We explicitly asked family members whether their ideas about what they thought was important had changed over time, that is, whether they thought different things were important when they were selecting a facility compared to what they now knew. As we reported earlier, family members in each focus group reported that their views had changed as they gained more experience with assisted living, as their loved one's care needs changed, and as facilities changed their service mix and policies in seeking to be more responsive to the changing needs of residents.
These focus group discussions have several implications. First, it is not possible to generate a "static" list of quality measures. What constitutes "quality" for family members depends on (1) their own knowledge base and level of experience; (2) the loved one's level of cognitive and functional impairment and their care needs; and (3) what they can afford. Second, quality is multidimensional from the perspective of family members. Staffing levels and staff attitudes, care practices that promote and maintain function, safety, and environmental amenities all play a role in determining the "quality" of an assisted living facility. Third, it appears that as a loved one's needs change, the quality of the staff and the quality of the care the resident receives that precedence over some of the environmental amenities that were initially central to family members. Fourth, what matters to family members may not always match the needs and interests of the resident with dementia.
Thus, appropriate quality measures must be sensitive to the level and type of impairment of the residents. In addition, quality measures should be comprehensive, covering key environmental, staffing and service dimensions. Further, informed family members are a potentially useful source of information about quality for individuals with dementia and communication difficulties. Finally, even studies of quality must consider the policy and cost issues that are particularly relevant to families.