not report dissatisfaction for fear of reprisals or because they are unclear about the standard of care they should expect. Also, how does one balance quality of life as illustrated by the constructs listed above with narrower concepts about adequate quality of care and the safety of residents? Although facilities must respect residents’ choices, in some facilities concerns for safety and physical well-being continue to overrule residents’ preferences for particular lifestyles. Nursing facilities’ concerns about legal and regulatory liability often militate toward safety first (Kapp, 1987).

Residential settings other than nursing facilities may permit more personal autonomy for residents (Mollica et al., 1992; Kane and Wilson, 1993), in part because fewer standards prevail about staffing, physical care, and safety. Some commentators are concerned, however, that such environments insufficiently protect many vulnerable adults. The hope is that new models of residential LTC will be developed that allow persons with severe disabilities to receive care while leading a normal lifestyle and achieving privacy and control over their immediate environment. Although good models of such care exist, perennial scandals suggest that many B&C homes offer very little service, in environments that fall far short of minimal adequacy.

Quality of life, like quality of care, can be measured by structure, process, and outcomes. Indeed, Wilson (1993), writing about assisted living, argues that some structural standards for the environment are essential to autonomy and a normal lifestyle. She advocates private occupancy rooms with full baths, kitchenettes, locking doors, and individual temperature controls. Procedures for handling such issues as individualized care planning, resident governance, complaints and grievances, lost property, room transfers, and informed consent may well facilitate quality of life; LTC ombudsmen in some jurisdictions have been active in efforts to establish such procedures. Also, staff behavior that is respectful of the dignity and choice of residents is a key factor in achieving a high standard of quality of life. However, quality of life is best measured by the subjective well-being and satisfaction of each individual resident.

ASSURING, ASSESSING, AND IMPROVING QUALITY

Assuring quality in LTC residential facilities should proceed in three steps: (1) define quality in operational terms and establish standards for performance, (2) assess care to determine whether standards are met, and (3) correct problems that have been identified. The following discussion focuses on the quality assurance systems in nursing facilities; similar systems for B&C facilities have not been developed to the same degree and vary a great deal among states (Hawes et al., 1993; Phillips et al., 1994).

Quality has been a preoccupation in nursing facilities for decades (IOM, 1986). The ombudsman program actually arose in response to the widespread



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