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ore than ever before, long-term care facilities are being required to demonstrate the effective impact they have on the residents they serve and to be accountable for the efficient use of limited resources. Government, private insurers, and licensing and accrediting agencies assess performance and define optimum practices using outcome assessment data. For this reason, long-term care facilities must deliver services that are results oriented.

Establishing Outcome Thinking in Long-Term Care Facilities
       The commitment to excellence and effectiveness must permeate every layer of the organization. Corporate executives, corporate employees, administrators, directors, supervisors, and direct care staff must believe that achieving goals and measuring performance is central to the future viability of the organization. Each level must ask itself some basic questions: What is our mission? What are our goals? How will we achieve them? Are our services improving the physical, mental, and psychosocial well being of the resident? If improvement in the resident's condition is not likely, are we slowing decline or minimizing complications? How will we measure our results or outcomes? Many facilities are so busy "fighting fires" that little time is spent pondering these concepts. Yet, it is the answer to these fundamental questions that should be used to shape the facility's policies and decisions.
       The mission statement is the starting point for a facility's outcome measurement efforts. The mission statement describes the facility's vision and core values. Outgrowths of the mission statement are strategic goals. Involving those who will be impacted by the mission statement and strategic goals is crucial. Gather input from each group that may be affected; consider all levels of staff in each department, administration, physicians, contract agencies, and of course, residents to name a few. Seek first to fully understand their interests and expectations, because they are often the ones who determine whether a plan succeeds or fails. Once the questions, "What is our mission?" and "What are our goals?" have been answered, a strategic plan is developed.

Establishing a Strategic Plan
       Strategic planning involves much more than adopting a new or revised set of clinical practices. For strategic planning to have the greatest impact, facilities must 1) identify and address forces that influence the facility's ability to attain their goals and 2) define systems and processes that will achieve the desired results.
       There are many forces that influence a facility's ability to attain their goals. These forces can be both internal and external. Internal forces include the level of expertise and experience, staff's philosophy, previous and current management practices, current clinical practices, financial resources, human resources, and organizational resources. For example, to achieve optimal results in wound care, dressings must be changed in a timely manner. The facility may have an excellent wound care protocol but might fail to change a wound dressing frequently enough simply because the evening shift nurse does not have access to the wound care supplies. Systematic methods available to facilities to recognize these internal forces include ongoing involvement and feedback from all levels of staff, monitoring systems to assure processes are followed, competency evaluations, surveys, and consultant audits.
       External forces are those forces that are outside of a facility's control; nevertheless, these forces can powerfully affect the facility's chances for success. In long-term care, these forces can include economic trends, social trends, technological trends, legal requirements, regulatory requirements, etc. Assessing these external forces and shifting the strategic plan according to the new expectations will maintain the facility in alignment with these forces.
       Next, facilities must design systems and processes to "get to" the desired results. One results-oriented system that has emerged is "clinical pathways." Other terms used to describe this system are "critical pathways," "care maps," "clinical maps," "clinical trajectories," and "integrated plans of care." Initially, pathways were established for hospital settings. The "pathway" began at admission and ended at discharge from the hospital. The halt of the pathway upon discharge from the hospital resulted in fragmented and duplicated services at the interface between the hospital and sub-acute or long-term care setting. Now as pathways are being utilized in sub-acute and long-term care settings, there is a potential for the pathway to focus on integration of care rather than on a fragment of care that is setting dependent.
       Pathways are interdisciplinary plans that arrange clinical services. They can be viewed as interdisciplinary practice guidelines with predetermined standards of care. The pathways have expected time frames and resources targeted to specific diagnosis and/or procedures. Frequently, the tracked clinical services are those that are high in volume and resource use and, therefore, costly. By prospectively and directly linking clinical care to expected time frames, resources can be allocated and actual costs can be tracked.

Measuring Outcomes
       When performance measures are incorporated into the pathway, evaluation of the effectiveness and efficiency of treatments and interventions can be accomplished. Measuring performance allows a facility to track progress or the lack thereof. Outcomes can be measured and shared at each organizational level to demonstrate the impact that each level has on the facility-wide strategic goal and mission. This feedback can be used to inspire changes in organizational and individual behavior. If, for example, a nursing assistant realizes that obtaining daily weights on a resident with congestive heart failure resulted in the resident remaining free of shortness of breath, then the nursing assistant might perceive the task of measuring weight as a contribution (and, by the way, it is!) rather than an additional burden.

Conclusion
       The emphasis on measuring outcomes presents opportunities for long-term care facilities to thoughtfully organize efforts to achieve mission-related goals. The design outlined in this article represents one course of action for facilities to consider. By using outcomes measurements, the facility can begin to build an arsenal of effective services that ultimately yield beneficial results for the resident and the providers.