Quality management isn't as tough as it looks.

There is little doubt that quality management is a critical (if not the most critical) component in managing a successful long-term care community. But many in the profession have assumed that it involves such a level of complexity and expense that they have feared placing it on an already overburdened list of "things to do." What's more, they just might have lost sight of the supposed beneficiary of these efforts: the resident "customer."

In the economic environment in which nursing facilities operate these days, perhaps it was inevitable that facilities would lose their "resident-centered" focus. With essentially only one payer for the services delivered--the government, usually via Medicaid--it was perhaps understandable that many nursing homes would confuse the payer (government) with the customer (resident).

In a true market-driven economy, however, it is the customer receiving the service who is in the best position to determine what that service should look like. By allowing the government to assume the role of customer, nursing homes guaranteed only that their product would meet government, not customer, expectations. Many would agree that the result is not a happy one.

Maybe--just maybe--it's time for the profession to reassume its legitimate responsibility for assessing customer need--but to do so in concert with customers themselves. That's really what quality management is all about. And I would argue that with an understanding of three basic principles and an adherence to three related caveats, its implementation need not be that difficult at all.

Quality management goes by any number of names: Total quality management (TQM) and continuous quality improvement (CQI) are the most commonplace. And then there are, specific to the nursing home profession, the Eden Alternative[TM], the Pioneer Network, and Wellspring. No matter the name, they all share basic principles. And they all begin (and end) with the customer.

Therein lies their relevance to long-term care. In seniors housing and care, resident-centered care is really the only kind of care that has staying power. It's certainly the only type of care that can elicit customer and, by inference, political support. A customer focus becomes, therefore, the first and most critical principle of quality management.

Let's move on to principle number two. Facilities don't provide care. People do. Adequate numbers of people. People possessing the necessary competencies. People working within well-understood systems and adhering to accepted standards established by management. And, most critically, people imbued with a culture of caring, people functioning as empowered members of a team that reflects that same culture, that same customer focus.

Without the underlying concept of a multidisciplinary team, meaningful services cannot be delivered and successful programs cannot be achieved, no matter what the geriatric setting. Home care, adult day care, assisted living, nursing facilities--they all cry out for application of the principles of teamwork. To speak of the need for teamwork in long-term care is to speak of the need to apply the geriatric model of service delivery--to speak of the unique nature of the elderly patient and the particular needs that separate him or her from other recipients of healthcare services. In any senior care setting, the multidisciplinary team is the very reflection of the needs of the geriatric patient. It is a necessary function of the unique needs of the person receiving care, not of the setting in which that care is delivered.

But the team cannot function without knowledge. And so we come to our third principle: the need for data---customer-focused data, data with measurable and achievable management goals as the primary purpose.

It all adds up to this: Quality management relies on a staff, working as a team, empowered and motivated to achieve measurable goals that are focused on achieving customer satisfaction. True quality management reflects: (1) a customer focus, (2) an empowered staff, and (3) a reliance on data. All three are critical. None can be ignored.

So, where do we start? A good beginning is to establish domains of care and service. What do we want to measure? What is important to measure? And why? Management's ultimate purpose is to imp rove services, including the resident's sense of satisfaction with those services. So, the domains of service and care should, to the extent possible, be areas of need as perceived by the resident, not by management.

And that brings us to caveat number one: A customer focus means just that. Facility priorities should be closely tied to customer perceptions. Management's involvement is important, but not preeminent. Have resident complaints been more pronounced recently in the dining room? About housekeeping? Where has line staff, which is closest to the customer, indicated a need for improvement?

As important as selecting areas of focus is establishing appropriate benchmarks. If we are going to measure within certain domains of service and care, how are we to judge ourselves? What are our goals? And how do we know when we've achieved them?

Certainly, in the nursing home profession (and particularly with respect to clinical indicators), government provides many of the tools for effective benchmarking. The MDS has taken its licks as an example of overbearing government regulation. That just might be an overreaction. If looked at as not just one more example of burdensome regulatory over sight but as an incredibly rich trove of management data, the MDS can be a real boon to quality improvement.

Take quality indicators as examples. On what is becoming almost a real-time basis, a nursing facility can judge its progress against any number of benchmarks: its standing compared to other facilities (either state- or nationwide), its historical record, and the goals it has set for itself.

The MDS does have its limitations. Although we do need to know what is happening to the customer clinically, perhaps of even greater importance is to know how the customer perceives what is happening to him or her. Both are essential. Rosalie Kane, one of the nation's most respected students of long-term care, sees this propensity of the MDS to "bypass" quality of life (as opposed to quality of care) as one of its greatest flaws. While it might assess rates of bedsores, and even risk-adjust them appropriately, it "misses what interests ordinary people," she writes.

Satisfaction can he difficult to measure. There are numerous questionnaires available purporting to be the definitive approach to measuring customer satisfaction. They are produced by academicians, consultants, providers, and the associations that represent them. The challenge is distinguishing between those whose primary purpose is marketing and those whose critical focus is management. That, by the way, is caveat number two.

We've all seen survey results that "demonstrate" astronomical levels of resident satisfaction. Indeed, they may help in keeping the facility fully occupied (although I personally doubt it), but they are of little use to a management team looking for areas on which to focus its quality improvement efforts. For that, we need to find out what the customer isn't happy with. Only then can we work on improving the customer's level of satisfaction.

Ultimately, a successful quality management program is a part of the very culture of the facility. It must be a critical facet of all its policies and procedures. It must be interwoven within the very fabric of the enterprise. A customer focus is not just the responsibility of social services. Data-driven management is not just the responsibility of nursing. Staff empowerment is not just the responsibility of housekeeping. All of these are everyone's responsibility. The only way to make that absolutely clear--to make it a part of the facility's culture--is for senior management to demonstrate regularly that it is a part of their culture, as well.

And that's caveat number three: Paying lip service to quality management is to sentence it to an untimely death. Staff is intelligent. Staff knows when words are just words, and when management is actually committed to those words as reflecting something of real significance.

Quality management is, after all, more than just a "feel good" concept, as important as that may be to our sense of professional self-esteem. It is just as much in line with our fiduciary responsibilities. The pioneers of quality management (W. Edwards Deming, Joseph M. Juran, Philip B. Crosby) did not see themselves as altruistic social-innovators. They were businessmen, looking to create tools for improving business results. Profitability was not, for them, a dirty word. They looked to quality management primarily as a means of improving profitability.

Critical also is the recognition that quality management is not a project. Rather, it is a process. That is, it never stops, it functions as a continuous loop. We determine priorities based on customer satisfaction. We measure. We empower staff to stimulate improvement. We re-examine priorities. And we measure again. But we must begin the journey by returning to a system that places people--the customers--first.

To comment on Dr. Willging's views, as expressed here, please send e-mail to [e-mail].

Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. For 16 years as president/CEO of the American Health Care Association, Dr. Willging went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center For the Seniors Housing & Care Industries), and later served as president/CEO of the Assisted Living Federation of America. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.