This report describes our review of the nursing home quality improvement programs initiated by the State of Florida. It begins with background information on the programs and how the visit and discussions were structured, and continues with a brief account of the origin and rationale for the programs. A description of the programs follows, along with the research team's findings. These findings are based on discussions with state employees, nursing facility respondents, and consumer representatives) regarding the perceived strengths and weaknesses of the programs. A discussion of the impact these programs have had on the quality of life and quality of care of Florida's nursing home residents follows. The report concludes with suggestions from program designers and participants to other states that might want to implement similar programs, a discussion of the sustainability of the various programs, and the respondents' opinions on the role of the Federal Government in quality improvement in nursing facilities.
Background
The study's Technical Advisory Group recommended that Florida be selected as a site visit state largely because of the state's Quality Monitoring program, a technical assistance program that was established in 1999. The state also has numerous other quality improvement programs, including recognition and reward programs and training/education efforts. In addition, the state has a public reporting system, risk management requirements, and mandated increases in minimum direct care staffing. All of these measures stem from two legislative mandates--the first passed in 1999 (HB 1971), and the second, SB1202, which followed in 2001. Each mandate was implemented in direct response to concerns regarding the quality of care in Florida nursing homes and the increase in the number of lawsuits filed against nursing homes.
Participants
Abt staff members Deborah Deitz and Donna Hurd accompanied by Jennie Harvell, project Task Order Officer (TOO), conducted discussions in Florida over a three-day period in September 2002, meeting with state survey agency staff, Medicaid staff and researchers, consumer advocates and provider association staff. Researchers were also able to accompany a Quality Monitor on a facility visit and speak with facility staff about the Quality Monitor program. The following individuals agreed to participate in discussions with the researchers:
Because the provider associations were unable to schedule meetings with their members while the research team was in Florida, conference calls were scheduled in late September/early October to discuss Florida quality improvement programs with Florida Health Care Association and Florida Association of Homes for the Aging members. Conference calls were also used for discussions with the Ombudsman and with staff from the Florida Policy Exchange Center on Aging at the University of South Florida.
Preparation
Prior to the on-site visit, information on the quality improvement program was gathered from a literature review, stakeholder discussions and the MyFlorida.com website. Information on the following aspects of the programs was gathered and organized in a table:
The table was forwarded to the survey agency contact, Dr. Susan Acker, prior to the on-site visit for her to review and provide additional or corrected information. The research team used the factual information in the tables as a starting point to develop interview questions that focused on more in-depth issues. Letters of endorsement explaining the project goals, state selection and interview processes were sent to prospective interviewees. Follow-up phone calls were made to arrange for convenient dates and times for interviews.
Structure
Meetings with the survey agency staff, provider associations staff members, Medicaid staff and researchers, consumer advocates and facility staff took place at their respective offices or on-site at the nursing facility and generally lasted one to two hours. The research team met with the Quality Monitoring nurse at the facility and was able to interview her prior to observing the Quality Monitor visit.
Follow-up phone calls were made to participants who were not available to meet with the researchers while on site. These were scheduled in late September/early October and conducted as conference calls with the Abt staff and the ASPE Task Order Officer.
In order to compare Florida's nursing home industry with the other study states, we present some descriptive characteristics. There are 734 facilities in Florida (AHCA web site) with 69,122 residents reported as of Spring 2001. The average number of beds per facility is 114, which is slightly higher than the national average of 108. The median occupancy rate per facility is 86.7 percent as compared to the national rate of 95.1 percent.
The percentage of for-profit homes in Florida is higher than other states, with 76 percent of homes operating for profit versus 65 percent nationally. The not-for profit-homes are lower at 23 percent vs. the national average of 28 percent. There are also fewer government-operated (2 percent vs. 7 percent) homes. The majority of homes operate as part of a chain (70 percent vs. the national average of 55 percent) and 10 percent of facilities are hospital-based, which is slightly less than the national average of 12 percent. The majority of homes are dually certified for Medicare and Medicaid (88 percent) as compared to the national average of 80 percent. There are approximately 2400 assisted living facilities and 1100 home heath agencies. (FPECA) (p. 17).
Florida's quality improvement programs are the result of legislation passed in 1999, 2000 and 2001. Prior to the passage of the legislation, respondents explained that the atmosphere in the state was unsettled with a number of issues facing nursing home providers, regulators and consumers. There was increasing concern with the quality of care in nursing facilities and how quality was to be defined and communicated to consumers.
In 1999, HB 1971 was passed, which included provisions for a technical assistance program, a quality recognition program, development of a website to post facility information for consumers, training programs and medical director standards. In 2000 a minor bill was passed that revised the measures that would be posted on the website and modified the types of documentation required for the discharge and transfer of residents.
At the same time these actions were taken, there was increasing concern about rising rates of litigation against nursing facilities and the effects of litigation on facilities' financial stability. Lawsuits had become common, affecting facilities regardless of their reputation for high or low quality care. Facilities were reportedly paying 500-fold increases in insurance rates while other facilities were unable to secure any insurance. During discussions with agency staff, it was stated that Florida ranked third in the nation for skilled nursing facility bankruptcies (behind Texas and California) and that Florida had 10 percent of the country's nursing home beds but 50 percent of the nursing home litigation. In response to these concerns, lawmakers created a 19-member Task Force to study the affordability and availability of long term care in Florida. The group was mandated to study and make recommendations on a number of issues pertaining to long-term care. Those specific to quality of care were the following:
The Florida Policy Exchange Center on Aging at the University of South Florida (FPECA) was named to provide staff support to the Task Force. FPECA's research indicated that the number of lawsuits against Florida nursing homes had in fact dramatically increased, that insurance rates had been going up, that insurance companies were writing fewer policies and that consumers were complaining of poor quality of care and violation of residents' rights. They studied risk management in hospitals and concluded that the institution of an internal risk management program in nursing facilities "could be an appropriate step…to bring about a comprehensive quality care approach. Such a step could both encourage improved quality of care and remedy the prevailing litigious climate in the industry."2
In a 700-page report, released in February 2001, the Task Force presented their findings on the major task areas including options for improving nursing home quality. SB 1202 was signed into law in May 2001 based in part on the findings from the Task Force. As part of the compromise between consumer advocates and industry representatives, consumers agreed to tort reform in the form of limiting the amount of settlements against long term care facilities on the condition that this was partnered with increased oversight on quality. The quality improvement legislation contained the following components:
The legislation was passed on May 15, 2001 and enacted immediately. There was no period for facilities to prepare or for the State to develop interpretations of the bill.
The vision of Florida's quality improvement programs, as expressed upon the passage of SB 1202, was to bring about an improvement in quality of care through a combination of risk management and internal quality assurance along with increased oversight and guidance to facilities. With liability insurance either unaffordable or not available, lawsuits affecting virtually all the long term entities in the state, and bankruptcies affecting 22 percent of skilled facilities, measures to deal with both the litigation crisis and quality of care problems in facilities were believed necessary to ensure the viability of the long term care industry in the state. FPECA staff we spoke with expressed the idea that the Task Force sought to "marry" the issues of quality of care in nursing homes, liability and insurance and home and community-based care.
During our visit, there was much discussion among stakeholders regarding the relationship between quality improvement and risk management, and the relative importance of each component. Providers stated that the quality of a nursing home had little effect on the number of lawsuits brought against it. Consumer advocates expressed the opinion that it was "embarrassing" to think that controlling litigation would bring about quality improvement. However, most participants expressed agreement with the Task Force that it was not appropriate to address the liability crisis separately from quality reforms.
Quality of Care Monitoring Program
In 1999, HB1971 established the Nursing Home Quality of Care Monitoring Program. It was designed to "create a positive partnership between the Agency and nursing homes and ultimately yield improved quality of care to residents". Initially the legislation called for yearly visits for monitoring of all facilities and quarterly for troubled facilities. The program is funded primarily by general revenue, with some matching federal funds.
SB 1202 increased the number of monitors from 13 to 19 and mandated quarterly visits to all facilities, with additional visits based on high-risk factors. Nursing homes that have been on the Nursing Home Watch List have the highest priority. Second priority facilities are those that have a combination of the following: A history of non-compliance or "yo-yo" compliance; nursing homes that upon analysis of quality indicator reports reflect potential weaknesses; nursing homes that have either changed ownership, changed administrators or changed Director of Nursing Services recently; and all new facilities.
Quality of Care Monitors must be registered nurses licensed in Florida, preferably with surveyor experience, and be Surveyor Minimum Qualifications Test (SMQT) qualified. Each monitor has a caseload of approximately 30 facilities assigned within a geographic area and each consults with other monitors on their area team who have particular areas of expertise.
Quality of Care Monitoring visits generally include touring the facility, observing residents and care providers in a variety of settings, as well as interviewing key staff, residents, and family who are present. They were originally mandated to be unannounced, but this is no longer adhered to when risk management duties require meeting with the facility risk manager. The visit may last anywhere from three hours to two days depending on the size of the facility and what a monitor finds. During visits, monitors seek to identify, at an early stage, any conditions that are potentially detrimental to the health, safety, and welfare of nursing home residents. Monitors may opt to identify a particular issue to focus on for a visit and not may discuss every triggered quality indicator. They may also opt to focus on an issue that the facility has identified as a problem.
Monitors are careful not to endorse a particular process--they can provide guidance and references, but the process has to be one that the facility identifies. They explained that their suggestions are very general. They are careful not to say, "Do it this way". They try "to keep the onus on the facility." They state that the facility must adapt the process to meet the needs of their residents. They offer educational resources and performance intervention models designed to improve care including materials available to share with facilities such as journal articles, websites and various protocols. They share information about good practices they have seen in other facilities. Monitors also interpret and clarify state and federal rules and regulations governing the facilities.
At the conclusion of each visit, the Quality of Care Monitor and the facility administrator meet to discuss findings. The administrator is advised that a written summary will follow, but that it's not to be construed as evidence of compliance or non-compliance. A copy is kept on file with the Agency and one is given to the nursing home so both can track progress. While the focus of the program is early detection, mandatory reporting of conditions which threaten the health or safety of a resident is required. Any such findings are officially reported to the Agency for regulatory action and, as appropriate or required by law, to law enforcement, adult protective services or other responsible agencies.
Since May 2002, monitors have also been given the responsibility to assess the operations of internal quality improvement, risk management programs and adverse incident reports. In addition, the Quality of Care Monitors collaborate and coordinate with the Field Office Managers in visiting facilities that are being financially monitored, closing, or in immediate jeopardy, to ensure the health and safety of residents. Monitors attend survey field office staff meetings and coordinate with the field office staff during a jeopardy situation. They also assist with training new surveyors.
Gold Seal Program
This program highlights facilities that provide superior care, creating a benchmark for others to strive to meet. The program was mandated by HB 1976, developed and implemented by the Governor's Panel on Excellence in Long-Term Care, and operates under the authority of the Executive Office of the Governor. The program was initiated in August 17, 2001 and the first awards were presented 7/24/02. A total of 10 "Gold Seals" have now been awarded. A nursing facility is eligible for Gold Seal consideration if it has been licensed and operated for at least 30 months, has not been rated "conditional" within that period and has had no Class I or Class II deficiencies within the previous 30 months of application. The facility must also have "financial soundness and stability" as evidenced by a financial audit. The legislation requires a Gold Seal facility to have an "outstanding record regarding the number and types of substantiated complaints reported to the State Long-Term Care Ombudsman Council within the previous 30 months." In addition, Gold Seal facilities must have a stable workforce with low turnover rates.
Early Warning/Rapid Response Teams
The Early Warning System sends surveyors on unannounced facility visits to identify facilities with financial or quality of care problems. Rapid response teams visit facilities identified by the early warning system. It is illegal for anyone to warn a facility of an unannounced inspection visit. These visits may be on nights, weekends, and holidays. They may also visit facilities that request assistance. They are not deployed for the purpose of helping a facility prepare for a regular survey. AHCA investigates serious quality of care complaints for residents still in a facility with a current conditional rating, or under special appraisal review within 72 hours from intake (previous policy--within 90 days). AHCA also changed the process for all other complaints against homes with a current conditional rating or under appraisal review by investigating within 10 days instead of within 90 days.
Risk Management/Internal Quality Assurance
SB 1202 mandated that every facility establish an internal risk management and quality assurance program with a risk manager responsible for implementation and oversight. The regulation does not require that the risk manager have particular credentials. Each facility must also form a risk management and quality assurance committee consisting of the facility risk manager, the administrator, the director of nursing, the medical director, and at least three other members of the facility staff. This committee shall meet at least monthly. The statutory language contains specific duties for this committee, including a process for reporting adverse incidents to AHCA. The goal is to identify incidents occurring in health care facilities, which have an outcome of patient injury and may reflect error in the course of the delivery of health care services.
As mandated in SB1202, each facility must also establish a grievance procedure and must respond to all grievances within a reasonable time after submission to the facility. This procedure must be available to all residents and families and must include: an explanation of how to pursue redress of a grievance; the names, job titles and telephone numbers of the employees responsible for implementing the grievance procedure; the address and toll free telephone numbers of the Ombudsman and AHCA; a simple description of how a resident may, at any time, contact the toll free numbers to report an unresolved grievance; and a procedure to assist residents who cannot prepare a written grievance without help. A facility must maintain records of all grievances and must report to AHCA annually the total number of grievances handled, a categorization of the cases underlying the grievances and the final disposition of the grievances.
Medicaid Up and Out
This was an initiative of Senator Locke Burt and was passed as part of SB1202. He was interested in replicating the Medicare HMO program Evercare for Medicaid patients in poor-performing nursing homes. The idea was to provide improved primary care for individual patients via a nurse practitioner who works with the Medical Director, the primary physician and the family to provide intensive case management.
The program has never been put into place. It was funded for $3 million dollars in 2001, but the funding was cut to $100K annually at the end of that legislative session. Evercare has provided a proposal which the State is reviewing. The proposal is in question because some are skeptical regarding whether implementation of the intervention at the individual level really will affect quality at the facility level. Evercare's reports show an improvement in some QIs, but not across the board. The State is unsure about how much latitude they have in spending the money and whether the proposal will be modified or eliminated.
Teaching Nursing Homes
Florida's Teaching Nursing Home (TNH) program was created in 1999 via State of Florida bill HB1971 and was funded in 2000 to establish an integrated long term care training curriculum for physicians and initiate an online geriatrics university. It is a statewide program coordinated by Dr. Bernie Roos, Director of the Stein Gerontological Institute of the Miami Jewish Home and administered by Richard Kelly of the Agency for Health Care Administration. SB1202 provided $700,000 for the Teaching Nursing Home Project at Miami Jewish Home and Hospital for the Aged at Douglas The 2001 Florida Legislature also allocated $100,000 to fund River Garden Hebrew Home/Wolfson Health & Aging Center in Jacksonville to develop a protocol to better identify and respond to physical pain in residents with dementia. To assist in this effort, River Garden has engaged the University of Florida Institute on Aging. To date, the TNH has produced a CD-ROM for LPNs on care of patients with Alzheimer Disease and related disorders. See Appendix E for more details on the state's Teaching Nursing Home Program.
Alzheimer Training
SB1202 required that nursing homes provide Department of Elder Affairs (DOEA) approved Alzheimer's disease training to specified employees. The Alzheimer's Association was at the table at the LTC task force and advocated strongly for this initiative. The goal is to provide a very basic understanding, information and working knowledge of how to work with Alzheimer Disease and related dementia populations. As a condition of licensure, facilities must provide to each of their employees, upon beginning employment, basic written information about interacting with persons with Alzheimer's disease or a related disorder. All employees who are expected to have direct contact with residents with Alzheimer's Disease must have one hour of training within three months of employment. All individuals who provide direct care must have an additional three hours of training within nine months of employment. If facilities are not in compliance with this, they will be cited by surveyors.
The rule published in February 2002 identifies the qualifications of the trainer They must have a Bachelor's Degree in health care, geriatrics or human services, or hold a license as an RN and possess one of the following three 1) teaching experience of caregivers or 2) have at least one year practical experience working with Alzheimer patients/related dementias or 3) have completed specialized training from a university or accredited program. A Masters Degree could substitute for the training experience. The Director of Nursing or the training coordinator usually functions as the trainer.
All nursing home Alzheimer's disease training providers and curricula must be submitted to DOEA's contractor, the University of South Florida, Florida Policy Exchange Center on Aging (FPECA). Curricula are developed by the facilities--some are based on the old state curriculum with some updates. USF/FPECA reviewed over 1,000 applications from trainers in the first 30 days of the program for approval. Many of the proposed training programs contained incorrect or out-of-date information (example: inappropriate meds) and had to be returned to facilities for correction and resubmission. The curricula must also be resubmitted every three years. Currently 130 different curricula have been approved. The website lists approved providers and curricula.
DOEA receives $100K from general funds per year to administer the program. Nursing homes were very concerned about the fiscal impact of this mandate since nursing facilities have to bear all the costs associated with training. A state official indicated funding for the initiative could be in trouble because the industry feels that the government should not be in the business of approving training and curricula. The legislature is also going to want to know whether the training is effective. Right now, the only evidence is the review of the curricula itself which showed that many of the proposed training programs contained incorrect or out-of-date information.
More information on the state's Alzheimer Training program can be found in Appendix D, which contains the Florida Steering Committee's Consensus Document of Core Competencies for Dementia Training of Licensed Practical Nurses (LPNs) in Long-Term Care.
The Nursing Home Guide
Florida's Nursing Home Guide is part of AHCA's effort to provide information to consumers and allows a search for a nursing home by geographic region or by the characteristics of the nursing homes. Descriptive information about the facility is provided, as well as the facility's performance on past inspections as represented by stars. Under the stars is a link "Inspection Details for this Facility", which links to a listing of the facility's citations over the past 45 months. Clicking on any citation links to a fuller explanation of that citation. The publication provides detailed information about each of Florida's nearly 700 licensed skilled nursing facilities, including location, ownership, number of beds, types of special services offered and the lowest daily charge. AHCA officials said they decided not to post the Quality Indicators out of concern that they were too confusing to residents and families. The web version has links to the facility inspection history and performance measures, based on geographical location. The electronic version is scheduled to be updated every quarter, although this has been difficult to accomplish. Appendix C shows the information contained in the Nursing Home Guide for a sample facility.
The Nursing Home Watch List
The Florida Nursing Home Watch List is published by the AHCA to assist consumers in evaluating the quality of nursing home care in Florida (see Appendix C for an excerpt of the most recent Watch List). The Watch List reflects facilities that met the criteria for a conditional status, on any day, on a quarterly basis. A conditional status indicates that a facility did not meet, or correct upon follow-up, minimum standards at the time of an annual or complaint inspection. The Watch List also lists all facilities that are in bankruptcy. AHCA mails a copy to each nursing facility where it must be posted in a prominent place accessible to all residents and to the general public. It is also mailed to assisted living facilities, hospital discharge planners, Ombudsmen, legislators and others upon request. All copies are also maintained on the AHCA website. The Watch List is also posted on-line at http://www.fdhc.state.fl.us/Nursing_Home_Guide/pdf/nhup0403.pdf.
The Quality of Care monitor program is funded through a Quality of Long-Term Care Facility Improvement Trust Fund that, in 2001, was created within the state's Agency for Health Care Administration. The trust fund supports activities and programs directly related to the care of nursing home and assisted living facility residents, and is funded through a combination of general revenues and 50 percent of any punitive damages awarded as part of a lawsuit against nursing homes or related health care facilities (Florida law 400.0238). Monies in the fund come from a percentage of punitive awards in nursing home and ALF court awards, gifts, endowments and other legal charitable contributions, along with specific appropriations by the Legislature.
According to the legislation that created the trust fund, expenditures from the trust fund can be made for direct support of the following:
Development and operation of a mentoring program for increasing the competence, professionalism, and career preparation of long-term care facility direct care staff, including nurses, nursing assistants, and social service and dietary personnel.
Development and implementation of specialized training programs for long-term care facility personnel who provide direct care for residents with Alzheimer's Disease and other dementias, residents at risk of developing pressure sores, and residents with special nutrition and hydration needs.
Provision of economic and other incentives to enhance the stability and career development of the nursing home direct care workforce, including paid sabbaticals for exemplary direct care career staff to visit facilities throughout the state to train and motivate younger workers to commit to careers in long-term care.
Promotion and support for the formation and active involvement of resident and family councils in the improvement of nursing home care.
For FY 2001-2003, the total cost of the state's Quality Monitoring program is about $1.65 million--this includes $1,395,911 for the quality monitors and $261,000 for other expenses. The legislation authorizing the quality monitor program also increased licensing fees for facilities (from $35 to $50 per bed), and this increase covered part of the costs of the TA program.3
Costs for other Florida quality improvement programs that were funded under Senate Bill 1202 (2001) are as follows: nursing home risk management and quality assurance program: $2.1 million in FY 2001-02 and $1.54 million in FY 2002-03. (This includes costs of about $450,000 for data system development) and staff costs; Nursing Home Care Alzheimer's training: $10.5 million in FY 2001-02 and $6.8 million in FY 2002-03; surveyor training: $66,000 (in both FY 2001-02 and FY 2002-03). The risk management program is paid for entirely by state funds, but federal funds cover more than 50 percent of the funding for the state's Alzheimer's Training Program, under which dementia-specific training is provided to staff who care for residents with Alzheimer's Disease.4
Some provider representatives asserted that the Quality Monitors, Gold Seal and Risk Management are programs that have impacted the quality of care in their facilities. Although opinion on the value of the Quality Monitor program was mixed, some provider representatives expressed that they found the visits to be very helpful, describing them as providing objective non-punitive advice. Providers also appreciate the Quality Monitors sharing information on best practices, recommending educational materials and offering interpretation and clarification of state and Federal rules and regulations.
The Gold Seal program was seen by some as a good marketing device that potentially can decrease the cost of liability insurance and drive up revenues. Consumer advocates praised the fact that it requires a financial audit. Participants reported that the Risk Management requirement had forced them to investigate incidents and accidents in greater detail, examine their facility processes for flawed practices, and make changes with the goal to prevent future problems.
Educational training programs including the Teaching Nursing Homes and Alzheimer Training were described as useful by several of the provider representatives with whom we spoke. Providers felt that the Alzheimer Training was most useful for non-nursing staff and for facilities that did not have a designated ADRD unit. The approval process for trainers and curricula for the Alzheimer Training program is considered innovative. Each submitted curricula is reviewed by a doctoral-level staff member at the Florida Policy Exchange Center on Aging at the University of South Florida. Many of the curricula as initially submitted, contained incorrect or out-of-date information and had to be returned to facilities for correction and resubmission. Although providers were aware of the compact disc developed for LPNs on Alzheimer's disease as part of the Teaching Nursing Homes program, and were pleased that it would be web disseminated, most indicated that they had not personally reviewed it.
Some discussion participants approved of the state's web-based Nursing Home Guide, particularly the star assessment system. FAHA staff and providers expressed that the star system does a reasonable job with some expressing the opinion that it does a better job of evaluating quality than the CMS Nursing Home Compare site.
Discussants also commented on the mandated staffing increases, noting that the gradual mandated nursing assistant staffing increases were seen as more reasonable than one large increase. Advocates were pleased that SB1202 created language to link facilities in large chains so that a staffing problem in one facility of a chain is viewed by the State as non-compliance across all the homes in the chain.
Although some discussion participants praised the Quality Monitoring program, consumer advocates voiced some concerns, primarily because of the changes that were made to the original role and responsibilities as laid out in HB 1971 in 1999. The program as initially enacted was seen as separate from the survey agency and allowed the monitors to focus on the more problematic facilities. In SB1202, the quality monitors' roles and responsibilities were expanded. It required the Quality Monitors to provide quarterly visits to each facility in his/her region, oversee the risk management program, verify that facilities were meeting the minimum staffing requirements and perform various surveyor activities as needed. Quality monitors are now responsible for monitoring facilities that were closing or in immediate jeopardy and provide orientation for new surveyors. By taking on surveyor tasks, the separation between quality monitoring and enforcement became less distinct. Provider association members reported that since the Quality Monitors are seen more as part of the risk management effort now, providers rarely think anymore about how they can use them for quality improvement.
Consumer advocates were concerned that the close ties between Quality Monitors and surveyors would lead to one group putting pressure on the other so that the information they presented about facilities was consistent between them. For example, a poor survey outcome could lead to the conclusion that the Quality Monitor was not providing effective oversight.
There was some concern expressed that Quality Monitors hired as a result of SB 1202 were not as qualified as the former surveyors hired in the first round, and that there was great variability in the quality of quality monitoring depending on region of the state. Providers noted that often they were asked to provide information for the Quality Monitors who did not necessarily have a background in long term care. They also stated that a problem existed with inconsistency between information being disseminated by Quality Monitors and surveyors. Some providers complained that visits were not occurring on a quarterly basis because of Quality Monitors being overwhelmed and the position experiencing high turnover rates. They also noted that often a survey followed a quality monitoring visit, focusing on the same issues that the monitor had raised, causing them to question whether the Quality Monitors were maintaining confidentiality of the visits.
Consumer advocates objected to the promotion of the best surveyors out of the enforcement agency, saying it weakened survey. They also stated that they did not agree that taxpayer funds should be used to provide advice to multi-facility chains on how to deliver care, likening it to the government providing training to Fed-Ex on how to deliver packages on time. They agreed that small, independent facilities often needed and should be entitled to such support, but it made more sense to shut down large for-profit chains if they provided poor quality care to residents. Concern was also expressed that because Quality Monitors must now oversee the risk management programs, visits are no longer always unannounced, since the Quality Monitor must meet with the facility's designated risk manager.
Respondents were critical of the Gold Seal program because the strict criteria eliminated the majority of facilities. The expense of a financial audit, which is required, was also a negative. Providers noted that there was not much incentive to seek a Gold Seal, as there was no change to the survey cycle, no immunity from lawsuits and no change in reimbursement.
Although some facilities praised the risk management process as teaching them how to critically evaluate their protocols, the reporting of adverse incidents and the confusion around the reporting requirements has put providers in a difficult situation. Facilities have been over reporting adverse incidents because they have trouble identifying incidents that are in their control and because the stakes for not reporting are so high. The failure to report an adverse incident to the survey agency can result in a G-level deficiency. A G-level deficiency citation results in placement on the Watch list. Two G-level deficiency citations may result in a six-month survey cycle and imposition of fines. Reporting of adverse incidents was intended to distinguish better performing facilities from problem facilities, thus encouraging insurance companies to come back into the state. In part because of the over-reporting issue, however, no progress has been made in improving the insurance situation. Participants also noted that no credentials or qualifications were mandated for the facility risk manager. Requiring credentialing was seen as one way to improve the program.
Both the Nursing Home Watch List and Nursing Home Guide are based on survey outcomes and were thus criticized because of the recognized inconsistency of survey results. Participants noted that information in both areas was often not available in a timely manner. The website star system is based on 45 months of data and participants noted that, "a lot can happen in 45 months." Consumer advocates did not agree with the star system, maintaining that giving the worst facilities in the state even a one-star rating was misleading. They also did not agree with the agency's practice of not posting information until appeals had been resolved. Advocates also recommended that the website should contain information on lawsuits and fines. Providers also noted that Florida consumers now have access to three types of sites with nursing home quality of care information--the CMS site, the proprietary sites and the AHCA site. Since information varies from site to site, they use different ratings, and show different levels of compliance, they question how this helps consumers.
Providers were very concerned that the mandated increase in nurse aide staffing to 2.9 ppd (due in January 2004) is going to be virtually impossible to attain. They are concerned that it will force facilities to compete with one another by offering bonuses and incentives. There was disagreement as to the adequacy of the workforce needed to meet the future requirements. Consumer advocates stated that there were plenty of nurse aides available in the state, with 250,000 on the registry and 10,000 new grads each year. They saw nurse aide shortages as the result of the poor conditions, benefit and pay provided by facilities and stated that improving working conditions and giving nurse aides 40 hour work weeks would go a long way to remedying the situation. Provider representatives, however, said that there was not an adequate supply to meet the demand "without significant wage pressure." Two-thirds of Florida's nursing homes are paid for by Medicaid and they will not be able to increase wages to engage in competition for employees.
Provider representatives also noted that they would like the State to relax the requirement that facilities self-impose an admission moratorium when unable to meet the staffing minimums. They would also like to see the staffing requirement relaxed for smaller facilities. Facilities are being forced to use temporary agency staff to meet the requirements. The cost is prohibitive and providers complain that they are not being reimbursed for it. They also fear that the legislature will not pass the funding necessary to increase the nurse aide hours, but that facilities will still be expected to meet the required staffing minimums.
Consumer advocates noted that they would prefer that staffing minimums be designated by shift rather than for a 24 hour period. They are also concerned that the industry circumvents the staffing requirements by shifting tasks and duties to nursing assistants. Provider association staff also expressed concern that some facilities were eliminating housekeeping positions and shifting housekeeping duties to nursing assistants.
