Focusing in on the Critical Role of Nursing Home Owners & Administrators

Last of a Series on the Survey Process

by Steven Levenson, MD, CMD

This series has examined the many forces influencing long-term care and the survey process. This, the final article in the series, provides a summary of key points and also looks at how nursing home owners and administrators can institute fundamental reforms that would lessen the need for regulations.

Route to Accountability

Currently, the two main routes to public accountability for nursing homes are licensure and certification. Each state grants nursing home owners (regardless of their for-profit or non-profit status) a license to operate. Actions taken by states against facilities are taken against the owner as the licensee.

Similarly, the federal government reimburses owners for providing covered services to Medicare recipients, and also funds the state-administered Medicaid programs. Each state must certify through the OBRA survey process that the facility qualifies to receive these federal funds.

Thus, surveys ultimately determine whether owners qualify for continued licensure and reimbursement from public funds. Owners are judged indirectly based on how their staff and practitioners provide care. But the care invariably reflects how well the organization functions.

Five Key Ingredients

Some owners and administrators are doing a fine job; their systems are sound and they don't need sanctions to identify and fix their problems. But others either don't know what they're doing or aren't doing what they need to do (see table below).

Owners and managers play a major role in ensuring the delivery of five critical ingredients for successful care. They ensure that care: 1) is based on sound principles and evidence; 2) accommodates but doesn't focus primarily on regulations; 3) is delivered via a proper care process; 4) is rendered by qualified individuals who perform their functions and know their roles; and 5) is guided by effective management, following basic management principles.

Sound Principles & Evidence

Competent care has a solid technical foundation. After all, nursing homes must provide complex medical and nursing care to individuals with multiple physical, functional, and psychosocial risks, needs, and problems.

But nursing homes that deliver competent personal care may do less well in managing common clinical situations. Good intentions are admirable, but insufficient.

There is ample information to support evidence-based practices for most conditions and problems of the nursing home population, including the risks and limits of medical care in the frail elderly and those with end-stage or terminal conditions. Management has a role in ensuring that staff and practitioners obtain and use that information.

Most relevant interventions are relatively straightforward and inexpensive. For example, it is vital to identify and address problems due to medications that cause adverse drug reactions, even if those particular medications are not mentioned in the regulations.

Management should see that the evidence is respected both in providing care and in evaluating outcomes. The care system should be able to identify the rationale for the number, nature, and scope of treatments being rendered to individual patients (see "Do Practices Make Perfect?" in the August 2002 issue, p. 6).

Accommodating, not Focusing on, Regulations

As this series has discussed, regulations alone don't cause poor care; however, misinterpretation or inappropriate application of regulations by surveyors, facility staff, and practitioners often does (see "Are the OBRA Regulations the Source of All Evil?" in the June 2002 issue, p. 22).

Of course, care providers should be mindful of regulatory requirements. But effective nursing home owners and managers recognize that regulations are an inadequate foundation for providing care. As this series has noted, human beings don't operate according to TAG numbers or definitions by third-party payors.

Effective patient-focused care--not discipline-centered, regulatory-centered, or reimbursement-centered care--should be promoted, regardless of whether the specifics of such care are mentioned in the regulations. In fact, effective owners and administrators focus everyone on appropriate care as the route to regulatory compliance, not vice-versa. And, they help staff respond effectively and rationally to inappropriate pressure from surveyors, rather than pushing staff to give in to such pressure.

A Proper Care Process

This series has discussed repeatedly the concept of a care-delivery process (see "LTC Regulations: Devil in the Details" in the August 2001 issue, p. 26). Owners and administrators don't diagnose or treat patients. But you don't need to be a practitioner to understand how a proper care process should proceed. For instance, conclusions (care plans, consultant recommendations, etc.) generally should follow--not precede--information collection and analyses of causes of symptoms. In addition, it is vital to identify causes before instituting treatments.

Nursing home management should not accept or support artificial divisions of care such as "medical" or "social" models. They should expect all disciplines to consider the "big picture," and not allow care to be based on isolated or uncoordinated conclusions or recommendations. And, they should discourage labeling patients based on their primary reasons for admission or principal treatments--for example, as a "wound care," "IV," or "rehabilitation" patient.

Qualified Individuals Playing Proper Roles

Nursing home care requires coordination among individuals of diverse backgrounds and skills. But someone must ensure that coordination and focus on a single rational plan for each patient. The interdisciplinary approach to care may be optimal, but often it's problematic (see "Interdisciplinary Approach: Dream Team or Nightmare?" in the July 2002 issue, p. 11). For example, the typical approach--an owner assigning an administrator to operate the business and a Director of Nursing to oversee the care process--may be ineffective, since care is a facility's principal business function.

In effective interdisciplinary settings, administrators facilitate coordinated, evidence-based care, and referee disagreements rather than letting personal beliefs or preferences dictate care practices. They support the medical director's authority to oversee care policies and practices and expect the medical director to act responsibly.

Primary care physicians and nurses, whose training emphasizes a "head-to-toe" perspective of patients, tie together the bits and pieces of information contributed by other disciplines. And management encourages staff to consider the "big picture" context before implementing consultant recommendations.

A Systems Approach

The nursing home industry has complained about the shortage of qualified staff and knowledgeable practitioners. But a chaotic workplace and dysfunctional management that fails to enforce workplace accountability--not management that holds tough, but fair, expectations--have been clearly identified as primary reasons why employees dislike or leave their jobs (Hodson R. Dignity at Work. Cambridge University Press, 2001).

Effective management can influence performance in any setting. Reasons for inadequate performance in nursing home staff and practitioners can be identified and addressed in most cases, using standard management approaches (see "Are the OBRA Regulations the Source of All Evil?" in the June 2002 issue, p. 22).

Effective nursing home owners recognize that they and their administrators set the tone for appropriate performance, overcoming obstacles and problems, and accepting responsibility.

They must ensure that managers use consistent, evidence-based management approaches to direct and oversee performance and correct performance problems.

Effective owners and administrators go beyond platitudes such as "we just need better communication" or "we need to work more as a team." They also hold people accountable for their performance and ensure that the entire organization is attuned to patient care and supports direct care staff.

The Bottom Line

Nursing home owners and operators are rightfully concerned about the serious consequences associated with surveys and related licensure and reimbursement sanctions. But so far, no approach to accountability--regulatory, political, or voluntary private--has succeeded enough to distinguish good and bad performers (see "Improving Enforcement & Plans of Correction" in the April 2002 issue, p. 31).

The result? Other interest groups are trying to dictate questionable corrective measures based on limited understanding of key causes (see "Who's Really Causing Harm in LTC?" in the September 2002 issue, p. 16). Nursing home owners and administrators can help the situation by promoting effective management skills and performance, and by pressuring problematic colleagues who are giving us all a bad name.

Comparing Effective & Inadequate Ownership/Management

Note: All articles in the LTC survey series that have been published to date in Caring are available online at www.amda.com/caring/surveyseries.htm.

Dr. Levenson is a Multi-Facility Medical Director in Baltimore and Chair of Caring's Editorial Board.

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