that the Department of Health and Human Services, by establishing Centers for the Advancement of Quality in Long-Term Care, initiate research, demonstration, and training programs for long-term care providers to redesign care processes consistent with best practices and improvements in quality of life.

The committee believes that the Centers for the Advancement of Quality in Long-Term Care could be research, development, and teaching sites. Their functions could be partially listed as follows:

• Implement and develop clinical or quality-of-life assessment protocols for all long-term care settings as described in Recommendation 4.1.

• Implement and evaluate care processes that are demonstrated to improve measures of clinical or life quality.

• Demonstrate the resource requirements for implementing all assessment and care processes including the costs of training and managing staff in the provision of care.

• Serve as training sites for long-term care providers who are willing to invest in improving capacity.

• Serve as test sites for policy makers who need a realistic appraisal of the cost and feasibility of implementing regulatory standards being considered for legislative approval.

This chapter argues that most nursing homes, even highly motivated ones, may lack the technical expertise and resources—including but not limited to staffing levels—necessary to translate OBRA 87 regulations, practice guidelines, and quality improvement systems into practice. A strong case is made in this and the previous chapter that nursing home staffing levels are inadequate and that there will be little improvement until this issue is addressed. However, increasing staffing without simultaneously improving management systems will most certainly result in less-than-expected improvement. The management problems related to accurate measurement described in this chapter, as well as numerous other management issues, will have to be addressed to realize fully the benefit of increased staffing. These problems should not be used by any stakeholders to justify abandoning efforts to improve care. The discussions in this chapter support realistic directions for improvement that should take long-term care to the next level of quality.