Administrators of quality improvement programs in study states also offered some specific advice for state officials interested in developing other QI initiatives:
Awards and Recognition Programs and Best Practice Initiatives. Participants thought it important to ensure that there is a consumer advocate position on the selection panel, and that this position is well defined so it does not default to "an industry representative who has a relative in a nursing home." They also recommended that the selection panel visit any facility nominated for an award, to validate nomination criteria and make sure the facility is in fact "doing something special" and not merely meeting minimum criteria. Stakeholders said it was important that the selection process be seen as objective--so that the award, in turn, is seen as truly recognizing outstanding quality. Stakeholders recommended that consideration be given to the criteria used to select facilities for awards. States advised caution about setting criteria too low or evaluating facilities over too short a period to ascertain whether the facilities chosen were maintaining good practice on a consistent basis. This is important to avoid the inevitable bad publicity and diminished consumer trust that result when facilities singled out for recognition later experience quality problems.
Training Initiatives. Several stakeholders advocated that the most effective training programs were those that included both interpretation of regulations and practical examples of integration of care principles. Some also recommended joint training for providers and LTC surveyors. This admittedly leads to some discomfort in both groups, but it provides an effective medium for dialogue between providers and surveyors, has the potential to promote greater understanding and cooperation, and ensures that both groups receive the same information. This, in turn, decreases the problem of different interpretations of the guidance offered. With respect to education more generally, some participants noted the need to educate (a) the public about realistic expectations regarding nursing home care outcomes and (b) facilities to better manage the expectations of patients and families.
Public Reporting Programs. Comments by some stakeholders suggest skepticism about consumer use of public report cards on nursing home quality. Nonetheless, in states that invest in public reporting, it became apparent during our discussions that a balance must be struck between providing enough information to consumers to assist them in making more informed decisions and overloading them with information and data that becomes too cumbersome to decipher. One solution recommended by several states is to develop a scoring system that incorporates multiple quality measures (e.g., survey and deficiency information and/or quality indicators). The advantage of such a system is that it reduces information overload and is easy for the consumer to understand. States caution, however, that the accuracy of these scoring systems as predicators of real quality is subject to considerable dispute and has not been empirically validated. States also advised caution regarding the potential negative impact on access, if facilities begin turning away heavier care residents patients because they fear their "consumer report cards" will be adversely affected by scoring systems that do not take sufficient account of facility differences in types of patients (and their differing care needs).