State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report




U.S. Department of Health and Human Services


State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report

Executive Summary

Alan White, Ph.D., Barbara Manard, Ph.D., Deborah Deitz, BSN, Terry Moore, MPH, RN, Donna Hurd, MSN, Christine Landino, MSW, MPH, Jennie Harvell, M.Ed.

Abt Associates, Inc.

May 15, 2003

This report was prepared under contract #282-98-0062 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Abt Associates. For additional information about the study, you may visit the DALTCP home page at or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is:


Nursing home quality continues to be a major policy concern for both State and Federal policymakers. In response to this concern, some states are using consultative, collaborative technical assistance (TA) programs in an effort to improve nursing home quality in addition to the traditional regulatory approach embedded in survey and enforcement process. As part of these TA programs, states provide on-site consultation, training, and/or sharing of best practices in an effort to improve nursing home quality of care. These state-initiated technical assistance programs are one way that states can meet facility needs for assistance in improving nursing home quality while continuing the adversarial regulatory focus inherent in the survey and certification process.

The purpose of this study is to inform state and federal policymakers about state-initiated quality improvement programs, with the particular goal of providing information to states that may wish to develop similar programs in their state. We focus primarily on activities under way in seven states--Florida, Iowa, Maine, Maryland, Missouri, Texas, and Washington. Our information is based on in-person and telephone discussions with key stakeholders in each state.

It was not the intent of the study to evaluate the effectiveness of the state-initiated quality improvement programs that we reviewed in improving quality of care. For several reasons, it was not possible to make definitive conclusions about the effectiveness of these programs. First, most programs have only been operating for a short period. Second, in most states several different types of quality improvement programs were introduced at around the same time, and it is not possible to measure the impact of individual programs. Third, and most fundamental, with the potential exception of Texas, none of the programs that we reviewed are collecting the type of evaluation information necessary for a rigorous impact analysis. Even so, some important lessons can be learned from these states that are applicable to other states considering quality improvement programs.

Key Decisions Regarding Quality TA Program Design

The design and focus of TA programs varies across states, but the programs share several defining characteristics. First, TA program staff provide on-site consultation, training, and/or sharing of best practices with nursing facility staff. Second, the programs emphasize a collaborative approach between facilities and the TA staff, which often contrasts with the relationship between facilities and LTC surveyors. Third, the programs are non-punitive, and results from the visit are typically not shared with the survey and certification agency unless serious violations are observed.

The circumstances leading to a particular state's decision to implement a TA program were unique to that state. But underlying the decision process in every study state was the same catalyst--a widespread desire to "try something new," to provide a positive stimulus to quality improvement in addition to the potentially more adversarial long-term care (LTC) survey process. In reviewing the quality improvement programs in our study states, we identified a series of key decisions that shaped the way these programs operate and could influence their probable impact.

The Primary Goal of Quality Improvement Programs: Promoting Regulatory Compliance or Improving Nursing Home Care Practices

While all of the programs that we studied had the common underlying goal of improving quality of care, they differed with respect to the extent to which this goal was pursued by a focus on improving the care furnished by nursing homes versus promoting regulatory compliance. This choice of program focus is the most fundamental choice a state must make in designing its quality improvement program, as it has a heavy influence on other key program design decisions.

The TA programs in Maine, Maryland, Missouri and Texas have a direct focus on improving nursing home care practices, for example by providing facilities with clinical practice care guidelines or training in how to care for residents with particular conditions. Maine's program has the narrowest focus, dealing only with particular nursing home residents with behavior problems. The Texas program also has a narrow scope, focusing on three issues (restraints, nutrition, and toileting) that were previously identified as key issues for the state. The goal of the Missouri TA program--improvement in quality indicators--is broader. The TA program in Maryland also has a broader focus that includes quality assurance, technical assistance, and sharing of best practices.

Underlying the choice of program focus in these states was a general belief that regulatory compliance, while important, was separate from quality improvement, and that compliance with survey and certification requirements would not necessarily ensure that facilities are furnishing high quality care. These states believe that tying quality improvement activities to the LTC survey conflicts with the fundamental aim of their TA program--to help facilities understand the principles and practice of quality care in a non-adversarial atmosphere. Many of programs with this focus have been able to build collaborative relationships with facilities that may serve as the foundation for more honest communication and, therefore, potentially more productive information exchange. Through out the rest of this paper we refer state programs using this model as TA programs with a focus on nursing home care practices.

One goal of the TA programs in Florida and Washington is to inform facilities of potential regulatory compliance and enforcement issues, enhancing facility compliance with survey and certification requirements. The Washington TA program emphasizes facility compliance with survey and certification requirements. Florida's quality monitors combine a care practice and regulatory focus--they will note areas where the facility could be cited, but also cover care issues as well. Underlying the choice of program focus in these states was a belief that an emphasis on monitoring and enforcement is the best way to improve quality. This focus, in effect, increases the number of times the survey agency is evaluating facility performance, giving the state greater knowledge of facility operations. Providers in these states stated that they found these programs to be valuable. We refer to state programs using this model as TA programs with a focus on promoting regulatory compliance.

