This section includes a brief description of each of Iowa's quality improvement programs followed by a discussion of program funding, governance and the management and staffing structure. The following quality improvement programs were reviewed:
- Nursing Home Report Card
- Quality-Based Inspections of State-Licensed Facilities
- Surveyor/Provider Training
- Best Practices
- Governor's Award for Quality Care
- Deficiency Free Certificates of Recognition
- Survey Questionnaire
Nursing Home Report Card
The Nursing Home Report Card is an Internet web site that contains information on all federally certified nursing facilities and skilled nursing facilities in the state. The Report Card allows users to search for facilities by name or location. It includes "quality indicators" (Note: These are F-tags and not the CMS quality indicators) based on survey results. The web site includes the full inspection report, including detailed write-ups of deficiencies and the facility responses/Plans of Correction. All survey/complaint investigations since June 1999 are listed, including those under appeal, with the appeal noted (see Appendix C for a sample facility Report Card). The Report Card also includes information on facility best practices. The legislation that created the Report Cards was passed in late 1997. At that point in time, the CMS Nursing Home Compare site was still under development, and there was little consumer information on nursing homes available on the Internet. The Iowa Nursing Home Report Card went on-line on November 5, 1999.
A goal of the Report Card is to provide consumers with information on nursing home quality so that they can make informed nursing home choices. It is believed that provision of this information will motivate facilities to improve quality. The department strongly believes in making information available to consumers, believing, according to Dr. Tooman, that the availability of public information is "sacrosanct" (except when it is necessary to protect confidentiality). Iowa is the only state that researchers are aware of that posts complete survey results on the Internet. The survey findings are posted to the Report Card web site two days after the survey is mailed to the facility.
According to an article in Insight, the Report Card website was designed over an 18-month period as DIA worked in collaboration with resident advocates and nursing home industry leaders. DIA met with stakeholders twice as they developed the report card. The group included representatives from the four provider groups, the Iowa Partners group, advocacy groups, ombudsmen, state legislators, and representatives from the Departments of Elder Affairs and Public Health. In the facilitated meetings, DIA presented a shell and asked for input from stakeholders.
Under the Quality-Based Inspection Program, facilities that are state-only licensed may be surveyed every six to 30 months, depending on facility performance. The program was intended to allow DIA to maximize its resources and concentrate more fully on the facilities in the state needing the greatest attention. Legislation authorizing the program was signed on May 11, 2000 (Senate Bill 2144). The quality based inspection program is reported to have originated from provider groups requesting the state to make changes in the survey process. Facilities opting to participate must complete a detailed application process based on the Malcolm Baldrige National Quality Program. The Baldrige Award is given by the President of the United States to businesses and education and health care organizations that apply and are judged to be outstanding in seven areas: leadership, strategic planning, customer and market focus, information and analysis, human resource focus, process management, and business results. Nationwide, there were five winners in 2001. DIA modified the Baldrige application process by shortening the application and broadening the categories to accommodate the limited resources of most nursing facilities.
The program, however, has not been truly successful. Very few facilities have opted to participate. There are ten nursing facilities statewide that do not participate in the Medicare or Medicaid programs, and are thus eligible for the program. Three facilities were invited to participate in a pilot program, but only one nursing facility has completed the self-assessment necessary to participate in the quality-based inspections program.
Furthermore, the potential benefits from participating (in terms of a less frequent survey cycle) are probably outweighed by the time and effort required to apply. A major component of the Baldrige National Quality Program is the feedback report, which is a written assessment of an organization's strengths and opportunities for improvement based on its application. Due largely to limited staff availability and budgetary restrictions, the Iowa-modified program does not provide any type of feedback report to its applicants. This feedback report had been envisioned as one way, among others, that the department could provide a type of technical assistance to facilities.
Begun in November 2000, the Best Practices Program aims to recognize and disseminate new and innovative approaches to providing nursing home care. Shortly after assuming the Division Administrator duties, Dr. Tooman observed a surveyor congratulating a director of nursing on a uniquely successful nursing procedure. He believed that the details on this practice should be shared with other facilities and that at the time there were no means to accomplish that. The goal for the program as described by DIA is to close the gap between knowledge and practice and point to positive approaches to integrating new knowledge and practices.
