Identifying & Implementing Effective Statewide Approaches to Nursing Home & Survey Reform

Part Fifteen of a Series on the Survey Process

by Steven Levenson, MD, CMD

This series has discussed both helpful and problematic influences on nursing home care and identified key elements of appropriate care and effective regulatory oversight. This month's column will consider efforts to change the current situation.

What Constitutes True Reform?

The current turmoil in long-term care has led to a good deal of re-examination. Recently, providers and the government have spent much time talking about reforming the approaches to overseeing and improving nursing home care. Yet, throughout the country, there is only sporadic coordination of such efforts, or of attempts to align common interests. Many of the parties who try to influence nursing home care do not fully understand the issues and thus attempt to impose arbitrary or problematic solutions (see "Who's Really Causing Harm in LTC?," in the September 2002 issue of Caring, p. 16). Through their representative state associations, many nursing homes have become increasingly self-protective if not reactionary. Meanwhile, CMS is heavily promoting a quality-improvement project based on public reporting of selected outcome indicators (see "Making (Up) the Grade: What You Need to Know About Nursing Home 'Report Cards'," in the August 2002 issue of Caring, p. 3).

The Michigan Experience

So, what shall we reform? And why are some efforts successful while others are failing? The box below lists the key elements of effective approaches to improving any health care situation, including long-term care. True reform requires accommodating, not sidestepping, these elements.

A state-wide project in Michigan illustrates these principles and shows how diverse entities can focus on identifying and promoting appropriate nursing home care.

Symptoms and causes Several years ago, Michigan's nursing home industry and the state survey agency were on a bitter collision course. Nursing homes worked with the state legislature to address their grievances about the "unfairness" of nursing home surveys. Finally, the legislature passed a law requiring the state survey agency to work with the representative nursing home associations (state chapters of the national for-profit American Health Care Association and national non-profit American Association of Homes and Services for the Aged), to clarify certain terms used in the survey, such as "harm" and "avoidable" outcomes.

Shared responsibility After a series of meetings in early 2001, the nursing home associations, survey agency, medical directors, and others reached some vital conclusions and made some critical decisions. Most of all, they recognized their shared responsibility for the current unsatisfactory state of nursing home care and their common need for improvement.

Critical elements The parties agreed that care in the state's nursing homes, as well as physician care and support for nursing home patients was--similar to other parts of the country--inconsistent and sometimes problematic. They understood that three critical elements were needed to improve performance--namely, everyone involved must know 1) what they are supposed to do; 2) why they are supposed to do things in a certain way; and 3) how to do the desired things correctly. Then, a concerted effort is needed to ensure that proper care is given and serious problems are corrected.

Participants understood that the OBRA regulations lacked sufficient detail about key elements of the care process, and could not be used as the primary reference for making everyday care decisions (see "Why OBRA Regulations & Surveys Can't Fix LTC" and "SOM Shortcomings: Why the Heart of the Survey is Missing Some Beats" in the October and November 2001 issues, respectively, of Caring). They realized that the procedures for conducting the survey were inconsistent and missing many important details (see Survey Series articles from December 2001 through May 2002).

The state agency noted that surveys did not always reflect a consistent or full understanding of appropriate care processes or findings. Medical directors acknowledged that only some medical directors were fulfilling their responsibilities and only some attending physicians understood or provided adequate support for key aspects of care. Nursing home representatives acknowledged that only some staff were implementing quality improvement by focusing on care-process consistency and evidence-based practices. All of the parties recognized that they hadn't been consistently identifying or addressing root causes of problematic care.

Care process as common ground The participants agreed to clarify their common interests, and recognized the care-delivery process as their common ground (see "LTC Regulations: Devil in the Details," in the August 2001 issue of Caring). Other issues were secondary. Without promoting the entire care process (not just the parts emphasized in the regulations), they acknowledged, truly effective care was not consistently attainable.

Once everyone agreed on the components of the care-delivery process, the critical next steps could occur. Clinicians could use relevant evidence about care processes and practices (see "Do Practices Make Perfect?," in the August 2002 issue of Caring) to help bridge the gap between evidence and practice. Effective implementation required explicit performance statements that promoted specific behaviors.

For instance, the evidence suggests that falling and pain have specific causes (as do all symptoms). Some causes can be corrected, thereby alleviating the symptoms. Therefore, practitioners must seek and address those causes. Identifying causes requires a sufficiently detailed description of the symptoms, and sometimes other tests and evaluations. Thus, the explicit expectation is for nursing facility staff to show how they adequately describe the symptoms, and for practitioners to demonstrate how they and the staff use that information to identify and address causes. Alternatively, the staff and practitioner should be able to explain why cause identification wasn't feasible or relevant.

By creating a series of process indicators and care-process expectations, every nursing facility staff person, practitioner, and surveyor now had a common ground for both providing and assessing care. Facility staff and practitioners understood that surveyors were looking for critical components of good care. And, nursing facility management could use the same information to ensure that staff and practitioners met their responsibilities.

