The Gerontologist 41:264-271 (2001)
© 2001 The Gerontological Society of America
National Standards for the Long-Term Care Ombudsman Program and a Tool to Assess Compliance
The Huber Badrak Borders Scales
Ruth Huber, PhDa,
Kevin W. Borders, MSSW, MDiva,
Kathy Badrakb,
F. Ellen Netting, PhDc and
H. Wayne Nelson, PhDd
a Kent School of Social Work, University of Louisville, Louisville, KY
b Long-Term Care Ombudsman Services of Santa Barbara County, CA
c Virginia Commonwealth University School of Social Work, Richmond, VA
d Department of Health Science, Towson University, Towson, MD
Correspondence: Ruth Huber, PhD, Kent School of Social Work, University of Louisville, Louisville, KY 40292. E-mail: ruth.huber{at}louisville.edu.
Eleanor S. McConnell, RN, PhD
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Abstract
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Purpose: We propose national standards previously recommended for the Long-Term Care Ombudsman Program by an Institute of Medicine program evaluation committee, and introduce a tool to measure the compliance of local ombudsman programs to those standards: the Huber Badrak Borders Scales. Methods: The best practices for ombudsman programs detailed in the committee's report were adapted to 43 Likert-type scales that were then averaged into 10 infrastructure component scales: (a) program structure, (b) qualifications of local ombudsmen, (c) legal authority, (d) financial resources, (e) management information systems, (f) legal resources, (g) human resources, (h) resident advocacy services, (i) systemic advocacy, and (j) educational services. The scales were pilot-tested in 1996 and 1999 with Kentucky ombudsmen. Results: The means of 9 of these 10 scales were higher in 1999 than in 1996, suggesting that local ombudsman programs were more in compliance with the proposed standards in 1999 than three years earlier. Implications: The development process consisted of 10 adopt-test-revise-retest steps that can be replicated by other types of programs to develop program compliance tools.
Key Words: Administration • Best practice • Evaluation • Implementation
Best-practice standards were recommended by the committee convened by the Institute of Medicine in October 1993 (IoM; Harris-Wehling, Feasley, and Estes 1995
) to evaluate the National Long-Term Care Ombudsman Program (LTCOP). The purposes of this article are (a) to describe the process of developing ombudsman program standards based on the IoM Committee's guidelines, and (b) to introduce a tool developed to assess compliance of local programs to these national standards.
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Background
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The LTCOP began in 1971. Today, local ombudsmen in all 50 states, the District of Columbia, and Puerto Rico identify, investigate, and work to resolve complaints initiated by, or on behalf of, residents in nursing homes, board- and care-homes, or similar adult care facilities (Administration on Aging [AoA], 1996). Although the program is federally mandated in the Older Americans Act, it is managed on the state level, resulting in a multitude of program designs (Cherry 1991). In 1997, 887 paid staff and 6,795 certified volunteer ombudsmen opened 130,709 cases and closed 113,027 cases that involved 191,005 complaints (AoA, 2000).
Researchers have studied the LTCOP since the early 1980s (Cherry 1991; Huber, Netting, and Paton 1993; Monk, Kaye, and Litwin 1984; Nelson 1995; Nelson, Huber, and Walter 1995). Particular attention has been paid to the reporting system that ombudsmen use to track complaints (Chelimsky, 1991; Huber 1994; Netting, Huber, and Kautz 1995; Netting, Paton, and Huber 1992; Paton, Huber, and Netting 1994). Seeking to address concerns raised by ombudsmen and researchers, AoA implemented the National Ombudsman Reporting System (NORS) in 1995. NORS has made it possible to analyze program outputs and outcomes and to even conduct cross-state comparisons (AoA, 2000; Huber, Borders, Netting, and Kautz 2000).
NORS is a comprehensive program evaluation tool to track complaint patterns and trends in the facilities monitored by ombudsmen, not to answer questions about quality of program implementation. Now that NORS is developed, the next step in a fully developed performance evaluation system is to focus on program quality (Grinnell 1997).