No formal evaluation of Florida's quality improvement programs has been performed to date. AHCA staff reported that they are interested in evaluating the success of the programs, particularly the TA component. However, because the programs have been operating only a short time, it is not yet possible to evaluate their impact. Because many of the programs were implemented simultaneously, it will be difficult to measure improvement or to attribute improvement solely to any one program. Uncertainty about appropriate measures also makes the evaluation complicated. A decrease in the number of deficiencies cited, a decrease in overall scope and severity, or a decrease in the number of citations have been considered as possible measures by AHCA, but none is yet considered to be reliable. AHCA has been tracking liability claims and reported that they have been tapering off since they peaked in October 2001 (which was the deadline for all claims). They produce an annual report on adverse events and survey citations, which was due to be published in December 2002. They stated that they have not seen big changes in the aggregate of deficiencies, but that it is too early to see changes especially those that would be related to the passage of SB1202. Agency staff are also aware of the impact staff turnover both at facilities and within the TA program has had on program effectiveness and sustainability, making them hesitant to begin an evaluation that does not take turnover into account. Facility staff turnover was described as being particularly concerning, with some QMs reporting that they were seeing a new Director of Nursing at each facility visit, and finding that QM reports and recommendations were often lost in the transition.
Dr. Acker stated that anecdotal evidence indicates the TA program is having positive effects, however. As described in the previous section, many providers we spoke to noted that they felt that the quality of care in their facilities had improved as a direct result of the visits. AHCA also has received positive feedback from surveys and feedback forms used to gauge the success of the Quality Monitoring program. They have conducted two surveys--one with field office managers on the relationship between monitors and field office staff, and one with providers on the value of the monitor program. AHCA also receives feedback from facility staff in the form of a paper questionnaire given to facility staff at the end of a visit, asking facilities to provide information rating the performance of the TA staff and how helpful the visit had been. Most comments have been complimentary, with observations such as the visits were helpful and that staff at facilities were pleased to have someone to ask when questions arose. However, at the time of our visit, AHCA was revising the form and hadn't used it for six months. Some providers we spoke with also said that they are reluctant to offer criticism on the questionnaire for fear that there could be negative repercussions from a Quality Monitoring staff that increasingly has ties with the survey process.
Regarding the Gold Seal Program, many comments we heard from providers and consumer advocates indicated they thought the program probably was unlikely to affect quality. Some stakeholders voiced the opinion that the award was primarily a marketing tool which may become increasingly relevant when bed occupancy is lower. They felt that the greatest impact may be on those facilities on the cusp of providing higher quality care which are deciding whether to make the investments that quality improvement requires. For those facilities, the Gold Seal program could make a positive difference.
Assessing the value of the Alzheimer training program, most stakeholders said they thought it provides good information, and that it is was most likely to have a positive impact for nursing aides and for facilities that do not have a specific dementia care unit. But some expressed the opinion that facilities would benefit more from being able to choose for themselves the training that would most benefit their facility. And some said mandatory training felt more like a "big brother is watching" regulatory approach than a valuable educational program that improved quality of care.
Florida's web-based public reporting program was considered sufficiently valuable by consumer representatives that they said they thought that every state should have one. But a number of stakeholders stated their belief that a several factors were currently limiting its impact on quality improvement. They thought that consumers frequently do not know that the Guides and Watch List exist, may not have internet access, or may not be proficient in navigating the internet. Some provider representatives also noted that some facilities have been on the Watch List many times, and that this does not appear to have provided sufficient motivation for those facilities to do a better job. Stakeholders said that they believe public reporting of deficiencies can improve quality of care provided by stimulating competition and sparking change in facility culture. However, one provider representative stated that since 90 percent of admissions come from the hospital, the discharge planner has the greatest influence on where patients go, rather than a family member who had taken the opportunity to review quality ratings. He posited that as consumers become more computer savvy, interest and impact will increase--and that would make facilities be more concerned about how they look on the public reporting website.
Opinions varied about whether the mandated increases in staffing had impacted quality. Some providers said they spent a huge amount of time and money on this issue and it had not made any impact on quality. Another said the belief that by increasing staffing, turnover will be decreased, and that increased staffing creates more flexibility, increases the ratio of staff to residents and improves the quality of life for the residents by allowing staff able to spend more time with them.
As with all of Florida's quality initiatives, the impact of the risk management program has not yet been formally evaluated. AHCA staff and provider representatives reported that the number of lawsuits has declined, but it is impossible to know whether this is due to improved quality processes, or whether the number of facilities "going bare" (operating without liability insurance) has made the state's facilities less attractive targets for litigation. Regardless, several providers expressed the belief that the risk management program had been one of the quality initiatives that had the greatest impact on nursing home quality of care. They reported that at first there was resistance to changes such as monthly meetings of the risk management committee, but they now see it as very useful. "It forces us to keep focused." One provider reported that they now do a lot of education around risk management with staff. When staff understand the goals, they stated that their participation and openness increases and they are less defensive. Another provider said that the way that they investigate bruises has changed dramatically since the risk management program was instituted and that how they do their investigation has impacted quality on each nursing unit in their facility.
Currently, funding for Florida's quality improvement programs comes from general revenue and licensure fees with some federal funding. AHCA staff noted that there is general support for quality initiatives among members of the legislature. Other state agency officials offered that there has been a focus on seniors, primarily because of the large elderly population, and that the governor and the legislature are committed to seniors' issues. State agency staff also noted that the programs are up for review every year and that the funding for the both the Medicaid Up and Out program and for the Consumer Satisfaction survey have been cut, and that continued support may be tied to demonstration of positive outcomes in the future.
We asked providers, state program administrators, and consumer representatives we spoke with in Florida for lessons they have learned and any recommendations they wished to offer other states considering quality improvement programs. Nearly all we spoke to would recommend the Quality Monitor program, which was generally characterized as having a positive impact on facility quality of care. Quality Monitors have been able to establish a more collaborative, less adversarial relationship with nursing facilities than is typical for surveyors, and this relationship allows providers the opportunity to have an open dialogue with TA staff about problems and issues in resident's care, to obtain information on good clinical care practices, and to receive feedback on how they can improve their care processes. Some stakeholders felt the intervention should be targeted either to the smaller free-standing facilities with no corporate support, or to facilities that were having more problems. Most providers said they wanted to see the program continue, remain confidential and separate from survey. They especially wanted the content of the visits not to be shared with surveyors or to be available for litigation. Most said they would prefer that the QM staff not overlap with survey staff--they should be kept entirely separate. However, some providers said that surveyors and Quality Monitors should be trained to provide consistent guidance, and felt that TA staff with past survey experience were most valuable in helping them interpret applicable regulations. All agreed that Quality Monitors needed to be well qualified and experienced in long-term care.
Discussants also had recommendations on several of the other quality improvement programs Florida has initiated. Consumer advocates supported the public reporting website as important for consumer decision-making. They believed that the algorithm for ranking facilities is good, but they don't like the fact that every facility gets a star regardless of how low its quality rating is, and would prefer a numeric ranking. Provider representatives recommended that the website resolve problems associated with the reporting of 45 months of survey and deficiency information by showing current performance alongside historical performance. They also thought that regular updating was critical for accurate representation of facilities.
Regarding the Gold Seal program, participants thought it important to ensure that there is a well-defined consumer advocate position on the selection panel and that the panel performs an on-site inspection of any facility being considered for an award. They also stated that the awards should be reserved for facilities that were truly doing something special for residents and not merely meeting minimum criteria. Provider representatives noted that there is a need for rewards beyond public recognition that make the Gold Seal worth pursuing and that in order to have an impact, it had to be more attainable for more facilities.
Finally, numerous stakeholders reported that the risk management program has real potential for prevention, managing losses and minimizing litigation and that it was helping facilities focus on how best to prevent adverse incidents.
Much of the feedback aimed at the Federal Government concerned the issue of reimbursement. One provider representative summed it up by saying that "You cannot separate money from care," and that Medicare and Medicaid programs have to pay reasonably for reasonable care. There has to be more emphasis on alternative care (home care, assisted living) to really decrease the financial pressure on nursing homes.
Some providers expressed concerns about some of CMS' policies on quality measures. For example, Florida has low restraint use, but high fall rates. Providers believe that CMS is not looking at how one area of care impacts another and about interdependencies like the relationship between restraint use and falls. They also described problems with CMS classifying resident-to-resident altercations and that special considerations needed to be made for special populations like dementia and head injury patients where they have no alternatives for placement.
State agency staff attempting to look at disease management outcomes and measure resource use said they wish that is was easier to access MDS data and resource use for dually eligible patients. Providers also expressed a need for the Federal Government to take a stronger role in the development of best practice recommendations. "We wish we still had AHCPR to do best practices. They were impartial and the information came from researchers and evaluators--not surveyors." Similar direction was sought on end of life care issues, unavoidable decline and the management of expectations of patients and families about realistic outcomes of nursing home care.
Since 1999, Florida has established and implemented a number of quality improvement programs including a technical assistance program, public reporting measures, recognition programs, training/education efforts, risk management requirements and mandated increases in minimum direct care staffing. All of these measures stem from legislative mandates implemented in direct response to concerns regarding the quality of care in Florida nursing homes and the liability insurance crisis.
The centerpiece of the quality improvement efforts is the Quality Monitor program first established in 1999. The monitors visit all facilities quarterly, providing education and monitoring for facility staff. They also seek to identify any conditions that are potentially detrimental to the health, safety, and welfare of nursing home residents. The role of the quality monitor has recently expanded to include providing support to field office staff during a closure or immediate jeopardy situation, reviewing the risk management program and records of adverse incidents, and ensuring that staffing requirements are being met. The majority of participants stated that they found the QM visits to be very helpful, describing them as providing objective, non-threatening advice. They particularly appreciated the Quality Monitors sharing information on best practices, recommending educational materials and offering interpretation and clarification of state and Federal rules and regulations. However, many were concerned about the increased blurring of monitor and surveyor roles and the negative impact this could potentially have on the willingness of facilities to openly discuss problems they were experiencing.
The risk management program implemented in 2001 is designed to identify incidents occurring in health care facilities, which have an outcome of patient injury and may reflect error in the course of the delivery of health care services. Providers reported that the risk management requirement had improved the quality of care by requiring them to investigate incidents and accidents in greater detail, examine their facility processes for flawed practices, and make changes with the goal to prevent future problems. Although the number of liability claims filed in the state has reportedly been tapering off since it peaked in October 2001, there has not yet been an easing in the liability insurance crisis.
Consumer advocates and provider representatives we spoke with had mixed reviews of the quality improvement programs. While nearly all stakeholders would recommend the Quality Monitor and risk management programs, not all believed strongly in the ability of any of the implemented programs to improve quality of care or resident outcomes. In fact, many stakeholders were skeptical that these efforts were sufficient to solve the quality of care problem in nursing homes. They named issues such as the pervasive problem of high staff turnover and inadequate reimbursement as barriers to high quality performance.
We are unable to draw conclusions as to what effect any of Florida's quality improvement programs will have on nursing home quality. First, the programs have been in operation for only a short period of time. Second, the state is not performing the type of evaluation necessary for a rigorous impact analysis. Furthermore, there are a multitude of initiatives underway, all enacted during the same timeframe and during a time of changes within the nursing home industry (e.g., declines in occupancy, Medicare skilled nursing facility prospective payment, public reporting of MDS-based quality indicators). Even so, by reviewing the experiences of Florida, we believe some important lessons can be learned that might be applicable to other states considering quality improvement programs. In addition to those described in the Lessons Learned section above, we would add that states planning to implement quality improvement programs should consider the potential need to evaluate these programs--which is being demanded increasingly by program funders in the current fiscal environment--and do their best to design the programs in a manner that will allow their evaluation needs to be met.
This report describes our exploration of the various quality improvement programs initiated by the State of Iowa. It begins with background information on the programs and how the visit and discussions were structured and continues with a brief history and rationale for how the various quality improvement programs were selected and implemented. A description of the programs follows along with the research team's findings (from discussions with state employees and nursing facility providers) regarding the overall strengths and weaknesses of the programs as well as a discussion on the impact that these programs have had on the quality of life and quality of care of Iowa nursing home residents. It concludes with lessons learned by the state, the sustainability of the various programs and the participants' opinions on the role of the Federal Government in quality improvement in nursing facilities.
Background
Although it does not have a technical assistance program, Iowa has a large number of innovative programs intended to improve nursing home quality. Despite the absence of a technical assistance program, the project's Technical Advisory Group believed that the study should include Iowa, as its programs may be substitutes for a technical assistance program and may include quality improvement models that other states may wish to replicate, potentially improving our study's ability to provide guidance to states considering implementing quality improvement projects. Iowa's quality improvement programs involve a wide variety of efforts including an Internet web-based Nursing Home Report Card, recognition programs for innovative practices and outstanding performance on licensure and certification surveys, training for providers and surveyors, feedback on surveys/surveyors and an alternative survey process for state-only licensed facilities meeting certain criteria.
Participants
Abt staff members Alan White and Donna Hurd met with individuals involved in the development, management and implementation of Iowa's programs, as well as representatives from two of the state's provider groups, the State's Long Term Care Ombudsmen, and others familiar with the state's programs. Over a three-day visit in June 2002, the research team met with individuals and groups associated with the following organizations:
Marvin Tooman, Ed.D., the HFD Administrator, was the primary contact for the Iowa site visit. He has been in this position for about two years and previously was a facility administrator (at On With Life, a non-profit post-acute rehabilitation facility that specializes in brain injury/neurological and pulmonary rehabilitation). Dr. Tooman leads the division responsible for many of the state's quality initiatives. The division has made an effort to recognize facilities doing exemplary work, to improve relations between providers and surveyors (i.e., through the joint surveyor-provider training), and to encourage facilities to engage in resident-centered care. Dr. Tooman was an excellent resource for us, and the work of him and his staff in helping to plan our visit is greatly appreciated. We found that everyone with whom we spoke were willing to speak freely on their impressions of the State's programs, and found a great deal of consistency in their responses.
Preparation
Prior to the on-site visit, factual information on the quality improvement programs was gathered based on our discussions with Dr. Tooman, stakeholder discussions, DIA's web site, and Insight, the department's quarterly newsletter for nursing facilities. Insight was a particularly valuable resource-- it had information on most of the state's quality improvement programs that gave the site visit team valuable background information. Information on the following aspects of the programs was gathered and organized in a table:
The table was forwarded to Marvin Tooman, prior to the on-site visit. He reviewed the table and added some additional details. The research team used the factual information in the table as a starting point to develop discussion questions that focused on more in-depth issues.
Structure
Discussions with everyone but the IAHSA representative took place at their office. (For logistical reasons, we met with the IAHSA representative at DIA's offices.) Meetings lasted from one to two hours.
In order to put Iowa in context with the other study states, we have included some descriptive characteristics of the State's nursing home environment. Comparative data presented are from the American Health Care Association (AHCA) web site (AHCA, 2002). There are 470 facilities in Iowa, with 29,535 residents reported as of Spring 2001. The average number of beds per facility is 96, which is slightly lower than the national average of 108. Iowa's median occupancy rate per facility is 84 percent as compared to the national rate of 95 percent.
The percentage of for-profit homes is lower than the national average, (52 percent vs. 65 percent) while the percentage of not-for-profit homes is higher (43 percent vs. 28 percent nationally) with few government-operated facilities (4.7 percent vs. 6.5 percent). Fewer of Iowa's facilities are hospital-based (11 percent vs. 12 percent nationally) and dually certified for Medicare and Medicaid (60 percent vs. 80 percent nationally).
No single event or series of events or situations within Iowa or outside the state were reported by participants as being the impetus for the Iowa quality improvement programs. The development of the programs appears to stem from the vision of several key contributors. First, Iowa Governor Tom Vilsack has long been a vocal supporter of nursing home issues, both as governor and while serving in the Iowa Senate. The appointment of Marvin Tooman, a former nursing facility provider, to the position of administrator of the Health Facilities Division greatly aided in promoting the issue of quality. The current programs are the result of a uniform vision within the restraints of the current state budget crisis.
The first quality improvement program, the nursing home report card, was initially the idea of bureau chief, Larry Lindblom back in 1996 or 1997. It started as a web page to provide information to the public, news, and links to CMS (formerly HCFA). He later thought that it could be improved by adding survey results. At the time the Report Card section of the web site was developed, only one other state (Arizona) had done any work in this area and the Federal Government's site was still under development. In 1999, during his first year in office, Governor Vilsack included among his legislative proposals the creation of the Governor's Award for Quality Care in Health Care Facilities.
The selection of Marvin Tooman in February 2000, as HFD administrator made him, reportedly, the first person outside the Department of Inspections and Appeals to hold that position. His background and education make him uniquely qualified for the position. Prior to his appointment, Tooman had been CEO and president of his own company, "On With Life," a non-profit post acute care program specializing in brain injury/neurological and pulmonary rehabilitation. Prior to starting "On With Life," Tooman spent 11 years as a resource manager for the Iowa Department of Education's Division of Vocational Rehabilitation. He holds a Bachelor's degree in Education, a Master's Degree in Counseling, and a Doctorate in Administration and he is an Adjunct Assistant Professor in the University of Iowa's College of Education. He received his quality improvement training in the military, having been trained on the Baldrige self-assessment process. He is also a Commission on Accreditation for Rehabilitation Facilities (CARF) surveyor. Toomam explained that CARF standards are very similar to the Baldrige criteria. At the time of our interviews, he was the president-elect of the Association of Health Facility Survey Agencies.
In the first nine months following his selection, the department introduced the Quality-Based inspections program in May 2000, the Joint Surveyor/Provider Training in June 2000; the Deficiency-Free certificates in October 2000 and Best Practices program in November 2000. Later in June 2001, the survey questionnaire was introduced.
The goal of quality improvement programs is viewed as promoting the "culture of quality." Tooman has expressed the department's vision for nursing home quality by writing regularly in DIA's quarterly newsletter, Insight. In the June 2001 issue, Tooman wrote about the department changing the HFD mission statement. He wrote:
"Assuredly, within this experience, we are accountable to the state and federal rules that provide a "baseline" for the quality of care that our residents and clients receive. However, we should not be satisfied with merely maintaining the minimum standard of state and federal rules. To that extent the HFD has changed it's mission statement.--"The mission of the HFD is to promote the quality and optimal outcomes of services through a survey process that centers on enhancing the lives of the people served."
Tooman puts the responsibility for success on the facilities that are able to introduce and maintain a "culture" of quality care. He went on to state that, "we need to insure compliance with state and federal rules. But rule compliance is a by-product of a quality improvement effort. …First, it is safe to say that the facility is not immune from the problems that nursing homes face on a daily basis. And there may be occasions where they may be deficient with a rule or two. …[T]hey have established a way of operation that speaks to quality services. Some may say that they have a "Quality Culture."
Bureau chiefs echoed Tooman's belief in a quality culture, noting that they recognize quality through mechanisms presented in the Baldrige criteria and that they had moved in that direction via a culture change. They explained that they saw themselves as a team "all pointing in the same direction" and that changes had been "strategized and well implemented."
This section includes a brief description of each of Iowa's quality improvement programs followed by a discussion of program funding, governance and the management and staffing structure. The following quality improvement programs were reviewed:
Nursing Home Report Card
The Nursing Home Report Card is an Internet web site that contains information on all federally certified nursing facilities and skilled nursing facilities in the state. The Report Card allows users to search for facilities by name or location. It includes "quality indicators" (Note: These are F-tags and not the CMS quality indicators) based on survey results. The web site includes the full inspection report, including detailed write-ups of deficiencies and the facility responses/Plans of Correction. All survey/complaint investigations since June 1999 are listed, including those under appeal, with the appeal noted (see Appendix C for a sample facility Report Card). The Report Card also includes information on facility best practices. The legislation that created the Report Cards was passed in late 1997. At that point in time, the CMS Nursing Home Compare site was still under development, and there was little consumer information on nursing homes available on the Internet. The Iowa Nursing Home Report Card went on-line on November 5, 1999.
A goal of the Report Card is to provide consumers with information on nursing home quality so that they can make informed nursing home choices. It is believed that provision of this information will motivate facilities to improve quality. The department strongly believes in making information available to consumers, believing, according to Dr. Tooman, that the availability of public information is "sacrosanct" (except when it is necessary to protect confidentiality). Iowa is the only state that researchers are aware of that posts complete survey results on the Internet. The survey findings are posted to the Report Card web site two days after the survey is mailed to the facility.
According to an article in Insight, the Report Card website was designed over an 18-month period as DIA worked in collaboration with resident advocates and nursing home industry leaders. DIA met with stakeholders twice as they developed the report card. The group included representatives from the four provider groups, the Iowa Partners group, advocacy groups, ombudsmen, state legislators, and representatives from the Departments of Elder Affairs and Public Health. In the facilitated meetings, DIA presented a shell and asked for input from stakeholders.
Quality-Based Inspections
Under the Quality-Based Inspection Program, facilities that are state-only licensed may be surveyed every six to 30 months, depending on facility performance. The program was intended to allow DIA to maximize its resources and concentrate more fully on the facilities in the state needing the greatest attention. Legislation authorizing the program was signed on May 11, 2000 (Senate Bill 2144). The quality based inspection program is reported to have originated from provider groups requesting the state to make changes in the survey process. Facilities opting to participate must complete a detailed application process based on the Malcolm Baldrige National Quality Program. The Baldrige Award is given by the President of the United States to businesses and education and health care organizations that apply and are judged to be outstanding in seven areas: leadership, strategic planning, customer and market focus, information and analysis, human resource focus, process management, and business results. Nationwide, there were five winners in 2001. DIA modified the Baldrige application process by shortening the application and broadening the categories to accommodate the limited resources of most nursing facilities.
The program, however, has not been truly successful. Very few facilities have opted to participate. There are ten nursing facilities statewide that do not participate in the Medicare or Medicaid programs, and are thus eligible for the program. Three facilities were invited to participate in a pilot program, but only one nursing facility has completed the self-assessment necessary to participate in the quality-based inspections program.
Furthermore, the potential benefits from participating (in terms of a less frequent survey cycle) are probably outweighed by the time and effort required to apply. A major component of the Baldrige National Quality Program is the feedback report, which is a written assessment of an organization's strengths and opportunities for improvement based on its application. Due largely to limited staff availability and budgetary restrictions, the Iowa-modified program does not provide any type of feedback report to its applicants. This feedback report had been envisioned as one way, among others, that the department could provide a type of technical assistance to facilities.
Best Practices
Begun in November 2000, the Best Practices Program aims to recognize and disseminate new and innovative approaches to providing nursing home care. Shortly after assuming the Division Administrator duties, Dr. Tooman observed a surveyor congratulating a director of nursing on a uniquely successful nursing procedure. He believed that the details on this practice should be shared with other facilities and that at the time there were no means to accomplish that. The goal for the program as described by DIA is to close the gap between knowledge and practice and point to positive approaches to integrating new knowledge and practices.
Facilities that believe they have developed an innovative practice report it to the surveyor during the annual inspection. The surveyors review the practice on site with the team leader, making the decision as to whether it qualifies as a Best Practice. Those practices deemed to be among the best in the state are recognized and posted on the division's Report Cards and in a separate listing on the web site. Best Practices are sought and recognized in nine categories--community integration, dietary, resident rights, nursing practices, human resource management, environmental, quality of life, habilitation/rehabilitation and end-of-life experiences.
Currently, there are 300 Best Practices listed on the web site (note that fewer than 300 facilities are represented since some facilities are recognized for more than one best practice.) Originally, the department's web site denoted best practices with a trophy icon, but this was later changed to a light bulb, as the department wanted to emphasize that the Best Practice program was designed to recognize a facility's practice, not the facility itself. Also, the practice of sending facilities Certificates of Recognition was later changed to the sending of a letter, because of confusion related to certain facilities receiving recognition and then later having problems with survey inspections and/or complaints. Appendix D includes the state's principles and procedures of Best Practices.
Joint Surveyor Provider Training
Beginning in June 2000, the DIA and the provider associations have collaborated to present four joint surveyor/provider training sessions, with another session scheduled in October 2002. Training sessions have been held on elopement, activity-focused care, dental needs of long term care residents and resident-centered living. The October 2002 session will address pain-related issues. The department initiated the joint training sessions in an effort to provide a common knowledge base for surveyors and providers and to enhance the quality of care and quality of life of the state's residents. The department utilizes local community colleges to assist with the organization of the training with experts in the topic recruited to conduct the actual training sessions. For example, two professors from the University of Iowa College of Dentistry led the training sessions on oral health and Eric Haider, from the Crestview Nursing Home in Bethany, Missouri spoke about his philosophy on resident-centered care. Nearly all of the state's 60 surveyors and 200- 350 providers have participated.
Governor's Quality Awards
The Governor's Award for Quality Care in Health Care Facilities recognizes quality services provided by long term care facilities, residential care facilities and intermediate care facilities for the mentally retarded or mentally ill. The award is based on the uniqueness of the services provided by the facilities to its residents, and any activities undertaken by the facility to enhance the quality of care or quality of life for its residents. The program was signed into law on May 11, 2000 with the first awards given in 2001 to eight health care facilities.
Nominations may be made by residents, family members, advocates and staff at other nursing homes. A stakeholder committee selected by the Director of the Department of Inspections and Appeals reviews nominations. Committee members evaluate each nomination and recommend facilities for further consideration. Prior to the selection of finalists, onsite reviews are made by DIA personnel to verify the accuracy of the information in the nomination. There can be up to two winners in each of the state's five Congressional districts. In 2001, there were 29 nominations and five winners. In the first year of the program, the awards were mailed to seven of the award-winning facilities, with the Governor making a personal presentation at one location. This past year, Governor Vilsack presented the awards at the Governor's Annual Conference on Aging.
Deficiency-Free Certificates of Recognition
Beginning in September 2000, DIA provides certificates of recognition to facilities that are deficiency-free in their annual inspection. The certificate is the department's way of acknowledging the "hard work and dedication" of the facility's staff in meeting the established standards of care. During the fiscal year that ended in September 2000, nearly 15 percent of the state's 800 long-term care, intermediate and residential care facilities had achieved deficiency free surveys. In March 2001, it was reported that 55 nursing facilities had received certificates.
Survey Questionnaire
Since June 2001, facilities have had the opportunity to complete a survey questionnaire that is presented at the conclusion of the regular survey. Completed surveys are returned to the Iowa Foundation for Medical Care (IFMC) for tabulation. IFMC estimates that 40-50 surveys are returned each month. The goal of the questionnaire is to improve the survey process in the state, ultimately improving the provision of health care services in the state. The survey includes information on surveyor conduct; facility opportunity to provide information and survey-related data; clarity of exit conference information; and whether the facility received information on the Best Practices program. Providers are also given the opportunity to provide general comments on the survey process, including suggestions on how to improve it.
IFMC produces a report for DIA in an Excel spreadsheet, which DIA in turn shares with their staff. In May 2002, the state average was 4.62 (on a one to five scale with five representing the most favorable rating). Data are stratified for each program coordinator so that specific areas for improvement can be identified and addressed.
Program Funding
The Nursing Home Report Card, Best Practices Program, Joint Surveyor/Provider Training, Deficiency-Free Certificates and Survey Questionnaires are funded through a combination of federal and state dollars, with 73 percent of budgeted costs paid by federal funds. Only the costs for the Governor's Award for Quality Care ($5,000) and the Quality-Based Inspections ($7,000) are funded entirely through state funds.
Current annual programming costs for the Nursing Home Report Cards are approximately $25,000 per year, with 73 percent paid by federal funds. In the 2002 budget, costs related to the division's web site were about $105,000, which included $31,500 for web maintenance, $10,800 for web hosting, $41,000 for electronic licensing, and $21,000 for scheduling software. The Best Practices program costs an estimated $15,000 per year, 73 percent of which is paid by the Federal Government. The cost associated with the Joint Surveyor/Provider Training sessions is approximately $50,000 per year, with 73 percent (approximately $36,500) paid by federal funds. The Deficiency-Free Certificates ($500 per year), and the Survey Questionnaire ($50,000 per year) each receive 73 percent of program costs from the Federal Government.
Governance of Programs
Each of the quality improvement programs is administered through the Iowa Department of Inspections and Appeals' Health Facilities Division.
Management and Staffing
Staff within the Department of Inspections and Appeals, Health Facilities Division, is involved in the management as well as the day-to-day operation of the various quality improvement programs. One Bureau Chief is responsible for routing of any questions (2-6 questions per day) that come through the web site to the appropriate person for a response. A clerical person scans the survey reports so that they can be posted to the web after the reports have been reviewed for removal of any confidential information.
Although participation in the Quality Based Inspections Program is very low, DIA staff is responsible for reviewing applications and determining the appropriate frequency of surveys based on facility applications. Joint Surveyor/Provider training is coordinated by two DIA trainers who are responsible for the planning, organization and recruitment of experts to conduct the sessions. Potential Best Practices are verified by the survey team leader during the survey process. Once verified, the HFD administrator and other staff further consider the identified practice. A stakeholder committee, chosen annually by the department Director, reviews the Governor's Award nominations.
