Thinking about you: using resident surveys to better evaluate quality-of-life in long-term care communities

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Thinking about you: using resident surveys to better evaluate quality-of-life in long-term care comm
Thinking about you: using resident surveys to better evaluate quality-of-life in long-term care comm
Most stakeholders would agree that effectively measuring long-term care quality requires a multi-pronged effort. Quality encompasses resident outcomes, staffing levels, minimum data set information, documentation, assessments and other elements.

Where resident satisfaction surveys factor into that equation, however, is a question that isn't easily answered these days, particularly because the Centers for Medicare & Medicare Services excludes resident satisfaction data from its Five-Star Quality Rating System. Although the CMS rating system was developed to help consumers compare nursing homes and better identify an operator's strengths and weaknesses, most providers and industry stakeholders contend that, without factoring in resident satisfaction, a critical piece of the evaluation puzzle is missing.

“Satisfaction surveys are instrumental in helping [assess] quality, and to help show what we're doing well and what we need to improve,” says Reita Hall, vice president of clinical services at Community Eldercare Services LLC, Tupelo, MS. “I believe that not having them factored into the Five-Star rating is a mistake.

“The satisfaction of our residents, their families and staff is very important to us. If satisfaction survey [results] come back mostly positive, but the Five-Star rating says something else, does that mean the satisfaction surveys don't mean anything? What if a [facility] gets a Five-Star rating, but its satisfaction scores tell a different story? Without factoring in the residents, I just don't know how you can accurately determine quality.”

Does not compute

Recent findings from national research firm Holleran support the notion that there's little or no correlation between a facility's Five-Star rating and resident and family member satisfaction. Holleran, which specializes in research within the not-for-profit senior living sector, discovered during its analysis that satisfaction ratings of residents and family members from five-star facilities (the highest ranking under the CMS rating system) do not differ from those in average-rated facilities. The firm examined data from more than 12,000 nursing home residents and family members from 32 states.

The company was receiving a lot of requests about the relationship between satisfaction and the rating system, said Lisa Lehman, a managing partner at Holleran.

“We decided to take a closer look at our existing data to see if there was a connection between satisfaction ratings and the Five-Star rating—not having any idea of what the data would show,” she said. “It turned out to support what a lot of people had been saying­—that something seems to be missing. If you look at our data, one could argue that there's a disconnect somewhere.”

Holleran's findings, along with recommendations from long-term care industry stakeholders on how to improve the controversial Five-Star Quality Rating System, have led CMS to take a closer look.

“We're trying to get CMS to approach resident satisfaction in a more positive way,” said Larry Minnix, president and CEO of the American Association of Homes and Services for the Aging. “We believe every provider should be using a resident and staff satisfaction survey that can stand up to the validity test. We've asked CMS to add a component of resident satisfaction to the Five-Star.”

Currently, the Five-Star Quality Rating System is composed of three rating components: survey results, staffing levels and quality measures.

“Allowing the results from resident satisfaction surveys to be factored into the mix could possibly improve the measurement system and make it stronger,” reasoned Susan Pearson, director of Illinois-based Life Service Network Inc.'s confidence satisfaction program. The reason is because  actual stakeholder feedback on services, quality of care, safety, and security are considered more reliable data, she said.

A CMS official indicated that the agency has indeed been considering adding a satisfaction survey component, but stressed that any changes, should they take place, would not be made in haste. It's also unclear how the satisfaction survey component would be factored into the overall rating. At a minimum, Minnix suggests that CMS could offer a point to facilities that consistently conduct satisfaction surveys using a valid survey tool.
Regulators unconvinced

So far, though, CMS contends it hasn't seen such an instrument. “At this point, we're informally talking to the industry and looking for what we would consider a valid survey instrument that would give an accurate, unbiased view of what life is like inside a facility,” said CMS spokeswoman Mary Kahn. “We are very interested and would love to find [such a tool], but so far, we've gotten very little feedback from the industry. Nothing we've seen so far meets our criteria.”

One satisfaction survey tool that was presented to CMS — which involves face-to-face surveys—may have met some of the criteria. But Kahn said CMS' limited resources would not make it a realistic option.

Resident satisfaction surveys are an excellent tool for getting feedback—and demonstrating the community's strong desire to take residents' and families' opinions into consideration, one survey provider says. Still, he said he's concerned about what he considers to be satisfaction surveys' fundamental flaw.

“While I understand why most long-term care providers may seem in favor of having resident satisfaction surveys factored into the Five-Star Ratings calculations, I'm concerned that, in the end, these surveys are going to be subjective,” explained Chip Kessler, general manager of Johnson City, TN-based Extended Care Products Inc., a provider of educational and risk management programs for long-term care.

