Part Three of a Three-Part Series

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he Assisted Living Federation of America (ALFA), the largest trade association dedicated exclusively to the assisted living industry, estimates that there are 30,000 to 40,000 assisted living facilities that serve approximately one million seniors.1 With this unprecedented demand for affordable long-term care and the lack of standardized protective regulations, it is essential to monitor the quality of care provided in our nation's assisted living facilities. Emphasizing customer satisfaction with service quality is an effective way of 1) holding those who provide and control these services more accountable to their consumers, 2) providing higher quality of life to the one million individuals who opt for assisted living arrangements, and 3) elucidating where service excellence will most likely lead to long-term financial returns for assisted living operations. Healthcare services researchers, regulators, and providers agree that the level of customer satisfaction with care is a legitimate measure of the quality of care provided.
       To examine customer perceptions of care, Press Ganey Associates mailed confidential surveys to the residents and family members of 35 assisted living facilities across the US. Between January and December 2001, 1,505 completed surveys were returned to the research firm and analyzed. Press Ganey Associates, headquartered in South Bend, Indiana, is the well-known leader in satisfaction measurement and improvement for the healthcare industry.
       The satisfaction questionnaire asked about central aspects of the assisted living experience, including apartment and facility issues, organized activities, food, management, and direct care providers (see Graph 1). While the marked customer displeasure with organized activities was a great surprise, the focus of this article will be on how assisted living customers evaluated the aides, administrators, and other staff members at their facilities.

Graph 1. Customers rate various aspects of their assisted living experience. (Satisfaction ratings are on a 100-point scale.)

       It was most encouraging to find that the survey's highest scoring measure was "extent to which employees treat you (the resident) with respect" (see Table 1); this rating reflects well on all staff members--aides, administrators, dining, maintenance, activity organizers, housekeeping, and drivers--given that it is the sum of their interactions that brings about this assessment.
       In assisted living, as we find across the spectrum of healthcare settings, it is the staff's attitude and interpersonal manner, as opposed to amenities and other service attributes, that drive positive word of mouth referrals and overall customer satisfaction (see Table 2). In other words, it would be most efficient to first focus systematic improvement efforts on staff-resident interactions. Facilities that already are doing well in this area are also the ones enjoying more customer referrals. Physical layout and condition of the facility, such as noise level, storage space, or attractiveness of the bathroom, possess much less power to drive customer recommendations and would appear at the very bottom of a list of issues that are most strongly associated with a customer's willingness to recommend an assisted living facility to other people.

Graph 2: Overall rating of assistance and care provided. Percentage of "very good" marks provides a measure of customer loyalty.

       A simple and effective way of monitoring customer satisfaction is by tracking the percentage of customers who are completely satisfied with service delivery. In survey research, the respondent's checking the most favorable category on an unbiased rating scale indicates complete satisfaction. The Press Ganey survey asks healthcare customers to rate a series of service attributes on a 5-point scale that looks like this: very poor = 1; poor = 2; fair = 3; good = 4; very good = 5.
       The percentage of customers that rate a service as "very good" (or "5" on a 5-point scale) reflects the percentage of customers that can be considered completely satisfied and, with that, loyal and likely to remain loyal to the facility being rated. A loyal customer is one who will stay with a service provider, who will return if the need for similar services arises, who will speak favorably of his or her experience, and who will recommend that service provider to others. Only completely satisfied customers remain loyal so that small changes in complete satisfaction can have large changes in loyalty.2 With rare exceptions, according to the Harvard Business Review, "Complete customer satisfaction is the key to securing customer loyalty and generating superior long-term financial performance."3
       As it has been shown that the investment required to create and keep a completely satisfied customer will provide an attractive financial return, let us examine the extent to which assisted living customers across the country are currently completely satisfied and what it will take to move in that direction those customers who are "just" satisfied.
       In this national sample, 39 percent of customers are completely satisfied in their overall assessment of the assistance and care provided at their assisted living facility and, consequently, can be considered loyal customers to their respective facilities (see Graph 2).
       At the facility level, the range of customer loyalty varies greatly, spanning 6 to 76 percent.

Graph 3: Percent of customers who are completely satisfied with aides.

       The difference between the highest and lowest scoring facilities lies in the proportion of customers who feel satisfied (the percentage of customers who marked "good") versus completely satisfied (the percentage of customers who marked "very good") with the care and services provided. Therefore, the goal for any assisted living facility interested in solidifying customer loyalty and market share should be to turn merely satisfied customers into completely satisfied customers. For this to happen, facilities will have to truly listen to their customers. Facilities that can boast high percentages of completely satisfied customers are those that offer exceptional care and service that surpass their customers' expectations for meeting their needs, solving their problems, and catering to their preferences. This high level of service will inevitably give the impression of being customized to the individual resident's particular care needs.
       To better understand what assisted living customers want from their care providers, we can look to the particular qualities that residents and administrators deem necessary for high quality care and consequential in their assessments of care providers. Graphs 3 to 5 show how satisfied assisted living customers are with the very qualities they seek most in their care providers.

Graph 4: Percent of customers who are completely satisfied with management.

       To illustrate, the first bar in Graph 3 shows that on average, 40 percent of respondents are completely satisfied with their aides' concern for the resident's well being. On average, another 46 percent of those surveyed rated their aides' concern for the resident's well being as "good." As explained above, saying that 86 percent of those surveyed are either satisfied or completely satisfied with this quality is numerically correct, but it is also misleading if it lures providers into a false sense of security. It is crucial to recognize that customers who rate a service using the second highest response option (e.g., "good" as opposed to "very good") are often registering their dissatisfaction. Combining the number of respondents who check the top two categories loses the distinction between the easily swayed customers and the loyal customers.
       Throughout, this article highlights the particular qualities assisted living customers are looking for in their care providers. Not surprisingly, they prefer concerned, supportive aides capable of anticipating their needs and responsive, accessible administrators willing to solve their problems. Giving customers reason to become and stay completely satisfied in their relationships with their care providers is a surefire way of ensuring customer satisfaction, loyalty, and invaluable referrals.

Graph 5: Percent of customers who are completely satisfied with employees

       The sample of residents used in this study was 20 percent male, 80 percent female. Residents averaged 86 years of age. Average length of stay was three and a half years, with roughly 50 percent of respondents rating a facility they (or their family member) had lived in for one year or less, 30 percent of respondents rating a facility they (or their family member) had lived in for two to three years, and 20 percent of respondents rating a facility they (or their family member) had lived in for four or more years. Of the residents who responded, 60 percent had assistance completing the questionnaire, and in most cases, it was a family member who assisted.