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The Development of National Standards
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The adoption of national standards from the work of experts is not a new concept (Brennan and Kaplan 1993; Flaherty 1999; Nash, Markson, Howell, and Hildreth 1993). Propst 1992 noted that such standards answer questions about program philosophies and purposes. Beyea and Nicoll 1999 noted that "voluntary standards are those developed by... practitioners and often are the work of a professional organization" (p. 495). Moxley 1993 described five uses for clubhouse standards to address value-based intrinsic qualities of the program, asserting that "the standards are a living document, subject to modification every 2 years..." (p. 178). Clubhouse programs serve mentally ill clients (members).
Some disciplines are prolific in the development of guidelines and standards. For example, McKinnon and colleagues 1999 proposed minimum requirements for home care pharmacies, and Walker, Howard, Walker, Lambert, and Suchinsky 1995 described the burgeoning guidelines for addictions programs (Book et al. 1996; Kelly and Toepp 1992). Other medical specialties have also developed numerous guidelines for physicians (Fiester 1978); child and adolescent psychiatry (Bernet 1999); surgical nursing (Ide and Fleming 1999); school psychology (Batsche, Knoff, and Peterson 1989); and social work (Howard and Jenson 1999; Wambach, Haynes, and White 1999). Lichtenberg and colleagues 1998 proposed psychological standards for practice in long-term care facilities, and Myers 1992 spoke of competencies for gerontological counselors. More recently, Harrington and coworkers 2000 found that experts had recommended minimum nurse staffing standards for U.S. nursing facilities. Developing national standards is not limited to the United States (e.g., Bagshaw 1999; Beecham 1999; Bell 1996; Ogloff and Oley 1998; McIvor 1994; Mitchell, Harvey, and Rolls 1998).
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Ombudsman Standards
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The Institute of Medicine (IoM) was commissioned by AoA to study the ombudsman program (Harris-Wehling et al. 1995). Chaired by Dr. Carroll Estes, the committee consisted of 16 leading gerontologists: Carroll L. Estes, Chair; Janice M. Caldwell, Donald L. Custis, Worth B. Daniels, Jr., Rebecca D. Elon, Christine Gianopoulos, Elma L. Holder, Rosalie A. Kane, Vivian Omagbemi, Mary D. Poole, Joanne Rader, Charles P. Sabatino, Jeanne V. Sanders, Peter W. Shaughnessy, John H. Skinner, and Hollis G. Turnham. Their valuable work provided the guidelines from which we have worked. One of the IoM committee's recommendations was to "... build upon the committee's proposed set of exemplary, essential, and unacceptable practices to develop and implement an objective method to assess compliance of state long-term care ombudsman programs" (Harris-Wehling et al. 1995, p. 155). Our goal is to fulfill this recommendation—to further refine these practices into a tool to be used in assessing compliance.
In a best-practices format, the committee presented a series of tables to which one could look for quality program characteristics. We propose that these tables be conceptualized as the basis for national standards against which ombudsman programs can be assessed for compliance. The main components are shown in Fig. 1. Unacceptable practices are those that do not conform to the objectives of the Older Americans Act. Essential practices refer to the basic minimum requirements for programs, and Exemplary practices are those seen in the most successful ombudsman programs—perhaps a small percentage.
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Figure 1. Conceptualization of scaling in the Huber Badrak Borders Local Ombudsman Program Compliance Scales, derived from the recommendations of the Institute of Medicine in its evaluation of the Long-Term Care Ombudsman Program. The Huber Badrak Borders Scales are derived from Harris-Wehling, Feasley, and Estes 1995.
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We need to be very clear that the development of the assessment tool introduced here was derived from the work of Dr. Estes' committee and the IoM staff (Harris-Wehling et al. 1995; see an excerpt of Table 5 in the Table A1 1). The presence (or not) and strengths of program qualities identified by IoM are reflected in the Huber Badrak Borders Scales, a tool introduced here to assess the extent to which local ombudsman programs comply with national standards.
