Quality-of-life Assessment
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RULE #2: QUESTION THE QUESTIONS
We turn now to the question of the questions themselves. Direct satisfaction questions, like those used by Nursing Facility A ("How satisfied are you with…[fill in the blank]?"), are a staple of consumer satisfaction surveys, but are not an ideal choice for querying nursing home residents for two reasons.
The first is that they are prone to an acquiescent response bias; that is, residents will tend to respond favorably to these questions, despite known problems with the quality of care they are receiving. In effect, residents are giving answers that they think you want, not necessarily expressing their own views.
Any questionnaire can inadvertently elicit an acquiescence bias among respondents, but consumer satisfaction surveys conducted with nursing home residents are especially likely to do this for several reasons. Older adults, and women in particular, tend to report higher rates of satisfaction with health care services; thus, there is a good chance that extremely old and frail nursing home residents, who are predominantly female, will report high rates of satisfaction with substandard or inadequate care. In addition, many residents over time in the facility lower their expectations for care. Their experience teaches them to expect and accept poor quality of care. The fact that residents also are dependent on staff for daily care and many are isolated from family and friends can only decrease their willingness to express dissatisfaction with care due to fear of reprisal.
In order to collect data useful for quality improvement, your assessment questions must reveal both your facility's strengths and weaknesses. You will not be able to identify areas that need improvement if resident responses to all or most of your questions cluster at the "highly satisfied" end of the scale, as responses to direct, forced-choice questions about satisfaction tend to do (4,7,8). You need, therefore, to ask questions that are more sensitive to differences in satisfaction levels.
Your questions also should elicit information that will help guide improvement efforts. A second problem with direct satisfaction questions is that they fail to do this. Though they may be able to tell you whether residents are generally satisfied or dissatisfied with a certain aspect of care, they shed no light on how to correct identified problems or how to tailor care to the individual. Does the person want more privacy or less? Does she want to eat in the dining room or her own room? Does he receive enough help with toileting or does he want more? With quality improvement, as with many things in life, the devil is in the details. But the details are absent in direct satisfaction questions.
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