A Hard Look at Alternatives to the Current Survey Process

Part Fourteen of a Series on the Survey Process

by Steven Levenson, MD, CMD

Many people assert that the federal nursing home survey process is irreparably broken and that it should be replaced by some alternative. But is there an acceptable substitute? Or, can the current survey process be revamped?

Any alternative, regardless of the method used, must meet certain criteria for effectiveness (as must the current survey process). Some proposed alternatives may be feasible, while others are unrealistic because they lack adequate detail or are based on unsupportable premises. This column looks at the strengths and weaknesses of the options that have been put forth, and suggests additional considerations.

Principal Approaches

In 1996, Congress authorized the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) to study private accreditation and deemed status, regulatory and non-regulatory incentives to improve nursing home care, and the effectiveness of the current system of survey and certification of nursing homes. The report, Study of Private Accreditation (Deeming) of Nursing Homes, Regulatory Incentives and Non-Regulatory Initiatives, and Effectiveness of the Survey and Certification System, identified six principal alternative approaches to trying to ensure quality nursing home care (see box at right).

Other identified approaches with some potential to influence and/or assess quality include: 1) intensified federal government efforts to combat fraud and abuse, and 2) quality improvement programs implemented by Peer Review Organizations (PROs).

Market Mechanisms
Market mechanisms rely on the notion that consumers can influence nursing home care quality by choosing facilities that offer good quality care and avoiding those that don't. In this way, problematic facilities either are pressured to improve or are driven out of business. This appears to be part of the basis for the current public reporting initiative via nursing home "report cards."

The idea has some potential. Greater awareness of what the public has a right to expect and what constitutes good care is essential in all health care settings.

Some current approaches are helpful. Governments and consumer groups have informed the public about relevant topics and provided some pertinent criteria about the care environment--for example, about facility odors and staff interactions with residents. But so far, no one has really helped consumers understand how to properly evaluate technical aspects of care, such as when pressure ulcers or continued functional decline reflect "medically unavoidable" outcomes.

In order for this approach to work, the public must be able to judge care quality, to differentiate the good and the bad. They need clear, realistic expectations of what should happen at each step of the care process. And, they need to know why certain desired outcomes may not occur despite appropriate care. Many nursing homes do some things well and some things poorly; the public needs to understand the difference. But little has been developed to provide them with the right criteria.

Many people still go to a nursing home because they have no other option, and choose a specific nursing home because it is conveniently located. Therefore, market mechanisms are nowhere close to their potential to improve nursing home care quality. Yet, even if they were, they still cannot adequately address care problems in problematic facilities or protect vulnerable individuals from harm due to poor care.

Professional Knowledge
Professional knowledge could improve nursing home care by giving facility staff information about proper care processes and practices. But for this approach to work, facility staff must identify and willingly adopt those practices and processes.

Trouble is, only a handful of nursing homes use professional knowledge voluntarily. As pointed out in this column (see "Do Practices Make Perfect?" in the August 2002 issue of Caring, p. 6), some alleged "best practices" are more habitual than substantive, while others are irrelevant or even problematic.

For example, for at least 30 years, clinical reports and studies have recommended against routinely treating asymptomatic bacteriuria, especially in catheterized individuals. Despite this, many nursing home staff still obtain unnecessary urine cultures and institute inappropriate antibiotic treatment. Many nursing homes have no policies and procedures to cover such situations, don't try to get their medical director to intervene with physicians, or train their nursing staff to limit requests for urine cultures and avoid antibiotic treatment based only on culture results.

Furthermore, many reasons for inadequate performance and facility failure go beyond education or training. They involve specific management issues and failures of individual accountability that are not addressed by academic input and professional knowledge.

So, professional knowledge could help if it were more pertinent, if relevant materials were used, if implementation issues were addressed, and if the authority of competent medical directors was respected and people were held accountable for using it (JAMDA 2002;3:79-94).

Payment Systems
Payment mechanisms can help by providing the proper incentives and by not providing contradictory incentives to giving quality care. They may influence quality by helping to ensure access and quality while containing costs; for example, some case-mix reimbursement systems provide incentives to care for heavy care individuals.

Payment systems could have profound influence if they recognized the factors that influenced care costs and outcomes. While those factors have been identified and could be applied more consistently, payers, providers, and public policies often emphasize or reimburse the wrong things.

For example, evidence suggests that individuals with more active comorbidities will take longer and cost more to achieve desired levels of functional recovery. Thus, when less effort is expended during hospitalization to address risk factors and prevent complications, a greater burden is placed on post-acute care providers. Yet, some payers overlook this information; they pay hospitals more and more money to render less and less care, discharge unstable patients, and shortchange critical primary medical and nursing post-acute care while reimbursing for less relevant care.