Firmer foundation With this foundation, other important issues could be addressed. Although the state survey agency had to follow federal surveying requirements, it now had critical guidance to fill gaps in the survey instructions. Surveyors could better distinguish appropriate and inadequate care. By better understanding why outcomes occur, and why negative outcomes may occur despite appropriate care, all parties could more effectively consider when negative outcomes might relate to care-process problems. And, when inadequate care was identified, there was a clear, objective way to explain what needed correction. This would minimize erroneous interpretations by all parties.

Participants agreed to use the American Medical Directors Association's clinical practice guidelines (CPGs) as a key tool for clarifying care-process expectations, noting that the CPGs were developed by individuals familiar with nursing home care; reflect reliable evidence and consensus; emphasize a uniform care process; and provide detailed guidance for physicians.

Critical link Participants also realized that efforts to improve care should take basic human psychological realities into consideration. Many facility staff were unlikely to change their approaches voluntarily, unless they recognized that there were some positive--and no significant negative--consequences for doing so, as well as potentially undesired consequences for not doing so (see "Improving Enforcement & Plans of Correction," in the April 2002 issue of Caring).

Thus, the Michigan project established this vital link: where the OBRA surveyor guidance did not cover a care topic sufficiently or was not clear, surveyors would refer to the care process guidance developed by the project when considering whether a facility had provided appropriate care and complied with regulatory requirements. It would be considered favorably if staff and practitioners could demonstrate that they had followed desired care processes and could explain their practices. Facilities that did not choose to use the agreed-upon approaches had to show that their chosen approach was comparable.

These principles enabled critical alignment between good care and regulatory requirements. Facility staff and practitioners had to show that they had followed appropriate care processes. But everyone now knew the expectations ahead of time. They had ample opportunity and enough details to prepare sufficiently. What they should do, document, and be able to explain and show were clear. Because expectations were compatible with proper care processes, the focus could be on proper care as the foundation for regulatory compliance, instead of vice-versa.

Overcoming objections Participants also recognized that care processes depend on having adequate care systems, supported by facility management, that hold everyone accountable. They acknowledged that state agencies and surveyors can point out, but cannot correct, systemic problems and internal management failures.

Nursing home associations recognized that they must effectively exert peer pressure on their members. They committed to not only support and promote effective care processes and practices, but also to inform their members that they would not support indifference to the project or try to justify inadequate performance. This essential but uncommon commitment is key to nursing home improvement everywhere.

Participants agreed that those who try hard to perform appropriately but make mistakes occasionally must be distinguished from those who don't try and don't care--and more serious consequences should focus on those who fail repeatedly to meet expectations or to effectively improve performance.

Consistency and persistence Participants recognized that this was a long-term project; there were no quick fixes. Only some nursing facility staff, practitioners, and surveyors would embrace these notions; others would actively resist changes. Thus, the Michigan project identified how nursing facilities can better influence the performance of key players, such as physicians. Once the right foundation was established, participants agreed, they simply needed to provide consistent reinforcement over time. Participants also recognized the need to avoid the "fad du jour"; care-process and performance-improvement principles, they noted, are universal and enduring. The relentless imposition of new projects, laws, regulations, and demands, and the continually shifting political and regulatory landscape, merely exhaust and confuse those trying to provide care.

Training users The project included ways to disseminate and reinforce critical information. This was done via joint provider and surveyor training, posting of all materials on the state agency's Web site, and concentrated efforts to promote the project statewide.

Evaluating results Preliminary results are encouraging, with some evidence for both process and outcome improvements. There is better understanding of key goals and alignment of diverse efforts. Also, the project helps to confirm what many providers and practitioners already know: in nursing homes, appropriate care does not necessarily lead to desired results, and we must therefore look at processes--not just outcomes--in assessing quality of care.

The QIO Project

As indicated earlier, CMS has heavily promoted a nationwide quality-improvement project to try to address nursing home care improvement through non-regulatory methods. Quality Improvement Organizations (QIOs) are expected to spearhead the project in each state.

The QIO project appears to include two primary methods: 1) encouraging nursing facilities to use standard quality-improvement tools, including root-cause analysis, to identify and correct care problems, and 2) encouraging the use of relevant guidelines and protocols, without providing specific advice about specific practices or processes.

The QIO project may potentially help improve nursing home care by shifting attention to the use of evidence-based practices for care provision, and the use of standard quality-improvement practices to improve care internally. But the QIO project only provides some of the essential elements for reform. It may help to catalyze a more coordinated effort in each state, which is essential for progress. But it won't get far unless it is combined with other critical elements of reform, as outlined above.

In Michigan, the QIO has agreed to base its analyses of care and its quality-improvement efforts on clinical-process guidelines on pressure sores and chronic and acute pain developed under the existing care-process improvement project, as described above. Although the QIO project is not intended to be regulatory, this consistency should help reinforce the quality-improvement messages given to nursing homes from various sources.

Above all, genuine reform requires a widespread focus on residents and patients, promotion of the basic care-delivery process (see "LTC Regulations: Devil in the Details," in the August 2001 issue of Caring), and a deliberate shift away from other agendas. Trying to influence nursing home care without promoting a correct care process is like trying to oversee the aviation industry without understanding what it takes to fly planes safely. Now is the time to learn from those who are working toward a process that does things right, and to avoid countless past--and present--mistakes.

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.cfm.

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

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