Cultural Change Key to Nursing Home Quality Initiative
by Joanna Shoffner
By publicly disclosing information on nursing home quality, the Bush administration is zeroing in on quality improvement as its first major nursing home initiative. The administration hopes the initiative will stimulate competition and spark cultural change within the nation's nursing homes, said Tommy G. Thompson, Secretary of the Department of Health and Human Services, when he unveiled the initiative--which launched in January--at a media briefing here.
"The challenge presented here is for the senior lestanadership in the nation's nursing homes--the administrator, director of nursing, and the medical director--to create an environment that empowers staff and promotes information sharing. This type of cultural change is the key to moving to the next level of care," said geriatrician David Gifford, MD, MPH, Assistant Professor of Medicine and Community Health at Brown University School of Medicine in Providence, RI.
The Centers for Medicare and Medicaid Services and the National Quality Forum (NQF), a nonprofit voluntary, standard-setting organization, have selected for public reporting 11 measures of nursing home quality that are deemed most likely to affect consumer decision making; these include seven chronic and four post-acute quality indicators (QIs; see box at right) that are being tested in a pilot program to determine if they are accurate measures of nursing home care.
| QIs Measured by the CMS Initiative |
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Chronic Indicators
Declines in ADLs: Measures functional decline by a two-point change in eating, bed mobility, transfer, and toileting, or a one-level decline in two or more late-loss ADLs.
Physical restraints: Prevalence of daily use of a limb or trunk restraint or chair that prevents rising.
Pressure ulcers: Prevalence of ulcers occurring within the facility. Rates for high-risk vs. low-risk residents are considered separately, and new admissions and re-admissions are excluded.
Weight loss: Prevalence of new weight loss between calendar quarters.
New infections: Increased prevalence of any of the following: pneumonia, respiratory infection, septicemia, urinary tract infection, viral hepatitis, wound infection, fever, or recurrent lung aspiration.
Pain management: Measures the number of residents who experience moderate pain at least daily.
Anti-psychotic drug use: Measures the use of anti-psychotic drugs in residents with no psychiatric diagnosis and stratifies use into high-risk vs. low-risk residents.
Post-Acute Indicators
Managing delirium: Incidents of persistent delirium symptoms, with second assessment excluding individuals with end-stage disease.
Pain management: Number of individuals who experience moderate pain at least daily, or severe or excruciating pain at any frequency.
Improvement in walking: Number of individuals who maintain walking at the highest level of independence or who improve in walking independence with second assessment.
Re-hospitalizations: Number of individuals who are re-hospitalized directly from the nursing home.
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Facilities are already required to submit these data from the Minimum Data Set (MDS), but this initiative marks the first time that the agency has put the information together in a risk-adjusted format for consumers, Secretary Thompson noted. The challenge will be to present the data in a way that consumers understand.
The pilot program is running in Maryland, Colorado, Rhode Island, Washington, Ohio, and Florida. CMS will begin reporting data from these states next month, and the information will be accessible to consumers on the Internet, in local newspapers, and through toll-free telephone numbers. Results of the pilot will be analyzed and used to develop a final set of indicators--which may be different from those used in the pilot--that will be applied nationwide by October.
CMS will also conduct a series of national hearings on nursing home quality as a follow-up to the initiative.
Public Reporting Here to Stay
In our market-driven health care system, reporting performance measures not only introduces competition among providers, but also supplies consumers with information about quality. This type of public reporting--i.e., report cards--already exists in other areas of the health care system such as health plans, health maintenance organizations, hospitals, and medical groups.
The challenge for long-term care will be to resist being defensive about public reporting and to use the data in a productive way that benefits residents and improves the quality of care they receive and their perception of that quality. Such public reporting of quality data could also help change the public's perception of nursing homes. According to a recent survey conducted by the Kaiser Family Foundation and PBS' Jim Lehrer NewsHour, nearly half of the US public believes that being in a nursing home makes people worse off than they were prior to entering the nursing home. Fifty-five percent of respondents said that they would prefer a hospital to a nursing home if they were hospitalized and needed around-the-clock care (www.kff.org/content/2002/3171).
"Public reporting is a way to provide information so that the public is aware of the care offered in nursing homes, but it also will give good nursing homes an opportunity to receive the praise they deserve. Many nursing homes are providing good care, and it is unfair to continuously lump good nursing homes with the bad," said Dr. Gifford.
Role of QIOs
The centerpiece of the administration's plan involves Quality Improvement Organizations, (QIOs, formerly peer review organizations). During the pilot and at the national rollout later this year, QIOs will serve as a resource for states and nursing homes by providing clinical information, such as practice guidelines, to help facilities seeking assistance in identifying gaps in their care processes.
For instance, a nursing facility's leadership may recognize that weight loss is a concern among its residents. Acknowledging this concern, the facility contacts its local QIO for assistance in implementing a program to reduce weight loss in their facility, an action separate from the survey process. QIOs would then inform the facilities of best practices used by other nursing homes and, if necessary, provide facilities with guides and checklists for step-by-step implementation.
"This kind of information-sharing dramatically speeds the adoption of quality-enhancing techniques, compared to what happens when providers are left entirely to their own devices to figure out what is wrong and what they can do about it," commented David Schulke, the Executive Director of the American Health Quality Association, the national organization representing QIOs.