The Deficiency-Free Certificate program does not require any additional staff, as it is handled as part of the normal survey process. The state's QIO (the Iowa Foundation for Medical Care) handles data entry of responses on the Survey Questionnaires. No analysis of the data is generated. However, a summary report is forwarded to the department on a regular basis.
Provider representatives overwhelmingly agreed that recognition programs (Deficiency Free Certificates, Governor's Quality Award, and Best Practices) did much to boost nursing facilities' morale. Over and over, participants stated that in the heavily regulated and scrutinized nursing home environment, facilities were grateful for positive recognition. Stakeholders told us that receipt of such awards was sometimes publicized in community newspapers and local media. Both provider associations agreed that the Best Practices program was a good informational resource for facilities as well as providing recognition for exemplary programs.
The Nursing Home Report Card was generally recognized as reporting current, accurate information, although there is considerable controversy regarding the posting of survey results that are under appeal (see further discussion below). Bureau chiefs reported that it had cut down on telephone requests for survey information and had saved considerable staff time sending out paper copies of survey results. Bureau chiefs and the Ombudsman agreed that the report card had done a good job improving consumer access to public information. According to division web site statistics, the web site is widely used with 14,664 sessions recorded in June 2002 (this does not represent unique users since some individuals may have accessed the web site multiple times). The Report Card pages are among the most accessed on the division's web site, with 7,050 hits to the report card result summaries, 5,945 hits on the detailed facility results, almost 5,000 hits to the report card search page and 2,292 viewings of the detailed survey findings. Although it is not possible to determine the identity of web site users, they do represent nearly every state, as well as Europe and Asia.
According to one of the Bureau Chiefs, report card utilization had gone up 50 percent in the last six months. In September 2000, GovNetworks and eGovernment magazine recognized the division web site with their Digital Award of Excellence, which is intended for deserving web sites that benefit the public.
Joint Surveyor/Provider trainings have been well attended--600 attended the first programs (elopement prevention), 200 attended the programs on creative care giving, 300 attended the oral health training, and 300 participated in the programs on resident centered care. Joint trainings may have helped improve relations between facilities and surveyors. Based on feedback forms, providers find these sessions very informative and useful.
The Survey Questionnaire reportedly has increased surveyor accountability, and has encouraged them to be more courteous, communicative, professional and approachable. Provider associations were pleased to have had input in the development of the questionnaire.
Although there was agreement that nursing facilities appreciated recognition for good performance, there was concern expressed by the Ombudsman that these awards gave consumers a false sense of security. In their experience, they noted that consumers seeing a Best Practice icon on the website or a Deficiency Free Certificate assumed that the facility was performing well in all care areas on a consistent basis. In fact, as they pointed out, a Deficiency Free Certificate only attested to the facilities' ability to meet minimal standards for the days that the surveyors were in the building. Likewise, recognition of one good area of practice did not mean that all practice areas were exemplary. HFD surveyor trainers noted that advocacy groups had been critical that these award programs were seen as bringing the regulatory agency too close to the entity they were supposed to be regulating.
The Ombudsman also noted that the requirement that the Best Practice be reported and evaluated during the survey was burdensome for facilities. They recommended that the recognition of Best Practices not be tied to a particular facility, but listed separately on the website.
One of the most difficult situations for all parties to contend with concerned those facilities that had received recognition for a practice or deficiency free survey and then later had compliance problems. These situations had been widely reported in the news media by an individual reporter who focused on long-term care issues. Initial praise and recognition of a facility that subsequently falls into disfavor was reported by participants as making the whole process look suspect. Another very controversial issue concerned the posting of all deficiencies on the web site, including those that were under appeal. The HFD policy is to post them two days after they are mailed to facilities and if appealed by the facility to mark them as such on the website. Both provider associations had unsuccessfully attempted to block the posting of deficiencies under appeal. Provider associations stated that even when deficiencies were later overturned, the damage from the initial posting and subsequent publication in the media was not readily reversed. Appealed postings are noted as pending appeal. The third most widely expressed concern with the Nursing Home Report Card posting of deficiencies is that it is claimed by some industry representatives to have had an impact on nursing home liability insurance rates. According to the AHCA representative, based on the number of deficiencies, some insurance companies were not writing policies and others had increased rates to the point that they were unaffordable by facilities. According to the department's Deputy Director, the governor convened a task force to examine insurance issues generally. The Task Force report does not note any connection between rates/availability of insurance and the web site report card postings.
Other more minor issues with the Nursing Home Report Card concerned the ease of consumer use. The Ombudsman pointed out that consumers were confused by the listing of complaints that were found unsubstantiated. Complaints that are not substantiated are not written out in their entirety. They recommended that all complaints be posted so that trends over time could be evaluated. The provider associations also felt that more collateral materials should be included on the website to aide consumer understanding of the information posted. They also disagreed with the inclusion of the names of directors of nursing and administrators in several years worth of data, noting that if these individuals are no longer employed because of poor performance their information remains on the web site.
Participants were mixed in their impressions as to how widely the Report Card was used by consumers. Consumer advocates noted that many consumers do not know that it is out there and that especially in many rural situations, there may only be one facility within a reasonable distance of family members and in this situation there could be little benefit to using the report card for facility selection.
There was widespread agreement from all participants that the Quality-Based Inspections program had not been successful as the application process was generally too burdensome for the majority of facilities to complete. Only ten nursing facilities are state-only licensed and even though the program had been modified in an attempt to streamline the process, only one had applied to participate in the program. Additionally, the benefits from applying for the quality-based inspections were reported as, "not worth the effort." The potential benefit is that the survey cycle could be extended to as long as 30 months. And, even for facilities that qualify for an extended survey cycle, some type of annual follow-up (a validation review) is required to make sure that the facility is still performing at the high level required to justify the longer survey cycle. The validation review involves one or two surveyors on site for no more than two days and involves a quality assessment based on the program's criteria. The State's Ombudsman reported that the philosophy of the quality-based inspection program "scared them." They believed that there could be large changes in provider quality after the inspection (i.e., in the case of "yo-yo compliance") and are opposed to any program that would increase the length of time between inspections.
Provider representatives reported that facilities were not convinced that responses on the survey questionnaire were completely anonymous. Even though the forms are sent to the Iowa Foundation for Medical Care for tabulation, providers are fearful that surveyors have access to the survey feedback information. Provider associations reported that comments they received from facilities regarding surveys were not consistent with the survey results that they had received from HFD. Either facilities were not completing the survey or were being overly generous to HFD in their rankings. The provider association also believed that individual surveyors should be named on the questionnaire rather than be reported at the coordinator/supervisor level. In their opinion, the naming of individual surveyors would lead to individual employment counseling where indicated. IHCA has developed and begun distributing its own questionnaire, which is similar to that used by DIA (except that it includes surveyor-specific questions) so that the association may compare its results with those obtained from the department questionnaires.
Joint provider/surveyor training was praised for providing access for both groups to up-to-date clinical information although progress toward its secondary goal of opening up communication between the two groups was seen as marginal. Participants noted reluctance on the part of both groups to asking questions in the group setting, as providers did not want to share areas of facility weakness and surveyors did not want to look uninformed in front of providers. Surveyor trainers also noted that by providing these joint training sessions, they necessarily had to cut back on the number of surveyor-only meetings for budgetary reasons. Also, provider associations initially objected to the issuing of continuing education units for these programs, as the income from offering educational programs has traditionally made up a major part of their revenue.
No evaluation of the impact of these programs has been made to date. Some decrease in the number of deficiencies has been noted in recent years, but it is not clear that there is any connection between the quality improvement programs and the number of deficiencies cited. Although there are statistics available on how many people access the website, there is no information as to whether these users are consumers, policymakers, researchers, or others. It is not known how the Report Cards affect consumer choices or facility quality. With only one nursing home in the state having applied to participate in the Quality-Based Inspections program, it is clear that this program, as implemented, has not had any impact on the quality of care or the quality of life for Iowa nursing home residents. Based on informal polling of providers, Dr. Tooman reported that the majority of providers have at least looked at the best practices, and he has anecdotal evidence that some facilities have adopted the best practices of other facilities.
Ombudsman did not note any significant improvement in care since the implementation of the quality improvement programs. They explained that, for example, the Governor's Award program, "It's nice and warm and fuzzy, but we don't really know that it improves care." They went on to say that these programs have focused on the average and above average facilities and have not raised the standards or done enough to deal with the poor performers. They believe that many of the best practices just represent activities that the facility should be performing routinely and do not represent exceptional care. They also believe that many facilities do not nominate themselves for a Best Practice Award believing that these practices are simply, "part of their job."
One provider representative stated that, "nothing improves quality more than reimbursement." She went on to say that although award programs are going in the right direction--the number one and two issues for facilities are reimbursement and consultative assistance and that these are the issues that facilities would like addressed--the "rest of this is just window dressing."
Except for the Quality-Based Inspections program, discussion participants did not identify any programs noted as unsuccessful or at risk of discontinuation. The department places great importance on making information available to consumers. There were no plans to add additional items (e.g., staffing information or MDS quality indicators) to the Nursing Home Report Cards. When CMS begins posting the quality indicators, the department will include a link to this site.
AHCA representatives advised other states to carefully consider all aspects of a report card and to have as much detail on the description, development and implementation as possible written into the legislation. They advised other states to consider what information will be seen by the public, how it will be displayed, timeframes for display, and how much collaboration there will be in the development process as examples of the types of topics that should be clearly defined prior to enactment. They noted that when the legislation to develop the Iowa report card was passed, it sounded acceptable, but later they found that DIA's interpretation of the legislation varied significantly from their interpretation, which led to the current problems regarding the posting of deficiencies prior to the resolution of appeals. Ombudsmen stated that they would like to see all complaints posted, including those that are not substantiated. They also advised that more advertising is needed to let consumers know that the report card is available.
There was general agreement that the application for the Quality-Based Inspections program needs to be simplified and the benefits for eligible facilities enhanced. Until CMS is willing to consider an alternative survey process which differentiates between good and poor performers, programs designed to make it possible for good facilities to be surveyed less often will not work if they can only be applied to state-licensed only nursing homes, given that most homes participate in Medicaid and/or Medicare.
Participants believed that programs rewarding best practices and deficiency-free surveys were valuable, despite the potential fall-out if those facilities later run into problems. They pointed out that it was important to have an objective process by which facilities are judged, so that the award is seen as truly recognizing outstanding quality and not based on other factors such as politics.
Both provider groups and the department indicated that they were pleased with the joint training programs and would recommend these to other states. High attendance at the sessions is indicative of the value that providers place on the training. DIA trainers suggest that states collaborate with community colleges and universities in the development of curriculum and presentation of materials. They also suggested that since provider associations usually have had more experience in planning and presenting educational programs, the states use them as resources. States should also consult with provider associations so as not to duplicate topics. DIA trainers also noted that states should avoid controversial topics, such as regulatory issues, and select "safer" topics, such as clinical issues.
The survey questionnaire was reported to be a relatively inexpensive way of improving the survey process, increasing surveyor accountability, and allowing facilities to provide feedback to the department. DIA recommends it to other states interested in these outcomes.
Dr. Tooman explained that he prefers that the Federal Government take the lead on providing "technical advisement" to states and facilities on quality-based cultures and organizational processes. Although the Quality-Based Inspections program, based on the Baldrige criteria was less than successful in Iowa because of its complexity and the limited resources available to most nursing homes, he remains a strong proponent of the process, having been a trainer prior to joining HFD. He believes that through technical assistance, facilities can be "equipped to do a better job.
Budgetary issues emerged as having a significant impact on the department's current programs and plans for future quality improvement programs. Iowa had experienced a 4.6 percent cut in last year's budget, plus additional cuts that amount to about 4.6 percent for this year. Despite the Governor's support for long-term care issues (he introduced a bill that would have allowed the state to shift resources so that budget cuts would not need to be as large) the general assembly rejected this proposal. Due to the budget cuts and expanded responsibilities (DIA recently assumed the responsibility for regulating assisted living programs), the concern for DIA has been to maintain current QI programs, as it is currently not feasible to implement new programs.
Provider group representatives expressed their desire for a consultative component to the survey process. They appreciate the recognition programs and awards, but identify the lack of "someone they could call for help," as a problem. Other than higher reimbursement, some type of technical assistance is what facilities want most from the state. Dr. Tooman noted that he has interest in implementing a technical assistance program, but the lack of available state funding in combination with additional DIA responsibilities make such an undertaking not feasible at this time. Funding remains a difficult issue.
Another significant influence on quality improvement programs in Iowa comes from the media. The State's major newspaper, the Des Moines Register, has focused a great deal of attention on long-term care issues, raising public awareness of quality in nursing homes and assisted living programs. The Nursing Home Report Cards are a major source of information for these articles and attention has been given to homes that receive awards, but are later cited for major deficiencies. During the site visit, the Register began a major series on assisted living programs. The attention generated from previous articles on these programs reportedly led to the change in oversight responsibility from the Department of Elder Affairs to DIA.
Finally, Dr. Tooman's background as a former facility chief executive officer and administrator and his sensitivity to facility issues appear to have contributed to the direction that DIA has taken in developing and implementing its quality improvement programs. DIA has made an effort to recognize facilities doing exemplary work, to improve relations between providers and surveyors, and to encourage facilities to engage in continuous quality improvement.
AHCA. State Summaries of Nursing Facilities, 2001/www.ahca.org/research/keynotes/statefactsheets-2001.pdf.
Iowa Department of Inspections and Appeals. Governor Unveils Nursing Home Report Card Site. Insight, February 2000.
Tooman, M.L., Department, Health Care Providers Share Common Responsibilities. Iowa Department of Inspections and Appeals. Insight, June 2001.
Tooman, M.L., Presentation Sparks Motivation for Quality Care. Iowa Department of Inspections and Appeals. Insight, September 2001.
Maine was selected for a site visit because it met the criteria established by the research team and Technical Advisory Group in that it has established and funded quality improvement programs, which are not reimbursement related. Researchers were particularly interested in Maine because of the unique technical assistance component within the quality improvement programs. Maine's technical assistance program, in existence since 1994, consists of one nurse who provides consultation and educational inservices statewide to any long term care facility on problem resident behaviors. The Technical Advisory Group believed that Maine's small technical assistance program might serve as a model to other states that were interested in providing technical assistance to nursing facilities but not able to implement a large-scale program. The State also recently enacted legislation that mandated a Best Practices Program, a consumer satisfaction survey and measures to significantly increase their minimum nurse staffing ratios.
Participants
Abt staff members Donna Hurd and Leighna Kim spent one day in Augusta, Maine on September 12, 2002. The following individuals agreed to participate in in-person and telephone discussions with the researchers:
Laura Cote and Brenda Gallant were the primary contacts for our Maine visit. Ms. Cote and her supervisor, Diane Jones participated in both in-person and telephone discussions. Ms. Cote also provided written information about the behavioral consulting program and a list of directors of nursing who would be willing to speak with us about her services. Ms. Gallant and Ms. Grasso were helpful in providing information on the quality improvement programs enacted as part of the April 2000 omnibus legislation. Ms. Gallant provided copies of the final legislation. Dr. Kane provided valuable information on the development of the legislation.
Preparation
Prior to the on-site visit, factual information on the quality improvement program was gathered from a literature review, stakeholder discussions and Maine Department of Human Services web site. Information on the following aspects of the programs was gathered and organized in a table:
The research team used the factual information in the tables as a starting point to develop discussion questions that focused on more in-depth issues. Letters of endorsement explaining the project goals, state selection and discussion processes were formulated and sent to prospective participants. Follow-up phone calls were made to arrange for convenient dates and times for meetings.
Structure
Discussions with Ms. Jones and Ms. Gallant took place at their offices. Ms. Cote, who works from her home, met with the researchers at the Division of Licensing and Certification offices. These meetings lasted from one to two hours. Discussions were generally loosely structured with researchers presenting both prepared and spontaneous questions and recording participants' responses in writing.
Follow-up calls were made with two directors of nursing and one assistant director of nursing of the facilities that Ms. Cote recommended, the Director of Communications at the Maine Health Care Association, and Thomas Kane, the state legislator who chairs the Health and Human Services Committee.
In order to put Maine in context with other study states, we have included some descriptive characteristics of the state's nursing home environment. Comparative data presented are from the American Health Care Association (AHCA) website (AHCA, 2002). There are 126 facilities in Maine, with 7,309 residents reported as of Spring 2001. The average number of beds per facility is 65, which is lower than the national average of 108. Maine's median occupancy rate per facility is 91 percent as compared to the national rate of 87 percent.
The percentage of for-profit homes is higher than the national average, (71 percent vs. 65 percent) while the percentage of not-for-profit homes is lower (25 percent vs. 28 percent nationally) with few government-operated facilities (4 percent vs. 6.5 percent). Fewer of Maine's facilities are hospital-based (9.5 percent vs. 12 percent nationally), but there is a higher percent of facilities that are dually certified for Medicare and Medicaid in Maine (100 percent vs. 80 percent nationally).
The state has seen a dramatic shift in the composition of its nursing home population in the past nine years, most likely as a response to the state's case mix reimbursement system and other long-term care reform (e.g., requiring facilities to increase their participation in Medicare by certifying more beds) that were implemented beginning in 1994.5
Behavioral Consultation
The technical assistance component of Maine's quality improvement programs began in 1994, prompted by the closure of a nursing facility whose population was made up primarily of residents with major psychiatric diagnoses and problem behaviors. The 50-bed facility had accepted residents that other facilities would not admit and experienced significant resident-to-resident and resident-to-staff abuse. When the decision was made that the facility would close because of state and federal regulatory violations, a transition team was assembled. Laura Cote, who had been the psychiatric liaison at the facility as well as the resident care coordinator and the staff development coordinator, was recruited as a member of the transition team. Ms. Cote followed the residents as they were evaluated and placed at new facilities between February and June 1994. She worked closely with the accepting facilities (40 in Maine and 1 in Massachusetts) to teach staff about each resident and his/her behavioral issues, assist them in understanding the issues, and to develop a care plan. At the end of the transition period, the Director of the Bureau of Medical Services asked if Ms. Cote would expand her work to provide consultative assistance on problem behaviors to all long term care facilities in the state. Working first as a consultant and then as a state employee within the Licensing and Certification Department, she continues to provide both consultative services and inservice programs for all long-term facilities in Maine.
Cote explained that while participating in the closure of the facility, she recognized that educational programs available to long term care staff were generally held outside the facility, requiring that a representative of the facility attend the program and carry the information back to the staff. She envisioned a program that would more effectively provide educational and support services in the environment of the residents and the direct care staff. She aimed to equally divide her efforts between educational training and consultation. Consultation is primarily directed at assisting staff to understand and manage resident behavior, rather than counseling or treating residents.
Best Practices, Consumer Satisfaction and Minimum Nurse Staffing Ratios
The Best Practices program, the study on consumer satisfaction and the Minimum Nurse Staffing Ratios were all included in the Omnibus Legislation (LD 42) signed into law (PL 49, chapter 731, part BBBB) on 4/25/00. This legislation was constructed based on input from stakeholders on what they felt were the most pressing issues in long-term care. One respondent believed that the impetus for the legislation came out of the climate of the 1990s when there was lack of communication and an atmosphere of distrust between providers and the Department of Human Services. At the same time there had been significant shifting of resources out of the long-term care system and a tightening of admission criteria.
Also contributing to the legislation was work done by the Joint Standing Committee on Health and Human Services. Meeting during the fall and winter of 1999-2000, their goal was to develop a framework for how the long-term care system should operate. They met to examine the issues of long term care delivery systems and the availability and financing of long term care services and to identify fundamental principles that would guide current and future legislation on long-term care. They recognized that key areas for focus included: a commitment to quality, empowerment of consumers, partnership between providers and the regulators, accountability on the part of providers and the responsibility of the state to provide oversight and technical assistance. Facilitated by a senior policy analyst from the Muskie School of Public Service, University of Southern Maine, the committee identified what they believed to be guiding principles and recommended actions on long term care. The only person outside of the legislature who participated in the committee discussions was the State Long Term Care Ombudsman, included because she was believed to represent a knowledgeable, impartial and objective viewpoint. In January 2000 they published their report on long-term care in Maine in which three guiding principles were identified:
Within each guiding principle, recommendations and proposals for immediate action were identified by the committee.
The Best Practices workshops and minimum staffing ratios were proposed under the second guiding principle and its accompanying recommendation that, "All long term care services should be adequately and appropriately staffed." A committee consisting of the State Ombudsman, representatives from the Maine Health Care Association, the Maine Hospital Association, the Division of Licensing and Certification, the Alzheimer Association and Legal Services for the Elderly was formed to identify topics for educational programming. The minimum staffing ratios were studied by a Task Force, consisting of representatives from the Division of Licensing and Certification, providers, the Ombudsman, legislators, nursing and nursing assistants. They originally wanted to identify an acuity-based formula to determine staffing ratios, but were unable to identify an acceptable measurement and eventually abandoned the idea.
The proposed increase in minimum nurse staffing ratios was initially met with some skepticism on the part of providers. However, when the for-profit association canvassed the members as to their ability to meet the minimum requirements, providers responded that they were currently meeting the staffing requirements and did not see it as a problem. The association was pleased to be able to support the legislation that was seen as a positive move for residents and consumers. The language of the legislation when finalized, however, required that the minimum direct care staffing ratios be met every shift every day. Facilities, when indicating their ability to meet the ratios had based their responses on staffing in the aggregate, over weeks or months. The regulation allows for staff to be aggregated over the entire building (not by unit), but must be met each shift (morning, evening and night). The association had requested language be included in the law that facilities would not be cited if they had made an effort to cover the shift(s) so long as there was no harm to residents. This addition was not included in the final regulation.
The funding for a consumer satisfaction survey was introduced under the third principle and the accompanying recommendation that, "The Department of Human Services should enhance its efforts to provide technical assistance to long-term care providers in the spirit of continuous quality improvement. While the Department should not abandon its oversight role regarding providers, it should offer positive and constructive consultation to providers whenever possible." Consumer and family satisfaction surveys were listed as one method of measuring high quality care.
There are two goals identified for the Behavioral Consultative services. The first is that by assisting facilities to provide better services, the risk of abuse and neglect of these residents with problem behaviors will be reduced. Secondly, the number of discharges of these residents from facilities because the facility cannot deal with the resident will also be reduced.
Best Practices, Consumer Satisfaction and Minimum Nurse Staffing Ratios are intended to improve quality outcomes, according the legislative study. Best Practices and minimum staffing were envisioned as means to enhance the lives and safety of the consumers. The committee developing the educational Best Practice programs sought to provide both regulatory and practical guidance for facilities on meeting resident needs. Innovative ideas from nursing facilities were solicited to aid other facilities in maximizing quality outcomes within the confines of limited staffing resources. Contacts in the Ombudsman office believe that a multidimensional approach to measure quality is necessary--no single measure can do an adequate job. They expressed their belief that the consumer satisfaction survey would be one component along with quality measures and enforcement activities to improve quality for Maine long-term care residents.
This section includes a brief description of each of Maine's quality improvement programs followed by a discussion of program funding, governance and the management and staffing structure. The following quality improvement programs were reviewed:
Behavior Consultation
Laura Cote RN is the sole technical assistant in Maine, providing on-site consultation to any long-term care facility (nursing facilities, assisted living facilities, intermediate care for the mentally ill, facilities caring for head injured, adult family care homes and boarding homes) on problem resident behaviors any where in the state. Growing out of her experience as a member of a transition team closing a facility that cared for primarily psychiatric residents, she became aware of the need for support and education for long term care staff. She currently provides consultations in the morning and inservice programs in the afternoons on a full-time basis, working from her home office.
Technically an employee of the Division of Licensing and Certification, she receives referrals from facilities and schedules on-site visits and inservice programs throughout the state. Ms. Cote describes the goals of these services as "to assist staff in dealing more effectively with difficult behaviors by giving them a better understanding of the resident, why the behaviors are occurring, making recommendations, involving them in team problem solving where their input is valued, and providing them the education that will enable them to do their jobs more effectively and safely--as well as improving quality of care and ultimately quality of life for the resident."6 Ms. Cote, depending on the severity of the problem, prioritizes responses to facility requests. Visits are generally made within two weeks of the request. Inservice programs are very popular and are currently being booked well into 2003.
On-site consultation visits involve a chart review, problem-solving sessions with staff (including all staff involved in care), a brief meeting with the resident, written recommendations, and a follow up if needed. When speaking with the staff during the problem solving session, they discuss the problem behaviors in detail, including what the warning signs are, what helps, and what doesn't help. Using staff input, she writes her recommendations by hand because she believes that they are more personal. The recommendations are geared to the care providers and reflect the information that they offered in the earlier session. Copies of her recommendations are forwarded to the facility and to the Division of Licensing and Certification. Facility recommendations are available for surveyors' review although facilities are not held accountable for implementing Ms. Cote's recommendations. Appendix B contains a sample of the facility feedback report that is prepared at the end of a behavioral consultation visit.
Ms. Cote has also developed seven in-service programs, which she conducts at facilities on request. Program topics include: Behavioral Approach, Documentation of Behaviors, Alzheimer's--Practical Hints for Caregivers, Intimidating Behaviors, Problem Solving for Difficult Behaviors, Behavior Profile Cards, and Elopement--Risk Factors and Prevention. In-service outlines are included in Appendix B.
No formal evaluation has been done, but Ms. Cote distributes evaluation sheets intermittently to see if there are ways she can improve her service.
Best Practices
Best Practice workshops were mandated as part of the April 2000 legislation to address nursing home issues. The Department of Human Services was charged with participating in a "series of best practices forums to provide educational workshops and opportunities to providers of long term care services." Led by the Assistant Director of Licensing and Certification, a task force was assembled to implement the legislation. Beginning first with determining a definition of a best practice the task force proceeded to identify topics and plan two workshop programs.
The first program on Nutrition and Hydration was an all day workshop offered in two locations. It began with a presentation on the federal regulations regarding nutrition and hydration led by a federal surveyor followed by a panel presentation by providers who discussed nutritional practices that worked best for them. Prior to the workshop, all providers in the state had been asked to submit examples of nutritional best practices. Panel participants were selected from those who had provided a best practice. The audience included administrators, directors of nursing, staff nurses and nursing assistants. The Licensing and Certification division reported that 90 percent of all homes in the state sent staff to one of the workshops. The second program was on Incontinence and featured an expert speaker. The audience consisted mainly of nurses because of the more clinical nature of the forum. The second workshop was not as well attended as the first due to inclement weather on the scheduled date. No formal evaluation of the impact of either program has been conducted as yet.
Minimum Staffing Ratios
Also included in the April 2000 legislative mandate was an increase in nurse staffing requirements. Nurse staffing is defined in terms of ratios of direct care staff to residents by shift. Direct care staff include charge nurses, medication nurses and aides and nursing assistants, but not nurse managers, supervisors, directors of nursing or MDS coordinators. Day shift ratios increased from 1:8 to 1:5; evening shift ratios increased from 1:12 to 1:10; and night shift ratios increased from 1:20 to 1:15. Staffing is reviewed during the annual survey (and during any complaint investigations related to staffing) for a two-week period prior to the date of survey. If problems are noted, surveyors will review other periods as well. If a facility is out of compliance on one shift on one day, they may be cited.
Consumer Satisfaction Survey
Funds to develop a consumer satisfaction survey were included in the April 2000 legislation. Proposals were solicited and a contract was awarded in the Fall of 2002 to Market Decisions, LLC, a Maine survey research firm. This company will conduct a face-to-face survey of a sample of nursing facility residents to determine their satisfaction with their surroundings and the care they receive. The study report is expected in late Spring 2003.
Program Funding
The Behavioral Consultation program services are available to any long-term care facility in the state of Maine at no cost to the facility or the resident. The cost of this program is Ms. Cote's salary and administrative support, which is part of the Licensing and Certification budget.
The funding for the Best Practices program comes from money obtained through civil money penalties. The cost of each forum was estimated to range from under $2000 to approximately $3000. The costs were incurred to reserve conference space, to transport the surveyors to the forum, and to cover the cost of the speaker.
Funding to increase minimum staffing included $1,336,000 from general funds and $2,610,241 for the associated federal match for fiscal year 2000-2001.
Governance of Programs
The behavioral consultation, best practices and minimum staffing requirements are all administered through the Bureau of Medical Services, the Department of Human Services.
Management and Staffing
Technical assistance visits are conducted solely by Ms. Cote, who is a registered nurse (RN) with geriatric and psychiatric training, in addition to many years of acute, home and long-term care experience. She is employed by Licensing and Certification, but is not trained as a surveyor and does not participate in surveyor meetings or activities. She works independently from an office in her home and provides copies of her facility recommendations and summary reports to her supervisor on a weekly basis.
The Behavioral Consultation offered in Maine is well received partially because although organizationally housed within the Division of Licensing and Certification, it is completely separate from regulatory activities and because there is no cost involved for facilities. Contributing equally to the program's effectiveness is the experience and qualifications of the individual who is solely responsible for it's structure and content. Laura Cote is seen as knowledgeable, credible, familiar with the long-term care environment and able to communicate well with both licensed and unlicensed staff. Because Ms. Cote works from her home, facility staff were often not aware that technically she works within the Division of Licensing and Certification.