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Development of the Huber Badrak Borders Scales
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It is important to first place this instrument in both political and programmatic contexts. Politically, the results of efforts to assess quality programming can be used for unintended purposes, and they may be ignored if they do not support popular beliefs (Quinn and Magill 1994). Similarly, it is difficult to fully develop and use a compliance assessment tool in environments in which the results can be used in ways that can affect ombudsmen's careers and agency reputations. It is critical that data be used within the context of their purposes (Huber et al. 2000). On the other hand, it is necessary to place the instrument in the overall context of program implementation and the critical need to evaluate those elements necessary for quality service delivery. Before outputs and outcomes can emerge, programs must have appropriate infrastructures, and infrastructures are likely to change in social programs.
Armed with the IoM report, the first and third authors met at a national conference in Fall 1995 and drafted a program assessment tool based on the seminal Table 5 in the IoM report (see excerpt in the Table A1 1). We worked from only the items in IoM's Table 5 that pertain to local ombudsman programs (similar work is beginning on scales for the practices of the offices of state long-term care ombudsmen). The assumption behind IoM's Table 5 is that quality programs will provide better services to clients than programs whose practice characteristics are either unacceptable or minimal (only the bare essential elements in place). We therefore propose that this best-practice model be adopted as a set of national standards for local and state ombudsman programs.
To transform the standards into a quantifiable format, many hours were spent with ombudsmen at all levels of the Kentucky program: local and regional (Western, Central, and Eastern Kentucky) within the state, and the Kentucky State Ombudsman. Ten steps were taken in the development process: (a) the initial work of the first and third authors; (b) revisions by the Kentucky State Ombudsman; (c) review by Kentucky's regional and local ombudsmen; (d) another revision based on their input; (e) pilot implementation in 1996; (f) results of the pilot study presented to and discussed with Kentucky ombudsmen at all levels; (g) second review by Kentucky's regional and local ombudsmen; (h) synthesis of input by researchers in consultation with state and regional ombudsmen; (i) a second implementation in 1999; and (j) presentation of results to all Kentucky ombudsmen.
We conceptualized IoM's range of practices on a reverse continuum from that shown in IoM's Table 5. Notice that the excerpt from IoM's Table 5 in the Table A1 1 shows Exemplary practices on the left of the table, Essential in the middle, and Unacceptable on the right. We kept the basic content (albeit revised many times) but conceptualized it on a 1–10 continuum, where 1 is the lowest rating (on the left) and 10 is the highest (on the right). The 1–10 scales are overlaid with IoM's three levels of practice characteristics: Unacceptable (ratings 1, 2, or 3 on the scales), Essential (4, 5, 6, 7), and Exemplary (8, 9, 10). Similarly, we adapted each of IoM's Table 5 sections, (e.g., 5.2, 5.3, 5.4) into a scale with several 1–10 subscales. For example, IoM's Table 5.2, Structure of the Office of the State LTC Ombudsman and Elements of the Host Agency(s) for the State and Local Entities, became Structure of Local Ombudsman Programs in the Huber Badrak Borders Scales, and contains the following four 1–10 subscales: (a) working relationships; (b) fit of host agency; (c) autonomy; and (d) resources. Table 1 shows the complete structure of the Huber Badrak Borders Scales.
The Instrument.
The Huber Badrak Borders Scales have been implemented on two different occasions in Kentucky, 1996 and 1999. Feedback in 1996 revealed problems with both the form and its implementation, which we subsequently corrected. Now the three quality areas are defined more concretely: (a) ratings in the Unacceptable range suggest that the program either does not have the desired characteristic or capability at all, or has it in a minimal and ineffective manner; (b) ratings in the Essential range indicate that the local ombudsman program has the essence of that element, but may lack the freedom or skills to use it to the fullest extent; and (c) ratings in the Exemplary range mean that the program not only enjoys the freedom or resources in the element, but that ombudsmen capitalize on that strength to better serve their clients (Gary Hammonds, personal communication, September 19, 1995). See Fig. 2.
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Figure 2. Adaptation of IoM's recommendations for local long-term care ombudsman programs: The structure of local ombudsman programs subscale. Source: pp. 162–163, Table 5.2 in Harris-Wehling, Feasley, and Estes 1995.
