State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Program Focus: Improving Care Practice or Regulatory Compliance


The focus of a state's TA program is a fundamental choice that influences all the subsequent program design decisions. States tended to choose one of two directions. One group of states created programs that focused on direct promotion of quality improvement through efforts to assist facilities in improving their care practices. In the other group of states, the focus of the TA programs promoted quality through an emphasis on monitoring compliance with survey and certification requirements. Programs in this second group of states do offer technical assistance to facilities on quality related issues beyond the scope of the survey and do not have the punitive aspects of the survey process. However, they tend to focus more on monitoring care and regulatory compliance than on helping facilities to improve their care processes.

The distinction between the foci of the two groups of states was conspicuous, and state representatives, providers, and consumer advocates talked extensively about the orientation of the TA program. Although not explicitly stated by any of the stakeholders with whom we spoke, several statements taken together made it clear that some states believe that emphasizing monitoring and enforcement of survey requirements can and does raise the level of care quality. For example, in Washington, a state with a TA program that emphasizes regulatory compliance, virtually all of those with whom we spoke--state personnel, providers and consumer representatives--reported that one of the best things about the state's QAN program was its close ties to the survey. These stakeholders expressed a belief that TA programs should emphasize regulatory compliance, and be linked with survey activities and staff. Other states viewed such linkages as conflicting with what they saw as the primary aim of the TA program, through the provision of an alternative to the survey process. In states that focused on improving care practices, the belief was that when the focus was on improving quality of care for residents, regulatory compliance would logically follow (rather than the other way around).

Programs with a Focus on Directly Improving Care Practices

The majority of our study states (Maine, Maryland, Missouri, and Texas) have chosen to focus their TA programs directly on helping nursing facilities to improve their care practices, using an approach that is separate from the LTC survey process.

  • The Second Survey in Maryland assists facilities to develop and maintain quality improvement processes. No deficiency citations are made during this visit, although facilities may be required to develop a plan of correction for serious problems.

  • Staff in Missouri's Quality Improvement Program provide clinical consultation based on helping facilities to improve their performance on the quality indicators developed by the Center for Health Systems Research and Analysis (CHRSA). Visits are made upon facility request and have no ties to the survey agency. Staff are not survey trained and do not offer advice on issues related to regulatory compliance.

  • Texas TA staff make visits to determine the appropriateness of care based on evidence-based practice models. The goal is to engage facilities to identify and focus on facility systems issues that are barriers to the provision of quality care. Initial visits are scheduled based on a facility's risk for a bad survey and are announced. Subsequent visits are unannounced with frequency dependent on performance in prior visits.

  • The Consultant Nurse in Maine provides on-site visits as requested by facilities, during which the nurse meets with staff and assists the facility to develop an effective care plan. Facilities are not held accountable for implementing the TA nurse's recommendations.

Programs with a More Regulatory Focus

The focus of the TA programs in Washington and Florida is more on promoting regulatory compliance.

  • Washington's program is focused in part on facility compliance with LTC survey requirements and utilizes protocols that identify areas of inquiry based on cited survey deficiencies. The visit is seen, by TA staff and by facilities, as an opportunity to inform facilities of potential compliance issues and of statewide (or nationwide) enforcement issues that can be expected on the LTC survey. Quality Assurance Nurses have five functions: (1) sharing information with facilities that "may be of assistance to the facility in meeting long-term care requirements"; (2) conducting reviews of MDS accuracy (related to the State's casemix payment system) in those facilities; (3) conducting discharge reviews; (4) operating as surveyors both conducting regular surveys and occasionally serving as complaint investigators; and (5) serving as monitors of facilities that are in compliance trouble.

  • The primary stated goal of the Quality Monitoring Program in Florida is to monitor the care provided to nursing home residents. The TA staff interpret and clarify state and federal rules and regulations governing facilities, and also offer educational resources and models designed to improve care. They also provide support to LTC surveyors, including compliance reviews of staffing and risk management programs, as well as training new surveyors.

While the primary focus of the types of programs (i.e., those with a focus on improving care practices vs. those with a focus on promoting regulatory compliance) is clear, there is a certain overlap between these two types of programs. For example:

  • Maryland's TA staff (with a more improvement of care processes focus) advise facilities on implementing quality improvement activities that are part of regulations recently enacted by the state legislature. In May 2000, the state of Maryland's regulations were modified to require that facilities implement a Quality Assurance Plan that includes procedures for evaluating residents with a change in clinical status, ongoing monitoring of all aspects of resident care, addressing resident and family complaints, and reporting and investigating accidents, incidents, abuse and neglect. Thus, a goal of the Maryland TA program is to ensure that facilities comply with the new regulations.

  • Similarly, the Quality Monitors in Florida review and report to the State Survey Agency facility compliance with risk management regulations and state staffing requirements, but also see their role as providing information and guidance on best practices.

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