Although the feedback from facilities on the value and effectiveness of the various aspects of the QIPMO program was very positive, it was reported that less than half (45 percent) of Missouri facilities take advantage of the free program. When questioned as to reasons for non-participation, those we spoke with stated that facilities that were part of a chain sometimes felt that those types of supportive services were already being provided for them. Other reasons offered were that facilities were either not aware of the program, did not understand it, did not trust that there was no connection to the survey agency or did not see the value.
There was evidence that some providers, particularly those associated with the for-profit association, did not understand the program. Some of the confusion seemed to result from the early days of the program when QIPMO was used as a substitute for the interim survey that Missouri facilities receive six months after the regular survey. This was a short-lived experiment that was not supported by Marilyn Rantz and which everyone agrees did not work well. For these providers, doing well on their survey was their measure of quality and their primary focus. If QIPMO visits did not help them prepare for and accomplish a good survey, they could not see the value of participating. Furthermore, in the early days of the program when the QIPMO visit could substitute for an interim survey, there were situations in which facilities may have had a productive QIPMO visit, but then received multiple deficiency citations on their next survey, primarily because the QIPMO nurses were not trained in the state regulations and did not provide any counseling around those issues.
Some participants suggested that facilities are not aware that the program exists, despite efforts to publicize the program, given high turnover among directors of nursing and administrators.
Also, because the program was initially associated with the survey process, some facilities do not realize (or believe) that QIPMO is totally separate from the survey agency and does not report its findings to the survey agency. Some facilities are hesitant to allow outsiders into their buildings to review records and observe care. There were also comments that facilities were uncertain as to how to schedule a visit, believing that facilities were made "to jump through hoops" and had to make requests for QIPMO visits in writing.
A few facilities regard QIPMO as a program that "just means more work" for facilities. Given that the program is voluntary, it is likely that QIPMO is not reaching facilities with very poor performance. Such facilities may have little reserves to take on a new project when faced with the day-to-day struggles to keep a facility running, lacking the staff and infrastructure necessary for the QIPMO nurses to work with. The QIO representative who had worked with some of the QIPMO materials felt that some of their forms were too academic and involved for the average facility. She reported taking their fall investigation form and shortening it from four pages to two to make it a more user-friendly.