Participants were unanimous that Ms. Cote's consultation was helpful not only to residents but to staff as well. One director of nursing stated that by soliciting staff input, particularly from nursing assistants that Ms. Cote was able to diffuse difficult situations that could potentially lead to physical and/or verbal abuse. Ms. Cote has a reputation of being able to glean from a record relevant care information that staff had either missed or considered insignificant. Another nursing director noted that even though the problem behaviors often could not be eliminated, the discussion around them gave all levels of staff, the nursing assistants in particular, insight as to why these behaviors were occurring and support to continue their efforts at dealing with them. The separation from the surveyors makes the facility staff feel comfortable interacting with Ms. Cote. One director of nursing noted that often their record of having consulted with Ms. Cote improved survey outcomes as it demonstrated to the surveyors that the facility was taking appropriate action to improve certain problematic situations. Providers noted that the careplans that Ms. Cote develops and leaves with the facility were organized, detailed and very useful, but emphasized that the process of speaking with (and listening to) staff was an equally important part of her service.
The inservice programs that Ms. Cote offers were noted to be well attended, to the degree that facility staff came in on their days off so as not to miss them. Nursing directors explained that Ms. Cote's presentations are "down to earth," and appropriate for all staff. The programs include many examples from Ms. Cote's own experience that staff are able to relate to and learn from.
Providers also praised the Best Practices workshops and hoped that additional ones would be planned. The panel discussion that occurred as part of the Nutrition and Hydration workshop was noted to be particularly helpful. One nursing director stated that their facility had initiated some new approaches to dining after attending that workshop and had adopted some of the ideas into their quality improvement program.
Although participants were overwhelmingly pleased with Laura Cote's work providing behavioral consultation for nursing facilities, some noted that having only one person to cover the entire state did not allow adequate follow-up activities with facilities. With additional staff more inservices could be provided, response time could be shortened (although not considered a problem by facility staff contacted) and a greater degree of follow-up consultation could be provided.
The minimum staffing requirement, although no one would disagree that it was an important component to improving quality, was difficult for facilities to meet in view of the current nursing shortage in the state. Facilities reported having trouble finding an adequate number of qualified staff before the required staffing was increased and now frequently have to rely on temporary agency staff, a practice they feel does not contribute to quality of care. When initially proposed, the required staffing was discussed in the aggregate and not as ratios of direct care staff per shift. Facilities are reportedly being cited for numbers below the requirement. One facility stated they had been cited for staffing on the day shift of 5.06 residents per direct care worker when the requirement was 5.00 residents per staff person. Facilities also stated they would have preferred a greater degree of flexibility in the regulation so that they could staff according to their residents' needs--staffing even higher than required during certain peak times of the day and less when residents' needs were less intense.
Staffing below the required numbers is supposed to lead to a self-imposed moratorium on admissions. Facilities that are Medicaid certified must maintain a 90 percent occupancy rate to avoid having their funding affected. This creates a difficult situation where facilities must chose between regulatory and financial compliance.
Participants believed that the quality of life for residents referred to Ms. Cote for behavioral consultation was definitely improved because staff are able to provide better care to this difficult population. Although no formal evaluation has been conducted, anecdotal feedback from survey staff, ombudsman and providers indicated that the consultations have led to changes in plans of care that have had positive results for both residents and staff. The survey staff respondent indicated that based on informal feedback she has received, the education and support given to staff has decreased medication use among the residents and has also decreased the number of discharges due to behavioral issues. In her experience, in homes without support, the staff had on occasion become so frustrated with problem residents they would discharge the resident to an acute care setting and refuse to readmit them, preferring to take the deficiency citation rather than continue dealing with the resident.
There has been no formal evaluation of the impact that the Best Practices program or the increase in minimum staffing requirements have had on quality of care or quality of life. Providers reported adopting ideas presented at the Best Practices workshop, particularly the one on Nutrition and Hydration and incorporating these practices in to their quality improvement programs.
Participants did not indicate any plans to change the behavioral consultation visits, although some recommended that expanding the program would be advantageous. Current budget constraints limit any plans in this direction. The survey respondent stated that any additional funds would most likely to be used to hire more surveyors.
The legislative mandate that created the Best Practices program was not specific to the number of educational programs that were to be provided, except to state that the "Department of Human Services will participate in a series of best practices forums…" The survey respondent who headed up the program planned to reconvene the program's Task Force to begin planning future activities. Some ideas, although not firm were to investigate activities in this area in other states and/or possibly make Best Practices available in some sort of publication.
There was some discussion by participants to re-examine the minimum staffing requirement. Although all contacts voiced support for the principle of improved staffing, there were some thoughts of possibly modifying the language of the regulation to allow facility staff more latitude in managing the numbers. Proponents of the increased minimum ratios did not want to have to go back to the legislature to re-write the regulation, but rather were hoping for increased flexibility in the interpretation of the regulation in view of the current nursing labor shortage. Participants advised other states that funding passed to implement increased staffing should be proposed as ongoing and not limited to the year the measure was passed.
When questioned regarding recommendations for other states, participants enthusiastically advised that, "Every state should have a Laura Cote." One respondent cautioned, however, that every state is unique and what works in one state may not work in another. This comment addressed the fact that Ms. Cote works alone covering the whole state and that often facilities wait up to two weeks for a requested consultation. Facilities in Maine accepted the two-week wait for consultative visits, possibly because many of them are located in rural areas, and are accustomed to not having services readily available.
Participants advised that with any consultative or technical assistance program that the qualifications and experience of the hired consultants was critical. For behavioral consultations to be successful, they noted that a potential consultant needed to be well versed in clinical, psychiatric and long-term care issues. Because of the diversity of diagnoses present in the long term care population, being an expert in only one of the aforementioned areas would not be adequate to provide facilities with valid and useful information.
The Ombudsman stated that regulations alone are not enough to improve quality. She believes that multiple and varied approaches must be utilized to assist facilities in their quality efforts. Adequate numbers of, and respect for, staff is one such area. Another approach involves improving access for facilities to clinical informational resources and the provision of technical assistance. Lastly she pointed out that efforts to decrease staff turnover must occur.
According to the Ombudsman, the role of the Federal Government should be to provide education. The survey agency respondent agreed stating that the Federal Government should continue to provide enforcement but also add training and initiatives focused on helping facilities deal with problems. Providers had expressed interest in accessing information on Best Practices, particularly in the areas of pain management and elopement.
Maine's quality improvement programs consist of the long-standing but limited behavioral consultation and the recently enacted educational and staffing requirements. Both programs have limitations--the technical assistance is very limited in scope and focus and the Best Practices and minimum staffing requirements have been underway for just one year. The programs, however, include distinct features in their development and continuing processes that distinguish them from other states and which could serve as valuable models to other states.
The technical assistance program involves one nurse providing behavioral consultation statewide to any long-term facility upon request. Its success in improving resident outcomes through a combination of consultative and educational support is apparent, although not formally proven. On a small scale it demonstrates the value of an individual facility/resident approach, the need to involve all staff in care planning and problem solving, and the benefits of distancing technical assistance from enforcement activities and of providing education that is tailored to the direct care staff.
Although only two Best Practices workshops have been presented, one of them utilized a unique approach of incorporating information on regulatory compliance with practical implementation guidance. A surveyor provided interpretation of regulations followed by a panel discussion/presentations by facilities that had submitted best practices around a particular clinical area. This combination of reporting enforcement interpretation and successful clinical outcomes captured the attention and interest of administration and clinical staff with subsequent changes in policy and care planning.
Lastly, the manner in which the legislation covering the quality improvement programs was written was an attempt by the legislature to first identify guiding principles and goals and then use them to develop a targeted approach to accomplish the goals, rather than reacting to isolated issues. The development of a framework for how the Maine long-term care system should operate and the identification of key principles to guide public policy decisions on long-term care was seen as a novel approach. It remains to be seen how and to what degree these principles will impact future long-term care legislation.
AHCA. State Summaries of Nursing Facilities, 2001/www.ahca.org/research/keynotes/statefactsheets-2001.pdf.
State of Maine Public Law 49, Chapter 731, Part BBBB, Sections BBBB-1 through BBBB-16, Signed April 25, 2000.
State of Maine, 119th Legislature, Second Regular Session, "Long Term Care in Maine--A Progress Report." Joint Standing Committee on Health and Human Services, January 2000.
State of Maine, "Long Term Care Status Report, Bureau of Elder and Adult Services, December 2002. (http://www.state.me.us/dhs/beas/ltc/2002/ltc_2002.htm#nursing).
This report describes findings from our exploration of the State of Maryland's quality improvement projects (QIPs). We first present some background information about Maryland and about the project team's site visit to that state. Next, a history and rationale for Maryland's movement toward state-initiated quality improvement is presented. This is followed by a description of each program reviewed by the project team. Findings regarding the strengths and weaknesses (as identified by state and nursing home industry representatives) are presented, as is a discussion of the impact of the QIPs on quality of care and quality of life of nursing facility residents. Finally, lessons learned by the state are presented, along with a brief description of the perceived sustainability of the various QIPs.
Background
Following the completion of the literature review, discussions with stakeholders and the meeting of the Technical Advisory Group, Maryland was identified as one of seven states meeting the project criteria for states with state-initiated quality improvement programs. These criteria include (1) having state-initiated programs in place, (2) having programs that were not reimbursement or payment related, and which (3) included aspects of technical assistance and/or quality improvement. In response to concerns from within the state and the nation at large, Maryland had enacted a number of measures aimed at improving the quality of care in nursing homes. Some (e.g., the quality improvement plan, the "Second Survey") were regulatory measures, while others ranged from educational services to research endeavors that were voluntary programs. Maryland was identified as the initial site visit because their technical assistance and quality improvement programs had been underway for approximately one year and the state is in close geographic proximity to Massachusetts and Washington, D.C. where members of the research team are located.
Participants
Abt staff members Terry Moore and Donna Hurd accompanied by Task Order Officer Jennie Harvell and consultant Barbara Manard met with individuals involved in the development, management and implementation of the programs, and with nursing facility staff that had been surveyed under the technical assistance program. Over a three-day visit in April 2002, the research team met with individuals and groups associated with the following organizations:
Carol Benner, OHCQ director, was the primary contact for the Maryland site visit. With 14 years experience in her position and author of the state's nursing home reform package, she was an excellent resource on the political environment in her agency and the state at large. During the preparation phase and on-site discussions, she was a willing and enthusiastic informant on the various reform programs in place. Likewise, the Technical Assistance Surveyors and other members of the OHCQ staff were willing to share their experiences and impressions of the impact of the program. Some of the provider representatives were initially more guarded in their presentation and focused their discussions on the issues that they felt were most important to their members. Other provider representatives were less concerned about staffing and funding issues and were more open to giving us their comments about the variety of quality improvement programs initiated by the state.
Preparation
Prior to the on-site visit, factual information on the quality improvement programs was gathered from the literature review, stakeholder discussions and Maryland state web site. Information on the following aspects of the programs was gathered and organized in a table:
The table was forwarded to Carol Benner prior to the on-site visit for her to review and provide any additional or corrected information. The research team used the factual information in the table as a starting point to develop discussion guides that focused on more in-depth issues. Letters of endorsement explaining the project goals, state selection and planned discussions were formulated and sent to prospective discussants. Follow-up phone calls were made to arrange for convenient dates and times for in-person meetings.
Structure
Discussions with the survey agency staff, provider associations, ombudsman and nursing facility staff took place at their respective offices or on-site at the nursing facility and generally lasted approximately two hours per conversation. In each case, the research team encouraged the organization, agency or nursing facility to include as many of their staff as they thought would be interested or would have valuable information to share. The research team was able to observe a portion of a technical assistance survey on site. During a break in the technical assistance survey, the research team met briefly to talk with the surveyors and then observed the technical assistance process as surveyors discussed their findings with the facility staff.
Discussions were generally structured with one researcher presenting both prepared and spontaneous questions while the other researchers recorded responses in writing.
To put Maryland in context with other health care environments around the country, and with others studied here, we describe several characteristics of the state's nursing home environment. Comparative data presented are from the AHCA web site (AHCA, 2002). Maryland facilities are slightly larger than those in the rest of the country, with an average of 121 beds per facility (vs. 108). Fewer of Maryland's facilities are for-profit (57 percent vs. 65 percent), 13 percent are hospital-based, and 50 percent are chain-owned. There are a total of 262 facilities in the State, the majority of which (89.7 percent) are dually certified for Medicare and Medicaid.
The impetus for the enactment of the Maryland quality improvement programs in 2000 as explained by the provider associations and the survey agency appears to have been based on a series of events and activities that occurred both within and outside the state in the preceding ten years. Beginning in 1989, deplorable conditions existing in a Maryland facility were reported in the media, which led (over the next three years) to multiple nursing facility closures. In 1997, findings from the California study of death certificates were published in Time Magazine. This led to a U.S. General Accounting Office (GAO) investigation in 1998 on California nursing homes (USGAO, 1998) and in 1999 on federal and state complaint and enforcement practices (USGAO, 1999). The 1999 GAO study noted problems with Maryland's complaint investigations, stating that the process was too slow. That same year, negative personal experiences by several influential state senators in Maryland nursing homes, along with damaging testimony before the legislature by OHCQ staff on the issue of complaints, pressed the legislature to tie the passage of a nursing home funding bill to the creation of a Nursing Home Task Force to study quality and oversight in Maryland. The for-profit provider association explained to the project team that their primary concern at that time was the restoration of full Medicaid funding that was promised in the bill. Although both provider associations indicated that they did not agree with the proposed member composition of the Task Force, specifically that stakeholders were included only on subcommittees, they were compelled to support the bill to ensure funding.
The Task Force began meeting during the summer of 1999 and presented their recommendations in January 2000. The Task Force identified the following:
In May 2000 a broad Nursing Home Reform Package was introduced containing six bills covering the following areas:
Carol Benner explained that the six bills, which she wrote, represented a "six prong approach to improve quality." She stated that the general approach in the past had been to strengthen regulations and sanctions to weed out the bad providers, but that there had been no provisions to address quality. According to Benner, at the heart of the bills was the quality improvement program. HFAM reported that the key aspect of the legislation had to do with Medicaid funding for additional staffing and benefits.
Within each specific bill, there were components that the various stakeholders pushed to modify; however, no bill was defeated in its entirety. One provider explained that members of the Task Force agreed on the principles of the reform but differed on the operationalization of reforms and the timing for implementation. For example, Benner had proposed that the quality improvement programs in each facility be lead by a full-time nurse. Due to opposition by HFAM, this was modified to remove the requirement of a nurse. The legislature had initially promoted four surveys per year while the survey agency and provider groups were satisfied with two surveys. The final bill passed called for two nursing home surveys per year.
Comments from the provider associations and the survey agency, and the language of the legislature, all differ in the emphasis that they place on the various components of the quality improvement programs. There were clearly additional regulations introduced to strengthen the survey agency's oversight and ability to sanction; at the same time, provisions were added for greater consumer advocacy and technical assistance.
The language in the proposed legislation stated that the bills were drafted because it had become clear to everyone that the nursing home industry needed significant reform to improve the quality of life for residents. The proposal was aimed at strengthening state regulations in areas where the applicable federal standard was not sufficient to protect the public health, safety or welfare of Maryland citizens. The proposal identifies areas that federal regulations either do not address or are deemed to be too weak. Federal regulations do not address the relocation of residents or appropriate procedures to minimize relocation trauma, nor do they address the posting of staffing ratios and staff assignments, which Maryland legislators wanted to see defined. Federal regulations for quality assurance were also seen as deficient, not going far enough in terms of defining the framework for an acceptable quality improvement program.
According to Carol Benner, the purpose of the nursing home reform was to "give [the state] effective tools to gain and sustain compliance in Maryland homes." She noted a need to change the culture of both surveyors and nursing facility staff to focus on quality and resident safety, as opposed to regulation and enforcement. She also stated that, "although the survey agency seems to be effective at removing poor performing nursing homes from the system, there is no evidence that the current survey process is effective at improving quality. In fact, little is known about what does improve quality in nursing homes. To improve quality, Maryland is trying a variety of efforts." In one presentation she stated, "We decided to do anything that worked to improve quality--the 'throw the spaghetti at the refrigerator and see what sticks' approach."
The quality improvement programs that were initiated by legislation passed in the Maryland General Assembly are described in detail below. They are followed by a description of programs initiated by OHCQ, subsequent to the passage of the Maryland Nursing Home Reform Act, in an effort to improve nursing home performance.
Programs and regulations mandated by the Nursing Home Reform Act
The programs described below are directed at nursing facilities and resulted from Maryland's nursing home reform package; all receive oversight from OHCQ. No additional funding was appropriated to assist facilities in their implementation or to assist OHCQ in their enforcement.
Facility Quality Assurance Program (COMAR 10.07.02.45)
As of January 1, 2001, legislation mandated that each Maryland nursing facility establish an effective quality assurance program. The program was developed by the Nursing Home Task Force (described earlier) with the goal of changing the culture within the nursing home from one of living from survey to survey, to one focused on internal quality improvement. It contains guidance that exceeds the existing applicable federal regulations on nursing home quality assurance programs (42 CFR 483.75(o)).
Program requirements include the appointment of a qualified individual to manage quality assurance activities within the nursing facility, and the creation of a quality assurance (QA) committee. The regulation is silent with regard to the qualifications of the individual who must manage the QA activities, and OHCQ staff describe this position as being held by directors of nursing, administrators, QA nurses, and others. Membership of the QA committee must include at least the director of nursing, the administrator, the medical director, and a social worker, dietician, and geriatric nursing assistant. The committee must designate a chairperson to manage committee activities, must meet monthly to implement the QA plan, and must prepare monthly reports for the ombudsman, family council and resident's council. Quality assurance records must be available to the OHCQ for the purposes of ensuring implementation and effectiveness of the program.
The QA committee's primary responsibility is to assist in developing and approving the facility's initial quality assurance plan, and for assisting in the on-going implementation of that plan. They are responsible for submitting the QA plan to the OHCQ at the time of licensure or at the time of license renewal, and submitting any change in the QA plan to the OHCQ within 30 days of the change. They are also responsible for reviewing and approving the facility's QA plan at least yearly.
Quality Assurance Plan (COMAR 10.07.02.46)
The QA plan must include procedures for concurrent review of resident status, ongoing monitoring of resident status, handling and reporting of patient complaints, procedures for accidents and incidents, and procedures for implementing abuse and neglect regulations (e.g., family notification).
The QA plan must also include methodology for data collection and evaluation in these patient care areas, analysis of data to determine trends, description of the thresholds and performance parameters, timeframes for follow-up, and description of documentation.
Essentially, the "concurrent review" component of the QA Plan requirement prescribes to the facility that resident status must be evaluated daily and must be evaluated in specific aspects of resident functioning (e.g., appetite, skin). The ongoing monitoring component of the QA Plan prescribes particular quality indicators for which the facility will be held accountable. For example, all Maryland facilities must monitor patient outcomes in the seven specified areas (e.g., medication administration, pressure ulcers) listed above.
Patient complaints--The QA plan must include a description of a complaint process that effectively addresses resident or family concerns. It must identify the designated person(s) and phone numbers to receive complaints or concerns, the method to be used to acknowledge complaints received, and the time frames for investigating complaints dependent upon the nature or seriousness of the complaint. The QA plan must also include a description of a logging system that will be used including the name of the complainant, the date that the complaint was received, the nature of the complaint, and the date that the complainant was notified of the disposition or resolution of the complaint. The QA plan shall also include procedures for notifying residents of their right to file a complaint with OHCQ, informing residents, families or guardians of the complaint process upon admission and posting the complaint process or making it available without the need to request it.
Accidents and incidents--The QA plan must include a definition of accident and injury that is appropriate to the type of resident served by the nursing home. It must describe the procedure for reporting accidents and injuries including who shall report incidents, the time frame for reporting incidents, and the procedure for reporting incidents. A description of how internal investigations of accidents and injuries will be handled including time frames for conducting the investigation, methods for assessment of any injury, interview of the resident, staff, and witness, and review of any relevant records including the resident's medical records, discharge summary, hospital records, etc. and how information will be referred to the QA committee. It must describe the process for notifying family or guardian about the incident, the process of notifying the QA committee and the process for ongoing evaluation to identify trends. It must also contain a policy statement saying that reporting incidents can be done without fear of reprisal.
Abuse and neglect--The QA plan must include a description of the process for implementing abuse regulations, including the family notification process, the evaluative process for identifying trends and patterns, and a description of how information will be shared with the QA committee.
Though the QA Plans are submitted to the state, all of the described components of the QA Plan requirement are not reviewed until the technical assistance, or "second", survey (described later in this document). Each component of the plan, as well as the status of the implementation of the plan, is reviewed and discussed with each facility by the State Quality Assurance Nurses.
The following requirements were also enacted through the Maryland Nursing Home Reform legislation.
Posting of Staffing (COMAR 10.07.02.48)
This statute requires each nursing home to post on each floor or unit, for each shift, a notice that explains the ratio of licensed and unlicensed staff to residents. The posting includes names of the staff members on duty and the room numbers of the residents that each is assigned to, the name of the charge nurse or person in charge of the unit, and the name of the person responsible for medication administration. At the time of our visit, approximately 65 percent of facilities were deemed to be in compliance with this regulation.
Mandated Staffing Patterns (COMAR 10.07.02.50)
In cases where the OHCQ determines that a deficiency or deficiencies exist, the Department may either mandate a staff pattern which specifies the number of personnel or personnel qualifications or both; or permit the facility the opportunity to correct the deficiencies by a specific date. If the facility does not correct the deficiency, OHCQ has the authority to specify the number of personnel or personnel qualifications or both.
Health Care Quality Account (COMAR 10.07.02.60)
In addition to the previously existing federal regulations, the Department has established a health care quality account funded by civil money penalties paid by nursing homes. Expenditure of the funds can be made for any purpose that will directly improve quality of care in nursing facilities and may include funding for the establishment and operation of a demonstration project, a grant award, or relocation of residents in crisis situations. The account may also be used or to fund educational programs to nursing facilities, the OHCQ, other government, professional, or advocacy agencies and consumers. Suggestions for the use of the funds may be submitted by members of the public, advocacy organizations, government agencies, professional organizations including trade associations, nursing homes; and nursing home associations. At the time of our visit, there was $230,000 in the state account and $1,300,000 in the federal account. OHCQ recently introduced a budget amendment to allow them to use money from the account for the Wellspring program. Previously, funds have been used for the Family Council Project, the Wellspring Project, Pets-on-Wheels, training, relocation services and end-of-life care.
Physician Services (COMAR 10.07.02.10)
The goal of this regulation is to improve physician accountability in nursing homes. It includes detailed regulations covering physician responsibility for assessment, visits, orders, documentation, the provision of appropriate care and adequate coverage.
Medical Director Qualifications (COMAR 10.07.02.11)
This regulation strengthens requirements for medical directors. It requires that the medical director act as a manager and administrator, attend QA meetings, perform peer review, and ensure that resident care meets accepted standards. Medical directors must have current license as a physician in the state, must have at least 2 years experience or specialized training in geriatrics or care of chronically ill and impaired residents, must have demonstrated successful completion of a curriculum in physician management or administration, and must have privileges at a hospital in the state, be a participant in an HMO network, or be credentialed by a credentialing organization approved by the Maryland Department of Health and Mental Hygiene.
Related Nursing Home Legislation
In addition to the quality initiatives described above, several other regulations were passed by the Maryland General Assembly as part of the nursing home reform package that were not evaluated for this study (as they do not meet our criteria for state-initiated quality improvement programs). They include regulations related to enforcement actions, and include: relocation of residents (COMAR 10.07.02.47); sanctions (.49); civil money penalties (.52, .53, .54, .55); criminal penalties (.56); emergency suspension (.57); license denial or revocation (.58); and hearings (.59). Complete descriptions of the legislation can be found at www.dsd.state.md.us.
Additional Quality Improvement Programs Undertaken by OHCQ
To supplement the changes mandated by legislation passed by the Nursing Home Reform Act, OHCQ has taken several organizational steps to try to improve nursing facility quality. Forty surveyors have been added since 1999 (doubling the number of surveyors on staff), a Chief Nurse and a Medical Director have been appointed, and a Technical Assistance Unit and Abuse Unit have been established. In addition, OHCQ has initiated the following programs as part of the effort to improve nursing home quality within the state.
State Technical Assistance Unit--Quality Assurance Survey
In November 2000, a Technical Assistance Unit was established in the OHCQ to encourage compliance efforts and best practices. The unit consists of a team of five nurses, one dietician, and a manager who are separate from and independent of the federal survey team. This unit is supported by $400,000 in state general funds. The state believed that the use of federal funds would limit its flexibility. The OHCQ received $250,000 from operations for the program.
The team performs a second annual survey, the Quality Assurance Survey, at each Maryland nursing facility. While no legislation mandates a specific quality related survey, regulations require two annual surveys be performed for each facility. OHCQ has chosen to design the "Second Survey" to focus on quality assurance, technical assistance, and sharing of best practices. The survey is unannounced, as required by Maryland law. It is intended to be collegial and consultative, rather than punitive, and total separation is maintained between the technical assistance survey and the federal certification survey. When serious violations are identified as part of the second survey, the QA team brings these to the attention of the nursing home staff and requires a plan of correction. Unless the violations are of an egregious nature and threaten resident safety, the QA team continues to track the violations and provides follow-up to ensure corrective action. In one instance (as of October 24, 2002), the violation was, in fact, referred to a federal survey team for treatment as a complaint.
Quality Indicator Study
The OHCQ examined quality indicators (QIs) for contractures, restraints, and pressure sores for all facilities, and identified 165 nursing homes that had one or more rates that were significantly higher than the state and national averages. Each home was notified in April 2001 and asked to review the quality indicator data and, if appropriate, develop an improvement plan. They were also asked to determine a reasonable decrease in the rate that could be anticipated for calendar year 2001, and to submit the plan and projected improvement to OHCQ. The Second Survey team has incorporated the review of these plans into their protocols. A review of the data after one year indicated significant reductions in all three areas for those nursing homes that were asked to participate in the study.
Best Practices/Training
The state sponsors joint training with surveyors and facility staff. The most recent training program, held in February 2002, was called "Enhancing Quality: Initiatives, Strategies, and Solutions." For this training, facilities were taught how to identify quality problems and how to improve quality. Since the February workshop, two additional follow-up sessions were held that focused on sharing individual QI successes and/or failures.
The Office of Health Care Quality also accepts grant proposals to implement innovative ideas or to conduct research that will improve the quality of care for nursing home residents. Grants are funded by Civil Money Penalty funds.
Clinical Alerts
The Office of Health Care Quality Clinical Alerts Newsletter for licensed providers, first published in December 2001, focuses on problems that the OHCQ has identified through its regulatory activities. OHCQ expects to publish the newsletter four to six times per year and to devote each issue to clinical topics that may pose problems in health care facilities across the state, providing information and references that will help in the day-to-day care of patients. The first "Clinical Observations and Notes" newsletter covers the topics of anticoagulation, the flu season, and physician notification. The Newsletter is available on-line at the OHCQ website. The second issue discussed end-of-life care, specifically requirements of a nursing home to follow advanced directives. Copies of these newsletters are included in Appendix D.
Wellspring Project
This is a collaborative project with the Mid-Atlantic Non-Profit Health and Housing Association (MANPHA) that focuses on increasing the use of clinical practice guidelines, sharing of best practices and empowerment of nursing assistants. To date, there have been training sessions and conferences, and facilities have expressed an interest. Funding was approved in September 2002 and the project, with ten facilities participating, will begin in January 2003.
Pets on Wheels
This is an evaluation of the extremely popular Pets on Wheels program. It is designed to provide quantitative data on the positive impact of pets in the nursing home environment on the quality of life. OHCQ has supplied funding ($51,000) from the Civil Money Penalty Account to do a literature review and conduct resident satisfaction surveys with pet programs in Maryland homes. Results of this evaluation are anticipated in early January 2003.
Family Council Project
This collaborative project with the National Citizens' Coalition for Nursing Home Reform (NCCNHR) is funded by a grant from OHCQ and aimed at improving knowledge and interaction between families and nursing home management. It encourages family run Family Councils through training of staff and families, newsletters and video. In Phase 1, NCCNHR initiated a quarterly newsletter for families and sponsored training workshops for family members and social workers covering topics such as the regulations applying to family councils, promoting participation, establishing family council structure and developing leadership, family council advocacy and communication, and overcoming obstacles to family council development. NCCNHR also conducted a survey of family members, ombudsmen, and nursing home facility personnel in Maryland to gather information about their experience working with family councils. Plans for Phase 2 include extending the work of the family council project and producing a video on family councils for use by family members, ombudsmen and nursing home staff. Project staff will produce the video, offer training at facilities around the state, sponsor workshops on forming and strengthening family councils, and start a website for family councils in Maryland.
Decubitus Ulcer Project
OHCQ is working with nursing homes and hospitals to ensure preventive measures for decubitus ulcers, particularly when residents are transferred between nursing homes and hospitals. Plans include a quality assurance seminar, with facilities developing their own QA plan and follow-up taking place in three to six months, along with recognition for improvements.