Content of TA--Technical Assistance and Training

States electing to design a TA program that is focused primarily on improving nurse home care practices varied with respect to the information sources used during the TA visit. One state uses evidence-based practice guidelines exclusively. However, the more usual practice is for TA staff to use a variety of sources, typically recognized reference material, with varying degrees of freedom for staff to use examples from their own experience. In some states, best practices are obtained from facilities who represent their experiences to be "best practices." Some stakeholders expressed concern that the latter approach does not always represent exemplary care and that superior facilities may not share information on their care practices, assuming that what they do in their facility is "normal" care delivery.

In addition, all of the study states include informal provider education during facility visits and all but one include some type of formalized training. Discussants reported that training sessions are usually well received and well attended. Determining topics for training is done in most states by identifying areas where providers are having the most difficulties as determined by survey and certification or TA staff. Two states provide joint training to providers and surveyors. Participants said that there is some resistance to joint training by both providers and survey staff. However, some also said that this training is valuable (a) so providers and surveyors receive the same information, and (b) because, though stressful, such sharing may ultimately improve provider-surveyor relations.

Mandatory or Voluntary TA Programs

Most of the TA programs in the study are mandatory. Maine and Missouri, the two states with voluntary programs, chose that route to encourage provider trust. The major concern with a voluntary approach is that the facilities that most need help may be the ones that choose not to participate. It is not coincidental that the two voluntary programs are focused on improvement through consultation rather than regulation. An emphasis on compliance is obviously not well served by a program that allows facilities to determine when, and even if, they are visited.

Structure and Length of the TA Visit

States vary with respect to the nature of the information shared during TA visits. An emphasis of the programs in Florida, Maryland, Missouri, and Texas is the sharing of best practices. In Maryland, Missouri, and Texas, this includes best practices based on clinical guidelines. In Florida the information that tends to be shared deals with care practices observed at other facilities. In Maine, the focus is on care plans for individual residents, and information on best practices is typically not shared. Washington TA staff avoid sharing information on best practices with facilities, instead encouraging facilities to network with one another to share best practices.

The length of the TA visit varied greatly. Visit length in Maine and Missouri, the two states with voluntary programs, tended to be shorter than visits in other states, typically lasting between 2 and 4 hours. In Maryland, which had the longest visit length, TA visits last for two days, with the TA program consisting of a legislatively mandated facility survey--called the "Second Survey" to distinguish it from the federally required certification survey.

Relationship Between the Technical Assistance and Survey Programs

The design and operation of state-initiated technical assistance programs depends, in part, on the relationship between the TA and survey programs and staff. States differed with respect to:

  • Whether the TA staff have surveyor training. Some states require that staff in the technical assistance program not only have surveyor training but also have survey experience. Other states require surveyor training but no surveyor experience. Finally, other States stipulate that TA staff must have no surveyor training.

  • Whether TA staff perform surveys. Study states vary in whether TA staff perform surveys, with some states requiring TA staff perform at least some survey functions while other states do not require TA staff to conduct surveys.

  • Extent to which TA findings are shared with surveyors. In four states (Florida, Maryland, Missouri, and Texas), TA findings are not formally reported to long-term care survey staff, except in rare cases of imminent or actual harm to residents. In Maine, copies of the TA reports are available to surveyors, and in Washington, TA staff share findings with survey staff.

  • Working relationships between TA staff and surveyors. In Washington and Florida, TA staff and surveyors work in the same department, attend meetings together, and share information. In Maryland and Maine, TA staff work within the survey agency but are separate from, and independent of the survey team. In Texas, the TA process is separate from the survey process, although surveyors are able to access TA site visit reports prior to their survey visit. Missouri is passionately committed to a system in which the two groups have no contact with each other and do not share their findings.

A close relationship between TA and survey programs is more important in states that have a program that is focused primarily on regulatory issues. In states where the TA program is closely linked to identifying compliance issues, surveyor training of program staff is an obvious asset. TA staff who also function as surveyors (i.e., have dual roles) can be perceived as having greater authority and more regulatory knowledge, and, for these reasons may be better able effect positive changes in resident care. Regulatory information given by TA staff who also function as surveyors may be more consistent with survey findings.

However, there are some potential negative implications resulting from a dual role for TA staff. The dual role has led to the diversion of TA staff to survey functions, reducing the frequency of TA visits. Some stakeholders also noted that closer relationships between the survey agency and TA programs can give rise to provider concerns about the extent to which information provided to the TA staff is shared with, and potentially acted on, by the survey and certification staff. This may inhibit honest and open assessment of programs and, thus, limit innovative ideas to improve quality. Keeping the findings from TA visits confidential may help achieve a more open and honest relationship with facilities.

In states where TA staff do not perform survey tasks but are required to have survey experience, some discussants commented that it was often hard for former surveyors to "change hats" from a regulatory and enforcement approach to an emphasis on facility care practices.

