The quality of care in America’s nursing homes has, beyond a doubt, become the most contentious issue in contemporary long-term care. The issue has polarized the political process; it has created an environment at cross-purposes with the very goal of enhancing quality and threatened the underpinnings of an entire industry. Clearly, something is wrong here.

How has our discourse regarding shared aspirations for improved long-term care quality descended to this level? While not inclined to place blame, which can only exacerbate the controversy, I can’t help but look to attitudes expressed by each of the parties involved: providers, government, consumer advocates, and the press. None can be ignored as we search for ways to overcome this problem. And if we’re serious about resolving it, none of these groups can avoid reconsidering its basic position.

Let’s start with the industry. Providers, for their part, must accept the reality of the quality problem. They must openly admit to the presence of poor providers among them and accept responsibility for working to eradicate their practices and, if necessary, the poor performers themselves. Few in the industry are unaware of the “bad apples” and their identities—and equally few are willing to admit this publicly.

Unfortunately, until recently, those who were willing to go on record usually accompanied their recognition of problem facilities with the age-old shibboleth of “inadequate reimbursement—an excuse unlikely to garner respect from an already skeptical public.

There is, though, some evidence of progress here. I refer here not to the current emphasis on “Quality First,” a campaign pushed by the industry’s major trade associations. Nothing is really new about “Quality First” except some repackaged programs. I recall, during my tenure as president of the American Health Care Association (AHCA), launching a similar project, also within the context of quality management. Materials were produced; sound bites were developed; and the media were engaged. And I doubt whether we changed any more minds about the industry’s intentions than will the current initiative.

The public is looking not for words, but for action. Not for form, but for substance. And some of that substance is, fortunately, now visible. I was impressed, for example, when another past president of AHCA, Charles H. Roadman II, PhD, CNA, addressed the age-old issue of inadequate staffing—first, by admitting to it and, second, by recognizing that solutions would result only from cooperating with those who had previously been seen mostly as antagonists. In announcing the formation of and AHCA’s participation in a National Commission on Nursing Workforce for Long Term Care (whose memberships includes the likes of AARP and the Service Employees International Union), he and AHCA’s elected leadership showed themselves ready—for the first time in a long time—to accept the reality of, in Dr. Roadman’s words, “a chronic workforce shortage that threatens care quality.” That may not sound like much—just acceptance of an issue that had long been apparent to many—but to me, it was one of the defining moments in AHCA’s history and, hopefully, in Washington’s perception of the industry itself.

Along with AHCA’s lessening inclination to confront rather than collaborate appeared an increasing willingness to admit to the presence of some bad actors in the provider community. However, accepting the reality of “poor performance” and being able to define it in a fashion understandable by all are two separate issues. Here is where government comes in. It must play a much different role than it has become accustomed to. If the provider community chooses, after years of official silence, to take on the responsibility of working to rid itself of bad apples, it must have some assurance that the definition of “poor care” is analytically based, understood, and accepted by all.

This issue—the issue of quality definition and measurement—is critical to the entire debate. Absent some common understanding as to how we measure quality, or the lack of it, how can we expect to join forces to improve quality and, moreover, fund that improvement? Avedis Donabedian, in his seminal work on quality assessment, posited three measures of quality: structure (the resources available to provide care), process (adherence to procedures), and outcomes (the results achieved by the patient). Our system of measurement is, unfortunately, still oriented primarily toward structure and process and less toward outcomes.

That approach has two major disadvantages, as has been pointed out eloquently by Rosalie and Robert Kane in a publication coauthored with Dick Ladd, The Heart of Long-Term Care. They write: “(1) The majority of the regulations are based not on empirical evidence of what activities are associated with better outcomes but on professional judgments, which quickly approach dogma. (2) Strict statements about what should be done for whom become rapidly restrictive at a time when long-term care dearly needs innovation and creativity. Especially because so little has been proven about how to deliver the best care (and there is every likelihood that more than one way is available to achieve this end), it is premature to ossify the process.”

Yet ossify the process we have, thanks to an enforcement system that has worked counter to the very goals the process was designed to foster. Punishment is a most appropriate reaction to those who have consciously abused and neglected their patients. However, for those who have inadvertently acted contrary to “professional judgment,” punishment (certainly punishment absent evidence of adverse outcomes) is totally inappropriate. It creates the very atmosphere in our nursing facilities that we all should abhor, an atmosphere attractive only to those whose interests are not in professional fulfillment but in simply “finding a job.” How can any industry attract the best and the brightest when the consequence of unintended error may well be a civil monetary penalty?

