Introducing quality assurance into long-term care for elderly people: a difficult and worthwhile process?

Improving quality of care in long term care homes could enhance the lives of many elderly people. Traditional inspection procedures, although preventing substandard care, have limited ability to increase residential quality of life. 2 A new generation of quality assurance procedures has the potential to change everyday practice in homes:' but the procedures also potentially pose problems. They require staff, who are already stretched, to set aside time to examine what they actually do. The process of peer review can be threatening for staff, many ofwhom may not have had much in the way of work related training or educational opportunities.' Managers or owners of private homes may wish to show to purchasers a commitment to improving quality of care by actively engaging in a quality assurance project, but they may lack the experience and resources to support such a project. The designers of quality assurance packages also face problems-for example, the well known difficulty of deciding what is a good outcome in long term care-and debate about realistic goals.7 Ideally the consumers-residents and their carers-should be consulted,8 9 but it is often difficult to get useful information from them, especially objective critical opinions.4' This article aims to convey some of the practical difficulties and benefits of introducing two new quality assurance procedures into two homes for elderly people. By introducing and fully participating in each quality assurance project over a period of two years in each case I was able to witness first hand the difficulties faced by staff and residents and how the problems were dealt with. To further evaluate the projects after completion, I interviewed the staff and residents with whom I had worked and whom, by that stage, I had got to know. My role as full participant, observer, and evaluative interviewer after completion provided unique insights into the worthwhile but sometimes difficult metamorphosis induced by quality assurance. By working with two contemporaneously designed but different projects I was able to compare the pros and cons of each and feed these back to the authors. The lessons learnt from this experience have been usefully incorporated into later revisions of the schemes. The quality assurance schemes referred to are the CARE scheme (continuous assessment review and evaluation)" designed by the Royal College of Physicians and British Geriatrics Society and IQA (inside quality assurance)1 designed by CESSA (Centre for Environmental and Social Studies in Ageing). These organisations set up pilots to assess the effectiveness of their schemes and it was at this stage that I became involved.