State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. 1.2 Study Description


The purpose of this study is to inform state and federal policymakers about the characteristics, objectives, and implementation of the quality improvement programs states have implemented. A particular study goal is to provide information to states that may wish to develop such programs in their state.

Originally, the study was to focus solely on Technical Assistance (TA) programs that provide on-site consultation, training, and/or sharing of best practices with nursing facility staff. Eight states (Florida, Maryland, Maine, Michigan, Missouri, Texas, Virginia, and Washington) currently have active TA programs.3 The design and focus of these TA programs vary across states, but they share several defining characteristics:

  • TA staff provide on-site consultation, training, and/or sharing of best practices with nursing facility staff. The on-site consultation may also include reviews of resident medical records and guidance on how facilities can use the CMS quality indicators or other data to monitor care quality. While many TA staff are surveyor trained, in most states, they typically do not focus on regulatory issues. Rather, they help facilities identify problems and work to help make improvements when needed.

  • TA programs emphasize a collaborative approach between facilities and the TA staff, which often contrasts with the frequently adversarial relationship between facilities and LTC surveyors.

  • TA programs are non-punitive, and results from the visit are typically not shared with the survey and certification agency unless serious violations are observed.

  • Most of the TA programs in operation are paid for entirely with state funds, although some combine state with federal funding.

Our study focus expanded, however, as our research revealed state-initiated quality improvement initiatives in addition to TA. In addition to providing TA, some states also train nursing home providers on compliance with regulations and other topics, and make information available to consumers through public reporting of information.

To select states to be included in this study, we collected basic information about the quality improvement programs in states through a combination of discussions with stakeholders and a review of relevant written information. The study focused on a group of states that had state-initiated quality improvement programs that included aspects of technical assistance and that were not reimbursement or payment related. The states we ultimately selected were Florida, Iowa, Maine, Maryland, Missouri, Texas, and Washington.4 All except Iowa have formal TA programs in place. Iowa was added because it had particularly interesting other quality improvement initiatives.5

Our data are from structured discussions with key stakeholders in each study state. Key representatives from the state agency responsible for the quality improvement programs were contacted to arrange face-to-face meetings with stakeholders. Participants in these discussions included state Survey and Certification Agency Directors and staff; Directors of Quality Improvement Projects and staff; state Medicaid Agency Directors; representative(s) of for-profit and not-for-profit nursing home associations; nursing home providers; and consumer advocacy representatives and the state's long-term care Ombudsmen. Most discussions lasted about two hours. Our research team encouraged the organization, agency, or nursing facility involved to include as many of their staff as they thought would be interested or have valuable information to share. In several states, the research team was able to observe a portion of a TA survey visit on site. Typically at least two researchers participated in each site visit--one researcher would guide the discussion; the other would take notes on participants' responses.

The discussions focused on the following topics:

  • Description of the quality improvement project(s);
  • Policy environment leading to its (their) introduction;
  • Program design;
  • Program goals;
  • Program evaluation;
  • Facility involvement;
  • Funding amount and source;
  • Perceived program effectiveness;
  • Desired federal role in state-initiated quality improvement programs; and
  • Advice for other states considering similar programs.

Appendix A contains summary reports documenting each state visit.

We found a range of philosophical influences combining to shape quality improvement efforts in particular states. Major influences include state legislatures, personal involvement of individual state legislators in long-term care issues, campaigning by consumer advocacy organizations, complaints from the industry about "over-regulation" by both state and Federal Governments, and a considerable body of research documenting the inadequacy of care delivered to residents of U.S. nursing facilities.6 These issues are often interrelated--an interrelation that serves as the catalyst for a state's decision to embark on its own quality initiative.

  1. California, Indiana, North Carolina, Ohio, and Wisconsin plan to implement TA programs, but these programs had not yet started at the time we were collecting data for this report.

  2. Michigan and Virginia were not included in the study because of the limited number of facilities that have participated in their TA programs.

  3. Despite the absence of a technical assistance program, the project's Technical Advisory Group believed that the study should include Iowa, as its programs may be substitutes for a technical assistance program and may include quality improvement models that other states may wish to replicate, potentially improving our study's ability to provide guidance to states considering implementing quality improvement projects. Iowa's quality improvement programs involve a wide variety of efforts including an internet web-based Nursing Home Report Card, recognition programs for exemplary practices and performance on licensure and certification surveys, training for providers and surveyors, feedback on surveys/surveyors and an alternative survey process for state-only licensed facilities meeting certain criteria. (See Appendix A for more details).

  4. For example, a 2002 report from the Office of the Inspector General concluded that "problems with quality of care continue to exist in nursing homes. The study found that the number of quality-of-care deficiencies has increased in recent years, as has the number of nursing home workers excluded from the Medicare and Medicaid programs as a result of patient abuse or neglect (OEI, 2002). A 2001 report prepared by the U.S. House of Representatives Special Investigations Division found that more than 30 percent of nursing homes had been cited for abuse violations between 1999 and 2001.

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