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Revisions focused on consistency across the three program levels to be sure, for example, that the same constructs were being compared across program levels (Unacceptable, Essential, and Exemplary). This required several revisions, as the initial characteristics in IoM's Table 5 did not always meet this criterion.
Implementation.
Several ombudsmen had difficulty distinguishing between using the instrument to evaluate their local programs versus seeing the instrument as a tool for personal performance evaluation. While this is a natural reaction and understandable, the unit of analysis is the program, not the local ombudsman. Local ombudsmen can affect some of the elements, but others may not fall under their influence. For example, an ombudsman in a program located in a Legal Services for the Elderly organization may have on-call access to an attorney, whereas ombudsmen in Area Agencies on Aging may not have direct access to attorneys.
Because of fluctuating personnel in Kentucky, the pilot implementation of the instrument in 1996 was not conducted in a consistent format across the state's 15 local programs. During revision meetings, consistent procedures for implementation were also agreed upon: Both the local ombudsmen and their regional supervisors (for the Western, Central, and Eastern parts of the state) completed the document for individual programs. Then local ombudsmen met with their regional ombudsmen to compare their ratings and arrive at decisions about the rating for each of the 43 1–10 subscales. The range of numbers within each program level (Unacceptable 1-2-3; Essential 4-5-6-7; and Exemplary 8-9-10) accommodates progress, even though local host agency restrictions or limited resources, for example, may prohibit a higher rating. The word "improvement" is not used in the 1–10 scales. Movement on the scales over time demonstrates progress or lack thereof, and the instrument can be implemented on a regular basis, for example, once or twice a year to build a growth history (or absence thereof) for each local program.
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Discussion
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Fig. 3 shows only the means of the 10 major scales for Kentucky's local ombudsman programs from the 1996 and 1999 implementations. In all of these scales except one, the means for 1999 were higher, indicating progress. The one scale where the mean for 1999 was not higher is on the Qualifications of the Ombudsman scale. The explanation given by the ombudsmen was that in 1999 they had a better sense of how to rate themselves on this scale. At first glance, this scale can be interpreted as a rating of their own effectiveness as ombudsmen. Interpreted this way, there could be a temptation for ombudsmen to score themselves higher. However, three of the eight subscales are about the restraints or lack of restraints placed upon ombudsmen in performing their duties: Long-Term Care Ties and Regulatory Ties (both of which suggest conflicts of interest), and Adult Protective Service and Guardianship Issues. Unacceptable scores on these subscales are not a reflection of the ombudsman's work, but could result from bureaucratic restrictions. Low ratings on these scales could give the state ombudsmen information about the program that could then be used to strengthen program support.
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Figure 3. Means of Huber Badrak Borders Scales for local ombudsman program compliance, by year implemented.
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We repeatedly reinforced the idea with ombudsmen that the tool does not necessarily reflect good or poor work of ombudsmen themselves. An ombudsman might be the most efficient and effective ombudsman in the state and still have low ratings on several scales if they are in restrictive host settings. The largest local program in the state, for instance, is organizationally free-standing and, therefore, has complete freedom to raise additional funds and allocate them at will. Unrestricted by answering to a host agency, this program can recruit and even pay stipends to "volunteers" to monitor care in nursing homes. Other local programs, however, are severely restricted in fundraising, volunteer recruitment, community education, and training activities.
For the data to be useful, ombudsmen must strive for absolute honesty in their assessments. Local ombudsmen rating their own programs on the Huber Badrak Borders Scales are faced with some dilemmas. There may be a temptation to rate one's own program rather high on the scales to look good. On the other hand, if the final, collaborative ratings are high, there are two potential problems: (a) it is hard to show progress toward higher ratings over time if the original ratings are inflated, and (b) the ombudsman may lose documentation or evidence for grant writing and advocacy purposes if a positive response bias occurs. For example, one scale pertains to ombudsmen's knowledge of regulatory policies and procedures (i.e., licensing, surveys, Medicaid, and rate setting). If this rating is inflated, the opportunity to secure a grant for training may be lost. Conversely, if this rating is low, the ombudsman has a bit of empirical data on which to base a request for training monies. A grant request could, hypothetically, contain language such as: This ombudsman program has consistently earned the lowest ratings in the state on regulatory and guardianship expertise. Therefore, funds for training are central to the integrity of the program. The IoM committee, however, found that both "state and local ombudsmen were willing to acknowledge openly the weaknesses of their programs" (Harris-Wehling et al. 1995, p. 88). The same is true of Kentucky ombudsmen, and we believe that their programmatic assessments are quite candid.