“While a resident's and family's opinion is highly valuable, it is still just an opinion. Each and every resident's situation is unique, as it their family's.”

Beyond that, survey results cannot be benchmarked against “like” communities, and some surveys also fall short in regard to who is measuring the satisfaction—the organization or the resident/family member, added LSN's Pearson. If it's the organization, she reasoned that operations, service and staff performance will matter most, whereas, residents and their family members will typically focus on safety, promptness of service delivery and convenience.

“Surveys that fail to address what's important to the resident and family miss the mark,” she said. “Having the buy-in of stakeholders is key to gathering accurate, reliable data. Residents must be excited about completing the survey and not have an attitude of ‘What's in it for me?'”

Using surveys wisely

As CMS continues its search for what it considers a reliable, unbiased survey tool, experts agreed that long-term care providers should continue using their existing survey tools to their best advantage. And if an operator hasn't yet implemented a survey process, he or she should.

Doing so could help facilities better leverage themselves within the community—with both existing and prospective residents. It also could potentially help improve the public's perception of the facility in the event that it received a below-average Five-Star rating.

“It's great that people are advocating for change [regarding the rating system] and it's great that the CMS is considering it, but people need to recognize that any changes that may take place won't happen very rapidly,” said Peter Fugaro, director of technology services for PentaStar Collaborative, Bridgeville, PA. “We're trying to help [long-term care providers] improve themselves now—with the rating system that's currently in place.”

PentaStar is a strategic alliance between Prymak LLC, a technology consulting firm based in Greensboro, NC, and CommuniTech LLC, a full-service marketing firm based in Pittsburgh, PA. Fugaro and Pam Rak, PentaStar's director of marketing services, stressed that facilities should not be relying solely on their Five-Star rating to send the message on quality.

If a facility scored low in the CMS rating system, they said it's prudent to share positive resident satisfaction survey scores with residents, families, staff—and perhaps even the general community—and also identify the steps the facility is taking to address the weaknesses identified by Five-Star. Of course, it's also a golden opportunity to tout any identified strengths.

“A lot of the [perception] is within facilities' control. If they have positive information to share, they should be shouting it from the rooftops—and they shouldn't be shy about educating markets on how they plan on turning their weaknesses into strengths,” Rak said. “Instead of getting stuck in the mire of what's going on with CMS, they should be rising above and taking charge right now.”

Well-designed and properly used satisfaction surveys can go a long way toward building and maintaining a strong census, according to Kessler. Resident satisfaction surveys should meet two specific goals: to show residents and families that their thoughts and opinions about the facility's care and services matter, and to obtain meaningful data that will help staff improve and maintain a high level of quality care and services, he said.

“We encourage and teach facilities that keeping open the lines of communication can lead to happy and satisfied residents and families. In turn, families are out in the community saying good things about the facility, which produces word-of-mouth advertising and other families remembering the facility when it comes time to place a loved one into a long-term care facility,” Kessler said.

Tying survey results back to quality improvement programs may also more directly benefit facilities. While this usually involves more analysis than simply tabulating percentages of satisfied customers, Pearson reasoned that going the extra mile will provide more useful interpretations of results and help identify drivers that most influence customers' feelings and responses about services and programs.

“Informing respondents of the importance of their opinions to the community's future growth and development needs to be outlined at the beginning,” Pearson noted. “What changes may be made that will impact the resident on a day-to-day basic should be explained. Additionally, staff must be involved to offer help to families and residents so they understand and fill out the surveys completely.”

She recommends that facilities administer surveys on an annual basis to help identify and track any emerging trends.

Beyond Five-Star

Community Eldercare Services is one provider that doesn't view its Five-Star rating as the final word on quality.

The community, which is now in its second year of implementing a third-party survey instrument, was surprised by its below-average Five-Star rating, particularly because its overwhelmingly positive satisfaction survey scores told a far different story on residents' perception of quality.

“Our Five-Star review wasn't where we wanted it to be,” said Hall, the clinical services director. “When that rating came out, we sent out a release to each of our communities and immediately began discussions at the management level on how we were going to talk to the public about the rating and [outline] our plans for improvement.”

Part of the approach was informing the public of the components of the Five-Star rating system and how CMS makes its calculations. Community Eldercare Services also made a significant investment in technology to improve data quality and capture.

Not only have surveyors been responsive to the new technology, Hall said the new technology also has boosted staff, resident and family satisfaction.

Although it's too soon to tell how the changes will affect the provider's Five-Star rating, Hall said she's confident that satisfaction scores will continue to reflect the facilities' commitment to quality.