Inadequate Care Systems & Processes

The OBRA regulations and related guidelines were intended to help surveyors review care, not give facility staff their primary source of instruction about caring for frail older patients. While they don't clarify all the things that nursing home staff and practitioners should know, they also don't stop anyone from seeking and using essential geriatrics information or from employing a comprehensive care delivery process.

Capable facility staff recognize that they cannot rely on regulations as the primary guidance on how to care for sick, frail, or chronically ill individuals. They realize that the regulations offer suggestions and possibilities, but contain no effective guidance about how to identify the specific causes and treatments of problems in specific individuals. They also recognize that regulations mainly emphasize functional and cognitive assessments, and do not guide nurses or doctors in competent assessment of physical problems or medical conditions. Therefore, they utilize appropriate guidance contained in basic nursing and medical or geriatrics references and elsewhere.

In contrast, problematic facility staff practice "regulatory geriatrics." Or, they may rely on a "fundamentalist" interpretation--that is, they do what the regulations contain, even if it is not relevant to an individual's care, and don't consider as relevant factors that the regulations don't mention. Typically, they don't review much of the geriatrics literature or seek or adapt the information contained in reliable protocols and guidelines. They are not guided by detailed policies and procedures; instead, they rely on the personal preferences and habits of key individuals, leading to inconsistent and often inappropriate practices.

Often, the staff and physicians of problematic facilities do little more than guess at the causes of symptoms or the proper treatments, rather than providing rational explanations for their conclusions or treatment selections. For instance, some problematic physicians don't treat pain adequately, whereas others put almost everyone with pain on narcotics without considering underlying causes.

Facility management or medical directors may simply assume--erroneously--that their nurses and physicians do adequate, appropriate basic assessments. They allow new staff or practitioners to change current approaches indiscriminately, without considering whether existing approaches were optimal. Or, they may allow long-standing staff, practitioners, or supervisors to resist or refuse to change their habits even when evidence clearly shows that those habitual approaches are misguided. They may not help their staff or practitioners keep up with relevant new research findings or recommended changes in practice.

Although the regulations don't help nursing facility owners and management implement and oversee effective care processes and practices, they don't direct them to do these things incorrectly or inhibit them from helping staff and practitioners get the right training and knowledge.

Inadequate Management Policies & Practices

The OBRA regulations and related guidelines offer a few general statements about the roles and responsibilities of key facility management, including the director of nursing, medical director, and administrator. They don't provide details on how to run an effective long-term care organization, or analyze and fix performance or systems problems.

However, they also do not prevent facilities from having effective management or efficient operations, nor do they cause nursing home owners, administrators, or management staff to provide ineffective management or oversight.

Capable administrators and management staff apply well-established quality-improvement and management principles to operate and oversee an effective care delivery system. Problematic administrators fail to adequately manage or oversee their staff and practitioners.

Typically, problematic administrators and owners don't understand what their management and staff are supposed to do, or how to know when they do it right. They don't provide clear enough job descriptions or explain job responsibilities. They lack systems for observing and matching performance with expectations; fail to hold staff and physicians accountable for inadequate performance; don't provide regular or pertinent feedback; cannot identify or correct root causes of performance failures; and fail to suppress dysfunctional behavior and interactions among department managers and supervisory personnel.

For example, they won't help their staff develop and implement an effective approach to advance care planning, or require maintenance personnel to maintain an effective preventive maintenance schedule for equipment needed for patient care, or require business office personnel to help nursing staff update critical contact information such as the phone numbers or addresses of key family members.

The regulations don't direct them to do these things improperly, or inhibit them from getting the proper training and knowledge to run a complex organization effectively. They don't stop anyone from being a good or efficient manager, or from enforcing universal accountability.

Regulatory Misinterpretation or Phobia

The OBRA regulations and related guidelines created unprecedented expectations for nursing homes. The OBRA enforcement provisions and sanctions have greatly raised the consequences for noncompliance. Yet, the regulations set out only basic criteria for compliance; they don't tell facility staff how to care for patients in a manner that enables regulatory compliance.

On the other hand, they do not direct nursing home staff to overlook good care practices, nor do they tell facility staff to consider the annual survey as their primary or only reliable source of feedback about the quality of their practices and care systems.

Capable facility staff understand that the principal route to regulatory compliance is by providing effective care based on a solid care process and rational management practices. Regulations are not the primary purpose of their business. They 1) recognize that survey deficiencies are usually symptomatic of other problems; 2) seek and address underlying causes; and 3) adjust or adapt evidence-based approaches in order to accommodate regulatory expectations.

They don't mistakenly use regulatory tag numbers as the primary basis for their approaches to care. For example, problems with medications are not just directed at consultant pharmacists, and problems with falls are not just considered to be nursing or rehabilitation issues.

In contrast, problematic facility staff worry so much about regulatory compliance or reimbursement that they do inappropriate things that actually worsen the care and their compliance problems. For example, an administrator may tell staff to call physicians immediately at any time for all resident incidents or lab test results, because surveyors found one or two failures to identify and manage significant abnormal test results. This approach does not work, because it fails to address the root causes of such problems--e.g., the failures of nurses to recognize the significance of results or of physicians to respond in a timely fashion to significantly abnormal results, or the lack of an organized approach to monitoring patients with significant abnormalities until such issues are resolved.

Problematic facility owners and administrators may let lawyers dictate or unduly influence clinical policies, such as those related to advance directives or decisions about artificial nutrition and hydration in people who lose weight. They may let accountants or reimbursement consultants tell the staff what patient issues they should address (primarily based on the RUGs or other payment systems) or how to document clinical findings in the chart. They overreact to survey deficiencies, forcing staff to make superficial corrections for survey compliance but failing to seek or address root causes.

In addition, problematic facility management may hire outside consultants who do not understand the care process or how to identify these root causes. Or, they may not understand the nature of clinical problems, and instead confuse a citation with the discipline responsible for causing or correcting the problem. For example, a dietitian may be hired to correct a survey deficiency related to weight loss, when the real cause of weight loss is related to undetected adverse drug reactions or physicians' failure to address other correctable causes of anorexia. Sometimes, facility administrators, owners, or directors of nursing ask surveyors about how to correct their problems, and prefer any answer--however farfetched--from a surveyor or state agency to sound advice from a competent medical director.

Problematic owners and administrators tend to find and fire scapegoats--often the very individuals who are trying to fix the problems--while failing to hold the true offenders accountable. When effective consultants identify problems such as inadequate physician or medical director performance, administrators or owners of problematic facilities either cannot or will not address these problems.

Yet, the regulations don't direct nursing homes to allow unknowledgeable individuals to give poor advice that leads to ineffective problem solving, nor do they inhibit facilities from following relevant quality improvement principles to solve problems definitively.

Does the Devil Make Us Do It Wrong?

Many owners, staff, and practitioners involved in the nation's nursing homes recognize the factors--including reimbursement peculiarities, an inadequate work force, and certain elements of the regulations and the survey process--that make it harder to perform adequately. Nonetheless, they accept responsibility for their decisions and actions, and recognize the need to identify and correct problems and improve their practices.

Others, however, find it far too easy to blame the OBRA regulations for everything from the nursing shortage to their own internal care problems.

But the OBRA regulatory system does not cause--and should not be blamed for--many of the common inadequacies and recurrent mistakes that occur in too many facilities. Most of these problems are predictable, resulting from the failure to adhere to simple, universal management and clinical principles that are independent of nursing homes and the OBRA regulations. Proper adherence to such principles can prevent and correct these problems.

With apologies to Shakespeare, we may truly say that "the fault, dear friends, often lies not in our regulations, but in ourselves."

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

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