Some states have tried using incentive payments for nursing homes that attain certain performance goals. Yet this, too, has only partially succeeded. These efforts have only occasionally identified and rewarded the critical factors that influence outcomes. Ultimately, they cannot correct other reasons for performance failure. And, they are subject to manipulation and don't ensure that those who take the money will definitively address their care issues.

Private Accreditation
Private organizations--most notably JCAHO--offer various accreditation programs. Accreditation could potentially help improve nursing home care by supplementing or supplanting other approaches, including the regulatory process.

Some nursing homes are accredited by JCAHO for residential or subacute care. In the 1990s, the nursing home industry tried unsuccessfully to get "deemed status" approved to replace the OBRA survey. Deeming means that privately conferred accreditation status is accepted as proof of compliance with federal requirements. But the Department of Health and Human Services must determine that private accreditation offers "reasonable assurance" that Medicare conditions of participation are met.

Consumer groups such as the National Citizens' Coalition for Nursing Home Reform, as well as state surveyor associations and trade unions, staunchly opposed such efforts. The deeming study mentioned earlier concluded that although LTC facilities may choose to be accredited by JCAHO, deeming for nursing homes was not presently warranted and would not fulfill the government's responsibility to protect the vulnerable nursing home population.

Concerns about private accreditation of nursing homes include the fact that a triennial review relies heavily on facility staff's intentions and ability to perform properly without being watched. And, although private accreditation focuses more than do regulations on systems and processes that are essential to effective care, the process rarely includes judgments of the actual care of specific patients; also, it does not include significant consequences for serious care failures.

In addition, the private accreditation process does not necessarily help facilities identify and correct root causes of care failures, and it cannot reliably provide the essential combination of incentives and consequences to facility staff who don't implement necessary corrective actions. Some argue that private accrediting bodies are not accountable to the public or to the government, and that such accreditation has not succeeded sufficiently in any setting.

Regulations As this series has pointed out in detail, state and federal regulatory approaches are sometimes on target. But their implementation is inconsistent and flawed, and often influenced by erroneous thinking, conflicting forces, misguided processes, and the vagaries of state governments and politics.

Regulations could be much more effective if the related guidance was more explicit and evidence-based, and reflected the care process more closely, and if they balanced outcome measures with process expectations, utilized relevant plans of correction, and promoted the correction of root causes of care problems.

It is an oversimplification to say that regulations are coercive and voluntary accreditation is supportive. As noted throughout this series, the regulatory process should follow basic principles of providing positive and negative incentives. Conversely, positive consequences work for many practitioners, but others will not improve performance without frequent oversight and either the threat or application of negative consequences. Therefore, some enforcement measures--regulatory or otherwise--are essential, especially when a vulnerable population is involved.

Non-regulatory QI Interventions
Many nursing home staff have advocated and tried quality improvement initiatives, based on continuous quality improvement and other related principles. After all, enforcement of good practice doesn't have to be governmental; it could be based on self-policing and private initiatives.

For example, CMS' new Quality Improvement Organization (QIO) project (see the August issue of Caring, pages 1 and 3) is intended to promote improved practices in nursing homes independently of any enforcement activities. The project could potentially help improve some aspects of care--for example, problem recognition and identification of key issues.

But, like other voluntary quality-improvement activities, the QIO initiative represents only a partial solution. Next month's column will consider the QIO project in more detail.

Need for Alignment

All of the major mechanisms for influencing care quality in nursing homes have the potential to be beneficial, but none of them are sufficient by themselves. The potential for improvement would be far greater if a basic regulatory foundation were combined with substantial constructive public pressure, better practitioner oversight, proper financial incentives and political decisions, effective use of knowledge and evidence, and voluntary quality-improvement activities and peer pressure.

Any approach to nursing home care improvement must meet certain criteria. These include:

Clarifying expectations for all relevant aspects of care. Performance objectives must be as clear as desired outcomes.

Distinguishing appropriate and inadequate performance using a valid performance review system that includes a review of actual cases. The system should balance a review of outcomes with underlying processes; distinguish between isolated errors and systems failures, and help identify root causes or require facility staff to do so under appropriate guidance.

Influencing performance by identifying the different categories of reasons for performance failure and providing a balanced understanding of the role of incentives and consequences. Corrective approaches should be consistent with basic psychological and management principles, not false assumptions (for example, that everyone can self-correct) or wishful thinking (for example, that everyone wants to do the right thing if they're given enough guidance).

There should also be an effective means for followup and feedback over time, because performance does not improve with just annual or less frequent visits. And, the approach should include the authority to mandate certain actions when voluntary compliance efforts are not feasible or fail.

In other words, the challenge of improving long-term care requires the same coordinated effort needed to improve every segment of the health care system.

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

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