Maryland's Nursing Home Performance Evaluation Guide
Maryland also established one of the first state public reporting tools. In 1999, the Maryland General Assembly established the Maryland Health Care Commission (MHCC) to carry out several health care reforms in the state, including development of information on nursing home quality. The MHCC worked with the Department of Health and Mental Hygiene and the Department of Aging, experts in long-term care, representatives of the nursing home industry in Maryland, as well as nursing home advocates and long-term care ombudsmen to produce the Nursing Home Performance Evaluation Guide.
There are several ways to search for information about nursing homes in the Guide, including by name, by location, and by characteristics such as size, ownership and specialty care offered. Once a facility is selected, the user can view facility characteristics (e.g., profit status, number of beds, specialty units); resident characteristics (e.g.; gender, age and functional status); and quality ratings based on the CHSRA MDS-based Quality Indicators (QIs).
The QIs are grouped into the four sub-categories of clinical, functional, psychosocial and medication-prescribing care with ratings given for 21 measures. The quality ratings are represented by filled, empty, and half-filled circles. A full circle is utilized for a facility's QI that is at or below the 20th percentile (fewer adverse events), an empty circle for QIs that are at or above the 90th percentile (more adverse events), and a half-filled circle for the middle 70%. Drilling down in each facility's sub-category score allows the user to view the state-wide range of ratings among all facilities for each of the QIs. The Guide also contains information on inspection survey history including the type, scope and severity of deficiencies noted. Information on interpreting and using the data is also presented, as well as a Consumer's Nursing Home Checklist and advice on how to pay for nursing home care.
The Performance Evaluation Guide is available on-line at www.mhcc.state.md.us/nhguide. A sample performance report is included in Appendix C.
Both the QA Plan requirement and the Second Survey were noted by those we spoke with to be positive aspects of the Maryland quality initiatives. Comments regarding the QA Plan were that a requirement that "formalized" quality assurance was good, and encouraged providers to look at whether they had a comprehensive enough approach. One provider stated that the "formalized approach" to QA makes them stay attuned to issues, in a way they may not without a formal requirement. A facility representative believed that the requirement to meet and review QA activities monthly is positive because it "makes the QA program more meaningful" and helped to give nursing home administrators and management a better understanding of quality issues. Another provider stated that having the quality improvement programs as a focus allows facility nurses to feel empowered, and gives them the perspective that they can have an effect on their environment. This is a great enhancement over the former feeling that the best they could do in terms of performance was score a "zero" on their number of deficiency citations. Finally, the Ombudsmen stated that the process of the facility sitting down and talking with the medical director and each other during the QA meeting has had a very positive effect, and that the QA requirement has made facilities more aware and more accountable.
The Second Survey was seen as a positive aspect of Maryland's quality improvement initiatives. HFAM believes the second survey program is a positive change, and the sharing of best practice information is positive. One facility reported that the second survey was a welcome relief after the state LTC certification survey ("during certification surveys we were grilled, exhausted and I felt kicked"). This group stated that it is a relief to be able to have an open dialogue about problems and issues in resident care, and to obtain advise and feedback. Although there was initially a great deal of suspicion, those we spoke with stated that the Second Survey has changed the relationship between the State and providers and has enabled providers to identify problems and implement corrections.
Other general comments regarding what seems to work well in Maryland had to do with the use of quality indicators in the second survey and in other quality initiatives, and the more positive relationship between the state and the provider community. HFAM noted that the new focus on quality indicators and quality improvement was a good outcome of the QA requirements, and that the focus no longer revolves simply around deficiencies. The Ombudsmen stated that the relationship between the state and providers had improved since the implementation of the quality improvement initiatives. OHCQ is perceived as having attempted to make the survey process less adversarial. Ombudsmen report fewer complaints from facilities about the LTC certification surveys than previously.
Additional positive observations made by providers included the following:
The central themes regarding aspects of the Maryland quality initiatives that were less successful were around communication of quality initiatives with the Ombudsman, provider access to funding, and the minimum staffing requirement. With the exception of one person we spoke with (a supervisor), Ombudsman were not at all familiar with the Second Survey, and wished that they were more informed about this. In general, ombudsmen were unaware of or at least personally unfamiliar with two other initiatives: the clinical alerts and the decubitus ulcer project. They also objected to facilities' inconsistent approach to communicating with them regarding QA meetings and QA activities. All received different levels of communication from their facilities regarding the QA meetings, some inconsistently received meeting minutes, and all wished to be kept abreast of QA activities on a regular basis.
HFAM believes that the health quality account could be more accessible (argues that state has $2 million in CMP monies that they should be able to access for QIPs). Lifespan agreed that more money needed to be made available for quality improvement projects such as WellSpring (Lifespan has applied for grant money from state, but still awaiting approval and funding).
In terms of the staffing requirements, two main areas of program weakness were noted. Ombudsman stated that--despite the facilities' seeming compliance with the posting of staff mandate--facilities often post the number of staff that were on the schedule, not necessarily those that actually reported for work or are actually working on that particular unit. Also some facilities posted the information, but not always in a visible location. This can be confusing for family members. With regard to the minimum staffing requirement, most providers we spoke to believe this requirement to be unnecessary, as the levels required were described as "the bare minimum" and claimed that most facilities staff well above those minimums.
One comment was made regarding potential improvements to the Quality Indicator Study. The state reported that many nursing facilities had unrealistic expectations regarding their expected performance on quality indicators. For example, some facilities may have set goals to have a zero percent QI rate, rather than simply attempting to decrease the rate by a certain percentage. Improved understanding of this issue will be required in order to assist providers in attaining quality improvement goals. The state has begun to conduct an evaluation of this program by looking at baseline data and follow up rates of the three targeted quality indicators.
Another comment was made about the medical director requirement, which was that medical directors are concerned that they do not have enough time to fulfill their responsibilities. For this reason, some questioned the ability of this regulation to have any impact.
Aspects of the QA Plan requirement were seen as having a positive impact on quality of care, and one HFAM representative believed that - though it's too soon to tell if the Medical Director requirements will have an affect on quality--this requirement has the potential to have a positive effect. Those who believed that quality of care were positively influenced by the QA requirement made the following observations:
HFAM stated that the regulations may have merely "fine-tuned" programs already in place intended to enhance quality.
Providers believe that the focus on quality improvement and QIs, combined with the Second Survey, has actually worked to improve quality.
A potential negative impact on resident quality of life was cited by the Ombudsmen as being attributable to the QA requirements. Some facilities have reportedly initiated "Grand body rounds" or "full body checks" in response to need for QA and daily monitoring. This process involves a team (of three staff) rounding on all patients and inspecting their skin (at times including genitalia). The Ombudsmen consider this a violation of patient rights and of privacy, and believe that facilities have begun the practice in response to the QA requirements.
While perceived to have a positive effect, the true effectiveness of the Maryland quality improvement initiatives has not yet been measured. The next phase, per the state, is to evaluate the effectiveness of the programs. According to OHCQ, the eventual evaluation will look at complaint rates, correlations between deficiency citations and areas targeted for facility quality improvement, and facility satisfaction with the Second Survey.
There was no discussion among those we spoke to of any of the nursing home reform legislation being repealed, or any quality initiatives being at risk of termination due to budget cuts or other reasons. This lack of discussion or concern, combined with a generally positive attitude among the provider community about the quality initiatives, indicate that most Maryland QIPs appear quite sustainable. Carol Benner reported that most programs are of cost to providers (vs. the state), and that the Second Survey is likely to continue. "The Second Survey people are protected…they aren't federally funded…".
There were many lessons learned cited by the state staff, and a couple of comments made regarding how the quality initiatives could have been better implemented. A provider stated that the state could have moved more slowly in implementing regulations, as facilities were not adequately prepared for newly required QA activities.
General lessons learned by OHCQ staff in Maryland include:
States need to have creative ways to look for balance between punitive and non-punitive programs.
It is important to obtain industry (and legislative) buy-in. According to Carol Benner, "A lot of the program success is attributable to public relations--getting your ideas out there and promoting them".
States should disclose their goals and be very upfront with facilities when launching such programs.
States should take a multi-faceted approach, since it's unclear what exactly works in improving nursing home quality.
States should conduct intensive training for program staffs on newly enacted regulations before implementation (surveyors thought Maryland might have done this better).
States should take the time to study other quality improvement models, as Maryland did, prior to designing and implementing any new programs.
Program-specific comments had to do with the Medical Director requirement and the implementation of the Second Survey. In terms of the Medical Director requirement, the state reported that, if they had to do this all again, they probably would have engaged in more collaboration with the industry and physician groups to get buy-in from these groups before the Medical Director regulation went into effect. They would, however, advise other states to follow their lead and pass strong regulations to make physicians accountable.
Lessons learned regarding the Second Survey included that, since a process like this is a dramatic departure from the usual "surveyor" mindset, the personality of the technical assistance surveyors is the key to success. The surveyors themselves commented that it is very important early in implementation to assure that everyone involved in the program "be on the same page." They found that, early on in the process, they were not always consistent in their message to facilities. This has improved over time, but could have been dealt with more effectively by more thorough communication.
The Second Survey is evolving with time and as lessons are learned by the surveyors. For example, a standardized tool has been developed for the Second Survey that examines the facility's ability to internally monitor falls, malnutrition and dehydration, pressure ulcers, medication administration, accidents and injuries, changes in physical/mental status, quality indicators, and other important aspects of care. At the time of our visit, all nursing homes had been surveyed once and baseline data had been collected. The Technical Assistance Unit is in the process of reviewing lessons learned from the first year and establishing the focus for the second round of surveys.
Comments on the role of the Federal Government in promoting quality improvement were quite limited. One facility administrator stated that she saw the Federal Government's role focused on data collection, but that the states should be taking the lead on quality improvement programs. The corporate vice president for clinical services stated that she wasn't certain exactly what the role of the Federal Government should be, but that their involvement was critical, primarily because of their responsibility for funding. She noted several possible areas for the Federal Government involvement--data management, producing national trends, and disseminating best practices. She felt that an effort to maximize the utility and applicability of the data to multiple agencies and organizations was important.
The project team was impressed with the level of support that most QIPs received from the various providers that participated in our discussions. The general attitude expressed was that most of the QIPs introduced in the Nursing Home Reform package were feasible, appropriately directed, and able to be implemented by most (if not all) nursing facilities. Some areas for improvement were noted, of course, but by and large those we spoke to were supportive of the programs. Areas noted for improvement were an increase in communication about QIPs between OHCQ and the Ombudsmen and between facilities and the Ombudsmen, and a greater degree of accessibility among providers to special funds for quality improvement projects.
This is not to say that all nursing facility representatives with whom we met in Maryland believed strongly in the ability of the programs to improve resident outcomes. To the contrary, providers were skeptical that these QIPs were sufficient to solve the quality of care problem in nursing homes. They named issues of staffing and of the long-term care survey and certification process as barriers to high quality performance. Providers attributed the biggest problems to promoting or increasing nursing home quality to:
Provider representatives met with also stated that the long-term care survey and certification requirements must be changed, as the process and penalties are so severe that it is impossible for facilities to ever feel positive about performance when the best result that can stem from the long-term care survey is a "zero" deficiency.
Another opinion expressed in general about the quality initiatives was with regard to quality indicators used for measuring facility performance. The opinion was expressed that quality indicators should focus on positive outcomes, rather than just on negative measures. An example of a positive indicator of quality cited was the number of hours the Medical Director is in the facility.
From this project's point of view, it is difficult to say with certainty what will work in Maryland and what may not work to improve nursing home quality. There are a multitude of initiatives underway, all enacted during the same timeframe, all enacted in a climate of decreases in nurse staffing and other changes affecting the nursing home industry (e.g., declines in occupancy, Medicare skilled nursing facility prospective payment, public reporting MDS-based quality indicators). No formal evaluation is currently underway to examine the affect of any of these programs on resident outcomes. Such an evaluation would assist the state in refining and improving upon the current set of quality initiatives.
AHCA. State Summaries of Nursing Facilities, 2001. www.ahca.org/research/keynotes/statefactsheets-2001.pdf.
Time Magazine. Fatal Neglect: In possible thousands of cases, nursing home residents are dying from a lack of food and water and the most basic level of hygiene. October 27, 1997.
U.S. General Accounting Office. California Nursing Homes: Care Problems Persist Despite Federal and State Oversight. HEHS-98-202. July 27, 1998.
U.S. General Accounting Office. Nursing Homes: Stronger Complaint and Enforcement Practices Needed to Better Ensure Adequate Care. T-HEHS-99-89. March 22, 1999.
Missouri was selected for a state site visit because of the project team's interest in the quality improvement projects that have been implemented in the state by Marilyn Rantz and her colleagues at the University of Missouri-Columbia Sinclair School of Nursing. They have developed and implemented the following quality improvement programs in the state: the Missouri "Show-Me Quality Indicator Report" (implemented in 1999), the Quality Improvement Program for Missouri (QIPMO) (pilot tested in 1999 and implemented in 2000), a staff education program for the state's surveyors (which started in the early 1990s), a support group for MDS coordinators (which started in 2001), and a nursing home staff education program (which started in 1997). They think of these as various components of a single quality improvement effort rather than separate programs.
Missouri is the only state with this type of partnership between the state survey agency and a university. The QIPMO program includes on-site technical assistance, educational programs and support groups for facility staff and an educational component for survey agency staff. A Best Practices program is also funded by the state and run by Central Missouri University.
Participants
Abt staff members Alan White and Donna Hurd spent three days in Jefferson City and Columbia, Missouri in July 2002, meeting with state survey agency staff, ombudsman, provider association staff and members, state Quality Improvement Organization (QIO) staff, QIPMO nurses and developer Marilyn Rantz as well as facility staff who had participated in QIPMO visits. Researchers were also allowed to accompany QIPMO nurses on a site visit to observe the TA visit in progress. The following individuals agreed to participate in discussions with the researchers:
Marilyn Rantz and her colleagues at the University of Missouri-Columbia Sinclair School of Nursing were our primary contacts for the Missouri site visit. Dr. Rantz was very generous with her time providing information on state politics, history, development and implementation of the various components of the program both prior to our visit and while we were there. The two QIPMO nurses with whom we met, Amy Vogelsmeir and De Minner were extremely helpful in explaining and demonstrating their role in the program as well as the program's philosophy and in arranging for us to accompany them on a visit. Everyone that we contacted prior to our arrival was open to participating in discussions. Both provider associations invited members in to their office for meetings. Initially, the executive director of the AHCA affiliate had responded that he did not believe that many of his member facilities had participated in the QIPMO program. When assured that the research team was also interested in the reasons that facilities may have chosen not to participate, he was fully cooperative and invited member facilities to be present for our meeting. Interestingly, he was not able to be at the meeting as he was testifying in a lawsuit brought by the association against the governor over nursing home reimbursement. Our contact at the state survey agency included his immediate supervisors in our meetings as well as the individual who had had the most contact with the QIPMO nurses. The Missouri QIO director of nursing home activities contacted us prior to our site visit and requested that in addition to a scheduled meeting with her and members of her staff that she be allowed to sit in on visits with other groups as she too was gathering information on the QIPMO program in conjunction with their work for CMS on the Nursing Home Quality Initiative.
Preparation
Prior to the on-site visit, factual information on the quality improvement program was gathered from a literature review, stakeholder discussions and Missouri DHHS and University web sites. Information on the following aspects of the programs was gathered and organized in a table:
The table was forwarded to Marilyn Rantz prior to the on-site visit for her to review and provide additional or corrected information. The research team used the factual information in the table as a starting point to develop discussion questions that focused on more in-depth issues. Letters of endorsement explaining the project goals, state selection and discussion processes were formulated and sent to prospective participants. In response to a request by the AHCA affiliate, letters of invitation to participate in group discussions were written and forwarded to the provider associations for use with their members. Follow-up phone calls were made to arrange for convenient dates and times for meetings.
Structure
Meetings with the survey agency staff, provider association staff and members, ombudsman, university, state QIO and nursing facility staff took place at their respective offices or on-site at the nursing facility and generally lasted one to two hours. The research team met with the QIPMO nurses at an off-site location and then accompanied them to the nursing facility to observe the technical assistance visit.
Discussions were generally loosely structured with researchers presenting both prepared and spontaneous questions and recording participants' responses in writing.
In order to compare Missouri's nursing home industry with the other study states, we present some descriptive characteristics. There are 552 facilities in Missouri (AHCA web site) with 38,671 residents reported as of Spring 2001. The average number of beds per facility is 99, which is slightly lower than the national average of 108. Missouri's average occupancy rate for its nursing homes (80 percent) is one of the lowest in the nation as reported by the Missouri auditor (2001). The median occupancy rate per facility is 75.9 percent as compared to the national rate of 95.1 percent.
The percentage of for profit and not for profit homes in Missouri is very close to the national averages with 67 percent of Missouri homes operating for profit (vs. 65 percent national average) and 24 percent as non-profit homes (vs. 28 percent national average). There are slightly more homes government operated (9 percent vs. 7 percent). The state has a below-average percentage of chain-affiliated facilities (48 percent vs. the national average of 55 percent). Twelve percent of the state's nursing facilities are hospital-based, which is the same as the national average. The majority of homes are dually certified for Medicare and Medicaid (75 percent) as compared to the national average of 80 percent.
The QIPMO programs originated from the vision of Marilyn Rantz and supporters at the Division of Aging. Dr. Rantz holds a Ph.D. in Nursing from the University of Wisconsin-Milwaukee, Masters of Science in Nursing from Marquette University, and Master of Arts in Teaching from the University of Wisconsin-Whitewater. She has also been a nursing home administrator. While at Wisconsin, she worked under David Zimmerman and provided clinical input to the development of the CHSRA quality indicators.
Dr. Rantz was interested in using MDS data to track nursing home quality and came to the University of Missouri because she would have access to MDS data. Dr. Rantz worked with Paul Shumate, who was then the Director of Long-Term Care Regulation to introduce quality improvement programs. He was interested in seeing that the MDS data be used and improved. She began in 1993 to put the research team together.
A statute establishing the Nursing Facility Quality of Care Fund was introduced in 1994 and made effective in 1995. According to a staff member at the Missouri QIO who had been employed in the survey agency for over 20 years, at the time the Quality of Care Fund was introduced, there had been a great deal of tension between facilities and the Division of Aging. The proposal was introduced as a way to use the nursing home fines to fund quality improvement programs--a way to utilize the fines to prevent future fines. The survey agency accepted the proposition because it provided some assistance for facilities in a manner that did not compromise their role in regulatory enforcement. The statue required that any activities funded under this statute had to be approved by both provider associations.
In 1999, the University ran the pilot study testing the impact of using advanced practice nurses to provide technical assistance to nursing facilities. When the pilot demonstrated that on-going on-site visits were effective in improving resident outcomes, Paul Shumate wanted to expand the program to include all nursing facilities. Around the same time, the state auditor reported that the state was behind on their surveys. Missouri requires an annual certification and licensure survey as well as a briefer interim survey. The AHCA affiliate director did not believe that facilities would accept QIPMO visits without some sort of incentive. He promoted the idea of using the QIPMO visit as the interim survey. As Dr. Rantz explained, she was not in favor of this, as she believed the focus of QIPMO visits should be on quality and did not like being this closely linked to the survey process. Resident advocates feared that the change would weaken enforcement mechanisms. Ombudsman and resident advocates agreed with Dr. Rantz on this. However, in an effort to get the program implemented, she went along with the proposal hoping that the process could later be revised. Linkage to the interim survey lasted only about six months--a regulation was passed requiring that all surveys be unannounced and because QIPMO visits were scheduled in advance with facilities, QIPMO visits could no longer take the place of interim surveys.
Recent changes in the organization of the Division of Aging also appear to have had at least some indirect effect on quality improvement programs. During Governor Carnahan's tenure, there had been an attempt to pass a constitutional amendment to create a separate Department of Aging. This was defeated however, in a statewide referendum. After Carnahan's death in October 2000, the acting governor moved the Division of Aging to the Department of Health and Senior Services by means of an executive order. The intent was to focus more attention on aging issues by moving it into a smaller department (the Department of Social Services had at the time over 10,000 employees). According to informants, the move took approximately one year to organize and had just recently been completed. As part of the transition, the Institutional Services Section of the former Division of Aging became the Section for Long Term Care Regulation under the Division of Health Standards and Licensure within the Department of Health and Senior Services.
During our discussions with stakeholders, and in subsequent correspondence with state survey agency personnel, we received differing opinions of the effect of the reorganization. According to some we spoke to, during the reorganization, there has been significant turnover and staff changes at both the surveyor and management levels, with a resultant loss of much "history" and institutional knowledge, particularly related to QIPMO. David Morgan, Manager of the state's Section for Long-Term Care Regulation, stated that there has not been a great deal of turnover in response to the reorganization. He also notes that the changes that have occurred have given the agency "new perspectives that may find other issues with programs prior staff were blind to."
Concern was also voiced that changes that have occurred as a result of the reorganization have strained the ability of the Section for Long Term Care Regulation to operate effectively, and that the agency is not able to target poorly performing facilities as aggressively as it had previously. However, recent audits have identified several areas of improvement in the management and performance of the state's survey agency. The number of facilities receiving notices of non-compliance has remained stable, and it is not clear whether the reorganization has impacted the effectiveness of the state's survey and certification activities.
Regardless of whether the organizational changes have been beneficial or deleterious overall, many stakeholders expressed the concern that the changes, coupled with the state's budget crisis and the new nursing home quality initiatives launched by the state's QIO, have created a tenuous situation for continued QIPMO funding. Dr. Rantz was able to use her analyses of the effectiveness of QIPMO to secure funding for this year, convincing the state that the program is effective in improving nursing home quality and a prudent funding choice in an atmosphere of competing agency needs.
Marilyn Rantz states that the guiding principle of QIPMO is that "things can be done differently." She explains that much of the care provided in nursing homes is routine and is provided the way it is simply because "it's always been done that way." The QIPMO nurses challenge facilities to think about care planning differently and to make changes in how care is provided to improve quality of care. The program is focused on raising standards of care for the elderly by helping the facility to identify and solve their care problems. QIPMO nurses use the quality indicator reports for quality improvement, not survey improvement. The survey process is focused on meeting minimum regulatory standards, but QIPMO is focused on best practices and applying the current care guidelines to achieve something beyond minimal outcomes. Dr. Rantz believes that if standard care practices are met, it is likely that the facility will not have problems with the survey process.
Quality Improvement Principles and QIPMO
As we compare the various state programs, the research team determined that it would be useful to identify a standard for quality improvement that could be applied to the various state programs as a means by which to compare them. The following key principle and framework for quality improvement as described by Dr. M. Rashad Massoud was identified as such a standard. Dr. Massoud describes the following concepts:
As stated above, Dr. Rantz explained her vision for QIPMO as a program that would encourage nursing facility staff to look at the processes they currently use in a critical manner eliminating the standard, "this is the way we've always done it" approach. Her vision is very similar to Massoud's description of a fundamental principle for improvement. QIPMO focuses on data, as noted above and is highly focused on the needs of the client. Each facility visit agenda is determined by the particular needs of the nursing facility staff. QIPMO nurses work as a team, relying on each other's areas of expertise. They begin by attempting to understand the facility's systems for MDS completion as a first step to determining the accuracy of the data.
Massoud also describes a methodology for quality improvement, PDSA (Plan, Study, Do and Act) also referred to Shewhart's Cycle for Learning and Improvement. The QIPMO program was developed via this process as described above and the activities carried out by the QIPMO nurses in the nursing facilities also follow this standard process. Facility staff are encouraged to collect the baseline data from their "Show-Me" reports, work with the QIPMO nurses to determine the validity of the report and then develop a plan to change their care processes. They implement the change, monitor the results, study the effect as reported in subsequent "Show-Me" reports and either continue the change or modify it to achieve the desired results.
The Missouri Quality Improvement Program for Missouri (QIPMO) is an on-site clinical consultation program intended to assist nursing homes with their quality improvement programs. There are several distinctive features of the QIPMO program:
Nursing facility participation in the program is voluntary. Facilities self-select to have a QIPMO visit by contacting the QIPMO coordinator at the University of Missouri. In 2000 there were 459 QIPMO visits made to 212 nursing facilities. Through July 10, 345 site visits to 163 different facilities had been conducted. (There are about 600 nursing homes in Missouri, and about 45 percent of these have participated in the program).
The program operates separately from the state survey agency. QIPMO is a state-funded program, but the State's Long-Term Care Regulation department has virtually nothing to do with the day-to-day operation of the program, and provides only broad oversight of it (e.g., summary reports of QIPMO nurse activity). Missouri is the only state that operates its technical assistance program through a university.
QIPMO is entirely separate from the state survey and enforcement process. Unlike other states with technical assistance programs, QIPMO nurses are not surveyors and they have no training in the survey process. Instead, they are gerontological clinical nurse specialists. QIPMO visits are confidential (except in the rare cases where cases of immediate jeopardy or actual harm to residents are encountered). No details about QIPMO visits are reported to the survey agency (not even which facilities were visited). QIPMO nurses do not answer regulatory questions. They do not interpret regulations. Their focus is on best practices, evidence-based practice, and standards of care. This separation lets surveyors focus on regulation, while QIPMO focuses on quality of care.
QIPMO makes much greater use of the MDS quality indicators than do other states. The same researchers who developed QIPMO also developed the Missouri "Show-Me Quality Indicator Report," which helps facilities track trends in quality indicators derived from the MDS. A major focus of QIPMO is helping facilities to understand the "Show Me" reports and help them use the quality indicators to develop or refine their quality improvement program. Some QIPMO visits are focused on MDS coding issues, since these contribute to facility quality indicator scores.
The QIPMO program is research-based. The design of QIPMO was influenced by the results of a randomized clinical trial that was conducted in 1999. In this trial, facilities were assigned to one of three groups (facilities that received workshop and feedback reports only, facilities that also received clinical consultation, and a control group.) This research showed that on-going on-site clinical consultation is effective in influencing change in nursing care that affects resident outcomes. This research was the foundation for QIPMO and the "Show Me" reports.
The effectiveness of QIPMO has been studied in-depth. Dr. Rantz and her colleagues have studied the impact of QIPMO on CHRSA quality indicators in the state. Since the implementation of QIPMO, there have been improvements in 16 quality indicators and a decline in only six measures. In addition to analyzing median quality indicator scores, the research team analyzes trends for the 90th and 95th percentile, so that the effectiveness of the program in improving outcomes for low-quality facilities can be understood.
The QIPMO program includes several integral components:
The state also has a Best Practices program administered through the Central Missouri State University.
"Show-Me" Quality Indicator Reports
Electronic longitudinal "Show-Me" Quality Indicator Reports are compiled each quarter and available on-line via the statewide computer network for all nursing facilities in the state. These reports show how each facility is performing over the past five quarters for each CHSRA quality indicator in comparison to statewide tenth percentile thresholds. The reports were developed by Marilyn Rantz and colleagues and are used by the QIPMO nurses to structure and guide the on-site technical assistance visit.
The "Show-Me" Quality Indicator Report consists of the CHSRA quality indicator trend graphs and summary tables, displayed one indicator per page, along with a resident roster listing each resident with the quality indicator(s) that they trigger. The summary table contains by quarter, the facility's QI score, number of residents with the QI, number of residents included in the calculation, number of residents not in the calculation, the applicable MDS items and the statewide summary. Statewide summary includes the tenth percentile score and the facility's ranking in Missouri. Each page also includes a definition of the indicator and explanation of the upper and lower thresholds. Appendix B contains a sample "Show Me" report.
On-Site Clinical Consultation Visits
Beginning in mid-2000, specially trained QIPMO nurses have conducted technical assistance visits at nursing facilities, residential and intermediate care facilities. These visits are voluntary, consultative, confidential and intended to assist nursing homes with their quality improvement programs. The technical assistance component to QIPMO was pilot tested with 113 facilities in 1999. Results of the pilot indicated that on-going on-site clinical consultation by an advanced practice nurse was effective in improving care and outcomes for residents in nursing facilities.
Each visit is facility-specific and begins with a review of the facility's "Show-Me" Quality Indicator Reports. After an understanding of the QI definitions and reports is achieved, QIPMO visits often result in the identification of specific clinical indicators that may need further review. Facility staff are guided through the process to determine whether the QI result is an accurate representation of their residents, beginning with a check of the accuracy of the MDS item coding and progressing to a review of facility care processes in terms of their ability to meet accepted clinical standards. Using the resident roster generated as part of the "Show-Me" reports, QIPMO nurses use actual facility residents to focus discussion on MDS accuracy and resident-specific care processes.
There is no charge associated with the visit. In the course of a QIPMO visit, depending on the needs of the facility, the clinical team may conduct group discussions with members of the nursing care team including nursing assistants, observe care processes, review medical records and provide in-service programs on a variety of MDS-and clinical care-related topics.
