State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Best Practices, Consumer Satisfaction and Minimum Nurse Staffing Ratios


The Best Practices program, the study on consumer satisfaction and the Minimum Nurse Staffing Ratios were all included in the Omnibus Legislation (LD 42) signed into law (PL 49, chapter 731, part BBBB) on 4/25/00. This legislation was constructed based on input from stakeholders on what they felt were the most pressing issues in long-term care. One respondent believed that the impetus for the legislation came out of the climate of the 1990s when there was lack of communication and an atmosphere of distrust between providers and the Department of Human Services. At the same time there had been significant shifting of resources out of the long-term care system and a tightening of admission criteria.

Also contributing to the legislation was work done by the Joint Standing Committee on Health and Human Services. Meeting during the fall and winter of 1999-2000, their goal was to develop a framework for how the long-term care system should operate. They met to examine the issues of long term care delivery systems and the availability and financing of long term care services and to identify fundamental principles that would guide current and future legislation on long-term care. They recognized that key areas for focus included: a commitment to quality, empowerment of consumers, partnership between providers and the regulators, accountability on the part of providers and the responsibility of the state to provide oversight and technical assistance. Facilitated by a senior policy analyst from the Muskie School of Public Service, University of Southern Maine, the committee identified what they believed to be guiding principles and recommended actions on long term care. The only person outside of the legislature who participated in the committee discussions was the State Long Term Care Ombudsman, included because she was believed to represent a knowledgeable, impartial and objective viewpoint. In January 2000 they published their report on long-term care in Maine in which three guiding principles were identified:

  • Maine's long-term care system should be comprehensive and flexible and should be designed to meet the needs and preferences of consumers;
  • Maine's long term care system should enhance the lives and safety of consumers; and
  • Maine's long-term care system should provide high-quality, cost-effective, affordable care through partnerships between providers of care and the state.

Within each guiding principle, recommendations and proposals for immediate action were identified by the committee.

The Best Practices workshops and minimum staffing ratios were proposed under the second guiding principle and its accompanying recommendation that, "All long term care services should be adequately and appropriately staffed." A committee consisting of the State Ombudsman, representatives from the Maine Health Care Association, the Maine Hospital Association, the Division of Licensing and Certification, the Alzheimer Association and Legal Services for the Elderly was formed to identify topics for educational programming. The minimum staffing ratios were studied by a Task Force, consisting of representatives from the Division of Licensing and Certification, providers, the Ombudsman, legislators, nursing and nursing assistants. They originally wanted to identify an acuity-based formula to determine staffing ratios, but were unable to identify an acceptable measurement and eventually abandoned the idea.

The proposed increase in minimum nurse staffing ratios was initially met with some skepticism on the part of providers. However, when the for-profit association canvassed the members as to their ability to meet the minimum requirements, providers responded that they were currently meeting the staffing requirements and did not see it as a problem. The association was pleased to be able to support the legislation that was seen as a positive move for residents and consumers. The language of the legislation when finalized, however, required that the minimum direct care staffing ratios be met every shift every day. Facilities, when indicating their ability to meet the ratios had based their responses on staffing in the aggregate, over weeks or months. The regulation allows for staff to be aggregated over the entire building (not by unit), but must be met each shift (morning, evening and night). The association had requested language be included in the law that facilities would not be cited if they had made an effort to cover the shift(s) so long as there was no harm to residents. This addition was not included in the final regulation.

The funding for a consumer satisfaction survey was introduced under the third principle and the accompanying recommendation that, "The Department of Human Services should enhance its efforts to provide technical assistance to long-term care providers in the spirit of continuous quality improvement. While the Department should not abandon its oversight role regarding providers, it should offer positive and constructive consultation to providers whenever possible." Consumer and family satisfaction surveys were listed as one method of measuring high quality care.

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