Time to Put Survey Reform into Action

by Steven Levenson, MD, CMD

Winston Churchill once was quoted as saying that "Americans will always do the right thing--after they've exhausted all the alternatives." Regarding long-term care, the alternatives have been largely exhausted--and we are, too.

Over the past year and a half, the LTC Survey series, which closes with this issue, has presented many of the paradoxes of long-term care in the United States. For example, we can identify a distinct care delivery process--but the regulations and survey process only promote some of it. We can identify the components of effective chronic care--but state and federal laws and regulations often fail to incorporate them. We have spent billions to research and publish about what really makes a difference in outcomes--but then we pay billions more to people who ignore them.

We know that all human beings function as an integral unit--but then we fragment care and oversight into little pieces. We can identify facility staff and practitioners who are doing the right thing--but we don't seem to be able to transfer their example to the inadequate performers. We know that nursing home care is often appropriate or even heroic--but the mass media continually provokes public outrage with a one-sided picture. We know that negative outcomes in nursing home residents often occur despite appropriate care--but our judicial system has failed to incorporate appropriate evidentiary standards into the civil litigation process.

In the 1800s, Charles Dickens wrote A Tale of Two Cities to underscore the disparities between the few very rich and the many very poor. A similar dichotomy exists today in the nursing home industry--but this one's about performance, not money.

There's not just one, but several nursing home industries out there. One segment is capable, responsible, and gives remarkably competent care. Another is disheveled, defiant, and deserves condemnation. A third is willing but needs a lot more help. We could readily differentiate among these categories. Each segment needs a substantially different approach. Trouble is, we're treating everyone the same--and it's not working.

The nursing home situation in the United States is entirely fixable. To do so, we must shift our focus and our tactics. We're not really dealing just with nursing home problems or survey shortcomings.

Every other care setting--including hospitals, assisted living, and community care--has similar positive and negative results and performance.

It's time to coordinate our efforts and hold everyone in every setting accountable. Apply universally applicable care practices and management approaches. Promote desired performance and stop reinforcing undesired performance. Listen to individuals who truly understand how to find and fix root causes. Stop letting powerful and influential people who have made the problems try to force us to accept inadequate, shop-worn solutions. Use relevant guidelines and protocols. Pay enough to practitioners who make a real difference. Stop letting powerful special interests exploit the nursing home situation for their personal advantage. Let the public know how to really judge nursing home care effectively.

In other words, we have to stop doing it the "American" way--and instead, do it the right way. That is the integral message of the series.

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

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