OBRA regulations concentrate on data collection and care planning, and contain little about critical intermediate steps, such as problem definition and cause identification

OBRA guidelines offer many generalities and options about care, but cannot determine correct approaches in specific patients; they only allude to, but do not sufficiently emphasize, use of effective decision-making guidance such as process-oriented clinical practice guidelines

Regulations do not give either facilities or surveyors enough relevant detail about process expectations

The entire care process, not just parts of it, must be emphasized (8/01)

The survey process must acknowledge that regulations cannot guide specific interventions in specific patients. It should provide explicit process expectations and clarify external sources of desired practices (8/01, 10/01)

Regulations should provide much clearer process expectations (10/01, 2/02)

OBRA regulations are not a manual for providing effective geriatric care, despite beliefs to the contrary

Regulations and the survey process should be viewed as a means for surveyors and survey agencies to influence performance and review compliance; they should reflect--not try to create--a standard of care

Although regulatory compliance alone does not enable adequate care, the primary objective of many facility practices has become regulatory compliance

Regulations and survey guidance were never meant to provide comprehensive support for facility practices or processes

OBRA guidelines and the survey process should focus on reinforcing good care practice and processes; they should not position regulatory compliance as the means to improving care quality (10/01)

Surveyor guidelines contain too many details about potential treatments and practices, and not enough detailed procedures showing surveyors how to systematically identify proper care processes

Current information in the guidelines and protocols do not adequately show facilities how they can demonstrate a plausible basis for their care decisions

Guidelines should explain how facilities can show surveyors the basis for their care-and-treatment decisions, and not be overly prescriptive about interventions in specific situations

Surveyor guidance should provide more clear, detailed procedures to judge the adequacy of care processes, and shift away from trying to judge practices, especially where several reasonable treatment options exist (10/01)

Surveyor instructions should be reorganized and consolidated, providing clearer detail about how to gather and interpret information correctly (11/01, 12/01)

The current survey process only sometimes reinforces proper care processes or inhibits improper performance

Surveyor guidance often has disorganized, conflicting, or incomplete instructions that do not help state agencies to give facility staff detailed, technically correct, or consistent feedback

Surveyor guidance should be revamped to focus on detailed, systematic methods for collecting and analyzing information, correctly identifying and documenting problems, and starting facility staff down the proper path to process improvement (10/01)

Oversight of surveyor and state agency performance appears to focus mostly on whether deficiencies were written correctly, not on whether surveyors consistently follow proper investigative methods and draw clinically valid conclusions

There is little emphasis on having state survey agencies hold their surveyors accountable for consistently fair, impartial, accurate use of proper investigative procedures

Many surveyors are not given enough guidance or oversight, and their techniques for collecting data and drawing conclusions are not sufficiently reviewed or corrected

Survey instructions should emphasize consistent, accurate methodologies and surveyor performance as a critical route to facility improvement

Survey instructions should promote essential principles of how to give feedback to influence performance effectively

State agencies should scrutinize surveyor performance more effectively and provide proper feedback on procedural issues (10/01)

Surveyors may draw conclusions about facility and practitioner performance before gathering all relevant information

The State Operations Manual does not promote consistent rules of evidence and decision making

Some surveyor guidance permits, if not encourages, drawing conclusions based on limited evidence, especially when serious negative outcomes occur

Survey instructions should emphasize consistent approaches to gathering and interpreting information in all circumstances prior to drawing firm conclusions about compliance

Survey instructions should emphasize consistent information-gathering approaches regardless of severity of outcome (11/01, 1/02)

The survey process overemphasizes review of outcomes at the expense of a more careful analysis of whether and how processes contribute to results

The survey process overemphasizes finding negative outcomes of any level of severity at the expense of investigating serious process problems

Survey methods often tilt surveyors towards concluding that serious negative outcomes must be someone's fault until proven otherwise

Surveyors may be prone to jump to premature or unwarranted conclusions about how processes or practices relate to outcomes

Surveyors may fail to recognize situations in which facility performance has most likely contributed to negative outcomes

Surveyor conclusions about facility culpability may be based primarily on conjecture, without sufficient supporting evidence

Surveyor guidance should focus surveyors primarily on important negative outcomes where potential for process improvement exists (1/02)

The survey should emphasize process review and judge outcomes based on fair appraisals of potential contributions of process inadequacies to ultimate results (1/02)

Survey instructions should require surveyors to be able to identify a basis for conclusions that a facility could or should have acted differently and that acting differently would likely have produced a different result (12/01)

Surveyors need clearer guidance for determining appropriate or inappropriate practices related to specific aspects of care such as nutrition and behavior management (12/01)

General survey instructions must clarify how surveyors are to determine "avoidable" and "unavoidable" outcomes, based on improved approaches to collecting and analyzing information

The survey judges compliance about many small items, and uses the aggregate of individual compliance decisions to formulate an overall compliance determination

The current scope-and-severity system overemphasizes minutiae and Tag-number compliance at the expense of the "big picture"; it allows for the conclusion that a deficiency exists before considering the relevance of the alleged error or omission to overall facility practices and overall resident care

Surveyor guidance permits drawing conclusions about isolated procedural errors or omissions out of context, rather than in the context of overall processes and practices

The whole deficiency-determination process should be revamped (2/02)

All aspects of regulations need process indicators to guide surveyor review for compliance (12/01)

Scope-and-severity considerations should enter into deficiency determinations, not wait until after a conclusion is reached that a deficiency exists

The survey process should discard the implied notion that any mistake is one too many

The survey should require aggregating all reviews of individual processes and practices before determining facility compliance (11/01, 2/02)

Current scope-and-severity determinations are a confusing, often inconsistent and contradictory hodgepodge of fact, speculation, and opinion

Current guidance lacks clear, consistently usable criteria for determining levels of scope and severity

There are better, simpler, and fairer ways to identify levels of facility performance (3/02)

The current scope-and-severity approach should be revamped (1/02, 3/02)

Survey process emphasizes rapid plans of correction at the expense of appropriate root-cause analysis

Survey agencies may accept poorly done or irrelevant plans of correction

Most deficiencies based on Tag numbers reflect symptoms, not root causes, of poor care

Required plans of correction often overemphasize minor adjustments of care practices, rather than pinpointing widespread systems, process, and management failures that underlie care failures

State agencies are often pushed to impose punitive "remedies" that do not enable addressing root causes

The survey process does not promote definitive corrective actions based on careful root-cause analyses

Survey process should focus primarily on identifying and dealing definitively with truly poor performers and less on isolated problems in generally competent facilities

State agencies need clear, consistent instructions on how to target plans of correction to root causes rather than to symptoms reflected in Tag number deficiencies

The generally punitive tone of the survey process should be modified; a quality-improvement approach should be promoted

State agencies need clearer, more consistent, guidance on how to match combinations of enforcement to specific situations in which they are warranted emphasizing readily identifiable performance-improvement principles (4/02)