Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0133Quality of Care and Quality of Life inInstitutions for the AgedM. Powell LawtonPhiladelphia Geriatric Center, PA, USAAlthough the form and function of the institution for older peoplechanged considerably over the second half of the twentiethcentury in the USA, UK and other countries, the central taskendures—providing protective care for older people unable tocare independently for themselves. At the beginning of this periodthere were still people in the system whose lack of independencewas primarily financial. Physical ill-health and, later and into thepresent, mental and cognitive ill-health became the main reasonfor entry into an institution.The details of how such care was delivered differed in majorways across countries, to the point where knowledgeablecomparisons were possible only for highly specialized expertswho had the time to become familiar with more than one system.The present chapter is written when such differences are stillevident. It is thus necessary at the outset to acknowledge that anyattempted generalization about institutions for the aged must beinterpreted in the light of differing cross-national social andcultural traditions. Nonetheless, this chapter will assert that thereare characteristics common across localities that are universallyaccepted as indicators of quality of care and quality of life ininstitutions for older people (sometimes referred to as ‘‘nursinghomes’’, as in the USA).After establishing the importance of the quality concept, thischapter will review issues in maintaining quality in this type ofresidential case. Some of the recent literature will be reviewed,followed by the presentation of a model for defining quality ofcare and quality of life now under development by Rosalie Kane,Robert Kane and the author.WHY BE CONCERNED ABOUT QUALITY INNURSING HOMES?Quality has been an issue among US nursing homes from thebeginning of such institutions. Governmental monitoring ofquality has been a threat to for-profit entities because theirprofits might be threatened by external quality-monitoringefforts. Poor quality may also be found among governmentallysponsored and non-profit homes. Suffice it to say that there hasalways been a major gap between accepted standards and theactuality of care, sometimes to a shockingly unacceptabledegree, in the USA.Governmental regulation, although resisted by many elementsof the nursing home network, has been the major device used toenhance the quality of nursing home care in the USA. The systemnow in place requires each state to hire and train professionals(‘‘surveyors’’) to spend time at least every second year on site withstaff, residents and archival records to assess each institution on aseries of written standards.The procedure for monitoring nursing home quality requiredby the US government is instructive in defining currentstandards. There are 185 such regulations, which are organizedinto 15 categories: resident rights; admission/discharge rights;resident behavior and institutional practices; quality of life;resident assessment; quality of care; nursing services; dietaryservices; physician services; rehabilitation services; dental services;pharmacy services; infection control; physical environment;and administration 1 . Classification problems are immediatelyapparent. All categories are aspects of quality of care, and manymay also reflect quality of life. Both of these subcategories aredefined for monitoring purposes in a much more limited waythan seems appropriate to this author. In 1997 the 10 mostprevalent deficiencies in US nursing homes were: food sanitation;resident assessment; care plans; accidents; pressure sores; qualityof care; restraint use; housekeeping quality; dignity; and accidentprevention 2 .Citation for deficiencies may result in fines, temporarysuspension of reimbursement for care or, at worst, removal of alicense and closing of the institution. Suspension of reimbursementor license rarely occurs; in fact, the problems of finding carefor residents in the offending institution are viewed as morestressful than continued low-grade care. Regulation is quitedifferent, of course, in the UK. For instance, until recently it wasonly privately-administered facilities that were subjected tooutside regulation, on the theory that local authorities were, bydefinition, assuring adequate quality by the nature of their directresponsibility for care 3 . This separation has changed, however. Itseems likely that the phenomena of diversification of sponsorship(especially into the for-profit sector) and the need for localauthorities to lean more heavily on professionals for qualitycontrols than on local monitoring will make the two countries’systems become more similar in the future.DEFINING QUALITY OF CAREThe classic system view of the health-care institution denotes thestructural, given characteristics as input, care and treatment asprocess, and the resultant effect on the patient as output 4 . It hasbeen noted frequently that output is difficult to identify when theinstitution constitutes the last residence and the final outcome isdeath. In addition, research over the past couple of decades hasPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd