A Venture in Benchmarking.

After reading my Business Strategies article in May ("Benchmarking: How Does Your Organization Measure Up?" p. 12), many readers requested information about how to compare themselves to other organizations. The following is an effort to respond to those requests- from a single source, but it might serve as a good starting point.

Vital Research, LLC, located in Los Angeles, California, is a full-service research and consulting firm that assists clients in designing, collecting, measuring and analyzing performance data. This firm might be unique in applying these techniques to post-acute and long-term care. Gwen Uman, RN, PhD, a partner in the company, discussed how it applies benchmarking to these healthcare providers in a recent interview.

Hyatt: Tell me a little about your firm.

Dr. Uman: I began the business with one of my classmates at the University of Southern California, Harold Urman, PhD, in 1982 with the intent of helping doctoral students analyze their data for their dissertations. Our original business name was "Comp-U-Stat," but about five years ago we changed our name to reflect the broader nature of our work. Our clients include nonprofit, social service and healthcare organizations; government; university faculty and educational institutions; and corporations, ranging from banks and credit unions to fast food chains to international dotcoms.

In 1995, we were working with a geriatrics research group based at UCLA. We applied for a Small Business Innovation Research Grant (SBIR) from the National Institutes of Health (NIH) to develop a way of measuring resident and family satisfaction in nursing homes. This eventually resulted in the development of REAL (Resident Experience and Assessment of Life).

Hyatt: Describe REAL for our readers.

Dr. Uman: REAL is a quality improvement system for senior services that emphasizes the consumer perspective. One goal of the first NIH grant was to measure resident satisfaction, taking into account the possibility of cognitive impairment. We asked 30 Caucasian and African-American residents across all cognitive levels what made them happy or unhappy in the nursing home. Residents ranging from CPS 0 (cognitively intact) to CPS 3 (moderately impaired) were able to compose answers, and most at lower levels of function were able to answer yes or no to questions we created out of these residents' answers. We identified six domains of satisfaction, all of which seemed to represent quality of life: help and assistance; autonomy; communication; companionship; safety and security; and food and environment. (Written, open-ended responses by family members to a mailed survey were also content-analyzed and involved the same six domains plus three more.)

To make questions understandable for all residents and to provide readily useful information to nursing homes for their quality improvement activities, we developed concrete behavioral questions that were criterion-referenced. That is, they were not attitude scales, but targeted behaviors that every resident could observe and either did or did not happen. Examples: "Do the people who work here talk to you?" "Do they listen to what you say?"

Between the two NIH-funded studies was a period of about nine months during which time the American Association of Homes and Services for the Aging (AAHSA) sponsored a field trial to help us determine if the method could be generalized across the country and could be scaled up. The field trial involved 33 homes in 9 states-and it was more challenging than we had realized. During the project, AAHSA leadership changed three times, which posed other challenges. We learned how to do distance training, how to ensure the quality of the interviews from a distance and how to change a few items to make them meaningful in all regions of the country and across ethnic groups.

Hyatt: What were some of the findings related to this project?

Dr. Uman: By the end of the second NIH grant we learned that long-term care providers wanted to measure far more than nursing home satisfaction. We self-funded the development of the independent living and assisted living surveys that we now have in our quality improvement system, andwith contracts from the state of Michigan, we were able to develop interview guides for adult day care and in-home respite consumers. We also developed instruments for affordable housing and Alzheirner's activities programs.

For a more specific example, a large nursing facility that is part of a multilevel community in the East scored way below standard and benchmark levels in the areas of safety and security. It had a great opportunity to improve residents' satisfaction with the security of their personal belongings, their perception they were treated gently and afforded privacy, and that staff did not express anger at them physically or verbally.

In preparation for its HCFA survey, this facility formed a safety team made up of frontline staff and middle management to develop a plan to secure residents' belongings. New locks were provided and installed for all of these low-income residents. While this was going on, it was discovered that residents' stored belongings were being stolen postmortem. New policies and procedures were established to prevent these occurrences. Licensed upper management also investigated and resolved several reports of potential abuse or neglect, employing staff changes and interventions to prevent recurrences. Management continued to monitor resident perceptions of safety and security every six months for the next year and eventually documented markedly increased resident satisfaction in all areas.

Another example of the quality improvement function of our REAL instrument can be seen in one of our East Coast facilities that participated in measurement four times. The first review disclosed several major opportunities for improvement, including the areas of autonomy and choice, safety and communications. Frontline staff were asked to complete the survey as though they were residents, and their projected perceptions were compared with residents' actual results.

Staff were frequently more critical than residents, but in some cases they believed that a very good job was being done when residents did not. A case in point: Staff believed that residents' call lights were being answered right away. Residents responded differently. Once staff reviewed the appendix containing anonymous resident quotes sorted by interview question, they understood the residents' perspective and were willing to accept that judgment and change accordingly.

Specifically, frontline staff selected three indicators to work on and volunteered to be on various quality improvement teams, i.e., the "wrinkles" team, the "valuables" team or the "choices" team. The teams worked hard to improve the condition of residents' clothing, to in stall sturdy locks on residents' furniture and to increase choices of mealtimes and portions.

They were successful on the first two issues, but not on the latter, because the dietary department is separate from the clinical care department and was not included in information dissemination and quality improvement processes. The subsequent year, however, residents' perceived quality of life was much higher in relation to clothing choices and security of valuables. Interestingly, an 18-month hiatus in measurement resulted in a decrease in perceived quality in the three targeted areas, demonstrating the importance of the Cm continuous quality improvement. The staff is now regrouping their quality efforts.

Hyatt: What is the overall significance of benchmarking in long-term care?

Dr. Uman: Benchmarking is an important tool that aids in strategic planning, especially when it offers a national glimpse of others in the industry. Some of our customers prefer to exceed general standards and benchmarks and set their own internal standards at 90% of goal. They have found, longitudinally, however, that this level of perceived quality of life in nursing home residents is difficult to achieve across the board. Other customers have set a low across-the-board standard at 70%, and work on quality improvement in areas that fall below that standard. Also, some multi-facility groups are more interested in comparing their facilities with their own corporate benchmark.

Hyatt: In the current environment, what are some of the challenges of benchmarking in the long-term care industry?

Dr. Uman: To fully capitalize on benchmarking, the industry needs to break out of its negative focus and really examine opportunities for improvement. Realistically, it is not possible in the heavily regulated nursing home industry to concentrate so much on the consumer perspective at the expense of state regulatory requirements, at least some of which are relevant to quality of clinical care. These two areas (quality of life and quality of care) must also be balanced against financial pressures.

For more information on Dr. Uman's uses of and insights concerning benchmarking, contact her at [e-mail] or visit Vital Research's Web site at www.vitalresearch.com.

As always, I would like to thank the readers who write in support of this column. Ideas that you feel would be helpful should be addressed to Laura Hyatt at [e-mail]. Be sure to include your name, the name of your organization, address and phone number with area code.

Laura Hyatt, MBA, is president of Hyatt Associates and a member of the business faculty at Mount St. Mary's College.