Even when advances in performance are evident, those in government who should welcome them look instead for ways to explain them away. Hearings held last year before the Senate Finance Committee are illustrative. William J. Scanlon, PhD, of what is now called the Government Accountability Office (GAO), reported a 30% drop from July 2000 through January 2002 in nursing home deficiencies most likely to cause actual harm. Good news, right? Well, not in the views of Dr. Scanlon and Committee Chair Charles Grassley (R-Iowa). While begrudgingly accepting the reality of the positive numbers, Dr. Scanlon and Grassley attributed them largely to “underreporting” of deficiencies. Care hadn’t really improved all that much, in their view. Surveyors were simply going easier on facilities in citing deficiencies.

Give me a break! We know care is improving. Some of the most respected observers of industry practice (e.g., Catherine Hawes, PhD, in her studies of post-OBRA nursing home care) have shown the evidence of that. Yet Congress, less interested in an analytic exercise designed to showcase progress and honest efforts toward continuous improvement, prefers to play political football with nursing homes. For shame!

This propensity to make the issue one of politics rather than care has its conse-quences. I would contend that one of the most difficult labor markets in recent memory results partially from the atmosphere of fear engendered by a system of federal oversight that can only work to the detriment of patient care. Buildings do not provide care, people do. When 39.5% fewer candidates sit for licensure exams as long-term care administrators, as was the case in the 1997–2000 period, with declines occurring ever since, are we not seeing the handwriting on the wall? When annual turnover for certain categories of nursing home staff hovers around 100%, can we not assume some of this distaste with the industry is attributable to society’s exclusively punitive approach to monitoring quality and the mistrust that results?

What about the consumer advocates in this field? They are certainly to be commended for the tenacity with which they have worked to advance the cause of quality care in America’s nursing facilities. And let’s give them justifiable credit for helping enact OBRA ’87, a watershed event in the history of long-term care quality. The National Citizens’ Coalition for Nursing Home Reform (NCCNHR), for example, showed itself both politically adept and conscientiously focused during that critical public policy debate. But NCCNHR, too, must ask if the current system (particularly its enforcement provisions) is helping or hindering progress toward its goal of enhanced quality. It should question a system that tends to ignore intent and attitude when judging facility transgressions.

Here is a touchstone: A study published by the Institute of Medicine in 2000 attributed 98,000 deaths annually in the nation’s hospitals to medical mistakes. The title of that study was To Err Is Human. That title did not minimize the seriousness of the issue, nor did the audience to which it was directed take the problem any less lightly because of it. It did, however, recognize the distinction between a callous disregard for patient well-being on one hand and provider recognition of the compelling need for enhanced skills and improved procedures on the other.

But consumer advocates tend not to be so forgiving when it comes to long-term care, especially nursing facilities. I often wonder what the reaction would be on the part of our consumer friends if 98,000 deaths in America’s nursing homes were attributed principally to errors in judgment on the part of the professional staff. And what are Americans to think when one of the most respected consumer advocacy organizations in the country, Consumers Union (publisher of Consumer Reports), states in its Complete Guide to Health Services for Seniors that “bad or mediocre nursing homes always seem to outnumber good ones”? Or that the care delivered in the country’s nursing homes is generally “questionable”?

And then there’s the press. I won’t harp on the tendency of the media to focus on the bad and ignore the good. As CBS’s Dan Rather might say, “That dog won’t hunt.” Airlines probably feel the same way when the press picks up on the plane that crashes, rather than the thousands that land without incident every day. In short, if it’s commonplace, it ain’t news.

Even when the press picks up on good news, I often worry about its evident priorities and how this might exacerbate negative public perceptions. For example, a couple of trade publications within our own industry focused recently (in their cover stories, no less) on the chairman and CEO of the Sun Healthcare Group, Richard Matros. The good news was that Matros and his senior management have performed miracles in turning around Sun’s nursing home operations. Yet the emphasis in both cover stories was not on what the public might have considered the corporation’s most stellar accomplishment—dramatically improving quality of care—but on the real estate aspects of the company’s recovery. It was Matros’s success in stonewalling the real estate investment trusts that owned the company’s facilities that caught the trade media’s attention. While this, in itself, was a courageous approach and one that ultimately proved successful, the intense focus might have only perpetuated the myth that nursing homes are only real estate, not providers of healthcare—that our focus is less on people than on property.

So, I guess we’re all to blame—myself included. I’m probably one of the few players in this debate who has functioned in all four of the arenas described. I have, unfortunately, been complicit in many of the sins alluded to in this column. But I think those experiences have also helped me learn (hopefully not too late) one essential lesson: Only by working together can the four parties involved in this problem further its resolution. Absent that collaborative effort, the prospect is not for improved care, but only for heightened controversy.

Collaboration or controversy: Which direction will most benefit those who have been entrusted to our care?