"One of the objectives of this initiative is to have nursing homes who are not already using quality-improvement techniques and principles to begin looking at their policies, protocols, and ways in which they provide care for each of these clinical conditions," explained Dr. Gifford, who is the Principal Clinical Coordinator of Rhode Island Quality Partners (RIQP), the support QIO for the national initiative. "Problems are approached with the understanding that, by improving how nursing homes provide care for those conditions, they should see improvement reflected in their quality indicators."
"The QIOs are not intended to not focus on regulatory punitive processes, but to provide resources and help for those facilities who identify themselves as needing improvement in a given area," observed AMDA Past President and Public Policy Co-Chair Cheryl Phillips, MD, CMD. "The willingness of facilities to expose themselves by proactively asking for help represents a total shift in the approach to care problems in nursing homes," she stressed. Dr. Phillips represented AMDA on a technical expert panel convened by the RIQP to assist in identifying the most effective model for QIOs to assist nursing homes in developing quality improvement initiatives.
Successfully utilizing the resources offered by the initiative will require a certain level of commitment from the nursing facility and an active and involved medical director. Facilities will need the medical director to help educate other physician staff on clinical conditions and treatments specific to the nursing home population, especially as more community-based physicians are following their patients even after the patients have moved into a nursing home.
Stakeholder Response
Nursing home stakeholders offered cautious support for the pilot. Overall, most organizations believe that the initiative will succeed in giving the public greater access to quality information. Larry Minnix, Jr., President and CEO of the American Association of Homes and Services for the Aging, said the initiative is a "major first step" in providing more detailed information for consumer examination that will hopefully "improve hands-on care."
Speaking on behalf of the American Health Care Association, Chair Mary Ousley, expressed enthusiasm that CMS is implementing a performance measurement that includes accountability and is easily understood by consumers.
Dr. Phillips, who recently received an HHS Primary Health Care Policy Fellowship, added that the initiative could provide an opportunity for the long-term care community to intensify its focus on consumers by bridging the disconnect between consumer expectations about care and physicians' perspectives on care delivery. However, she emphasized that although such public reporting is beneficial, it does not replace the active involvement of a health care consumer looking for a nursing home for an elderly family member.
Organizations such as the National Citizens' Coalition for Nursing Home Reform (NCCNHR) expressed concern about the possible use of QIs to replace other aspects of the nursing home regulatory process such as survey-and-certification activities. Other concerns include the methodology CMS will use to adjust the indicators to reflect regional variations.
"Quality indicators can never substitute for annual on-site inspections, said NCCNHR's Executive Director, Donna R. Lenhoff, Esq. "Nevertheless, QI data can help consumers and states monitor nursing home care, and can be helpful to nursing homes themselves in identifying areas in which they need to improve." Ms. Lenhoff also expressed concern that the QI methodology should not mask problems by overadjusting data, thereby creating potentially misleading information.
Representing the health care workers in nursing homes and other health care settings, Andrew L. Stern, President of the Service Employees International Union, stressed that market competition, in itself, will not solve the quality-of-care problems that exist in many nursing homes across the country.
Closing Thoughts
Instituting this type of cultural change in nursing facilities will require a determined and specific effort to improve quality that extends beyond QIs and public reports. The national initiative can nudge facilities in the right direction, but the real successes will occur in individual nursing homes from relationships created at the local level among facilities, physicians, and consumers.
Joanna Shoffner is AMDA's Health Policy Analyst.
How QIOs Work
Medicare Quality Improvement Organizations (QIOs) are comprised of physicians and other health care professionals. At the facility level, QIOs promote three principles: specific care processes, care teams at the unit level, and pilot testing of changes before implementation.
Using pressure ulcers as an example, if a QIO is assisting a facility whose QIs reveal pressure ulcers to be highly prevalent, the starting point for the QIO would be to encourage the facility to closely examine its care--i.e., the specific ways in which its practitioners address pressure ulcers. This step is critical because high QI numbers do not automatically mean that there are gaps in the facility's care processes. The data simply provide a snapshot of the numbers of residents in the facility with a particular QI--in this case, pressure ulcers.
The QIO would then suggest that the facility create a team at the unit level made up of direct care and other staff. The team would develop an intervention strategy, beginning by asking who does the risk assessment, when the assessment is done, and how the appropriate forms get into the chart.
Facilities are also encouraged to select a physician, nurse practitioner, or medical director to be the facility's "clinical champion"--the person who acts as the facility's clinical resource when questions about pressure ulcers arise. The champion also ensures that staff are implementing the protocols, and reports back to the team periodically.
The last steps for the facility are to pilot test, then monitor, any newly implemented changes. An intervention that may work on one unit of the facility may not work facility-wide. Often, facilities omit this step or implement the change facility-wide before giving themselves an opportunity to adjust it for each specific unit.
By looking at all of these steps in the care process, the team is more able to identify and correct weak links.
Congress created PROs, now QIOs, in 1982 to promote quality health care and to protect Medicare beneficiaries. Prior to the 1990s, their primary function was case review, ensuring that Medicare reimbursed providers for medically necessary services.
QIOs now work across the health care system with physicians, hospitals, and nursing homes in community-based quality-improvement efforts.
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This article originally appeared in
Caring for the
Ages, March 2002; Vol. 3, No. 3, p. 1, 36-40.
Caring for the Ages is an official publication of the American
Medical Directors Association, published by Elsevier. This article may not be
reproduced in any form, print or electronic, without
permission.
The opinions expressed
by the authors are their own
and not necessarily those of AMDA or of Elsevier.
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