State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Overall Intent/Vision for Quality Improvement Programs


All but two of the programs described below (Liaison with Providers and Joint Training) are closely linked to each other and are managed by Dr. Cortes. The programs reflect his underlying vision of the meaning of "nursing home quality" and the need for mechanisms for quality improvement other than regulation/enforcement (e.g., via LTC survey or minimum staffing requirements) or the reimbursement system. Following the World Health Organization's definition, Dr. Cortes describes quality at the highest level as, "Doing the right thing in the right way at the right time for the right person in order to achieve the best possible outcome." A hallmark of the QIPs he supervises is the attention given to measurable, objective, evidence-based operational definitions of specific aspects of quality care.

A good example of this is the way in which the program is dealing with the issue of restraint use. A review of federally-mandated nursing home data made it clear that Texas has for many years rated among the states with the highest rate of restraint use. To determine what constituted quality care with respect to restraint use, DHS commissioned a detailed review of the literature with the results reviewed by a technical panel. Based on this review, they determined that there were six situations where restraint use was clinically appropriate. Other uses were, by this definition,"inappropriate," even though they might not warrant a citation on the federal survey, which incorporates different, more subjective criteria. Thus, improving quality in this area translated into the specific goal of reducing the number of residents who are restrained for reasons other than the few determined to be clinically appropriate. The Texas Quality Monitor Program is designed in part to teach facilities this evidence-based best practice with regard to restraint use, to provide periodic detailed measurement in facilities regarding this best practice, and to provide technical assistance about general ways to reduce inappropriate restraint use.

Another QIP, the legislatively-mandated "Statewide Quality Review" (discussed in more detail below), has been used to gather data relevant to this area such as the documented reasons for restraint use. In addition, this annual survey provides a means of tracking progress on changes in statewide quality with respect to selected issues, thus serving in part as a way to evaluate the effectiveness of the relevant QIPs. These programs work in tandem with educational efforts such as the Geriatric Symposium and QMWeb, also described below, that are used to further disseminate information about appropriate restraint use and other selected best practice areas.

The general theory underlying the QIPs as a whole is that as consumers, practitioners, providers, and policy-makers are educated with respect to nursing home performance on specific, measurable, evidence-based aspects of quality, system quality will improve. In addition, there is a strong emphasis on focusing on a limited number of important issues (e.g., restraint use, hydration, psychotropic drug use) at one time. Finally, most of these QIPs have an associated evaluation component, reflecting a commitment to hold the programs up to systematic scrutiny.

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