Although each state had its own set of reasons for designing and implementing its particular quality improvement programs, a similar driving force seemed typically to be behind the decision to implement a TA program--dissatisfaction with the survey process--stimulating a desire to "try something new" or focus attention on quality in a way other than regulation. This was particularly true for states with a TA program focused on improving care practices, and the cases of Missouri and Maryland illustrate this point.
The impetus in Missouri came from a set of pilot tests run in 1999 to study the impact of using advanced practice nurses to improve resident outcomes through technical assistance. This research showed that providing feedback on quality through reports and education was insufficient to improve clinical practices and resident outcomes.7 It found, further, that a stronger intervention of expert clinical consultation coupled with comparative feedback was needed to improve resident outcomes. Missouri also noted that TA visits were beneficial because they (1) recognize that facility staff are stretched to the limit, making it difficult for them to keep current on the latest clinical information; and (2) provide support to facility staff who want to do a good job, but need some ideas and encouragement (see Appendix A for more details on the Missouri TA program).
The impetus for Maryland's quality improvement programs, enacted in 2000, was a series of events and activities both within and outside the state over the preceding ten years. In 1989, the media reported on deplorable conditions in a Maryland nursing facility and subsequent scandals and multiple nursing facility closures over the next three years precipitated a 1999 General Accounting Office (GAO) study that found the complaint investigation process was unacceptably slow (the GAO made similar findings in other states). In 1999, the negative personal experiences of several influential state senators with respect to Maryland nursing homes, along with damaging testimony before the state legislature by Maryland Department of Health and Mental Hygiene/Office of Health Care Quality (OHCQ) staff on the issue of complaints, was influential in leading the legislature into tying passage of a nursing home funding bill to creation of a Nursing Home Task Force to study quality and oversight in Maryland.
The Task Force began meeting during the summer of 1999 and presented their recommendations in January 2000. In May 2000, a broad Nursing Home Reform Package was enacted in Maryland that did not focus simply on strengthening regulations and sanctions, but also included provisions specifically addressing quality improvement such as the addition of a technical assistance program through a required "Second Survey".
7. See Rantz MJ, Popejoy L, Petroski GF, Madsen RW, Mehr DR, Zygart-Stauffacher M, Hicks LL, Grando V, Wipke-Tevis DD, Bostick J, Porter R, Conn VS, Maas M (2001). "Randomized clinical trial of a quality improvement intervention in nursing homes. The Gerontologist 41(4), 525-538.