residents’ habits first. Emeritus’ Amparo seeks out and includes the most vocal residents and employees during site visits. “It doesn’t take much for residents to talk. Ask how their day is going, and you will hear about it,” Amparo says.
Between Visit Strategies
After a formal site survey is completed, assisted living experts report success with a range of strategies for keeping communities quality-oriented between visits.
Horizon Bay’s Arden holds weekly conference calls with the director of wellness at each community in her region to dis- cuss at-risk residents. Unlike paper trails and technology-based tracking, Arden believes that old-fashioned, person-to-person contact keeps the spotlight on each wellness director’s actions on behalf of each at-risk resident.
“It forces the director of wellness to ensure they’ve consulted all the pharmacists and outside providers and done all the interventions” from week to week, Arden says.
Like many companies, Brookdale recognizes and honors communities that excel during site visits, and communities compete for year-end awards for top quality in each division. Every staffer in the community who scores highest in the company’s quality index receives a monetary bonus and an award certificate. Communities that fared poorly during internal reviews are put on individual improvement plans.
That said, experts also advise resisting the urge to focus on summary scores and outcomes, rather than on improving the way your company reaches positive outcomes. Results of site visits to individual communities should be made known all the way up to the corporate suite, but the goal should be to identify and support what communities need, and learn from their success stories, rather than accountability alone. To take its site survey results a step further, Brookdale examines high-scoring communities and uses their strengths as models to continually raise the bar of what is considered “quality.” “Look at what it is about them that’s a recipe for success,” says Maguire.
Colon agrees. “It’s not just about where you fall on the scale. If people are solely concerned about that, we’re missing the point.”
Enhancing the Social Model
As the acuity level of assisted living residents creeps higher and care needs become more complex, customers’ expectations of quality tend to deepen accordingly. “They want to see that their loved one is well cared for,” says Maguire. “Then, when their care needs become more complex, they look to us as the experts.” Consumers want to know what providers have done to help reduce the risk of a fall, or of elopement, or of whatever problem that their particular loved one is prone to have.
But while assisted living providers increasingly must deal with such care challenges as pressure sores and dementia, Maguire cautions against resorting to a skilled nursing approach in the pursuit of quality. It’s important to remain clear about residents’ overall needs, not just their medical requirements. “While there are certainly good outcomes of that model, it would be a shame to just use that model and not look for a newer model,” she says. “So while you have to be vigilant [about quality care], you also have to look at customer satisfaction and that nebulous quality of life.”
Amparo agrees. “The only way to be able to meet residents’ needs is to think differently than 10 years ago,” he asserts. “It is still a social model, but you need to add more assistance in place to meet higher demands from our residents.”
Naturally, companies need to continually reassess their quality review process, to make it both relevant to the times and true to the ideals of assisted living. In order to keep the “resident-centered” approach to aging that is the hallmark of assisted living, Brookdale has identified six areas comprising “optimum life” for its residents. These include social, spiritual, physical, emotional, purposeful, and intellectual domains. Any site reviews and improvements to the site review process must address these areas. “The idea that quality can be measured within these realms, as well, is what we need to be looking for,” says Maguire. For example, the site visit reviewers look for tangible ways that these six domains have been put into action, Maguire says, and associates are asked to describe optimum life. “How are your residents engaged? Are you offering the right programs? We have to broaden to look at these less traditional measures, too,” she adds.
Of course, the most important feedback that sometimes yields the best measure of quality is less a formal metric and more akin to the “dinner rule.” It’s that elusive feeling of having observed quality-in-action during a site visit that comes from what Maguire calls the “climate check,” and Arden calls having “surveyor’s eyes.”
“Go into a community and if your residents are smiling, very friendly, and the same with your staff, very accommodating, you will sense it,” says Amparo. “Do not rely on just one indicator. Try for balance.”
“There are specific questions that you can ask to ensure the caregiver is doing certain things, but you can get so much more by observing the interaction,” Colon says.
Quality & Reputational Risk
In senior living, quality assessment is often straightforward—the results of strategic site visits, resident and family feedback, and occupancy rates are all quality- related indicators. But the “quality” of a company itself is ultimately a matter of perception and reputation, business experts say. In the February 2007 issue of Harvard Business Review, three experts argue that most companies have only a fuzzy idea of how to assess company quality and therefore manage reputational risk. “They tend to focus their energies on handling the threats to their reputations that have already surfaced. This is not risk management; it is crisis management,” write Robert G. Eccles, Scott C. Newquist, and Roland Schatz.
According to the authors, three things determine the extent to which a company is exposed to reputational risk. The first is whether its reputation exceeds its true character. The second is how much external beliefs and expectations change, which can widen or (less likely) narrow this gap. The third is the quality of internal coordination, which also can affect the gap.
Effectively managing reputational risk involves five steps:
Assess Reputation. What is the company’s reputation in each area (product quality, financial performance, and so on)? Why? How do these reputations compare with those of the firm’s peers? Various techniques exist for evaluating a company’s reputation. They include media analysis, surveys of stakeholders (customers, employees, investors) and industry executives, focus groups, and public opinion polls. Although all are useful, a detailed and structured analysis of what the media are saying is especially important because the media shape the perceptions of all stakeholders.
Evaluate Reality. Just as the reputation of a company must be assessed relative to its competitors, so must its reality. For example, performance-improvement targets based only on a company’s results for the previous year are meaningless if competitors are performing at a much higher level. The importance of benchmarking financial and stock performance and processes against peers’ and those of companies regarded as “best in class” is hardly a revelation. However, the degree of sophistication and detail as well as the accuracy or reliability of benchmarking data can vary enormously.
Close Gaps. When a company’s character exceeds its reputation, the gap can be closed with a more effective investor relations and corporate communications program. If a reputation is unjustifiably positive, the company must either improve its capabilities, behavior, and performance or moderate stakeholders’ perceptions.
Monitor Changing Beliefs. For instance, regular surveys of employees, customers, and other stakeholders can reveal whether their priorities are changing. While most well-run companies conduct such surveys, few take the additional step of considering whether the data suggest that a gap between reputation and reality is materializing or widening.
Appoint a Leader. Managing reputational risk isn’t an extraordinarily expensive undertaking that will require years to implement. At most well-managed companies, many of the elements are already in place in disparate parts of the organization. So the primary challenge is focus: recognizing that reputational risk is a distinct category of risk and giving one person unambiguous responsibility for managing it.
Excerpts from “Reputation and Its Risks” by Robert G. Eccles, Scott C. Newquist, and Roland Schatz. Harvard Business Review, February 2007. Reprinted with permission. |
By Whitney Redding, a contributing writer to Assisted Living Executive.
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