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In Brief: Quality Assurance for Long-Term Care: The Experiences of England, Australia, Germany and Japan

This In Brief summarizes the findings of the AARP Public Policy Institute Issue Paper “Quality Assurance for Long-Term Care: The Experiences of England, Australia, Germany and Japan.”i This research examines the long-term care quality assurance systems in four developed countries—England, Australia, Germany, and Japan. The approaches taken in the four countries and the United States represent a range of financing and delivery systems and use a variety of strategies to assure the quality of institutional and home and community services.

  • In England, regulation is a critical component of the Labour Government's “third way” approach to quality assurance, providing a way to influence provider behavior between the laissez-faire of unbridled markets and direct public ownership. England is most like the United States in its emphasis on regulation to enforce compliance with national standards for nursing homes, while allowing localities to impose additional standards.
  • The Australian system for quality assurance relies heavily on consultation and collaboration between the industry and governmental and quasi-governmental officials. Inspections of residential care are carried out by a quasi-governmental accrediting agency, but approving providers to receive federal funds and enforcement of quality standards remains a fully governmental responsibility. The Australian quality standards for residential care settings are very broad and non-specific to allow providers considerable latitude in demonstrating how they achieve quality goals.
  • Germany's approach relies on sickness funds to negotiate quality standards during the bargaining process over contracts with providers of institutional and home care services. “Sickness funds,” which are heavily regulated nonprofit organizations, administer the long-term care insurance program. These contracts articulate general expectations around provider quality as well as the structures and processes that providers should have in place to monitor and improve quality.
  • Japan's recently implemented public long-term care insurance program increased its resources to improve the quality of institutional and home care services as opposed to simply policing providers. Although formal quality assurance mechanisms are now more prominent, Japan relies heavily on training and certification to develop the skills of long-term care workers, on social networks and regular communications from the government and among providers to motivate and disseminate best practices, and on “care managers” to help clients and to assure quality.

Conclusions: Implications for the United States and Other Countries

Without systematic cross-country quantitative data, it is impossible to objectively assess differences in the quality of care and make judgments about which quality assurance system is best or which aspect of quality assurance is most effective in improving the care received by older people with disabilities. Nonetheless, the United States and other countries can fruitfully learn from the quality initiatives undertaken in each nation. The following issues emerged from the four study countries:

  • Long-term care financing makes a difference in the quality of care, but not simply along public versus private lines. For example, implementation of public long-term care insurance in Japan greatly expanded the supply of home care providers, which allows for more quality competition; however, nursing home demand increased more than supply, resulting in waiting lists that reduce facility incentives to compete for consumers by providing higher quality care. The key strategy should be to structure the financing system so that it supports improved quality.
  • Inspection and regulation are the cornerstones of quality assurance for long-term care in the four countries and the United States, but dissatisfaction with traditional inspection is leading to new approaches. For example, Australia uses very general standards in order to focus on broad issues of facility quality rather than compliance with detailed regulations. England recently moved away from yearly inspections to a system that pegs the frequency of inspections to provider performance in order to free resources to monitor poorly performing providers. Creating ways to encourage and reward high performance as well as penalize poor performance is an area that is likely to receive more attention in all countries.
  • Countries are looking for ways other than regulation to promote quality by providing more information to consumers, providing workforce training, funding demonstration projects, and disseminating promising practices. All of the countries except Germany place at least some quality information about providers on the Internet, although the information varies in how consumer-friendly it is. Staffing is recognized as a problem in all countries. The governments of England and Japan, in particular, play a strong role in the training and regulation of the direct care workforce. Experimentation with the use of private accreditation to supplement regulation, as in Germany and Japan, has been very limited.
  • All of the countries are shifting their delivery systems to encourage more consumer choice and more home and community services. For example, Germany's cash benefit option generally supports family caregiving and relies on the commitment of families rather than regulatory oversight to assure quality care. However, Japan's exclusive financing of agency-provided services was designed to liberate women from the burdens of family caregiving and relies heavily on training to assure quality.


Project Director: Joshua M. Wiener, Ph.D. RTI International. Authors: Joshua M. Wiener, Ph.D., Jane Tilly, Dr.P.H., Anna Howe, Ph.D., Colleen Doyle, Ph.D., Alison Evans Cuellar, Ph.D., John Campbell, Ph.D., and Naoki Ikegami, M.D., Ph.D. PPI Issue Paper #2007-05. February 2007.

In Brief prepared by Donald L. Redfoot, AARP Public Policy Institute
February 2007
©2007 AARP
All rights are reserved and content may be reproduced, downloaded, disseminated, or transferred, for single use, or by nonprofit organizations for educational purposes, if correct attribution is made to AARP.
Public Policy Institute, AARP, 601 E Street, NW, Washington, DC 20049

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