By Jack Cumming

It’s survey time. In California, and likely in some other states, senior living providers are required to survey their residents from time to time (California Health and Safety Code, Section 1771.8). Aside from that mandate, it’s a good idea for providers to strive for resident (customer) satisfaction, to take actions to create an inspired living offering, and to seek a positive reputation.

Not surprisingly, providers try to tilt the surveys to give them what one surveying enterprise calls “a competitive advantage.” That “competitive advantage” firm uses the standard 5-point scale. Most often with such a scale, 5 may be great, 1 may be terrible, and 3 is usually neutral. Not with the firm in question. Their trick was to class the top 3 ratings together as positive, with the bottom 2 indicating a need for improvement.

What’s a “Resident” Survey?

The distortion of that use of a purportedly scientific tool led a group of residents some years ago to devise their own survey. Imagine that, a scientific survey initiated by residents. It was a learning experience. The first survey was in 2009, and some of the questions were framed negatively while others were ambiguous.

An example of negative phrasing was, “I fear that I may outlive my assets.” That negativity made it difficult to compare later with more positively phrased items. It would have been better phrased as, say, “I have no fear of outliving my assets.”

Also, there had been a change in ownership, so one item read, “I would feel more secure if the prior enterprise had stayed in charge.” The survey developers knew that to be a common sentiment, but the phrasing was off. Better might have been, “The change in ownership has made me feel more secure.” Then the negative resident reaction would have popped out among the summary of the results.

Lessons Learned

An example of ambiguity was an item, “Management listens to my ideas and responds effectively.” The residents who crafted the survey learned that there were two problems with that phrasing, First, respondents said that some managers listen while others don’t. Second, some respondents said that “management” listens but does not respond effectively.

The other lesson learned was that residents much prefer a one-page survey. The first-year survey was two sides of a sheet of paper. That was more than many residents were willing to give time to. The second year, especial care was taken to phrase all items positively, to avoid ambiguity, and to reduce the survey to one side of one page. The residents also collected demographic information, which the provider had but refused to share.

Primacy of Integrity

The other focus for the resident survey team was to maintain the absolute integrity of the results. Only one person, respected for her absolute integrity and her meticulous commitment to accuracy, summarized the responses. There were management-friendly residents who wanted to get involved, but integrity took precedence over everything else.

In the interests of integrity, when respondents entered clearly erroneous information, that error was preserved. In the demographic table, one resident checked the “over 100” category, though at the time, there were no centenarians. That was retained in the tabulation of the results — integrity above all else. The resident may have felt that he or she was over 100.

Moreover, no pressure or artificial incentives were used to get higher resident participation. Participation was what occurred naturally, since that too is an aspect of integrity. Indifference to the survey was evident when some chose not to respond. Others lacked the cognitive capacity to respond. The resident council didn’t want the artificiality and distortion of having people “help” those with diminished cognition to complete the survey “appropriately.”

National Attention

The residents then proposed presenting what they had done at the national LeadingAge meeting held that year in Los Angeles. Their proposal was accepted, provided they added a provider to the panel since LeadingAge is a provider organization. If this interests you, click here and choose “Resident Surveys” to see the results and more, including the audio from the LeadingAge meeting.

Perhaps not surprisingly, local management discouraged resident-initiated surveys, so after just a couple of years, a change in the resident council ended the surveys. The use of provider-dominated surveying is not unique to any single enterprise. The evidence is that most companies treat resident surveys as a marketing function.

What’s a Provider Survey?

Still, there continues that mandate for periodic resident satisfaction surveys. It’s now survey time. It’s intriguing to see how one surveying enterprise’s survey compares with that earlier resident-initiated effort. In the interests of fairness, we’ve withheld that enterprise’s identity.

Recognizing that most such surveys share the same challenges as those that the residents encountered when they tried to develop their own impartial survey, here are some notes from a survey currently underway.

Ambiguity

Many questions are ambiguous, thereby requiring interpretation to analyze. Here are some actual examples.