In states with TA programs that have no link to the survey agency, some providers said it was troublesome when TA staff cannot provide interpretive regulatory guidance and when advice given by TA staff is inconsistent with surveyor findings.

Other Quality Improvement Programs

In none of the study states was a TA program instituted in a vacuum, but along with a variety of other quality improvement initiatives. Most of these fall into one of two types:

  • Public Reporting. Florida, Iowa, Maryland, and Texas have developed internet-based pubic reporting systems for providing nursing home quality information to the public. The public reporting systems vary with respect to the types of information that is included. Florida, Iowa, and Texas report information on survey deficiencies. Maryland and Texas include information on MDS-based quality indicators. One goal of these public reporting systems is to furnish consumers information for making an informed decision about nursing home quality. It is not known the extent to which consumers use these systems. Respondents expressed concern that consumer use of these public reporting systems may be limited because consumers may not have internet access or be able to access the information, may find the amount of information provided to be overwhelming and confusing, and because some of the information that is reported may be outdated and not reflective of current facility conditions.

  • Facility Recognition. Florida and Iowa recognize facilities for doing exemplary work. Providers view recognition as a tool for enhancing revenues and combating the negative stereotype of nursing homes so often presented to the public. Consumers view it as a potentially useful source of information for consumers. However, selection criteria vary substantially in their rigor. Concerns center on whether the best facilities in a state are receiving the recognition, whether (in the more rigorous selection processes) small, non-affiliated facilities can afford to compete, and whether such recognition could potentially mislead consumers should a facility's practices change.

Funding for Quality Improvement

Federal law makes available federal funding for certain quality improvement activities and States avail themselves of these funds for quality improvement activities related to training and facility recognition. The study states, however, make limited use federal funds for their technical assistance programs. States typically fund their technical assistance activities out of general revenue funds, often supplemented by the state portion of Civil Monetary Penalty (CMP) or fees levied on facilities. Some states explained that there were "too many strings attached" to use federal funding for these TA activities.

Pending before Congress are two legislative proposals that, if passed, would fund state initiated quality improvement efforts--the Nursing Home Staffing and Quality Improvement Act of 2001, and the Medicare and Medicaid Nursing Facility Quality Improvement Act of 2002. The Nursing Home Staffing and Quality Improvement Act is aimed at promoting staff recruitment and retention and improving nursing home quality of care. The Medicare and Medicaid Nursing Facility Quality Improvement Act of 2002 would permit alternatives to the federal survey and certification process for nursing facilities in up to eight states and includes language that would allow survey and certification staff to provide TA to facilities.

Lessons Learned

Feedback from those stakeholders with whom we spoke in the states we visited indicates a significant interest in and desire for TA and other collaborative programs. Many nursing facility staff seem to value the opportunity to have an open dialogue with TA staff about problems and issues in resident care, to obtain information on good clinical practices, and to receive training and feedback on how they can improve their care processes. A few stakeholders reported of problems when TA advice conflicted with what surveyors told the facility. But these appear to be isolated instances. There are, as noted, many differences across the study states in the design and goal of their TA programs. But several clear lessons emerge.

Defining the Relationship Between TA and the Survey Program is a Critical Decision Point

The principal reasons for choosing whether the TA program should emphasize improving care practices or promoting regulatory compliance appear to be primarily related to the philosophy of the state and the availability of federal funding. In states where the relationship between the technical assistance and survey programs is close, programs tend to focus their TA less on facility care practices and more on regulatory and compliance issues. While many facilities welcome this type of assistance, in states where the TA has a regulatory focus, the distinction between the two programs tends to become blurred. This may affect the types of information that facilities are willing to share with nursing facility staff, which may reduce the ability of the program to impact nursing facility care practices. During the period when a new TA program is being implemented, a clear separation between the TA program and the survey process was perceived to be particularly important.

Non-Mandatory TA Programs may not Reach Facilities most in need of Help

A problem with implementing a voluntary TA program is that the facilities most in need of help may decline the assistance. Study participants reported that the facilities with the lowest quality are often the ones that do not participate in TA programs. These facilities may not benefit from programs with mandatory participation either, however, given that they may be too overwhelmed by trying to comply with requirements to be able to participate in quality improvement initiatives.

The facilities that do participate in voluntary programs are likely to be those that want to improve their care practices based on what they learn during the TA visit. A non-mandatory program may be the only option for some states with budget limitations that allow for only a small program that cannot reach every facility.

Evaluation Needs to be Part of the Initial Program Design

As noted, evaluating how well the TA programs work at improving the quality of care will be particularly difficult. Of particular concern from an evaluation perspective is the simultaneous statewide implementation of several quality improvement programs. It is understandable that states have lots of ideas about ways to improve nursing home quality and a desire to try new programs. But states planning to implement TA or other quality improvement programs should consider the potential need for evaluation--which is being increasingly demanded by program funders in the current fiscal environment--and design their programs so that their evaluation needs can be met.

The Full Report is also available from the DALTCP website ( or directly at