Standardization of MDS Education
Recognizing that accurate QI reports would provide the foundation for quality improvement efforts and that accurate MDS assessment data was critical to valid QI reports, University of Missouri faculty partnered with the Missouri Division of Aging to convene a group of industry representatives to guide the on-going state needs for staff education on the MDS. The group included representatives from the Missouri Health Care Association, the Missouri Hospital Association, the Missouri Association for Homes and Services for the Aging and the Missouri League of Nursing Home Administrators. Their goal was to provide consistent and accurate information on the MDS and use the MDS data for quality improvement. The group began meeting in March 1997 and continues to meet on a quarterly basis. In the first year, they developed standardized educational materials on the MDS which are currently required to be used by any individual or organization providing MDS education in the state.
Training materials consist of an "Item-by-Item Guide to the MDS" and a "Case Study: Mrs. M." The Item-By-Item Guide is a reference for correct coding and definitions of MDS items. The Case Study is used for teaching the Resident Assessment Protocols and care planning. They are intended for use with the interdisciplinary team and not just for nursing staff. Workshops are provided several times a year at varied locations throughout the state.
Monthly Support Groups for MDS Coordinators
As they conducted their technical assistance visits, QIPMO nurses became increasingly aware of the high turnover of MDS Coordinators. Believing that the turnover was related to a lack of resources, a lack of support, lack of understanding of their role by administrative staff and co-workers and feelings of stress in their positions, the QIPMO nurses initiated monthly support group meetings in May 2000 in the St. Louis area. Since then, monthly meetings have expanded to the seven geographic regions of the state covered by the seven QIPMO nurses. The support group goals include: (1) Improve MDS coding accuracy, (2) Enhance job satisfaction for MDS Coordinators, and (3) Increase overall staff retention rates.
Meetings are facilitated by QIPMO nurses and are held at volunteer facilities in each region. There is no charge for the meeting, with expenses for mailings covered by the host facility. QIPMO nurses schedule the meetings, select topics or speakers and serve as resources. Meeting formats vary based on the interests and concerns of the group, and problem solving occurs collaboratively. The state regulatory agency, particularly the state MDS coordinator, has been supportive of the group and has visited each region to give the participants the opportunity to ask questions. State technical support staff have also attended meetings, as have regional surveyors.
Surveyor Training, Provider Meeting Participation and other Educational Programming
QIPMO nurses participate in educational programs for state surveyors, providing both annual statewide training and regional training that focuses on clinical topics and the MDS/RAI process. The goal is to provide education for surveyors that is consistent with the information presented to nursing home staff as part of QIPMO. QIPMO nurses also participate in statewide provider meetings conducted and sponsored by the Division of Aging. In 2000 and 2001, provider meetings were held in various cities throughout the state. There was a one-day session sponsored by the Department of Health and Senior Services (DHSS) in which information about the regulatory process was discussed. At the meeting, which was attended by several hundred providers, the QIPMO nurses spoke about their program, which is strongly endorsed by DHSS staff.
Best Practices Program
The Best Practices Program is administered by Central Missouri State University and is unaffiliated with the state survey agency, although it is supported by state funds. A statewide committee, which includes seven representatives from each of the two provider associations and several staff from the state Ombudsman's office, reviews applications from facilities. The committee determines the topics and solicits applications. Thirty facility practices were nominated in 2001. These nominated practices are published and disseminated by the university. Until last year (when there was no conference), award winners were recognized at the Governor's Conference on Aging.
Program Funding
There are three sources of funding for state quality improvement programs: (1) Nursing facility quality improvement fund, (2) Annual nursing facility licensing fee and (3) Civil Money Penalty fines. The state has a bed tax based on the number of residents in each facility. By law, a portion of the tax must be spent on quality improvement. Because QIPMO is funded in part by facility contributions to this fund, regulations state that the use of the funds must be approved by both provider associations. Funds from this tax may also be used for surveyor hiring and training and to purchase equipment. There are no federal funds used for the programs. The DHSS staff that we spoke to were too new to their positions to provide any information about whether the state had ever looked into the possibility of getting Federal funding. They were not aware of any Federal statutes that the state might use to seek Federal funding. It seemed unlikely that the state would fund QIPMO if not for the requirement that the state have a quality improvement program and that the funding would not go back into the state's general fund if not spent on quality improvement.
In 2000-2002, the University received a $625,947 grant for its quality improvement programs. This was less than the $743,424 for 2000-2001, but an increase over the $492,258 that was received in 1998-1999. Funding covers 15-20 percent of Dr. Rantz's time, ½ a Full Time Equivalent (FTE) for a statistician, ½ FTE for a research nurse, seven QIPMO nurses at ¾ FTE each and ½ an FTE of secretarial support. The grant is made to the Sinclair School of Nursing and the Biostatistics Group of the School of Medicine, University of Missouri-Columbia.
Governance of Programs
QIPMO programs are completely separate from the state survey agency and the Division of Aging provides only broad oversight, receiving summary reports of QIPMO activity which identify the number of facilities visited with no facility names specified. All QIPMO programs and staff are the responsibility of the University of Missouri-Columbia MDS and Nursing Home Quality Research Team. The team includes faculty in the Sinclair School of Nursing, the Department of Family and Community Medicine, Department of Statistics, School of Social Work, and School of Medicine.
Management and Staffing
Technical assistance visits are conducted by seven QIPMO nurses, with each nurse covering one of the seven geographic areas of the state. Requests for visits are received by the program coordinator at the University School of Nursing who in turn contacts the nurse covering that particular region. Educational programs are provided by both the QIPMO nurses and Marilyn Rantz. Nurses meet monthly, rotating between an in-person meeting and a conference call. The main purpose of these meetings is to be certain that they are providing consistent information. On a quarterly basis, a nurse from one area will accompany a team in another region in a peer review process to ensure that they are providing information in a consistent manner and that the processes are following QIPMO guidelines.
The QIPMO nurses are gerontological clinical nurse specialists, some with advanced degrees, selected for their clinical expertise and general lack of knowledge of the regulatory process. They are not surveyors, are not survey trained and not currently or in the past affiliated with the state survey agency. Marilyn Rantz, who has a master's degree in education and has done technical assistance in the past, provides training for the QIPMO nurses using role modeling and coaching methods. Dr. Rantz points out that "a nurse is not a nurse is not a nurse," emphasizing that the clinical skills of the QIPMO nurses are key. She states that not just any nurse can do the type of technical assistance that is required in these situations. The technical assistance nurses need to be expert nurses who can help the facilities change their belief systems.
Most of the stakeholders contacted believed that the program as a whole was very beneficial. Feedback from providers that is collected on evaluation forms following technical assistance visits by the QIPMO nurses was overwhelmingly positive. A facility director of nursing expressed that "QIPMO visits are free, not punitive, supportive and encouraging." QIPMO visits have been available since mid-2000 and current facility participation runs around 45 percent. Monthly support groups, initiated in May 2000, seem to be instrumental in introducing the QIPMO nurses to the community, providing education and networking support for the MDS Coordinators and at the same time indirectly promoting the program.
The fact that the quality improvement activities operate separately from the survey activities and that each entity favors and respects the separation was seen as a positive aspect of the program. Surveyors appear to defer to QIPMO nurses on clinical issues, while the QIPMO nurses do not get involved in enforcement/regulatory issues. The survey agency has taken a strong stance in maintaining their role as monitors and regulators and distancing themselves from any consultative role.
The strong leadership and vision of Marilyn Rantz is seen as another positive aspect to the program. Others were impressed by her knowledge of issues related to quality of care in nursing homes and her research skills, as well as her passion for improving quality and her determination in obtaining support for quality improvement programs. She has had to use all of these qualities to successfully implement QIPMO in Missouri. Her experience having worked under David Zimmerman and her familiarity with the CHSRA QIs along with her employment as a nursing home administrator for a 400-bed county home prepared her both as a quality expert and as someone experienced in dealing with the politics sometimes necessary to achieve one's goals. Her strong background in education has been critical to the development and structure of QIPMO and to the training of the QIPMO nurses.
The fact that the QIPMO program is research based puts the program ahead in other states in terms of evaluation and demonstrated effectiveness. The technical assistance visits grew out of a pilot program that demonstrated the effectiveness of on-going, on-site visits by advanced practice nurses on resident outcomes. Dr. Rantz and her colleagues have completed numerous studies on the impact of QIPMO on nursing home residents as measured by the CHSRA quality indicators.
Although the feedback from facilities on the value and effectiveness of the various aspects of the QIPMO program was very positive, it was reported that less than half (45 percent) of Missouri facilities take advantage of the free program. When questioned as to reasons for non-participation, those we spoke with stated that facilities that were part of a chain sometimes felt that those types of supportive services were already being provided for them. Other reasons offered were that facilities were either not aware of the program, did not understand it, did not trust that there was no connection to the survey agency or did not see the value.
There was evidence that some providers, particularly those associated with the for-profit association, did not understand the program. Some of the confusion seemed to result from the early days of the program when QIPMO was used as a substitute for the interim survey that Missouri facilities receive six months after the regular survey. This was a short-lived experiment that was not supported by Marilyn Rantz and which everyone agrees did not work well. For these providers, doing well on their survey was their measure of quality and their primary focus. If QIPMO visits did not help them prepare for and accomplish a good survey, they could not see the value of participating. Furthermore, in the early days of the program when the QIPMO visit could substitute for an interim survey, there were situations in which facilities may have had a productive QIPMO visit, but then received multiple deficiency citations on their next survey, primarily because the QIPMO nurses were not trained in the state regulations and did not provide any counseling around those issues.
Some participants suggested that facilities are not aware that the program exists, despite efforts to publicize the program, given high turnover among directors of nursing and administrators.
Also, because the program was initially associated with the survey process, some facilities do not realize (or believe) that QIPMO is totally separate from the survey agency and does not report its findings to the survey agency. Some facilities are hesitant to allow outsiders into their buildings to review records and observe care. There were also comments that facilities were uncertain as to how to schedule a visit, believing that facilities were made "to jump through hoops" and had to make requests for QIPMO visits in writing.
A few facilities regard QIPMO as a program that "just means more work" for facilities. Given that the program is voluntary, it is likely that QIPMO is not reaching facilities with very poor performance. Such facilities may have little reserves to take on a new project when faced with the day-to-day struggles to keep a facility running, lacking the staff and infrastructure necessary for the QIPMO nurses to work with. The QIO representative who had worked with some of the QIPMO materials felt that some of their forms were too academic and involved for the average facility. She reported taking their fall investigation form and shortening it from four pages to two to make it a more user-friendly.
Missouri is far ahead of other states in terms of evaluating the impact of its quality improvement programs. Dr. Rantz uses MDS data to measure the change in quality indicators associated with the program and has published several journal articles that report these results. In addition, facilities that receive QIPMO visits provide feedback through an evaluation form that they are given at the end of each visit. Analysis of MDS data, suggests that even poor performers are doing better, either due to QIPMO or other changes that have occurred in the past few years.
QIPMO nurses are noting increased levels of MDS understanding and more sophisticated questions, suggesting that the information offered in the support groups is having a positive effect. Participants in the meetings find them to be an extremely valuable resource--a common theme is that knowing that they are not the only one facing particular issues is a major help. One coordinator said that if "they had this kind of support at my last job, they wouldn't have taken me out of the facility on a stretcher with oxygen." The MDS Coordinator at one nursing home the researchers visited participates in the support groups, which she describes as being "very helpful."
Since the implementation of QIPMO, there have been improvements in 16 quality indicators and a decline in only six measures. In addition to analyzing median quality indicator scores, the research team analyzes trends for the 90th and 95th percentile, so that the effectiveness of the program in improving outcomes for low-quality facilities can be understood. Improvement in the following measures has been noted:
Behavioral symptoms (for both high and low-risk residents)--Median low risk prevalence fell from 8.3 percent to 0 between 1998 and 2001; high-risk prevalence fell from 29.7 percent to 25.6 percent.
Prevalence of depression--Median fell from 12.9 percent to 9.1 percent. 95th percentile fell from 39.6 to 32.6 percent.
Prevalence of depression with no treatment--Median fell from 7.1 percent to 3.1 percent. 95th percentile fell from 29.7 to 16.7 percent.
Cognitive impairment--Median fell from 11.7 to 6.7 percent; 90th percentile fell from 27.9 to 21.4 percent.
Prevalence of occasional or frequent bladder or bowel incontinence without a toileting plan--Median fell from 26.7 to 21.3 percent; 95th percentile fell from 92 to 90 percent.
Fecal impaction--Median prevalence for the 90th percentile fell from 2.4 to 0.8 percent.
Dehydration--90th percentile fell from 2.2 to 1.6 percent; 95th percentile fell from 3.6 to 2.3 percent.
Prevalence of bedfast residents--Median fell from 3.1 to 2.3 percent; 90th percentile fell from 9 to 7 percent.
Decline in late loss ADLs for low-risk residents--Median fell from 11 to 10 percent; 90th percentile increased slightly, from 20 to 21 percent.
Decline in range of motion, overall and for both high and low-risk residents--The median fell from 5.7 to 5 percent; the 95th percentile fell from 26 to 21 percent.
Antipsychotic/hypnotic use--Median prevalence fell from 17.5 to 16.7 percent.
Hypnotic use more than two times in last week--The median prevalence fell from 2.1 to 1.9 percent; 95th percentile fell from 9.4 to 8.3 percent.
Prevalence of little or no activity--The median fell sharply, from 26.3 to 14.3 percent; the 90th percentile fell from 50 to 38 percent.
Pressure ulcers for both low and high risk residents--Overall median prevalence fell from 6.9 to 6.2 percent; for low-risk patients, the median fell from 2.6 to 0 percent; for high-risk residents, median prevalence fell from 14.3 to 11.5 percent.
(Note that, as a researcher grounded in solid evaluation skills, Dr. Rantz has not compared outcomes for QIPMO participants vs. non-participants, although the state is now asking her to do this. Such a comparison would confound programmatic effects vs. selection effects, due to the non-random selection of facilities into QIPMO.)
Several quality indicators have gotten worse in Missouri since the implementation of QIPMO, including behavior problems for high-risk residents, patients receiving nine or more medications, range of motion training/practice, and antipsychotics use in the absence of an appropriate diagnosis. Preliminary investigations suggest that these declines may reflect MDS coding issues rather than actual decline of care.
QIPMO faces an uncertain future and during our visit Dr. Rantz had voiced serious concerns about the program's chances for survival. The transition of the survey agency into the Department of Health with the resulting loss in staff that had previously supported the program coupled with the QIO initiative has created an uncertain situation. Rantz stated that it had been difficult to keep the funding this year as the new survey agency staff needed to be convinced that funding for QIPMO was preferable to hiring more surveyors. She was able to demonstrate some of the good outcomes associated with QIPMO and by working with a few supportive legislators, was able to save the program this year.
The new QIO initiative is similar to QIPMO in that it also involves the provision of technical assistance to nursing facilities targeting certain quality indicators for improvement. As the QIO effort got underway, there was concern that the state would see the two programs as duplicative and decide not to continue funding QIPMO. At the time of our visit, the Missouri QIO with whom we had met several times was eager to work with QIPMO and design their programs to complement, not duplicate QIPMO. But, an obvious question that arose was if the state can get the Federal Government to pay for its quality improvement program through the QIO, why then should they also pay for QIPMO? Dr. Rantz stated almost regretfully that she had "helped light the fire" of the QIO program by demonstrating that facility outcomes can be improved through on-site visits and at a relatively small cost.
In a follow-up conversation with Dr. Rantz in November 2002, she indicated that a subcontract for QIPMO nurses to do on-site visits and provide technical assistance to nursing facilities within the QIO scope of work had been successfully negotiated with the QIO and approved by CMS. Dr. Rantz is pleased to collaborate with the QIO as it appears that the QIO work will enhance and not duplicate QIPMO work with facilities.
Marilyn Rantz pointed out that for a program to demonstrate effectiveness, it must be data driven. Data must be presented in a format that is understandable to facility staff and education must be provided around the concept of quality and goal setting. Facilities are too often satisfied with just average performance. Data must assist users to identify the specific residents involved and show changes over time.
Marilyn Rantz believes that the Federal Government should support and expand programs like QIPMO into other states. The partnership between the university and the Department of Health and Senior Services could serve as a model for other states. She also believes that the partnership could be expanded to include the state QIO as well as the state survey agency and an academic institution with a strong clinical focus on gerontology. Together these groups may be able to bring about the necessary changes in facility practices to achieve the desired level of quality. The current involvement of the QIOs in providing technical assistance to nursing facilities concerns Dr Rantz as she fears that CMS' interest in this initiative will not be sustained and that in a few years they may change their focus and direct their efforts and funding elsewhere.
Dr. Rantz would like to see the "Show-Me" Quality Indicator Reports made available to all states and made a formal request to CMS that the CHSRA QIs be expanded to include "Show-Me" reports. She also shared information on the "Show-Me" Reports with the QIOs as an option to include in their programs.
Provider representatives that we spoke with were harsh in their criticism of the Federal Government. The relationship between the state and federal agency was described as being "hostile" and "out of hand," and providers urged the Federal Government to "get off the state's back." Providers were especially upset by a belief that a deficiency-free survey by the state is an indicator of a survey that was not done correctly. There is a belief that a deficiency-free survey by the state often triggers a federal survey. Provider groups encourage the Federal Government to reward good nursing homes with less frequent surveys and to focus resources on poor performing facilities. Their presence in good homes causes a diversion of resources, taking time away from resident care. There was also support for an "outcomes-based survey" and a need to make "penalties consistent" by considering the amount of evidence when making decisions about deficiencies.
Providers also identified inadequate reimbursement as a major cause of poor quality care. Higher reimbursement would eliminate a lot of quality problems, provider representatives contend. The potential reduction in Medicare funding could cause bankruptcy for many Missouri nursing homes.
In addition, the CMS quality indicators, which will be posted on the Nursing Home Compare web site, were criticized for being "too complicated." Because these quality indicators use multivariate risk adjustment techniques, facilities cannot track their scores back to particular residents, thus making it difficult to use for quality improvement purposes.
Lastly, state survey agency staff cited a need for improvements to the CMS Long Term Care Enforcement System, which tracks complaints, particularly for facilities with multiple complaints.
The Missouri program is unique for several reasons. First, it is the only quality improvement program identified by the research team that involves an agreement between a state survey agency and a university. The activities of the university are entirely separate from that of the state survey agency and each appears to respect the others' area of expertise. Surveyors defer to the QIPMO nurses on clinical issues and QIPMO nurses do not give advice regarding enforcement regulations. The future of the QIPMO program is uncertain, however, as support within the agency and the legislature is no longer sure. The QIO initiative at this particular time adds to the uncertainty by introducing a program that by some opinion duplicates what the state is paying the university to provide.
Secondly, the program has a tireless proponent in Marilyn Rantz. She is a uniquely talented individual, highly trained and experienced in research protocols who brings enthusiasm, vision and commitment to the elderly, the long term care community and quality improvement efforts. The QIPMO program reports voluntary participation of 45 percent of facilities, despite the initial and unfortunate connection to the survey process. Facilities that use the program overwhelmingly praise the assistance and support offered by the QIPMO nurses.
Lastly, the QIPMO program is unique in that it is research-based. The design of QIPMO was influenced by the results of a randomized clinical trial that was conducted in 1999. In this trial, facilities were assigned to one of three groups (facilities that received workshop and feedback reports only, facilities that also received clinical consultation and a control group.) This research indicated that on-going clinical consultation is effective in influencing change in nursing care that affects resident outcomes. This was the foundation for QIPMO and the "Show-Me" reports. Dr. Rantz and her colleagues have also studied the impact of QIPMO on CHSRA quality indicators in the state. In addition to analyzing median quality indicator scores, the research team analyzes trends for the 90th and 95th percentile, so that the effectives of the program in improving outcomes for low-quality facilities can be understood.
AHCA. State Summaries of Nursing Facilities, 2001/www.ahca.org/research/heynotes/statefactsheets-2001.pdf.
Massoud, MRF. "Advances in Quality Improvement: Principles and Framework." QA Brief. Spring 2001. 9(1): 13-17
Missouri State Auditor. "Nursing Homes Medicaid Reimbursement Program." Report No. 2001-27. March 28, 2001.
This report describes our review of nursing home quality improvement programs that have been implemented in the State of Texas. We first present background information about the project team's site visit and the history and rationale for Texas's movement toward state-initiated quality improvement. This is followed by a description of each program reviewed by the project team. Findings regarding the strengths and weaknesses (as identified by those who participated in discussions) are presented, as is a discussion of the impact of the QIPs on quality of care and quality of life of nursing facility residents. Finally, lessons learned by the state are presented, along with a brief description of the perceived sustainability of the various QIPs.
Background
Following the completion of the literature review, discussions with stakeholders and the meeting of the Technical Advisory Group, Texas was selected as a site visit state because we were interested in the state's Quality Monitor Program, which started in 2002. Quality Monitoring is a key component of the DHS Long Term Care Quality Outreach program created by Texas Senate Bill 1839 that was passed in 2001. Other components of the program include joint provider/surveyor training and liaison with providers, both of which are designed to improve knowledge of the survey and enhance communication between providers and state regulatory staff.
In addition, Texas has three quality improvement programs that pre-date or were developed independently of the 2001 legislation but that are managed by the same staff as the Quality Monitor Program and are conceptually linked to it. These are:
Participants
Abt staff member Christine Hale and consultant Barbara Manard were responsible for the site visit. Over a four-day visit in August 2002, the research team met with individuals involved in the development and operation of relevant programs; held roundtable discussions with 5 providers (who had recently experienced a Quality Monitor visit) at each of the two major provider associations; spoke with representatives and staff from two consumer-oriented organization; and attended a half-day training program for Quality Monitors during which the research staff talked informally with approximately 10 quality monitors. Formal discussions were held with the following people.
Leslie Cortes, the Director of Medical Quality Assurance, was the primary contact for the Texas site visit. Dr. Cortes oversees most of the quality improvement initiatives discussed below. He is a geriatrician with substantial experience in computer systems and health care quality issues and was responsible for the detailed design and implementation of the Quality Monitor program and several other initiatives discussed below. There were personnel changes in two key positions just prior to our visit. Bettye Mitchell became the new Deputy Commissioner for Long Term Care at the Department of Human Services (DHS) effective July 15, 2002. Evelyn Delgato had just replaced Jim Lehrman who was the Assistant Deputy Commissioner for Long Term Care Regulatory (the agency responsible for the survey and for two initiatives discussed below) for the past five years.
Preparation
Prior to the on-site visit, factual information on the quality improvement programs was gathered from the literature review; stakeholder discussions held in Washington, DC; the Texas state web site; and preliminary telephone interviews with Dr. Cortes and others. Information on the following aspects of the programs was gathered and organized in a table. Questions were generated for areas where information was lacking or was unclear. Activities that were related or similar to each other were grouped together: Information was organized into the following points:
Discussions took place primarily in the offices of agency staff or stakeholders and lasted from one to three hours. Discussions were generally structured with one researcher presenting both prepared and spontaneous questions while the other researcher took notes.
To put Texas in context with the other study states, we have included some comparative data from the American HealthCare Association's 2001 State Summaries of Nursing Facilities.7 As of Spring 2001, there were 1,251 nursing facilities in Texas, with 87,299 residents. Texas facilities are slightly smaller than those in the rest of the country, with an average of 102 beds per facility (vs. 108 nationwide). More of Texas' facilities are for-profit (81 percent vs. 65 percent nationwide) and more are part of a multi-facility chain (72 percent vs. 55 percent nationwide). Median nursing facility occupancy in Texas is substantially lower than in the country as a whole (73 percent vs. 87 percent). Direct care staff hours per resident, according to the OSCAR data reported by AHCA are somewhat lower than the national average (3.09 hours per resident day vs. 3.24 hours).
Impetus for Texas's Quality Improvement Programs
Over the last several years, policy-makers in Texas have undertaken several initiatives designed to address long-standing quality issues. According to those we spoke with, legislative activities and related administrative actions in recent years up through the 2000-2001 biennium tended in the direction of toughening regulations, enforcement, oversight, and accountability. But this direction was reversed (or more balance was introduced, depending on one's perspective) during the 77th legislative session.
Many of the initiatives during the "get tougher" period relate to survey activities and/or provider reimbursement and hence are outside the scope of this project. For example, during the FY 2000-2001 biennium, the legislature mandated a change in the Medicaid payment formula designed to enhance accountability for spending on direct care and encourage improved nursing home staffing. Some of the quality improvement programs described below have their origins during the same period. For example, the state implemented one of the nation's first web-based consumer information systems with facility-specific quality rankings in 1999 and substantially enhanced the system the following year. In addition, the 76th Legislature (2000-2001) mandated and funded the first two annual statewide reviews of quality to identify and quantify specific quality issues.
The Nursing Home Quality of Care Act of 2001 passed during the 77th legislative session and is widely referred to as "Senate Bill 1839." By many accounts, it reflected a more provider-friendly legislative stance. That bill mandated the Quality Monitor program and several other initiatives designed to improve communications (or reduce friction) between providers and the state regulatory agency. They were funded by a shift of approximately $5 million in state and federal funds from the survey and complaint investigations to these alternative activities. This amounted to 82 FTEs transferred out the survey function by the legislature, of which 50 were transferred to the Quality Monitor Program, 16 to a joint training initiative, 14 to function as liaison with providers, and two to a program for resolving conflicts over survey findings. For this reason, the initiatives were seen by some as an effort to gut the regulatory system, which lost approximately 22 percent of its workforce.
While there was general agreement among those we spoke to regarding the origins of key features of SB 1839, the precise origin of the controversial funding mechanism (which was contained in a rider to the appropriations bill) was obscure, with both nursing home associations disclaiming responsibility. Some we spoke to, notably THCA staff, described the intent of SB 1839 as a good faith effort to implement new ways of improving quality, emphasizing greater collaboration between the state and providers, with the state helping by sharing its expertise rather than simply acting as a policeman. Some reported that SB 1839 had its origins in a call from a state senator long active in nursing home quality issues to various stakeholders for ideas about improving quality. The Quality Monitor program was suggested by THCA, based on similar legislation recently passed in Florida.
Responsibility for implementing the quality improvement projects contained in SB 1839 fell to the Department of Human Services (DHS), with the Quality Monitoring program assigned to Dr. Cortes' Medical Quality Assurance group. Since the law was quite general with regard to the Quality Monitor program, DHS leadership tried to fashion a program that was consistent both with the law and on-going efforts such as the statewide quality review and quality reporting system. The resulting program, described below, is significantly different from the Florida program with regard to key details. Two meetings with stakeholders and an outside facilitator were held by DHS to solicit ideas regarding details of the Quality Monitor program. A major concern expressed by consumer representatives at those meetings was the lack of any way for the State to enforce recommendations for quality improvement that might emerge from visits by the new Quality Monitors to facilities. Some saw the new program as a waste of resources because it "lacked teeth". Some providers, however, asserted that whole point of the new program was to try something different from the old regulation and enforcement paradigm, arguing for complete separation of the Quality Monitor program and survey efforts. The compromise fashioned by DHS was to keep the Quality Monitor program and survey separate with two exceptions. First, as specified in the law, Quality Monitors are to report any observed instances of immediate jeopardy. Second, Quality Monitor reports are available over the IntraNet to surveyors and are reviewed as part of preparation for surveys.
All but two of the programs described below (Liaison with Providers and Joint Training) are closely linked to each other and are managed by Dr. Cortes. The programs reflect his underlying vision of the meaning of "nursing home quality" and the need for mechanisms for quality improvement other than regulation/enforcement (e.g., via LTC survey or minimum staffing requirements) or the reimbursement system. Following the World Health Organization's definition, Dr. Cortes describes quality at the highest level as, "Doing the right thing in the right way at the right time for the right person in order to achieve the best possible outcome." A hallmark of the QIPs he supervises is the attention given to measurable, objective, evidence-based operational definitions of specific aspects of quality care.
A good example of this is the way in which the program is dealing with the issue of restraint use. A review of federally-mandated nursing home data made it clear that Texas has for many years rated among the states with the highest rate of restraint use. To determine what constituted quality care with respect to restraint use, DHS commissioned a detailed review of the literature with the results reviewed by a technical panel. Based on this review, they determined that there were six situations where restraint use was clinically appropriate. Other uses were, by this definition,"inappropriate," even though they might not warrant a citation on the federal survey, which incorporates different, more subjective criteria. Thus, improving quality in this area translated into the specific goal of reducing the number of residents who are restrained for reasons other than the few determined to be clinically appropriate. The Texas Quality Monitor Program is designed in part to teach facilities this evidence-based best practice with regard to restraint use, to provide periodic detailed measurement in facilities regarding this best practice, and to provide technical assistance about general ways to reduce inappropriate restraint use.
Another QIP, the legislatively-mandated "Statewide Quality Review" (discussed in more detail below), has been used to gather data relevant to this area such as the documented reasons for restraint use. In addition, this annual survey provides a means of tracking progress on changes in statewide quality with respect to selected issues, thus serving in part as a way to evaluate the effectiveness of the relevant QIPs. These programs work in tandem with educational efforts such as the Geriatric Symposium and QMWeb, also described below, that are used to further disseminate information about appropriate restraint use and other selected best practice areas.
