State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Observation of a QAN visit

05/15/2003

We observed part of a QAN visit, which was said to be "fairly typical." In preparation for the visit, the QAN nurse reviewed the following: the facility's Quality Indicator (QI) reports and trends, trends in casemix, complaint issues, and discharge issues. QAN visits were said to be generally focused on issues identified by the QAN in advance of the visit. In the case that we observed, the QAN nurse decided to focus on skin and bladder management issues. Reviewing the casemix audit information in preparation for the visit she had found several instances of urinary track infections (UTI) and stage 1 ulcers. Further, reviewing the QI showed a somewhat elevated low risk pressure ulcer rate (6.4 percent versus 4.3 percent statewide).

During the portion of the visit we observed, the QAN nurse toured the facility (i.e., did rounds); reviewed 2-3 resident records; interviewed staff and some residents; and observed skin care on 1 resident with a catheter, bowel incontinence, resolved UTI, skin issues, and newly prescribed medication for agitation. The QAN nurse's observations and interviews were structured by a written protocol--in the case we observed, the nurse was completing the skin integrity protocol. The QANs that we interviewed said that providers were enthusiastic about the protocols because they helped them understand the expectations for successful surveys. The QAN nurse whom we observed for part of her visit planned to return to the facility the next day to complete the skin integrity protocol and perhaps the bladder management protocol on 5 residents. In addition to sharing her protocol findings with the facility, she also planned to share the following information at the exit conference: information about immunization (since this is now a CMS focus); issues regarding dental care (a current issue for the survey); and will remind the facility to disseminate the "Dear Administrator" letters from the State with all staff.

The QAN staff we interviewed generally agreed that they do not tell facilities what they should do specifically (e.g., hire more staff). Rather, they said their job is to identify systems issues; for example, they might explain to a Director of Nursing (DON) "You're not getting the critical thinking part." However, one QAN mentioned that she was frustrated by the fact that it was clearly impossible for her to teach a particular DON the whole nursing process, and that she (the QAN) believed the best she could hope for with some was to help fix a specific problem observed in a single visit--for example, pointing out to the nursing staff a resident who clearly needed some help.

While the providers with whom we spoke generally liked it when QAN staff referred them to other facilities as examples of good practices in particular areas, the QAN nurses with whom we spoke differed in their own practices with respect to this aspect of information transfer. About half of the QAN nurses with whom we spoke said that they actually gave facilities the name of another facility to contact for suggestions. The others said that while they did not give out specific names, they did tell facilities about good practices they had seen in other facilities.

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