Both the QA Plan requirement and the Second Survey were noted by those we spoke with to be positive aspects of the Maryland quality initiatives. Comments regarding the QA Plan were that a requirement that "formalized" quality assurance was good, and encouraged providers to look at whether they had a comprehensive enough approach. One provider stated that the "formalized approach" to QA makes them stay attuned to issues, in a way they may not without a formal requirement. A facility representative believed that the requirement to meet and review QA activities monthly is positive because it "makes the QA program more meaningful" and helped to give nursing home administrators and management a better understanding of quality issues. Another provider stated that having the quality improvement programs as a focus allows facility nurses to feel empowered, and gives them the perspective that they can have an effect on their environment. This is a great enhancement over the former feeling that the best they could do in terms of performance was score a "zero" on their number of deficiency citations. Finally, the Ombudsmen stated that the process of the facility sitting down and talking with the medical director and each other during the QA meeting has had a very positive effect, and that the QA requirement has made facilities more aware and more accountable.
The Second Survey was seen as a positive aspect of Maryland's quality improvement initiatives. HFAM believes the second survey program is a positive change, and the sharing of best practice information is positive. One facility reported that the second survey was a welcome relief after the state LTC certification survey ("during certification surveys we were grilled, exhausted and I felt kicked"). This group stated that it is a relief to be able to have an open dialogue about problems and issues in resident care, and to obtain advise and feedback. Although there was initially a great deal of suspicion, those we spoke with stated that the Second Survey has changed the relationship between the State and providers and has enabled providers to identify problems and implement corrections.
Other general comments regarding what seems to work well in Maryland had to do with the use of quality indicators in the second survey and in other quality initiatives, and the more positive relationship between the state and the provider community. HFAM noted that the new focus on quality indicators and quality improvement was a good outcome of the QA requirements, and that the focus no longer revolves simply around deficiencies. The Ombudsmen stated that the relationship between the state and providers had improved since the implementation of the quality improvement initiatives. OHCQ is perceived as having attempted to make the survey process less adversarial. Ombudsmen report fewer complaints from facilities about the LTC certification surveys than previously.
Additional positive observations made by providers included the following:
- the QIs help facilities identify MDS coding problems;
- facilities need health information systems to more efficiently use MDS data for quality improvement;
- the monthly QA meetings provide facilities the opportunity to track the effect of quality improvement efforts; and
- quality improvement programs most benefit smaller facilities that have more limited resources; larger facilities can invest in many innovative approaches.