Facilities that believe they have developed an innovative practice report it to the surveyor during the annual inspection. The surveyors review the practice on site with the team leader, making the decision as to whether it qualifies as a Best Practice. Those practices deemed to be among the best in the state are recognized and posted on the division's Report Cards and in a separate listing on the web site. Best Practices are sought and recognized in nine categories--community integration, dietary, resident rights, nursing practices, human resource management, environmental, quality of life, habilitation/rehabilitation and end-of-life experiences.
Currently, there are 300 Best Practices listed on the web site (note that fewer than 300 facilities are represented since some facilities are recognized for more than one best practice.) Originally, the department's web site denoted best practices with a trophy icon, but this was later changed to a light bulb, as the department wanted to emphasize that the Best Practice program was designed to recognize a facility's practice, not the facility itself. Also, the practice of sending facilities Certificates of Recognition was later changed to the sending of a letter, because of confusion related to certain facilities receiving recognition and then later having problems with survey inspections and/or complaints.Appendix D includes the state's principles and procedures of Best Practices.
Joint Surveyor Provider Training
Beginning in June 2000, the DIA and the provider associations have collaborated to present four joint surveyor/provider training sessions, with another session scheduled in October 2002. Training sessions have been held on elopement, activity-focused care, dental needs of long term care residents and resident-centered living. The October 2002 session will address pain-related issues. The department initiated the joint training sessions in an effort to provide a common knowledge base for surveyors and providers and to enhance the quality of care and quality of life of the state's residents. The department utilizes local community colleges to assist with the organization of the training with experts in the topic recruited to conduct the actual training sessions. For example, two professors from the University of Iowa College of Dentistry led the training sessions on oral health and Eric Haider, from the Crestview Nursing Home in Bethany, Missouri spoke about his philosophy on resident-centered care. Nearly all of the state's 60 surveyors and 200- 350 providers have participated.
Governor's Quality Awards
The Governor's Award for Quality Care in Health Care Facilities recognizes quality services provided by long term care facilities, residential care facilities and intermediate care facilities for the mentally retarded or mentally ill. The award is based on the uniqueness of the services provided by the facilities to its residents, and any activities undertaken by the facility to enhance the quality of care or quality of life for its residents. The program was signed into law on May 11, 2000 with the first awards given in 2001 to eight health care facilities.
Nominations may be made by residents, family members, advocates and staff at other nursing homes. A stakeholder committee selected by the Director of the Department of Inspections and Appeals reviews nominations. Committee members evaluate each nomination and recommend facilities for further consideration. Prior to the selection of finalists, onsite reviews are made by DIA personnel to verify the accuracy of the information in the nomination. There can be up to two winners in each of the state's five Congressional districts. In 2001, there were 29 nominations and five winners. In the first year of the program, the awards were mailed to seven of the award-winning facilities, with the Governor making a personal presentation at one location. This past year, Governor Vilsack presented the awards at the Governor's Annual Conference on Aging.
Deficiency-Free Certificates of Recognition
Beginning in September 2000, DIA provides certificates of recognition to facilities that are deficiency-free in their annual inspection. The certificate is the department's way of acknowledging the "hard work and dedication" of the facility's staff in meeting the established standards of care. During the fiscal year that ended in September 2000, nearly 15 percent of the state's 800 long-term care, intermediate and residential care facilities had achieved deficiency free surveys. In March 2001, it was reported that 55 nursing facilities had received certificates.
Since June 2001, facilities have had the opportunity to complete a survey questionnaire that is presented at the conclusion of the regular survey. Completed surveys are returned to the Iowa Foundation for Medical Care (IFMC) for tabulation. IFMC estimates that 40-50 surveys are returned each month. The goal of the questionnaire is to improve the survey process in the state, ultimately improving the provision of health care services in the state. The survey includes information on surveyor conduct; facility opportunity to provide information and survey-related data; clarity of exit conference information; and whether the facility received information on the Best Practices program. Providers are also given the opportunity to provide general comments on the survey process, including suggestions on how to improve it.
IFMC produces a report for DIA in an Excel spreadsheet, which DIA in turn shares with their staff. In May 2002, the state average was 4.62 (on a one to five scale with five representing the most favorable rating). Data are stratified for each program coordinator so that specific areas for improvement can be identified and addressed.