Brandon Bradshaw

Brandon is a Licensed Administrator & registered nurse with over 8 years of experience.

Credos: The Secret Tool for Measuring Nursing Home Quality

March 16, 2020

Anyone who has ever had to face the daunting task of finding Skilled Nursing placement for a loved one knows that finding the RIGHT nursing home is of paramount importance. When choosing a nursing home, families routinely struggle with the same questions: cost, convenience, location, amenities, and medical services available are just a few of the many queries to be answered during the search.

All of these items are important; but perhaps the most important question of all is “How can I tell if the nursing care and services being provided at the facility are of quality?”

If we listen to CMS (who just so happens to influence the metrics being judged and the resulting payments given to nursing facilities) then we are forced to use their 5-Star rating system on their Nursing Home Compare website. There you will find all types of calculated scores for quality measures that are achieved only by data-driven percentages that can be determined through tangible physical measurement. A facility is then compared for quality against other facilities using the calculated data.
In theory, this should be an effective tool at measuring nursing home quality. After all, they’re using “truth” in numbers and numbers don’t lie, right?

As a Nursing Home Administrator I absolutely disagree with the current use of the 5-Star rating system for measuring a facility’s overall quality of care. The flaw of this system is in the hubris of the method of measurement being used.

Quality of care absolutely cannot be determined using mathematical comparison when we are in the business of caring for people. Quality itself is completely subjective based on our own individual opinions and experiences.

Think of it using the following example: Is the “quality” of the steak dinner I ate tonight better than the quality of the steak dinner I ate last night because I it cost more, the steak was 4oz larger, served to me 3 minutes faster, and was cooked using the services of two professional Chefs instead of just one? These are measurable facts that would indicate the quality of the steak dinner was better tonight.

The only problem is that I thought the cheaper cut of steak I ate last night tasted better, even though it was cooked by only one Chef. The 3 minutes extra the Chef took to prepare my steak caused it to be cooked to my preferred temperature. The waitress who served my steak to me last night was much friendlier, checked on me often and gave me free refills on my drink. The end result was that I left the restaurant last night more satisfied than I did tonight regardless of the “measurable” differences favoring tonight’s dinner.

We determine quality based on the satisfaction we get from an experience, such as the demeanor and temperament of the people serving us, the feelings of trust and safety that are present, the beauty and cleanliness we find in our surroundings, and the values & morals expressed within the culture. Convictions such as friendliness, empathy, trustworthiness, cleanliness and being respectful cannot be measured using mathematical percentages or tangible data obtained through a government mandated MDS assessment.

My point is that the definition of “quality” greatly transcends the idea of merely using physically measurable data.
Hopefully by now readers are thinking “Okay Brandon, I’ll bite. So what do you suggest we do otherwise to measure for Nursing Home quality?”
My answer is the company’s Credo. Nearly every company has a Credo or Mission Statement that makes up the foundation of their work culture and establishes employee expectations. Since nursing homes are in the business of caring for people, the ideas and values presented in a facility’s credo should absolutely parallel what most families are seeking in terms of providing “quality” care to their loved ones.

When taking a tour of a facility or discussing potential placement with facility management, don’t be afraid to ask to see a copy of their company Credo. Read through it and ask yourself if the items within the credo are matching up to the items which YOU consider valuable in terms of providing your loved one quality care. Do the values in their credo simply reflect the values within CMS’s measurement of “quality of clinical care” perfection, or do the values represent a more humanistic culture with the idea of “quality of life” being equally or better represented?

Too often the CMS indicators of quality resident care are incongruent with what families and caregivers consider quality resident care by ignoring the factor of “quality of life.” To better explain this concept, let’s look at one of the CMS Nursing Home Compare quality measures for “Short-stay resident quality of care.”

According to their metrics, nursing facilities are judged on quality of resident care for percentages of residents who had to be sent to the Emergency Department during their stay at a nursing home. Obviously, lower percentages are better and nursing homes which don’t send residents to the ER during medical emergencies get a higher rating than those that DO send residents to the ER more often. So by this rationale, nursing homes are incentivized to take risks and not send a patient to the ER during a medical emergency, rolling the dice with hopes that they can get the situation under control in their own facility without utilizing the more acute medical services that a hospital is able to provide.

How can this be considered better quality of care when a resident’s quality of life is not considered? In all of my years as a Healthcare worker, it has been my experience that when these acute medical situations arise, the suffering resident and/or their families demand that the resident be sent to the ER. Even in situations where our facility feels we can safely manage the acute condition, families & patients will STILL usually ask to send the resident to the ER. Any attempt at trying to dissuade them from this decision causes dissention between the facility and the patient/family and often results in a newly-found lack of trust in the facility caregivers.
But when we “respect” the residents’ and families’ decisions, a more satisfying outcome generally occurs for the customer, albeit at the cost of the facility’s rating with CMS for sending yet another person to the ER. This is what it means to value “quality of life” when caring for our patients.
Treating the residents and families with respect and honoring their choices, in my opinion, increases the overall quality of resident care in the eyes of my customers. However, using the CMS 5-Star rating quality measures, sending a patient to the ER will always negatively impact my scoring percentages which CMS uses to measure quality of resident care.
Since quality of care is a subjective concept and can only be measured by weighing your own personal opinions, convictions, and expectations against the experiences provided you by the facility, it is only reasonable to use a company’s credo to more accurately forecast the potential to achieve what you personally consider to be quality resident care.
But you shouldn’t stop there. Take the next step after reviewing the credo and tour the facility. Do the employees embody the values and convictions outlined in their credo? If the company credo makes a specific claim, observe if it seems to be true:

Is the staff friendly? Do they greet you with a smile? Do they appear to communicate and work together efficiently? Does the facility appear to meet your standards of cleanliness and safety? Is staff able to find answers for you even if they don’t have them immediately upon asking? DO residents appear happy? Does staff appear to be serving residents or commanding them? Are resident rights and opinions valued or does the staff display a “caregiver knows best” mentality?

If these types of ideas are conveyed in a company’s credo, observe to see if they are being carried out, and more importantly, determine if the credo is in alignment with what you consider to be “quality” services and convictions.

If the credo is in sync with your own values and expectations, the nursing home staff appears to embody that credo, and you have a realistic view that includes the likelihood of human error occasionally happening, then you have likely found a place where you can expect quality resident care to be provided which meets your personal satisfaction.