INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 7: 695-697 (1992)

EDITORIAL Quality Assurance in Residential Care

The horrors of eighteenth century madhouses engender disbelieving revulsion in the twentieth century yet throughout the last thirty years scandal after scandal has been reported in the press about conditions in some residential and nursing homes with depressing regularity and without the concern that might have been expected in an apparently liberal and caring society.

Mentally disordered elderly people are still sub- ject to grossly inhuman, degrading or cruel prac- tices and serious problems have surfaced in Britain in National Health Service hospitals, local auth- ority-run residential homes, small privately owned hostels and homes and units run by large profit- making corporations. No sector is immune from the problem though, fortunately, the reported scan- dals do appear to be relatively rare worst cases and are not the tip of some horrendous iceberg. Reports of scandalous conditions in homes are not confined to Britain and the United States. Most countries in Europe and Australasia have experienced the sudden exposure of a situation which had been fes- tering for months or years before being drawn to public attention.

Developing and maintaining standards of high quality practice in services providing ‘round the clock’ care in hospitals and residential homes is an uphill struggle. People who depend on others to provide the basic necessities of life for most of their lives are necessarily vulnerable as they are not in a position to complain effectively, ‘vote with their feet’ or refuse to be consumers of a bad service. Dr. Douglas Bennett, a psychiatrist renowned for his commitment to rehabilitation services, remarked that ‘dust will settle’ in facilities for con- tinuing care unless there is constant vigilance to maintain standards. I have seen residential homes, established on the surest clinical foundations with excellent staff, deteriorate within a couple of years to become merely average.

It is possible to identify the characteristics of organizations and institutions where scandals arise. There is usually poor professional leadership;

0 1992 by John Wiley & Sons, Ltd.

remote, ineffectual or invisible senior management; hazy systems of accountability; a high proportion of untrained and unsupervised staff; a poorly main- tained physical environment; and, above all, a consequent low staff morale. As the situation within the institution worsens, staff develop their own ethos, practices and policies to make life easier and more bearable in an unpleasant and dishearten- ing situation. Staff involved in scandals are nearly always the victims, too, of a system that has failed to recognise their need of both users and providers.

When services were concentrated in large hospi- tals and asylums, it was possible for good managers to keep a close watching eye open for the danger signals and though the physical and emotional environment may not have been of high quality, most residents would be properly fed and clothed and protected from abuse. Now that services are altogether more fragmented, it is very much more difficult for managers and the Inspectorates which are supposed to monitor them to keep a close eye on what is happening. It is therefore vital for service providing organisations to have a formal system in place for monitoring the standards of care being provided. Moreover, this needs to be supplemented by the further safeguard of an external, indepen- dent monitoring system.

‘Quality Assurance’ is the term we are now all familiar with for a programme of activities insti- gated by service managers to ensure that certain standards are met. Any quality assurance pro- gramme should encompass the concepts of effec- tiveness in achieving the benefits desired and efficiency in reaching and giving priority to the peo- ple the service is intended for; it is also important to ensure that money is spent effectively and not expended on other less important areas of need. But those who run services for elderly people, and indeed all ‘human care’ services, could learn a lot from the more successful service businesses on how to maintain quality of services in multiple remote locations. The franchised hamburger and fast food restaurants and hotel chains stand or fall

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on their ability to supply a reliable, predictable, high quality product or service in a situation which is remote from the centre and where the actual pro- vider is quite low down the corporate hierarchy. The most successful companies achieve success by:

0 Defining very specific standards for the minutiae of every procedure and for the physical environ- ment. Rules are written in great detail and reminders are posted everywhere.

0 Ensuring rules and standards are rigidly applied by intensive staff training on a continuing edu- cation and refresher course basis and by a ‘fall back’ disciplinary or, even, dismissal procedure.

0 Imbuing staff with specific cultural attitudes which they must constantly rehearse. Part of this consists of ensuring that staff are proud to be part of a highly elite team.

0 Having an absolute veto on local managers creating their own rules. Local entrepreneurial activity is outlawed unless specifically agreed by senior management.

0 Clearly devolving responsibility for delivering the service locally by pushing such responsibility as far down the hierarchy to the point of delivery as is reasonably possible. Also by ensuring that the local manager is placed in a hierarchy of managers, all with closely defined job descrip- tions from top to bottom of the organisation.

0 Encouraging local managers to use their entre- preneurial and leadership qualities by contribut- ing to the corporate planning and decision making structure. In other words, they can influence the future of services if they can con- vince colleagues and seniors that such change is justified across the organisation, but they can- not do whatever they want without authority.

0 Ensuring services stay up to set standards by employing a team of inspectors to monitor the service in detail.

0 Seeking the opinions of customers and adapting their services according to changing customer demands.

0 Monitoring rivals closely to copy good ideas and ensure they are keeping their services in the fore- front of developments.

0 Rewarding successful managers according to clearly agreed quality and performance criteria.

All these features are as relevant to running a high quality nursing home for elderly people as they are for selling hamburgers, and many services are now devising rules for ‘human’ care which can be moni- tored in exactly the same way, covering aspects of

the physical environment, care practices and pro- cedures and ‘customer satisfaction’ with the ser- vices. It is important to realise, of course, that while the system protecting care standards may be rigid and incapable of local, independent relaxation, the creative diversity of care activities and freedoms of choice for the individual can be endlessly varied. Thus the quality of the environment which is required to provide autonomy of action and per- sonal freedoms has to be rigidly defined in the care system but within this system the care provider has considerable freedom and responsibility. The two apparently opposing concepts of tight systems on the one hand, and considerable managerial auth- ority and responsibility on the other are by no means incompatible.

There are four key areas that any quality assur- ance programme should cover in its detailed sche- dules:

0 Human and physical resources and the physical environment.

0 External links and the relationship of the unit to the community.

0 Management procedures and policies and how residents spend their working, leisure and social lives.

0 Specific treatment and rehabilitation practices and how individual needs are met.

A key feature of any quality assurance programme should be a system whereby managers review differ- ent aspects of the service regularly and provide feed back to staff about their performance and the per- formance of the unit so that new objectives can be set for the next assessment period. Feedback is crucial otherwise staff feel uninvolved and unable to participate in improving service standards.

EXTERNAL MONITORING

Even a good quality assurance programme devised and run by managers of the service organisation may not provide a sufficient safeguard to ensure standards are developed and improved over the course of time. Service managers often hold the purse strings as well as being responsible for quality standards. The tensions implicit in this dual respon- sibility need to be recognised. Where such dual management function exists, it is essential to have an external group of people-inspectors- appointed to evaluate the performance against

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mutually agreed criteria. ‘Arm’s length monitoring’ of service quality by a public inspectorate system is well advanced in parts of Australia. The Com- monwealth government funds nursing home resi- dents in private homes and keeps a close watching brief on the quality of services provided within those homes. The threat of funding withdrawal or loss of full accreditation as a home which can be used by residents in receipt of public funds concen- trates the minds of nursing home proprietors won-

derfully. A similar system is developing in Britain under the NHS and Community Care Act. But external inspectorates can never be a substitute for internal quality assurance programmes put in place by local service managers and proprietors. If both systems are in place, working in tandem, then we may be able to avoid the shocking scandals that still occur with depressing regularity today.

ELAINE MURPHY