  1. “The staff is courteous and friendly.” Staff, like residents, comprise individuals, and some are friendlier than others, while some may be downright disgruntled and negative. Therefore, the answers to the question are meaningless and of little value if the aim is performance improvement, though the tendency of residents to want to be positive means that the results may help marketing.
  2. “I have meaningful relationships with staff and residents.” The ambiguity is self-evident. In many CCRCs there is an implicit rule against fraternization between staff and residents. Thus, it is unlikely that residents have meaningful relationships with staff, and certainly they don’t have such relationships universally with all staff. It is more likely that residents have relationships with other residents, though it is unlikely even among residents that many such relationships are more than cordial. Meaningful relationships are rare.
  3. “The Executive Director/Department Leaders are accessible.” Very tough question. Certain department leaders may be easy to talk with, while others may be more defensive or more fearful of corporate criticism. Similarly for the executive director, which is the single most important authority in a community. If the executive director is often distracted by corporate meetings and such like, the individual in that position may want to be accessible but can be too busy pleasing higher-ups to have time for residents. All this question can elicit is some kind of impression, and since residents want to be nice, the impression is likely to be positive, favoring marketing but not representative of reality.
  4. “Activities/programs meet my needs (i.e., cultural, intellectual, physical, spiritual).” The problem with this multipart assertion is again self-evident. Any particular resident (and remember that the survey is completed by individuals) may have unmet cultural needs, e.g., a Japanese speaker in an English-language community; unmet intellectual needs (senior living does not require intellect); unmet physical needs, as when fitness programs are geared only to those who are fit; and unmet spiritual needs if there are few social workers, or if chaplains are loyal to a particular denomination, creed, or beliefs.

Implicit Bias

One wouldn’t expect a provider-responsive survey to ask questions about how residents feel about their involvement in decision-making. In most CCRCs even a position as resident-oriented as life enrichment director does not report to residents but to upper management and corporate. In a cohousing context, in which residents are voting members or even cooperative owners, of course resident views about governance matter. The absence of such questions shows the implicit resident-subordinating tilt of most of today’s senior housing enterprises.

The particular survey at hand is structured for the client corporation around buzzwords that originated with the CEO. Thus, the top-down authority focus of the organization is implicit. The buzzwords are useful, though their usage is constrained. For instance, a “growth” catchword doesn’t include survey questions on matters like revenue enhancement, views about mergers, use of funds for expansion, or even overlooked business opportunities.

Other matters such as how residents feel about technology are entirely omitted. That conveys the impression that such matters are no business for residents. Technology is often handled at the central office corporate level even as more and more residents are integrating technology into their individual lives.

Moreover, it’s not uncommon for tech-savvy residents to be more knowledgeable and more cognizant about technology than those at the top of the corporate pyramid who have authority and responsibility for technology. Issues like technology, pricing, value proposition, corporate initiatives, and branding are left off the provider-initiated survey and may be threatening to some executives.

In all fairness, the provider biases implicit in these omissions may be self-fulfilling. CCRCs attract residents who don’t have much interest in these business matters. Providers can interpret that as confirmation that business policy should be within the executives’ sole purview. The result is that the residents are often complacent, compliant, and satisfied. Thus, a resident survey can confirm what the provider hopes will result.

More important for a corporate aim like “growth” is what those eligible prospects think who lead the increasingly common climate of opinion that resists moving into a “home.” Adapting to meet prospects’ needs and expectations might be uncomfortable for long-established operators and careerists, but pushing out of the comfort bubble may be where the growth opportunity is really to be found.

Competitiveness

One value which providers perceive from using national surveying firms is the opportunity to compare resident responses to particular questions to responses from other similarly situated enterprises. Such benchmarking can reveal areas of excellence and other areas that are lagging. One such question that seems intended for that benchmarking purpose is the ambiguous “The staff is courteous and friendly.” My impression is that I’ve seen that same faulty word construction on surveys from several survey enterprises.

I’ve never seen the equally ambiguous item, “The residents are courteous and friendly.” Marketing creates the resident culture as a by-product of its sales function. Some CCRCs are more friendly and less cliquish than others. That could be a powerful competitive force, and it is something that is politically and culturally sensitive but that with executive courage might be analyzed to ensure affinities among residents.

When all is said and done, occupancy and word-of-mouth reputation are probably the best measures for resident satisfaction. Surveys have their place, and they are mandated in California and perhaps other states. Still, a survey is only as valuable as the professionalism and integrity with which it is created, deployed, and interpreted. That is something that deserves more work.