'First, do no harm ...'.

More and more, indications are that there is one area in which long-term care managers and clinicians can have a positive impact on patients, families, and their own facility's health and success. That area is quality improvement (QI). To be successful, however, long-term care organizations must move from reacting solely to outside inspectors to acting from solid internal strategies. These efforts must be led from the top, undertaken by every employee and volunteer, ongoing, and organized to follow a consistent, data-driven approach. The days of "knowing" that we give excellent care most of the time are gone and must be replaced by a system of measuring, checking, and comparing key elements over time. Once a record is established, then when physicians, families, residents, state inspectors, and others ask about quality, the organization can show them the numbers and talk about plans that are under way to continue progress.

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A QI area that is often overlooked is the "customer's" point of view. Patients, residents, families, and referrers have perspectives and experiences that are quite different from those of a caregiver or administrator. These customers often come to long-term care facilities with a real fear that they will lose not only their independence but their own sense of "self." This is why it is important to have solid admissions and orientation procedures that establish two-way communication, set realistic expectations, and begin building trust at the outset. Then, in addition to improving clinical quality, attention should be paid to improving the experience for the resident and family member. To do this, staff must view life in a nursing facility from the residents' and family members' perspective and focus on improving those aspects of the experience that matter most to them as individuals.

Unfortunately, most QI efforts fail. They fail not because long-term care providers aren't smart enough or dedicated enough. No, QI efforts fail because they are seen as just another program added to an already heavy workload; they fail because no one took the time to plan how their unique organization would approach quality; and they fail because they never become an intrinsic part of the organization's daily operation. In long-term care in particular, QI efforts sometimes don't even get started because some organizations are so involved in reacting to day-to-day regulatory pressures and the avoidance of negative survey results that they can't even think about a proactive, provider-generated approach to protecting and improving the comfort and lives of their residents. Although this may be understandable, it is truly a sad and self-defeating situation.

Perhaps your organization feels that it can put off QI efforts to a future time when reimbursement is greater, the workload is lighter, staffing is better, or things just aren't as hectic as they are right now. Like anything else, QI efforts can be put off; the difficulty is determining the price of waiting and the potential cost of ongoing errors.

Introducing a formal, managed, planned approach to quality improvement can be a big change for any organization, and change always meets resistance. Expect this resistance and plan for it because healthcare providers really don't have a choice in the matter; they must improve safety and quality as soon as possible. Residents, families, and even society in general are all demanding that long-term care be improved and changed to become more homelike and humane.

What can be done? Where can long-term care leaders start in their QI journey?

* Read up on the subject. A great many good books and articles on the subject are available. Books by W. Edwards Deming, PhD, and J.M. Juran provide an excellent starting point.

* See what your colleagues in other facilities are doing. Do they have any advice? Are they interested in working together?

* Review the new models of care. Look into Wellspring, AAHSA and AHCA/NCAL's Quality First initiative, the Pioneer Network, and other programs that rely on QI as a major portion of their approach to care.

* Find out if a Quality Council is in your area. Many states and localities have established Quality Councils to help individuals and organizations succeed in quality improvement. Web sites to check include: The Minnesota Council for Quality's Quality Councils (www.councilforquality.org), the Institute for Healthcare Improvement (www.ihi.org/ihi), and the Agency for Healthcare Research and Quality (www.ahrq.gov).

* Learn about the Malcolm Baldrige National Quality Award criteria. Even organizations that do not intend to apply for the award can learn about QI by examining the Baldrige National Quality Award criteria. Visit www.quality.nist.gov for information.

* Learn about the Balanced Scorecard approach to managing. This method was first outlined by Robert S. Kaplan and David P. Norton in The Balanced Scorecard: Translating Strategy Into Action. It is a way to describe, talk about, and measure the implementation of strategy and mission, which creates the focus needed within an organization to carry out and measure its mission.

* Undertake an organizational self-assessment. Take a rigorous look at trends in your organization.

* Talk with your residents and other "customers." Where would they suggest you begin?

* Review differing QI approaches. Develop a systematic plan for installing continuous QI and quality control mechanisms and tools.

Remember, your first duty is to keep people safe--to do no harm. Of course, you must go well beyond providing a safe environment, so start something! Develop a project, establish measures, or do something positive. Then, don't give up, don't give in, and don't quit. Quality improvement is a never-ending (but often fun) job.

Kenneth G. Bast is a healthcare management consultant in the Minneapolis area with a national practice. In addition to his work helping clients establish processes to improve operations and strategies, he has senior management experience in several acute care hospitals, as CEO and as vice-president of operations. He has also served as vice-president of Health Services at John Knox Village, Lee's Summit, Mo. For more information, call [phone]. To send your comments to the author and editors, e-mail [e-mail]. To order reprints in quantities of 100 or more, call [phone].

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