State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Aspects of Texas's Quality Improvement Programs Noted to be Less Successful


During our visit we heard several concerns from provider representatives, particularly regarding the Quality Monitor Program. Many of these less positive comments appear to have been influenced by differences of opinion regarding the type of technical assistance that DHS should be giving providers under the new program. Some had expected that the program would involve Quality Monitors providing more direct consultative assistance such as help with problems with a specific resident's care, or help more focused on how the facility might better meet survey requirements. Some also had expected the Quality Monitors to suggest the names of facilities that were doing some things particularly well. Instead, some expressed the feeling that the Quality Monitor Program appeared to be introducing new and even higher standards than the survey.

Given the litigious climate in the state with respect to nursing home care and severe problems with liability insurance, providers were also particularly concerned that the Quality Monitor reports would be available to surveyors and ultimately discoverable in litigation. Most providers and association staff we spoke to were willing to give the program a chance, however, and thought that their most serious concerns might be addressed by toning down the language in the Quality Monitor's reports. Specifically, providers were quite concerned that the reports used phrases such as "inappropriate care," without making clear that this actually meant care not fully consistent with the particular best practices applied by the program. This problem was being addressed by DHS at the conclusion of our site visit.

An additional theme regarding both the Quality Monitoring Program and the QMWeb centered on a perceived need for more clearly and simply presented information. Most with whom we spoke commented that there is too much information to sift through on the QMWeb and that DHS needed to have increased awareness of facility staff's lack of time for reading an abundance of background materials. Similarly, some stated that the information left by the Quality Monitor was overwhelming and had not been read. Regarding web-based dissemination of information, some noted that facilities in more remote locations may not have access to the internet and that not all facility staff were savvy about navigating the web. Few appeared to understand the relationship between the Quality Monitor Program and the evidence-based best practice models. As noted previously, however, the program had just recently been initiated at the time of the site visit and DHS program staff have subsequently developed new videos and other training materials to educate providers the program.

Providers and consumer representatives raised some of the same issues with the Quality Reporting System as they did with the QMWeb. They were also concerned that the quality information suffered from a lack of timeliness, from frequent inaccuracies that take time to be corrected, and from a lack of risk adjustment in the quality indicators. Several providers were also concerned that deficiencies that have been appealed (and may be overturned) are still listed on the system.

With respect to Joint Training, program staff noted that curriculum development had taken more time than originally expected, slowing program implementation, and that the program needed to be more fully coordinated with the quality improvement efforts under Dr. Cortes' direction.

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