The general theory underlying the QIPs as a whole is that as consumers, practitioners, providers, and policy-makers are educated with respect to nursing home performance on specific, measurable, evidence-based aspects of quality, system quality will improve. In addition, there is a strong emphasis on focusing on a limited number of important issues (e.g., restraint use, hydration, psychotropic drug use) at one time. Finally, most of these QIPs have an associated evaluation component, reflecting a commitment to hold the programs up to systematic scrutiny.
This section includes a description of Texas' quality improvement programs. The following programs were reviewed in detail with those interviewed:
The description of those programs is followed by brief mention of two additional programs:
Statewide Quality Review8
The Statewide Quality Review provides an independent, structured assessment of the appropriateness of care for specific clinical issues identified by the state as quality improvement priorities. This initiative is a legislatively-mandated annual study of quality of care, quality of life, and consumer satisfaction in Texas nursing homes. First conducted in 2000, this survey is designed and analyzed by Dr. Cortes' division with participation by a technical review panel; the survey itself is conducted under a contract with the Texas Nurses Association. State funds (approximately $500,000 per year) support the effort, which includes on-site research in each of Texas' roughly 1,000 homes and data collection regarding a representative sample of 2000 nursing home residents.
The review has four primary purposes:
To identify opportunities for improvement in the quality of LTC services.
To track statewide trends in quality improvement.
To analyze the impact of presumed determinants of quality such as staffing, facility case mix and severity of resident impairment.
To provide a means for measuring the outcome of the Quality Outreach Program created by Senate Bill 1839 (SB 1839) from the 77th Legislature.9
The research is designed to help pin-point areas where there are substantial opportunities for improving quality, to provide information about the possible causes of perceived quality problems (including MDS data quality issues), and to provide a means of tracking statewide progress in selected areas of quality. Findings from the research are also now used as important elements of the Quality Monitoring Program, both as the research basis for determining priority areas for technical assistance and as a way to test protocols.
The 2002 Quality Review was based on the on-site assessment of 1972 nursing facility residents, and it focused five specific issues:
Based on analysis of almost 2,000 nursing home residents, the 2002 report had the following major conclusions:
The majority of residents with urinary incontinence would have potentially benefited from toileting. Fewer than 8 percent of these candidates actually had toileting plans. Neither staffing ratios nor facility case mix explained why toileting needs were not met; nor did these factors show any significant relationship to the appropriateness of toileting plans.
Inadequate clinical evaluation of the majority of residents with indwelling bladder catheters continued to be a significant opportunity for quality improvement. While chronic indwelling bladder catheters were more frequently used among residents who had greater impairments in Activities of Daily Living (ADL), the use was not necessarily appropriate.
During any given week, 19.5 percent of Texas nursing home residents were in waist, trunk or limb restraints. By expert criteria for unavoidable restraint use, 90 percent of all restraint use in Texas nursing facilities was avoidable and unnecessary.
The prevalence of anti-psychotic prescribing in Texas nursing facilities is higher than the national average, 29.4 percent versus 16.9 percent.
The Statewide Quality Review has been used to develop several recommendations for the Quality Monitoring program, including:
Applying the resources of the Quality Monitoring programs to disseminate restraint reduction information to facilities, physicians and families in order to eliminate needless restraints.
Using the Quality Monitors to monitor the management of urinary incontinence care and use of indwelling bladder catheters in order to assist providers whose practices do not meet evidence-based standards for best practice.
Supplementing the Quality Monitoring process with evidence-based best practice knowledge resources including training for providers.
Quality Monitoring Program
The Quality Monitoring program was mandated by SB 1839 that was passed in 2001. The program was implemented in April 2002, and had been in operation for only a few months at the time of our site visit to the state in August 2002.
The purpose of the program is to provide facilities with technical assistance that will help them to achieve improved resident outcomes through the consistent application of evidence-based resident care planning and care practices. By June 2002, half of Texas facilities had received an introductory visit from a Quality Monitor and about 10 percent had received an additional formal visit.
The legislation that created the Quality Monitor program specified only a few program features:10
Quality monitors must a registered pharmacist, or nutritionist who are experienced in long-term care facility regulation, standards of practice in long-term care.
Quality monitor visits are to be unannounced, and may occur during nights, evenings, weekends, and holidays.
Priority for monitoring visits shall be given to long-term care facilities with a history of patient care deficiencies.
Quality monitors may not be used in the conduct of routine, scheduled surveys.
Quality monitors are to assess the overall quality of life in the long-term care facility and specific conditions in the facility directly related to patient care.
Quality monitor visits should include observation of the care and services provided to residents and formal and informal interviews with residents, family members, facility staff, resident guests, volunteers, other regulatory staff, and representatives of a human rights advocacy committee.
Finding from monitoring visits, both positive and negative, should be provided orally and in writing to the facility administrator or director of nursing.
Quality monitors may recommend to the long-term care facility administrator procedural and policy changes and staff training to improve the care or quality of life of facility residents.
Conditions observed by the quality monitor that create an immediate threat to the health or safety of a resident must reported immediately to the regional survey and certification office for appropriate action and, as appropriate or as required by law, to law enforcement, adult protective services, other divisions of the department, or other responsible agencies.
Building on this legislative framework, DHS (with input from two stakeholder meetings) crafted an innovative program that complements other departmental quality improvement efforts. The mission of the Quality Monitoring Program is "to promote the consistent use of evidence-based resident care planning and resident care practices that offer residents the highest possible quality of care and life." A core feature of the program is a set of highly structured protocols and assessment instruments that Quality Monitors use during their visits to determine if care is being provided in accordance with evidence-based best practices. These best practices were determined by DHS through a systematic review of the literature and assistance from selected outside clinical experts.
The initial focus of the Quality Monitoring program is three specific clinical care issues. These are the use of psychoactive medications, the promotion of continence, and the use of restraints. The state selected these issues for special emphasis because they are areas that offer real opportunities for improving the care of the state's nursing facility residents. Each of these is objectively defined. Quality Monitors provide information regarding best practices and how to achieve them, give feedback to facilities regarding the degree to which the facility is providing care consistent with DHS best practice protocols, and help the facility identify system changes that could result in greater use of best practices.
Every nursing facility in Texas has been assigned a Quality Monitor. Caseloads (dictated by available resources) are approximately 30-40 facilities per registered nurse. The plan is for all facilities to have at least one monitor visit a year and for priority facilities to receive as many as are required to address identified problems. Visits are unannounced, and are prioritized based on a variety of factors including a troubled history of regulatory compliance, a history of poor resident outcomes, a DHS assessment of high risk for a poor survey outcome on the next survey visit, a high frequency of serious complaints, and other factors. This prioritization is intended to send monitors to the facilities where they may be able "to do the most good" in terms of helping the facility to improve resident care. Visits occur during work days, nights, evenings, weekends, and holidays.
Given the program's goal of making technical assistance available to nursing facilities, the state believes that it is important that the Quality Monitors develop stable collaborative relationships with individual providers similar to the relationships between facilities and Ombudsmen. To attempt to develop these types of stable relationships, each monitor is assigned a defined group of facilities.
The overall focus of this program is technical assistance, and as Dr. Cortes commented, an initial task can sometimes include getting facilities to recognize that they need the type of technical assistance the program provides. The goal of the Quality Monitor visit is to establish a relationship with the facility, identify system problems and trends in selected areas, and work to help facility staff make improvements as needed. The Quality Monitors are specifically instructed to refrain from telling a facility how to solve a particular problem with a particular resident. During the exit conference, the Quality Monitor is to brainstorm with facility staff regarding potential solutions to identified system problems. Rather than acting as surveyors, the Quality Monitor's job is to be a facilitator of a solution that the facility will "own".
Quality Monitor visits include a variety of activities that are intended to help the monitor and the facility staff to identify quality improvement opportunities. A visit includes an entrance conference, which gives facility staff the opportunity to provide information to the monitor about challenges and issues at the facility. The monitor uses resident assessment and record review to construct an objective picture of the quality of care concerning specific clinical issues. During the visit, facilities also can share their Quality Improvement progress and Quality Assurance Committee activities with the monitor. The monitor spends time time working with the staff to assess the effectiveness of its quality management activities. During the exit conference, the monitor will identify areas where progress has occurred as well as areas where improvement is needed.
After completing a visit, the Quality Monitor prepares a Visit Summary Report. This is a written report that is sent to the facility, typically by email, within ten working days of a monitoring visit. The facility has the opportunity to provide electronic feedback to program managers regarding the visit, the report, and the program in general. This provider feedback is part of the Quality Monitor Program's critical self-evaluation process.
Relationship to Survey Staff
The Visit Summary Report that is sent to the facility is also made available to surveyors for their pre-visit preparation. In addition, as described above, Quality Monitors have specific obligations to report any findings that they believe may indicate imminent danger to residents. In general, only issues that a monitor thinks may constitute abuse, neglect, exploitation, or imminent danger to resident health or safety are reported by the Quality Monitors to the survey agency.
Rapid Response Teams
SB 1839 also mandated the development of "Rapid Response Teams" (RRTs) that are used to conduct more comprehensive assessments of facility quality than a single monitor can accomplish. An RRT is made up of two or more Quality Monitors.
The RRT sometimes operates as a "SWAT Team", going unannounced to facilities that have been identified as being particularly problematic based on referral from the state's survey agency or other events or criteria identified by DHS. The RRT may also respond to a request for help from a facility.
The focus of Rapid Response Team visits depends on whether the visit was requested by the facility. For visits requested the facility, the primary focus is on providing technical assistance in areas of special concern to facilities. In this role, the RRTs can operate to provide technical assistance in areas of special concern to facilities, in contrast to the usual protocols of the regular Quality Monitor visits in which the focus areas are pre-determined by program staff. For example, one facility requested the help of an RRT when the new director of nurses noticed that there had been a large number of falls. The RRT visited the facility and reviewed the charts of the residents who had fallen. They discovered some systematic problems such as medication issues that were contributing to the falls. By law, however, the RRTs may not help a facility prepare for a survey, even though that is precisely the type of technical assistance that many seek.
For other RRT visits, the focus is primarily on the issues that caused the facility to be selected for a RRT visit.
Funding
The Quality Monitor Program is paid for with Title 19 funds and was budgeted for the first biennium of operation at approximately $2.7 million. The match is 50 percent federal and 50 percent state for the managers and 25 percent state, 75 percent federal for the nurses in the field. In order to fund its share of this program, the state transferred 50 FTEs from the survey to this new program. An additional 32 FTEs were transferred from actual survey work to other new functions (e.g., "liaison with providers") within the survey agency.
QMWeb/Development of Best Practices
QMWeb is an internet site (http://mqa.dhs.state.tx.us/QMWeb/) is a training resource of evidence-based practices meant to help long-term care facilities to be able to "do the right thing in the right way at the right time for the right person in order to achieve the best possible outcome."11 The state's goal is to help facilities "achieve optimal resident outcomes through the consistent application of evidence-based resident care planning and care practices." QMWeb presents information to help facilities achieve that goal with respect to selected issues in nursing home care.
QMWeb includes the following:
Selected presentations from DHS provider trainings.
Clinical literature reviews: There are comprehensive literature reviews for Restraint Use in Long-Term Care, Medical Direction and Staff Bylaws in Long-Term Care, The Role and Implementation of Ethics Committees in Long-Term Care Facilities, Interventions for Behavioral Symptoms in the Cognitively Impaired, and Congestive Heart Failure in Elderly Nursing Home Residents.
Calendar listings for long-term care educational events, including those sponsored by DHS and those sponsored by other organizations that requested that information be included on QMWeb.
E-mail addresses and phone numbers for key staff in the state's Medical Quality Assurance department.
A list of the top ten deficiencies in Texas nursing and assisted living facilities.
Quality Matter alerts (e.g., recommendations to nursing facilities concerning the West Nile Virus.)
A set of problem-oriented best practices that address topics such as end-of-life care, medical futility, ethics committees, group disparities in health outcomes (e.g., based on age, race, or gender), restraint reduction, palliative care, and tube feeding. For each of these topics, bibliographies of relevant clinical literature and links to external web resources are provided.
Web links to government agencies, clinical professionals, online journals, patient and family resources, and problem-oriented resources.
Selected presentations from DHS provider trainings, including written materials and streaming media.
A report that describes the pilot test of an innovative quality improvement project.
Several White Papers that were prepared by DHS staff related to long-term or other health care issues.
Information is prepared by DHS staff and subjected to outside peer review before publication. The web site is evolving as more information is assembled. At present, it includes substantial information on topics that are the current focus of the Quality Monitor Program such as incontinence care and restraint use.
One example of the way in which the website provides information for providers is the "resident-centered evaluation and care planning for restraint-free environments" section. This provides background information on the use of restraints in Texas from the 2000 Statewide Assessment, links to resources regarding approaches to reducing restraint use, information regarding best practices regarding restraint use derived from a detailed review of the literature, and a copy of the structured assessment form used in the Quality Monitor Program to assess appropriate restraint use in facilities. As explained above, Texas commissioned a detailed review of the literature in order to develop an evidence-based best practice protocol regarding restraint use (similar efforts are underway or planned regarding other care practices for which no evidence-based best practice guidelines exist). QMWeb contains a 23-page summary of key empirical studies and a 36-minute online streaming media presentation in which Dr. Cortes discusses the literature review and development of the best practice protocol regarding restraint use.
QMWeb is managed in-house as part of the regular duties of DHS staff and is not a separate budget line item. Appendix D and Appendix E show some of the information that is available through QM web--Appendix D shows the state's Problem Oriented Best Practices and Appendix E shows the state's conference calendar.
Quality Reporting System (QRS)
QRS is an evolving web-based consumer information system that provides detailed comparative data about all Texas nursing homes. Its primary purpose is to provide information to assist consumers in making choices about long-term care services. The system was originated by former DHS Commissioner Eric Bost and was first launched in 1999. Initially, the site was used to list, rate and compare Texas nursing homes to assist consumers in selecting nursing home care. In December 2000 a new version of QRS was introduced. The new version included information on hospital-based nursing facilities and new search features to help consumers find specific information more easily. In 2000, QRS also became a fully bilingual (English/Spanish) web site.
Design of the system was under the direction of Dr. Cortes' division of Medical Quality Assurance; work was overseen by an advisory group consisting of representatives from key stakeholder groups (providers, consumers, and the medical community); and a contractor was hired to assist with some of the technical work. The system is funded with Title 19 (Medicaid) monies in the amount of approximately $475,000 per year.
QRS provides quality information from three sources: MDS-based quality indicators (i.e., those developed by CHSRA), survey deficiencies, and the complaint system.12 From these sources, four separate scales are created; results for each home are presented using a system similar to that used in Consumer Reports--a circle that ranges from fully-darkened to fully open, indicating one of five levels of "quality." In addition, a summary score is presented for each home. This score is the simple average of each of the four separate scores. Finally, the system allows users to drill down to increasingly detailed data about each home, including a complete list of all deficiencies on the most recent survey and a summary of the facility's regulatory compliance history over the past few years.
Joint Surveyor-Provider Training
The Joint Training program is a bi-annual conference to educate surveyors and providers on topic areas identified by DHS. Each training has a component based on the top deficiencies in Texas. The first joint training conference was in March 2002 and the focus was on restraints, fall prevention, pharmacy, and incontinence. The next conference was scheduled for October 2002.
The Joint Training Program is carried out under "LTC Regulatory," the DHS division that is also responsible for the LTC survey. The legislature funded the state's share of this program by transferring 16 FTEs from the survey function to the new program. While some joint training has occurred for several years, a legislative mandate in SB 1839 formalized the program and made it more accountable to the legislature The legislation required at least two trainings per year. The joint training staff found this to be inadequate since not all staff could attend the trainings at one time, so the joint training staff are exceeding legislative requirements, and are holding the two required trainings at multiple times in multiple sites.
Liaison with Providers
SB 1839 also mandated this new program which provides a venue for providers and regulatory staff to come together on a frequent basis for discussions on regulations. The goal of the program is to assure that there is a common understanding of the regulations, to facilitate dialogue about concerns regarding inconsistencies in the application of the regulations across different regions of the state, and generally to work to reduce the sense of an adversarial relationship between the regulators and the regulated.
Liaisons are former surveyors who are considered to be particularly knowledgeable about regulatory issues, each of whom are assigned responsibility for one geographic area of the state. The legislature funded the state's share of this program by transferring approximately 14 FTEs from the survey function to the new program. The liaisons had just begun to go out and meet with providers at the time of the site visit.
DHS Geriatric Symposium Series
This educational initiative began in April 2000. The program is a self-sustaining effort funded through registration fees (about $20,000 per session). The purpose of the series is to provide a forum to disseminate information to facility staff and others (DHS surveyors, social workers, consulting pharmacists, LTC regulatory staff, LTC physicians, administrators, and nurses) on evidence-based clinical thinking regarding issues, such as incontinence care and restraint use, that are special concerns of the Quality Review Program. In 2001, the topics were expanded to include additional issues from the top ten deficiencies.
Texas Department on Aging/ Ombudsman Restraint Reduction Initiative
In addition to the programs described above, the Ombudsman and his staff, who have a presence in facilities, are conducting training on resident centered care. Restraints were chosen as a focus because they are a long-standing issue with consumer advocates, restraint use is notably high in Texas and currently a major DHS concern, and the Department of Insurance says that restraint use is a risk factor for liability. Educating families is particularly important because Texas researchers found during the 2000 Statewide Assessment that a substantial portion of clinically inappropriate restraint use was due to families requesting the use of restraints out of concern for their relative's safety. The program will help dispel myths about perceived benefits of restraints in resident safety and help educate staff and families about alternative options. Program content has been coordinated with the best practice protocols developed for the Quality Monitor program. The program is set up in three modules: training all ombudsmen volunteers (60 staff oversee the 850 volunteers), followed by those volunteers training facility administrators and key staff, and then the volunteers/staff educate families on the topic area. There is no mandatory requirement for facilities to participate. The goal of the program is to have ten percent of facilities adopt the program by August 2003.
With regard to the Quality Monitor Program, virtually all of the Quality Monitors with whom we spoke were enthusiastic about the program and the opportunity to make a difference. Several noted that the program provided an opportunity to do the type of teaching they felt was needed. Mid-level program managers noted that program leadership had been exceptionally good and consumer advocates agreed with this assessment. Most of the providers and their representatives also expressed confidence in the current DHS leadership team, reported that opportunities for communication were good, and commented that the Quality Monitors with whom they had had contact were courteous and professional. But consumer representatives and providers we interviewed had difficulty pointing out any other particular aspect of the Quality Monitor Program as excellent at this stage. Since the program is still being rolled out, many were in a "wait and see mode."
According to DHS, those providers who had taken the time to report their comments electronically to program managers as of August 2002 offered a generally positive picture of the Quality Monitor Program:
Among 68 providers expressing an opinion, 70 percent agreed or agreed strongly that the visit had helped them to focus on specific system issues.
Among 60 providers expressing an opinion, 70 percent agreed or agreed strongly that the visit had helped them formulate quality improvement strategies.
Among 70 providers expressing an opinion, 83 percent agreed or agreed strongly that the visit had yielded helpful resources.
Those we spoke with who had positive comments about QMWeb noted the ease with it can be navigated, the usefulness of the content, and the cost/effectiveness of that approach to helping keep practitioners informed. The QMWeb was unfamiliar to many, however, and some who had tried it found using it to be somewhat daunting.
With respect to the Quality Reporting System (QRS), consumer representatives and providers generally agreed about its strong points as well as some of the limitations (discussed below). The system was given high marks for being "consumer friendly" and easy to navigate. While those with whom we held discussions raised various levels of concern about the accuracy of the data and the validity of the rating system, virtually all said that in general, the rating system fairly accurately identified outliers (both excellent and poorer performers). Consumer representatives noted that they did suggest that potential consumers use the system as just one factor in making a decision about a nursing facility and stressed the importance of personal inspections and other sources of information. Providers noted that some facilities who scored well in the QRS were using the fact as a marketing tool.
Two of the newer educational programs, the Geriatric Symposium and Joint Training, were widely acclaimed by those providers who had had experience with them.
During our visit we heard several concerns from provider representatives, particularly regarding the Quality Monitor Program. Many of these less positive comments appear to have been influenced by differences of opinion regarding the type of technical assistance that DHS should be giving providers under the new program. Some had expected that the program would involve Quality Monitors providing more direct consultative assistance such as help with problems with a specific resident's care, or help more focused on how the facility might better meet survey requirements. Some also had expected the Quality Monitors to suggest the names of facilities that were doing some things particularly well. Instead, some expressed the feeling that the Quality Monitor Program appeared to be introducing new and even higher standards than the survey.
Given the litigious climate in the state with respect to nursing home care and severe problems with liability insurance, providers were also particularly concerned that the Quality Monitor reports would be available to surveyors and ultimately discoverable in litigation. Most providers and association staff we spoke to were willing to give the program a chance, however, and thought that their most serious concerns might be addressed by toning down the language in the Quality Monitor's reports. Specifically, providers were quite concerned that the reports used phrases such as "inappropriate care," without making clear that this actually meant care not fully consistent with the particular best practices applied by the program. This problem was being addressed by DHS at the conclusion of our site visit.
An additional theme regarding both the Quality Monitoring Program and the QMWeb centered on a perceived need for more clearly and simply presented information. Most with whom we spoke commented that there is too much information to sift through on the QMWeb and that DHS needed to have increased awareness of facility staff's lack of time for reading an abundance of background materials. Similarly, some stated that the information left by the Quality Monitor was overwhelming and had not been read. Regarding web-based dissemination of information, some noted that facilities in more remote locations may not have access to the internet and that not all facility staff were savvy about navigating the web. Few appeared to understand the relationship between the Quality Monitor Program and the evidence-based best practice models. As noted previously, however, the program had just recently been initiated at the time of the site visit and DHS program staff have subsequently developed new videos and other training materials to educate providers the program.
Providers and consumer representatives raised some of the same issues with the Quality Reporting System as they did with the QMWeb. They were also concerned that the quality information suffered from a lack of timeliness, from frequent inaccuracies that take time to be corrected, and from a lack of risk adjustment in the quality indicators. Several providers were also concerned that deficiencies that have been appealed (and may be overturned) are still listed on the system.
With respect to Joint Training, program staff noted that curriculum development had taken more time than originally expected, slowing program implementation, and that the program needed to be more fully coordinated with the quality improvement efforts under Dr. Cortes' direction.
There was a general consensus among those interviewed that it is to early to determine what impact, if any, the quality improvement activities undertaken in Texas will have on quality of care and quality of life in nursing homes. One consumer representative noted that in her view the new program was likely to have a marginal effect relative to the improvement in quality that might be realized were the state to mandate increased staffing. Some providers said that higher reimbursement rates would be a better lever to improve quality. The Ombudsman, by contrast, noted that the program was focusing on some areas that are very important to resident life and care and that changing practices in those areas would by definition positively affect quality.
The question that naturally arises is the degree to which the program will be able to actually stimulate sustained changes in practices. Among the five facilities that had had a Quality Monitor visit and subsequently participated in discussions with the research staff, one cited an actual change in practice attributable in part to the Quality Monitor visit that reduced restraint use; one stated firmly that the program would have absolutely no effect; and the others fell somewhere in between, with more tending towards the less enthusiastic side. Quality Monitor staff with whom informal discussions were held at a half-day training program could each cite some instances where providers thanked them for assistance provided and appeared to have been inspired to implement some new practices. However, those same staff estimated that as many as four out of ten of the facilities visited in the early stages of the program were at best neutral, and sometimes hostile, regarding the new program. Those anecdotes present a picture of the range of possible responses to the new program. As noted above, a quantitative evaluation of actual changes in quality as defined in the program is planned as part of the next Statewide Quality Review.
Since Texas, like most states, has substantial budget problems, virtually all programs are theoretically at greater risk now than in better economic times. Most of the programs are relatively inexpensive and during our visit, the only program that was said to be potentially vulnerable in the short term was the new Quality Monitor Program. Among those we spoke with, there was some discussion about the possibility of pressure being exerted on the legislature for repeal of the program, stimulated by one or more providers who are unhappy with the program's operation.
Program staff and providers were asked what advice they might give to another state considering implementing programs similar to those in Texas. General lessons learned by program staff from their experience in implementing the Quality Monitoring Program included the following:
It was easier to train nurses for Quality Monitoring positions if they had not had prior surveyor experience. Training former surveyors was difficult because they initially tended to "act like surveyors", sending a message that is counter to the intent of the new program.
Better coordination with respect to scheduling visits between the survey managers and the Quality Monitor staff would have been helpful. Unintended overlaps meant that Quality Monitors had to leave and return some other time, leading to some waste of time and effort.
Complete and well-executed training was found to be important to the success of the program. The monitors in the field are the most important ambassadors of the program. Selecting the right personnel who share the philosophy and goals of the program was crucial.
Salaries for the professional degree positions that will be needed to perform the quality monitoring duties need to be realistic. If there is a huge gap between state and private sector salaries, and/or there is a staffing shortage such as the case with pharmacists nationwide and nursing regionally, then this issue should be addressed upfront.
As noted above, providers had little experience with the program at the time of the site visit. A few we spoke to saw little benefit and advised other states not to implement a similar program. Others thought the program should be given a chance but thought a key lesson from the earliest days of the Texas program was the need for better information about the program's design and goals as well as greater collaboration between providers and DHS on key details. At the end of our site visit, one of the issues that most concerned providers--the wording of the Quality Monitor reports--was being addressed by program leadership.
Time constraints limited exploration of this issue to a brief discussion with DHS staff involved in the new quality improvement projects. They offered the following comments and suggestions:
The new "Quality Improvement Organizations" (QIOs) funded by the Federal Government appear to offer the potential to help states such as Texas leverage their own quality improvement projects; the QIOs should be funded appropriately and encouraged to work closely with states.
Additional federal support for developing, implementing, and evaluating innovative quality improvement projects would be helpful.
Federal regulations are so complex that many homes have great difficulty even understanding the requirements; in addition, trying to get over 1000 nursing facilities in 254 counties in compliance is very challenging. Greater attention to simplification and regulatory moderation would be appreciated.
Policy makers, practitioners, and advocates have long been concerned about quality issues in Texas nursing homes, with little agreement about the best way to address these. Over the last several years, the state has implemented a number of regulatory and other changes--including a major overall of the Medicaid reimbursement system--designed to address some key quality issues. Texas was one of the first states in the nation to implement (in 1999) a web-based quality reporting system. Some believe that these initiatives have focused on marginal issues and/or have involved the investment of too few resources to be effective. For example, a number of consumer groups believe that legislation requiring higher staffing would be the most effective action, while others believe that higher Medicaid reimbursement rates are essential. Some believe that the enforcement of quality regulations has been too lax, while others believe the opposite to be true.
In 2000, the legislature mandated and funded an annual statewide assessment of nursing home quality issues. This annual empirical research effort provides Texas policy-makers with far better information about the scope of problems and progress towards goals than is available in other states. Research to date has revealed a somewhat higher level of customer satisfaction with care than some had expected but also confirmed serious issues in a number of areas such as restraint use.
In 2001, the legislature again debated proposed approaches to address nursing home quality issues. While advocates of substantially higher payment rates and new staffing requirements were not successful, the legislature was responsive to a proposal, first suggested by providers, to try a different approach to harnessing state expertise to help providers improve quality. Some providers had long argued that surveyors focused solely on noting deficiencies, but did little to help homes actually understand what they might do to optimize quality. They proposed a program--initially modeled on one in Florida--in which state long term care experts in nursing, pharmacy, and nutrition would provide consultative technical assistance to homes, focusing first on those where the greatest problems appeared to exist. This initiative, called the "Quality Monitor Program," found support among some consumer advocates (at least initially) and key legislators long involved in nursing home reform efforts because it appeared to have the potential for providing additional state presence, focused on quality, in homes across the state. When the legislation passed, however, it was accompanied by a budget bill that funded the new program (and some smaller initiatives) by transferring 82 FTE from the survey, thus reducing resources available to regulatory enforcement by approximately 22 percent. For this reason, some consumer representatives and other stakeholders have come to view the new Quality Monitor Program's potential effect on quality with considerable skepticism, given the simultaneous reduction in resources available for regulatory enforcement.
When the legislature mandated the new Quality Monitor Program, DHS program implementers had few sources of information to guide them in developing details of a program that met the legislative mandate and also might reasonably be expected to have a positive effect on quality. There have been no formal evaluations of the one long-standing state technical assistance program (i.e. that in Washington State); further, the Texas legislature mandated that the new Quality Monitors operate separate from the surveyors, in contrast to the Washington State program where those providing technical assistance also serve as surveyors. Given this situation, DHS staff focused on designing the new Quality Monitor Program to complement other state quality improvement efforts.
