This report describes findings from our exploration of the State of Maryland's quality improvement projects (QIPs). We first present some background information about Maryland and about the project team's site visit to that state. Next, a history and rationale for Maryland's movement toward state-initiated quality improvement is presented. This is followed by a description of each program reviewed by the project team. Findings regarding the strengths and weaknesses (as identified by state and nursing home industry representatives) are presented, as is a discussion of the impact of the QIPs on quality of care and quality of life of nursing facility residents. Finally, lessons learned by the state are presented, along with a brief description of the perceived sustainability of the various QIPs.
Abt staff members Terry Moore and Donna Hurd accompanied by Task Order Officer Jennie Harvell and consultant Barbara Manard met with individuals involved in the development, management and implementation of the programs, and with nursing facility staff that had been surveyed under the technical assistance program. Over a three-day visit in April 2002, the research team met with individuals and groups associated with the following organizations:
- Maryland Department of Health and Mental Hygiene/Office of Health Care Quality (OHCQ)
- Carol Benner, Director
- Gene Heisler, Deputy Director
- William Vaughan RN, Chief Nurse
- Mark Kirwan RN, Surveyor
- Carmen Ulgen RD, LD, Surveyor
- LeeAnn Wheatley RN, Surveyor
- Linda Masterson RN, Special Assistant for Technical Assistance
- Tina Malara, RN, Surveyor
- Hollie Kratzer, RN, Surveyor
- Life Span--the American Association of Home and Services for the Aging affiliate in Maryland
- Isabella Firth, President
- Health Facilities Association of Maryland (HFAM) (the American Health Care Association affiliate)
- Adele Wilzack, President
- Mark Woodward, Government Relations
- Fran Miller, Clinical Director
- Margaret Chapin, QI Committee Co-Chair
- RNs from member facilities
- Maryland Department of Aging
- Fran Stoner, Ombudsman
- Pat Bayliss, State Long Term Care Ombudsman
- Michael Lemouth, Field Coordinator
- Lenora Yancy, Baltimore County
- Carol Perkins, Carroll County
- Continuing Care Retirement Community with 79 skilled beds
- Not-for-profit corporation
- Administrator, Director of Nursing, Medical Director, Social Worker
- 130 bed not-for-profit nursing facility
- Administrator, Director of Nursing, Quality Assurance Nurse
- FutureCare Health and Management Corporation
Carol Benner, OHCQ director, was the primary contact for the Maryland site visit. With 14 years experience in her position and author of the state's nursing home reform package, she was an excellent resource on the political environment in her agency and the state at large. During the preparation phase and on-site discussions, she was a willing and enthusiastic informant on the various reform programs in place. Likewise, the Technical Assistance Surveyors and other members of the OHCQ staff were willing to share their experiences and impressions of the impact of the program. Some of the provider representatives were initially more guarded in their presentation and focused their discussions on the issues that they felt were most important to their members. Other provider representatives were less concerned about staffing and funding issues and were more open to giving us their comments about the variety of quality improvement programs initiated by the state.
Prior to the on-site visit, factual information on the quality improvement programs was gathered from the literature review, stakeholder discussions and Maryland state web site. Information on the following aspects of the programs was gathered and organized in a table:
- Program title including a regulatory reference, if applicable;
- Program description;
- Agency contact--the person(s) most knowledgeable about the program protocols and implementation to date;
- Impetus--what prompted the development of the program;
- Designer--identify the individual(s) or group(s) responsible for program design and indicate agency affiliation(s);
- Goals--state the program objectives;
- Funding Source and Amount--state current funding amounts/sources and projections for future periods;
- Program Staff--indicate how many individuals are involved in the program implementation including administrative support, what is the organizational structure;
- Facility Involvement--is this a requirement for all facilities or a voluntary program, how are facilities selected for inclusion, if voluntary?
- Dates--what are the program beginning and end dates;
- Evaluation--indicate current and planned formal evaluation program(s).
The table was forwarded to Carol Benner prior to the on-site visit for her to review and provide any additional or corrected information. The research team used the factual information in the table as a starting point to develop discussion guides that focused on more in-depth issues. Letters of endorsement explaining the project goals, state selection and planned discussions were formulated and sent to prospective discussants. Follow-up phone calls were made to arrange for convenient dates and times for in-person meetings.
Discussions with the survey agency staff, provider associations, ombudsman and nursing facility staff took place at their respective offices or on-site at the nursing facility and generally lasted approximately two hours per conversation. In each case, the research team encouraged the organization, agency or nursing facility to include as many of their staff as they thought would be interested or would have valuable information to share. The research team was able to observe a portion of a technical assistance survey on site. During a break in the technical assistance survey, the research team met briefly to talk with the surveyors and then observed the technical assistance process as surveyors discussed their findings with the facility staff.
Discussions were generally structured with one researcher presenting both prepared and spontaneous questions while the other researchers recorded responses in writing.