Virtually all with whom we spoke said that it would be better if the QANs had more time for QANing. As one provider put it "What's discouraging is that [the QAN program] seems to have been out of commission for a while; they must be doing surveys." Several providers with whom we spoke reported not having a QAN visit in over a year; one reported only one visit in 3 years.
As noted above, most of the providers with whom we spoke also thought the program would be improved if the QAN nurses were not also surveyors. Of those holding this opinion, most said the problem was an inherent conflict of interest; a few thought the conflict of interest was not a problem, but that if the roles were separate, the QANs might have more time to be QANs.
The QAN nurses with whom we spoke had very few suggestions about potential program improvements, other than more time for QANing per se. All said that the caseload was fine (setting aside the need to spend so much time on surveys) and that the QAN job provided a great deal of professional satisfaction. Suggestions for improvement involved things such as a desire for additional training (particularly on the computer) and mentoring.
Some of the limited group of providers with whom we spoke had had some less than positive experiences with the program and these formed the basis of their comments regarding areas of the program that might be improved. Comments along these lines included the following:
"We've often been given conflicting information from the QAN and the surveyors regarding MDS coding" [all in the room during this discussion reported similar experiences].
"Sometimes their information [about quality care] is not a [federal or state] requirement…it's their own personal interpretation and it can be very subjective, based on local 'community standards.'"
"There is a disconnect between Central Office which wants to be helpful and has a consistent vision and the field. Central Office's idea is that this is a partnership, but in the field this doesn't really happen consistently."
"The program should be made more objective."
"The whole philosophy needs to change…they think the know best and they don't; we are the ones who really know the patients…there is too much 'Monday morning quarterbacking.'"
"We don't get enough opportunity to give feedback to Central Office. We know who the QANs are who ought to retire; we are afraid to report them because they might turn up as surveyors or complaint investigators. We're afraid of their retaliation."
The Ombudsmen with whom we spoke joined others interviewed in expressing concern that the QANs appeared to be being diverted to survey work. The Ombudsmen were particularly concerned because this was occurring at the same time that a change in the federal statement of work for survey agencies appeared to the Ombudsmen to give complaint investigation a lower priority than before. Thus, the Ombudsmen were concerned that the two early warning systems (complaint investigation and QANing) were both threatened at the same time. In addition, one Ombudsman with long experience in the field suggested, "The framework of the QAN program is the regulatory system. I'd like to reorient them to more innovation…they need a greater orientation towards quality of life." He further suggested that if a state were organizing a quality improvement program optimally, it should focus on empirically based, evidence-based practices. He reported that these exist in some areas that are also critical to resident quality of care and life (he saw these as inextricably intertwined) such as bathing, nutrition, and hydration.