Risk-aversion undermines nursing home care.

As every nursing home administrator knows, the world is full of potential turmoil - plaintiffs' lawyers waiting to pounce, a steady stream of surveyors poking about for possible citations, news media looking for "tomorrow's headline," and for-profit owners or not-for-profit boards warning, implicitly or explicitly, "No scenes. No waves. No problems."

What's the consequence? At a time when nursing homes are more and more resembling hospitals and servicing greater numbers of impaired and debilitated elderly, we are more in need than ever of creative solutions to ensure the quality of their lives. Unfortunately, at the same time, the people responsible for daily operations are becoming ever more afraid to think for themselves. It's not that they lack good hearts but, rather than give free rein to their imaginations and take some well-considered, innovative course of action that might improve the quality of their residents' lives, their first instinct is to ask, "Will I be cited?" "Will I be sued?" "Will I lose my license, or my job?" This unreasonable aversion to risk has an enormous social cost - in programs not implemented, in lessons not learned, in the quality of lives forever diminished.

It doesn't have to be that way. Consider, for example, the story of a resident who was admitted to my facility a number of years ago with brain tumors that had paralyzed his right and, progressively, left side and created a language deficit. On admission, the son, speaking for his father, insisted that his father be allowed to maximize his independence. Specifically, this meant: no seat belt to be worn in the wheelchair. "My father knows he is physically incapable of transferring out of the wheelchair safely," said the son. "But he would find it humiliating not to be trusted and be restrained from doing anything that might jeopardize his safety." What his son didn't know was that this had been the philosophy of Hebrew Rehabilitation Center for Aged long before regulations prohibited this type of restraint.

When his father died several years later, the son wrote to thank the nursing staff for complying with his father's wishes, even against their best caregiver instincts. "It would have been understandable for them not to trust a brain tumor patient they were just receiving and did not know," he said. "They could have insisted that the seat belt be worn for his own safety - also, to protect against potential lawsuits in the event of an accident. But they did not. They spoke with my father and with the entire family, weighed the potential damage to his dignity versus the potential physical danger, and allowed him not to use the seat belt. During his stay, my father did have one fall and required a few stitches in his head, but this was far better than tying him down like an animal and stripping him of his dignity."

Making that decision on behalf of that particular resident should not have been a big deal. Yet in most nursing homes, notwithstanding the customer's clearly stated wishes for maximizing a loved one's independence and dignity, a risk-averse administrator would likely have insisted on using the seat belt "for the resident's own good," rather than taking the chance of a fall. The resulting decrement to the resident's quality of life would not have shown up on any list of survey citations. Indeed, it would have been implicitly encouraged by the regulatory system, which tallies "bad" outcomes, such as falls, and benchmarks one facility's performance against another's.

Similarly, without the encouragement and support of the facility's management, nursing staff probably would have been very reluctant to act on the resident's wishes and risk a fall, for to take such a "dangerous" and "unwarranted" action could have placed their professional licenses in jeopardy.

Daily experience quickly suggests other examples: an elderly diabetic at the end of life being denied a dish of ice cream. An overweight nonagenarian who dearly loves to eat being put on a rigorous low-calorie diet. Such safe, yet dispiriting, responses to not very unusual situations suggest a larger dilemma. It is that somewhere along the way - quite possibly because of our society's growing dependence on Medicare and Medicaid dollars to finance long-term care - nursing home administrators and staff have ceded managerial responsibility to the regulatory authorities. They have become dependent on the "system" to solve their problems and define for them what quality care ought to be. Not surprisingly, the resulting system is loved by no one and liked by very few - and nursing home operators wonder why they have so many empty beds.

One possible corrective, I believe, is to be more market-driven. Specifically, I would recommend:

* That no more than, say, 75% of the beds in any nursing home be made available to people on Medicare or Medicaid, and separate sections for private-pay residents should not be allowed. Each nursing home would thus be required to attract a given percentage of individuals and their families who are used to making personal choices regarding their care, and to integrate them within the facility. Administrators and staff would inevitably become more attentive to the wishes of their cash-paying customers, but in the process the entire resident population - private- and public-pay alike - would benefit.

* The regulatory system ought to define "quality" in terms of what the customer and family believe to be important, as well as by the traditional standards of hot water temperature and extent of care plan documentation. Thus, as survey teams do their inspections and issue approvals, they would be required to give equal weight to the facility's performance on key family satisfaction measures, such as perceived quality of life, care, food service, activities programming and management responsiveness.

With these types of changes, the distressing tendency toward risk-aversion that is occurring in the management of long-term care facilities nationwide could be reversed. Nursing home administrators can learn to manage better, but first they require a system that allows - even encourages - them to be more innovative and courageous.

Maurice I. May is president and chief executive officer of Hebrew Rehabilitation Center for Aged, Boston, MA.