Dissemination of Best Practices
"Best practices" as applied to nursing facilities is a general term that refers to a range of activities centered on identifying excellence in clinical practice. The methods by which the study states identify best practices and disseminate this information, and the audience for whom they are intended, vary significantly.
Study states varied in terms of what was describe as best practices--in how best practices are defined, where they originate, and how these practices are used by the state's other quality improvement programs. Some states define a best practice as an expert-derived protocol that should be adopted by facilities to raise standards of practice. Others define a best practice as an innovative idea originating at the facility level that was seen as potentially valuable to other facilities. Still other states use both definitions. Examples of Best Practice protocols disseminated by study states are included in Appendix C.
In Texas, a panel of academic, clinical, and medical experts were used to develop evidence-based clinical practice guidelines that are a core feature of the Quality Monitoring Program. The initial focus has been limited to a small number of areas (e.g., restraint use, incontinence care, hydration). The intent is for the assistance provided by TA staff to reflect the consensus of pooled experts, not the opinion of an individual TA nurse or the survey agency. Quality Monitors provide information regarding best practices and how to achieve them, give feedback to facilities regarding the degree to which the facility is providing care consistent with the best practice protocols, and help the facility identify system changes that could result in greater use of best practices. The best practices are also posted on the QM Website (described in more detail in section 4.2.)
TA staff in Maryland, Florida, Washington, and Missouri also disseminate best practice information. In these states, however, this consists of information that the TA staff has collected from personal reading, interactions with other facilities, and personal networking. None of the information has been formally endorsed by the state or collected together and posted in a single location.
The Maryland TA staff carry with them a binder full of examples of documentation guidelines and "best practices" collected from various sources and facilities. They disseminate copies of these forms and guidelines, networking between facilities is encouraged, but specific advice is not rendered.
The Florida TA staff share materials with facilities on several topics including wound care, fall prevention programs, copies of federal and state regulations, interpretive guidelines of the regulations, and guides for water temperatures. The materials that the Quality Monitors share with nursing home providers are obtained from variety of sources including published literature, websites, and personal experience. The Quality Monitors also recommend particular videos or other training materials, provide website addresses, and pass along "best practice" information they have seen at other facilities. However, Quality Monitors are careful to keep suggestions very general, forcing the facility to select the processes appropriate to the needs of their residents.
In Washington, the TA staff advises facilities to network with one another but avoid telling them how to fix problems. In Washington, the TA intervention is based upon the subjective judgment of individual TA staff about the quality of care being rendered, though this judgment is influenced by use of protocols that guide the TA staff member to review specific clinical issues, depending upon the situation.
Missouri TA nurses bring along many resource materials and provide guidance on a variety of topics to the facilities they visit. Though the Missouri TA program emphasizes use of evidence-based clinical advice, its TA staff also provide subjective advice to facilities, based upon their own experience. All TA staff in this state carry with them extensive reference material, including practice guidelines from the Agency for Healthcare Research and Quality (AHRQ) and the American Medical Directors Association (AMDA).
The Maine TA nurse provides education to nursing facility staff that is intended to help staff to understand why problem behaviors are occurring and to allow them to do their jobs more effectively and safely. The state's TA nurse has also developed a number of in-service training programs related to residents with behavior problems.
TA Staff Composition
Florida, Missouri, Washington and Maine require their TA staff to be registered nurses (though not necessarily experienced in long-term care). Only Texas and Maryland's TA teams mimic the survey teams' composition, which includes other disciplines as well as nursing.
The structure of the TA visits varies widely across states and in some states across geographic region within a state. The latter is true of Maryland, where the TA visit is still evolving, and in Washington, where TA staff have the flexibility to organize the visit according to the specific issues to be addressed that day. The facility personnel they meet with also vary. TA staff may meet with the facility risk manager (Florida), for example, or QA coordinator (Maryland), as well as with other members of the facility quality assurance team (e.g., social workers, nurses, therapy, administration) during each visit. Texas has a formal debriefing session (or exit conference) that TA staff conduct with each facility visited. Visit length also varies, by state and by issue being addressed on-site. For example, a Maine TA visit lasts about four hours. A Maryland visit takes two days, with about six hours spent in resident medical record review to reconcile what the staff is saying with what has been recorded in the charts. The remaining time is spent reviewing the QA plan, and interviewing key facility staff. Staff may be interviewed to assess the facility's concurrent review process (a requirement related to QA plan). In Florida, the TA staff nurse places signs in facilities she is visiting, inviting residents and families to speak with her. The Maryland, Texas, and Washington TA visits may involve resident interview and observation, as well.