Another subscale pertains to personal liability, where Unacceptable means that under state law ombudsmen have no protection from the state against liability for the good faith performance of their duties. This is the case in Kentucky; therefore, local ombudsmen in the Commonwealth cannot rate themselves anywhere but in the Unacceptable range on this item. The Kentucky State Ombudsman could take charts to the legislature to show areas of growth and progress within the program, but also the huge deficit in the liability area, advocating for liability coverage for local ombudsmen. If the Huber Badrak Borders Scales are implemented in other states, state ombudsmen could also demonstrate differences in this area between the Kentucky ombudsman program and those in other states. Another major problem identified by IoM's committee pertains to conflicts of interest. Data that show the extent to which this is a problem in local programs could lead to policies and structural changes needed to eliminate this ethical quagmire.
The purpose of the Huber Badrak Borders Scales is not to measure outcomes, but to assess a program's compliance with national standards. In fact, it cannot be a consistent outcome measure if it is to be a living, dynamic instrument (Moxley 1993; Probst, 1992) that grows as program constituencies shift, or as political climates change. We have resisted the researcher's urge to conduct sophisticated analyses, (e.g., factor analysis that could totally reshape the instrument for use as an outcome instrument). To do so would violate the tool's basic/foundation purpose: to assess the extent to which local programs are in compliance with national standards. While it would be a methodological benefit for the Huber Badrak Borders Scales to be implemented intact in several states for comparisons, it may need to be tailored for each state to be the most useful.
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Conclusion
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The Huber Badrak Borders Scales can be seen as meeting IoM's recommendation 5.2 to "... develop and implement an objective method to assess compliance of state long-term care ombudsman programs" (Harris-Wehling et al. 1995, p. 154). Similar instruments can be developed for any program pertaining to any social service problem or population. Recall that this research team did not develop the basic content of the tool, but rather extracted and restructured the comprehensive work of the IoM committee. A next step is for the instrument to be used in other ombudsman programs across the country. Even if other programs choose not to use the tool, it is hoped that debate and discussion about how to assess program compliance with national standards will continue. Additional implementation will also make possible more extensive analysis of other program differences. For example, compliance with the standards can be analyzed by whether programs are hosted by Area Agencies on Aging, a controversial issue among ombudsmen (Huber, Netting, and Kautz 1996).
Program evaluation of the ombudsman program can be difficult to conduct because the ombudsman's world is not static. The Huber Badrak Borders Scales demonstrate the adaptation of the recommendations of a national committee into an assessment tool useful at the local level, recognizing that program quality is critically important in a rapidly changing environment. The IoM committee provided the framework for national standards and the Huber Badrak Borders Scales assesses compliance with them. It is now up to state and local programs to determine their usefulness for quality practice.
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Acknowledgments
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This work was supported, in part, by the Administration on Aging, Department of Health and Human Services, Grant 90AM0759. The contents of this article reflect the views of the authors and should not be construed as those of the Administration on Aging.
We support efforts toward gender-neutral language in the social sciences and prefer to use the term ombudsperson instead of ombudsman. We have learned, however, that program officials have decided to keep the original term as it came from Sweden. Our goal is to strengthen the program, not to offend ombudsmen, so we acquiesce to their preference of terms.
We thank the many state and local ombudsmen who have shared their experiences with us. We express appreciation to Bob Daugherty for his careful review of a previous draft of this article.
Received for publication July 14, 2000.
Accepted for publication November 3, 2000.
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Appendix
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References
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TOP
Abstract
Background