In contrast to a number of other quality improvement initiatives that states have implemented over the years, the new Texas Quality Monitor Program has a clearly identified, objective, and measurable goal; a rational program logic model; and an evaluation plan. The program's success in terms of actually affecting quality depends on the degree to which sustained behavioral changes can be stimulated principally by educational efforts. In part this will depend on provider acceptance of the value of the types of changes the program envisions--namely greater conformity with selected, specific evidence-based best practices. At the time of our site visit, as the program was just getting started, program goals and the best practice protocols were not well understood by most of those we interviewed. In addition, knowledgeable staff at the provider organizations raised some issues about the degree to which local practitioners might fully embrace DHS' best practice concepts.
Finally, most of the providers interviewed had expected a different sort of technical assistance than the Quality Monitors provide. Quality monitors are specifically trained not to instruct nursing facilities regarding specific solutions to specific problems with individual residents or issues; rather, they are to brainstorm with them, allowing facilities to "own" the system solutions. Recognizing the potential limitations of the program model (i.e., its dependence on education to effect sustained change), senior management was beginning to explore the idea of linking with the QIOs to provide more "hands-on" assistance for facilities.
This report describes our exploration of the nursing home quality improvement program initiated by the State of Washington. It begins with background information on the program and how the visit and discussions were structured and continues with a brief description of the origin and rationale for the program. A description of the program follows along with the research team's findings (from discussions with state employees, nursing facility respondents, and consumer representatives) regarding the overall strengths and weaknesses or the programs as well as a discussion of the effect that this program is said to have had on the quality of life and quality of care of Washington nursing home residents. It concludes with suggestions from program designers and participants to other states that might want to implement a similar program, the sustainability of the various programs and the respondents' opinions on the role of the Federal Government in quality improvement in nursing facilities.
Background
Washington State was chosen for a site visit because it has a long-standing statewide technical assistance program, called the "Quality Assurance Nurse" (QAN) program. In addition to the QAN program, Washington also has a program of "corporate visits." In that program, a senior administrator from the survey agency meets four times a year with corporate executives from the nursing home industry to discuss issues related to quality. Our discussions over the 3-day site visit concentrated on the QAN program.
Participants
Abt staff member Terry Moore and project team consultant Barbara Manard met with individuals involved in the management and operation of Washington's QAN program, as well as representatives from two of the state's provider groups, the state's Long Term Care Ombudsmen, and others familiar with the state's program. Over a three-day visit in September 2002, the research team met with individuals and groups associated with the following organizations:
Preparation
Prior to the on-site visit, factual information about the QAN program was gathered from discussions with the Technical Advisory Group and stakeholders (at the national level) and through review of program materials, including the program manual Quality Assurance Nurse Program (State of Washington, Residential Care Services Aging and Adult Services Administration, 2001).
Structure
Initial discussions were held with program administrators, then with a set of QANs at the central program office. Additional discussions were held with Ombudsmen (at their office) and with a set of providers at each of the two key nursing home associations. These meetings each lasted approximately two hours. In addition, research staff accompanied a QAN on a regularly scheduled visit to a home. Finally, research staff attended a meeting (at a nursing facility) of the Board of the Resident Councils of Washington and had the opportunity to discuss the QAN program with participants.
In order to put Washington in context with the other study states, we have included some comparative data from the American Health Care Association (AHCA) web site (AHCA, 2002). There are 275 facilities in Washington, with 21,195 residents reported as of September 2000. The average number of beds per facility is 94, which is slightly lower than the national average of 108. Washington's median occupancy rate per facility is 84 percent as compared to the national rate of 87 percent.
The percentage of for-profit homes is close to the national average (69 percent vs. 65 percent), as is the proportion of beds that are dually certified for Medicare and Medicaid (45 percent in Washington and nationally). The number of direct care staff hours per resident is slightly higher than the national average (3.53 hours vs. 3.24 hours).
Washington's QAN program has evolved over time. The state traces its origins to a program in the 1970s in which a "Nursing Care Consultant" from the state was in each facility about once a month to perform utilization review. Transformation of this role to include additional aspects of quality was spurred by Congressional passage of OBRA '87--the Nursing Home Reform Act. Implementing regulations for this law were delayed at the national level and Washington adopted the OBRA reforms in state law prior to full federal implementation. Washington adopted implementing regulations in 1989.
In the 1980s there were totally separate functions for the QAN nurses and the Survey staff. State program officials with whom we spoke noted, "There was a yellow line down the center of the office to separate the two staffs." Conducting surveys was added to the role of the QAN staff in the early 1990s. QAN nurses, however, generally do not act as surveyors in the same facilities where they provide special quality assistance. Two factors contributed to the decision to merge these roles. First, a stakeholder's task force on quality had concluded that it was important for all to "be on the same page" with respect to understanding the regulations. Second, the state had fallen behind in its surveys and needed additional trained staff available to help. Today, QAN nurses have five functions: (1) providing "information transfer" (described below) for a set of assigned facilities; (2) conducting reviews of MDS accuracy (related to the state's casemix payment system) in those facilities; (3) conducting discharge reviews; (4) operating as surveyors both conducting regular surveys and occasionally serving as complaint investigators; and (5) serving as monitors of facilities that are in compliance trouble.
Washington program officials with whom we spoke reported that in the early days of the QAN program federal officials frequently questioned the state about the appropriateness of the QAN program in the context of the survey, but that over time this concern had apparently lessened. Program officials noted the design of the QAN program has been influenced by a desire to "try to capitalize on federal funds." Thus, as the QAN nurses added surveys to their roles, the state was careful to keep the program in line with federal rules regarding appropriate roles for survey staff. For example, by state law the particular type of technical assistance provided by QAN nurses is called "information transfer." That term comes from federal procedures for the survey. According to a 1998 Report to Congress prepared by the Health Care Financing Administration (now CMS), "If some kind of activities [by survey staff] that could be construed as technical assistance are prohibited, it appears that other kinds of similar activities are permitted. Task IX in the [state Operations Manuel] Survey Procedures for Long Term Care Facilities states that:
'…the state should provide information to the facility about care and regulatory topics that would be useful to the facility for understanding and applying the best practices in the care and treatment of long term care residents.
This information exchange [italics added] is not a consultation with the facility, but is a means of disseminating information that may be of assistance to the facility in meeting long term care requirements. …
Performance of the function is at the discretion of the state and can be performed at various times, including during the standard survey, during follow-up or complaint surveys, during other conferences or workshops or at another time mutually agreeable to the survey agency and the facility…'13
The Report to Congress goes on to say, "…[T]he State of Washington may resolve, or at least balance, the inherent conflict between the traditional surveyor role of determining compliance and an expanded information transfer role by separating these two functions. The two functions are not performed at the same time, and generally not performed by the same person.14
Washington State views the QAN program as one part of a three part integrated system of quality assurance: "an objective survey process, a responsive complaint investigation process, and a proactive [QAN] process. Through these activities, Washington monitors, measures, and intervenes to ensure compliance with defined state and federal requirements."15 Quality assurance is thus closely tied conceptually to compliance with regulations. The QAN program is intended to contribute to quality through four key mechanisms: providing "an early warning system," providing "multiple opportunities throughout the year to proactively identify issues with potential for harm," collecting "meaningful data for" use by other segments of the quality assurance process, and "translating regulatory expectations for facility staff."16
The state's vision of the nature of the QAN program's information exchange (technical assistance) is detailed in the program manual:
"The QAN program is based on the concept that state agency staff members should set up a professional, supportive working relationship with nursing facility leaders and strive to keep the facility staff informed about potential compliance issues that are observed. Working closely with the facility Quality Assurance committee, resident's families and ombudsman, the QAN is effective in identifying potential problems and can provide technical assistance related to regulatory requirements and expectations. Correction of problems and achieving compliance is up to the discretion of facility staff. QAN staff do not consult on how to correct any issue. However, the frequent presence of QANs in the nursing facility helps to insure on-going, stable compliance with the intent of the regulations. This concept improves the survey process and is effective in preventing problems and ensuring on-going facility compliance to the ultimate benefit of the long-term care resident."17
In Washington, quality assurance activities occur at several different levels. The state is divided into six geographic regions, with a core staff of surveyors assigned to each region. In each region, there are dedicated complaint nurses who investigate complaints initiated by the public or facility self-reports. Each region also has a team of quality assurance nurses, who make routine monitoring visits to the state's nursing facilities. The focus of our discussions was the state's QAN program, and this section provides a brief description of Washington's quality improvement program followed by a discussion of program funding and staffing.
Overview of the QAN Program
As noted above, QAN staff are responsible for a number of activities such as conducting surveys in addition to their role providing information exchange (technical assistance). The latter activity is referred to as "QANing" and is the heart of the state's unique program.
Each of the state's 31 QAN nurses is assigned a particular territory for the purpose of QANing; caseloads range from approximately 8-12 facilities, with variations dependent on the amount of travel involved. There is a formal expectation that QAN visits to each facility will occur approximately once each quarter, although, as discussed below, this frequency does not appear to have been met consistently in recent times. In most cases, QAN nurses do not perform surveys in their own territories (i.e., in the facilities for which they are responsible for QANing). However, QAN nurses may cite a facility for deficiencies during a QAN visit, although this would be rare and would be based on an egregious violation which resulted in significant resident harm that was observed or discovered as part of the QAN visit. Other duties such as casemix accuracy review are generally performed in a QAN nurses' own territory.
QAN nurses are survey-trained, and participate as survey team members a minimum of four times per year. According to information prepared by the state's Aging and Adult Services Administration, these are the expectations of the state's QANs:
All QANs are survey trained and participate as a survey team member at least four times each year.
QANs review clinically targeted resident samples with the goal of determining systems that have or are at risk of deficient failed practice.
QANs trend data, make assessments of potential outcomes/harm, and develop follow-up plans for identified issues.
QANs provide quality assurance data for facilities to use in facility quality improvement processes.
QAN data are shared with the survey team as part of the preparation for a survey, as well as with complaint investigators when appropriate.
QAN case-mix accuracy review processes establish the expectation that accurate rates reflecting resident needs are validated, and that facilities must establish sound clinical practices in relationship to assessment.
QAN visits serve both as an "early warning system," and as an opportunity to provide technical assistance to facilities throughout the year. The early warning process occurs as QANs share information with surveyors.
Protocols used during QAN visits
In their external assessment of quality care, the QANs use protocols that incorporate the quality indicators developed by the Center for Health Systems Research and Analysis (CHRSA). Aggregated analyses of facility quality indicators are used in conjunction with other measures to identify facilities that may have more serious or particular types of care problems, based on comparison with their peers or through trend analysis. This is the first stage in a two-step process of assessing the quality of care. The second step, which the QANs perform as part of their facility visits, is to investigate further to determine whether the problem identifies by analysis of the data actually exists.
In general, the expectation is that a QAN visit will involve completing 1-2 protocols for approximately 5-8 residents. The state developed written protocols in selected areas in the mid 1990s, with final revisions in 1998. Each protocol includes a set of questions to be answered about care of a particular resident in a particular domain (e.g., skin integrity) with a place on which to mark the answer. For example, the skin integrity protocol asks among other things "[Was] skin impairment accurately assessed?" and "[Was] skin assessment comprehensive?" The protocols are closely tied to issues that are the focus of the survey even to the point of including reference to applicable F tags.
Observation of a QAN visit
We observed part of a QAN visit, which was said to be "fairly typical." In preparation for the visit, the QAN nurse reviewed the following: the facility's Quality Indicator (QI) reports and trends, trends in casemix, complaint issues, and discharge issues. QAN visits were said to be generally focused on issues identified by the QAN in advance of the visit. In the case that we observed, the QAN nurse decided to focus on skin and bladder management issues. Reviewing the casemix audit information in preparation for the visit she had found several instances of urinary track infections (UTI) and stage 1 ulcers. Further, reviewing the QI showed a somewhat elevated low risk pressure ulcer rate (6.4 percent versus 4.3 percent statewide).
During the portion of the visit we observed, the QAN nurse toured the facility (i.e., did rounds); reviewed 2-3 resident records; interviewed staff and some residents; and observed skin care on 1 resident with a catheter, bowel incontinence, resolved UTI, skin issues, and newly prescribed medication for agitation. The QAN nurse's observations and interviews were structured by a written protocol--in the case we observed, the nurse was completing the skin integrity protocol. The QANs that we interviewed said that providers were enthusiastic about the protocols because they helped them understand the expectations for successful surveys. The QAN nurse whom we observed for part of her visit planned to return to the facility the next day to complete the skin integrity protocol and perhaps the bladder management protocol on 5 residents. In addition to sharing her protocol findings with the facility, she also planned to share the following information at the exit conference: information about immunization (since this is now a CMS focus); issues regarding dental care (a current issue for the survey); and will remind the facility to disseminate the "Dear Administrator" letters from the State with all staff.
The QAN staff we interviewed generally agreed that they do not tell facilities what they should do specifically (e.g., hire more staff). Rather, they said their job is to identify systems issues; for example, they might explain to a Director of Nursing (DON) "You're not getting the critical thinking part." However, one QAN mentioned that she was frustrated by the fact that it was clearly impossible for her to teach a particular DON the whole nursing process, and that she (the QAN) believed the best she could hope for with some was to help fix a specific problem observed in a single visit--for example, pointing out to the nursing staff a resident who clearly needed some help.
While the providers with whom we spoke generally liked it when QAN staff referred them to other facilities as examples of good practices in particular areas, the QAN nurses with whom we spoke differed in their own practices with respect to this aspect of information transfer. About half of the QAN nurses with whom we spoke said that they actually gave facilities the name of another facility to contact for suggestions. The others said that while they did not give out specific names, they did tell facilities about good practices they had seen in other facilities.
QAN Staffing
The state hires only Masters level RNs for the survey position, and all QANs must be qualified surveyors. In addition, the state only hires as QANs those with considerable nursing experience, although this experience need not be in long term care--a point of contention with some providers with whom we spoke. Virtually all of the QANs with whom we spoke said, "This is the best possible job." Program managers report that there are waiting lists for the position. Salaries are said to be competitive with the private sector; in addition, the QANs have considerable independence and reportedly value the "opportunity to make a difference."
Program Funding
The annual cost for salaries and benefits of the QAN staff is approximately $3.72 million, with 75 percent of that allocated to QANing, and 25 percent of time to survey work. Travel and administration are additional. The cost of the QAN program is jointly borne by the state and the Federal Government. The state receives a 75 percent match on the QAN salaries and benefits for the QANing piece because that piece derives from its earlier utilization review (UR) function. Both the state and some providers said that there is a continued emphasis on UR through the discharge protocol. Further, UR is defined as seeing both that patients do not get too much care (i.e., appropriate discharge) and that the care they get is appropriate (the technical assistance piece). As such, the QAN is always functioning in a Utilization Review role, even during quality protocol reviews.
The QAN program is based on the concept that survey agency staff members can establish supportive, professional relationships with nursing facility leaders so that facility staff can be kept informed about potential compliance issues that are observed. Feedback from the Washington providers with whom we spoke suggests that the state has been effective in achieving this goal. Nearly all of those with whom we spoke were very positive about the work that QANs do as QANs (i.e., as opposed to their role as surveyors). Furthermore, virtually all of those with whom we spoke--state personnel, providers and consumer representatives--reported that one of the best things about the QAN program was its close ties to the Survey. Virtually all thought that the state's providing additional help to facilities regarding expected performance (i.e., as would be assessed in a survey) was important and helpful (although some thought that some other things might be more important to quality). Program features that contributed to this, including such things as the protocols and the information provided by QANs, were reported to be aspects of the program that work well.
Positive features cited by providers included these comments:
"When the QANs actually do come around as QANs they can tell you the perfect correction for a problem…they can tell you what the survey is focusing on."
"Its their experience that is helpful."
"They have the ability to assess and then interpret the assessment; they get this from their experience.
"Some of the QANs have been just outstanding…one we had was very prompt in answering questions."
"The accessibility of the QANs is the strength of the program…the facility can call them with questions."
"On the whole I like it; they can come in with an objective eye."
"The QANS and the surveyors talk, so if you know your QAN and have a good relationship, she can influence the surveyors."
"It's a lot better than the police [i.e., the surveyors] coming in once a year."
The Ombudsmen with whom we spoke emphasized some similar positive features noting, "The emphasis is on best practices rather than failed practices [as with the survey]," "It has the potential to develop a working relationship with the facility so that they will call the QAN when the need help; when it works, what makes it work is the relationship." Both the Ombudsman and state program managers reported that it was important that the program is in every facility. One Ombudsman contrasted this program feature with the QIO model saying, "With the QIO, a facility has to volunteer for help. Our experience is that poorer facilities are very fearful of people from the outside. Thus with the QIO model, the rich get richer and the poor get poorer."
Virtually all with whom we spoke said that it would be better if the QANs had more time for QANing. As one provider put it "What's discouraging is that [the QAN program] seems to have been out of commission for a while; they must be doing surveys." Several providers with whom we spoke reported not having a QAN visit in over a year; one reported only one visit in 3 years.
As noted above, most of the providers with whom we spoke also thought the program would be improved if the QAN nurses were not also surveyors. Of those holding this opinion, most said the problem was an inherent conflict of interest; a few thought the conflict of interest was not a problem, but that if the roles were separate, the QANs might have more time to be QANs.
The QAN nurses with whom we spoke had very few suggestions about potential program improvements, other than more time for QANing per se. All said that the caseload was fine (setting aside the need to spend so much time on surveys) and that the QAN job provided a great deal of professional satisfaction. Suggestions for improvement involved things such as a desire for additional training (particularly on the computer) and mentoring.
Some of the limited group of providers with whom we spoke had had some less than positive experiences with the program and these formed the basis of their comments regarding areas of the program that might be improved. Comments along these lines included the following:
"We've often been given conflicting information from the QAN and the surveyors regarding MDS coding" [all in the room during this discussion reported similar experiences].
"Sometimes their information [about quality care] is not a [federal or state] requirement…it's their own personal interpretation and it can be very subjective, based on local 'community standards.'"
"There is a disconnect between Central Office which wants to be helpful and has a consistent vision and the field. Central Office's idea is that this is a partnership, but in the field this doesn't really happen consistently."
"The program should be made more objective."
"The whole philosophy needs to change…they think the know best and they don't; we are the ones who really know the patients…there is too much 'Monday morning quarterbacking.'"
"We don't get enough opportunity to give feedback to Central Office. We know who the QANs are who ought to retire; we are afraid to report them because they might turn up as surveyors or complaint investigators. We're afraid of their retaliation."
The Ombudsmen with whom we spoke joined others interviewed in expressing concern that the QANs appeared to be being diverted to survey work. The Ombudsmen were particularly concerned because this was occurring at the same time that a change in the federal statement of work for survey agencies appeared to the Ombudsmen to give complaint investigation a lower priority than before. Thus, the Ombudsmen were concerned that the two early warning systems (complaint investigation and QANing) were both threatened at the same time. In addition, one Ombudsman with long experience in the field suggested, "The framework of the QAN program is the regulatory system. I'd like to reorient them to more innovation…they need a greater orientation towards quality of life." He further suggested that if a state were organizing a quality improvement program optimally, it should focus on empirically based, evidence-based practices. He reported that these exist in some areas that are also critical to resident quality of care and life (he saw these as inextricably intertwined) such as bathing, nutrition, and hydration.
No formal evaluation of the effect of the QAN program has been made to date. Program managers noted that it is very difficult to tell what influences quality given the numerous factors involved. One manager reported, "In regions with more limited QAN presence we get more complaints." From that and other evidence she had concluded, "Yes, I know that [the QAN program] is positively affecting outcomes and quality."
QAN nurses with whom we spoke were also generally quite positive about the effect of the program on quality. Most cited particular examples of positive changes related to the QAN program. For example, one nurse said, "Yes, I do believe it has an impact. I recently had a facility that had a bad reputation and lots of problems. Initially I was giving them [poor marks on the protocols]. Then we recently did a survey and it came out very well." But these nurses also noted the complexity of quality improvement. Several spoke about the difficulty and seeming futility of working with some facilities where, it was said, "The Administrator and Director of Nursing just can't get it together." In some cases the nurses said, the only thing that turns a facility around is when more and/or different staff are hired. The QAN nurses pointed out that the nursing shortage and current nursing training have a great deal to do with facility quality, regardless of the best efforts of the QAN program.
Providers and ombudsmen with whom we held discussions similarly noted ways in which they thought the QAN program positively affected quality, but also stressed the importance of other factors such as resources. For example, one provider said, "It can definitely have a positive effect on quality of life. For example, some residents won't tell nursing facility staff things they will tell a QAN or another independent person coming in." Another said, "There is potential with the program to correct problems; a good QAN can help facilities prioritize quality problems and can help new Directors of Nursing and facility staff to improve quality." An Ombudsman echoed the theme of early correcting of problems noting, "I think [the QAN program] does have a positive effect because it is taking care of problems at an early stage."
In general, most of those interviewed saw the clearest link between the QAN program and quality to be through the survey. That is, they viewed good performance on the survey as indicating better quality; to the extent that the QAN program helped facilities perform better on the survey--and many that we interviewed said that this happened--the QAN program could be said to positively affect quality.
The State of Washington currently has a $2 billion budget deficit; so all non-mandatory programs will be closely scrutinized. QAN program administrators, however, reported that the program has had the highest level of support by the Administration and that this has been true from the beginning--a critical factor in the program's success they say. One factor that may also help protect the QAN program from budget cuts is the numerous additional roles that the QAN staff plays in addition to QANing. Program managers said that they particularly emphasize the UR function and discharge review to the Legislature, as part of the Agency's mission to make sure that people in Washington State have appropriate choices for care. Further, QAN program managers purposely sought out the casemix review function (which they do as "contractors") because that was seen as a way to provide additional sustenance for the QAN program. By contrast, a newly implemented "Boarding Home/Assisted Living Quality Improvement Consultant (QIC) program that focused solely on quality consulting was recently stripped of its staff due to budget pressures.
Nearly all those with whom we spoke would recommend the QAN program to another state, although many cautioned that any program would need to be tailored to specific conditions in the state. The very few dissenters took issue with the relative effectiveness of this type of program versus another, cautioning other states "Don't do a QAN program if your intent is to improve quality because the effect is likely to be negligible."
The sharpest division among those interviewed regarded the issue of the dual role of the QAN nurses--as both surveyor and provider of information exchange (technical assistance). Program managers and QAN nurses all agreed that the two roles should be integrated, noting "We didn't truly understand the survey until we were trained on it" and "we started with the two roles separate but from experience put them together." Virtually all of the providers interviewed, however, said "The QANs should not also be surveyors," and "Keep the role pure."
Despite that difference, many agreed that the regulatory focus of the QAN assistance (i.e., its close ties to the survey) was a good aspect of the program, one that might well be emulated by other states. Many from both the state and provider sides also emphasized the critical importance of hiring truly top people for the QAN job, given the nature of the task. The program manual and the protocols were also suggested as models for others.
Washington State was a pilot state for the recent federal piloting of national public reporting of quality indicators (QIs). Many of the suggestions for the federal role were related to the federal QI and quality measures (QM) initiatives and to the QIOs. There were very mixed opinions of the QI/QM public reporting, though general agreement among those who commented that "quality indicator" rather than "quality measure" was a more accurate descriptor, since those interviewed did not believe that the QMs are the only aspect of quality that should be considered when making judgments about facility quality. On QIOs, providers, state program managers, and the Ombudsmen were not very enthusiastic about Washington's experience to date, noting among other things that the QIOs appeared to know relatively little about NFs. Many (among those who were not state employees) said that the money might have been better spent in Washington by giving it directly to the state. Some also suggested that there should be direct grants to the states for innovative quality programs. Among other things, an Ombudsman suggested "[The Federal Government] should focus more funding on best practice programs; they should not divert money to the QIOs, but instead to QAN-like programs."
Some providers expressed concerns about what they perceived to be over-regulation from the Federal Government; others were less concerned about the amount of oversight and most concerned about understandable regulations. One provider suggested that it would be very helpful if the Federal Government paid for a "pre survey," so that facilities would truly know what to expect. A number agreed with the provider who said, "We're over-regulated and under-funded."
Those consumers who were interviewed at a meeting of the Washington Resident Councils Board were intensely focused on the importance of staffing to quality. They said "The best thing the feds can do is whatever it takes to improve staffing," "We need minimum staffing," and "More staffing is essential; sometimes I have to wait 1 hour and 45 minutes to get help." These consumers were also skeptical of the QI/QM initiative, saying "The QIs are too clinical," "The QIs don't tell the quality story; you need to talk to residents and the low level staff know what's going on," and "These was no correlation between performance on those QIs in the pilot and 'real quality' as we can see it from our perspective." Finally, these consumers argued that the Federal Government should do more to assure that there is more consumer (resident) representation on federal quality initiatives such as the QI/QM and QIO projects.
Washington State was chosen for a site visit because it has a long-standing, statewide technical assistance program, called the "Quality Assurance Nurse" (QAN) program. The QAN program evolved from an earlier UR program. Today, QAN nurses have five functions: (1) providing "information transfer" (the official name for "technical assistance") for a set of assigned nursing facilities (caseload is 8-12 facilities/QAN); (2) conducting reviews of MDS accuracy (related to the state's casemix payment system) in those facilities; (3) operating as surveyors, both conducting regular surveys and occasionally serving as complaint investigators; (4) conducting discharge reviews to determine if resident rights are maintained when discharged/transferred; and (5) serving as monitors of facilities who are in compliance trouble.
Program administrators and the experienced QANs we interviewed in a roundtable discussion at the Aging and Adult Services Administration's (AASA) central office were very upbeat about the program. These QANs said it was the best possible job because they could actually help facilities improve, while retaining the "stick" of possibly giving citations for deficiencies should that be needed. Program administrators and these QANs thought that "100 percent of facilities" were positive about the program; that the major complaint we would hear would be the diversion of QAN time to work on surveys.
Providers and others (Ombudsmen, key staff at the 2 nursing home associations, and staff and members of the Board of the Resident Councils) did in fact repeatedly emphasize problems with the diversion of QAN time from "QANing" to other duties. As predicted, most said that their main issue with the program was that "QANs don't have enough time to be QANs." Additional issues, however, were also raised. Nearly all of the providers we interviewed (including those generally very positive about the program) said that the technical assistance functions and the survey functions were a conflict and advised other states not to adopt the "multiple hats" approach. All agreed that the success of the relationship between a facility and a QAN was very dependent on the particular situation…the skills of the QAN and a facility's own circumstances. Several of the providers we interviewed had had less than optimal experiences and believed that the program should be substantially changed to be far more objective (i.e., less discretion for the QAN nurse, more reliance on protocols); one firmly believed it should be discontinued. Both of the consumer groups with whom we held discussions were somewhat skeptical about the effect of the QAN program on quality and suggested alternatives.
In the absence of a formal evaluation (including interviews with a scientifically representative sample of providers), it is difficult to know the actual effect of the program or the true extent of provider satisfaction/dissatisfaction. However, the fact that the program--in operation for over 20 years--has withstood the test of time is itself an indication of some success.
Florida Policy Exchange Center on Aging, University of South Florida. "Informational Report of the Task Force on the Availability and Affordability of Long-Term Care for the Florida Legislature in Response to House Bill 1993." February 16, 2001, p. 9.
Florida Policy Exchange Center on Aging, p. 496.
According to analysis by the State Senate, licensure fees were expected to cover $783,000 of the costs of the quality monitoring program for FY 2001-02 and $721,000 for FY 2002-2003.
Source: Senate Staff Analysis and Economic Impact Statement, http://www.leg.state.fl.us/data/session/2001/Senate/bills/analysis/pdf/2001s1202.ap.pdf
The source of the information presented in this section is the State of Maine Long-Term Care Status Report, December 2002, http://www.state.me.us/dhs/beas/ltc/2002/ltc_2002.htm#nursing.
Laura Cote. Description of Behavior Management Consultation. September 2002.
Source: www.ahca.org/research/keynotes/statefactsheets-2001.pdf.
Much of the information in this section is taken from the Statewide Quality Review reports. The 2000, 2001, and 2002 Statewide Quality Review Reports are available on-line at the state's Quality Matters web site (http://mqa.dhs.state.tx.us/QMWeb).
Note that the 2002 Report contain baseline results against which future findings can be compared, thus serving as a basis for a future evaluation of the impact of the program.
The text of this bill is available on-line at http://www.capitol.state.tx.us/cgi-bin/tlo/textframe.cmd?LEG=77&SESS=R&CHAMBER=S&BILLTYPE= B&BILLSUFFIX=01839&VERSION=5&TYPE=B.
Source: QM web site (http://mqa.dhs.state.tx.us/QMWeb/).
See Appendix C for an overview of how the QRS evaluates the state's nursing facilities.
HCFA, Report to Congress: Study of Private Accreditation (Deeming) of Nursing Homes, Regulatory Incentives and Non-Regulatory Incentives, and Effectiveness of the Survey and Certification System, 1998; Section 13.5.4.2 9 (downloaded version, no pagination).
Ibid. Section 13.5.6 (downloaded version, no pagination).
State of Washington, Residential Care Services, Aging and Adult Services Administration, Quality Assurance Nurse Program, 2001, p. 3.
Ibid, p. 5.
Ibid, p. 10.
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