The Quality Monitoring program was mandated by SB 1839 that was passed in 2001. The program was implemented in April 2002, and had been in operation for only a few months at the time of our site visit to the state in August 2002.
The purpose of the program is to provide facilities with technical assistance that will help them to achieve improved resident outcomes through the consistent application of evidence-based resident care planning and care practices. By June 2002, half of Texas facilities had received an introductory visit from a Quality Monitor and about 10 percent had received an additional formal visit.
The legislation that created the Quality Monitor program specified only a few program features:10
Quality monitors must a registered pharmacist, or nutritionist who are experienced in long-term care facility regulation, standards of practice in long-term care.
Quality monitor visits are to be unannounced, and may occur during nights, evenings, weekends, and holidays.
Priority for monitoring visits shall be given to long-term care facilities with a history of patient care deficiencies.
Quality monitors may not be used in the conduct of routine, scheduled surveys.
Quality monitors are to assess the overall quality of life in the long-term care facility and specific conditions in the facility directly related to patient care.
Quality monitor visits should include observation of the care and services provided to residents and formal and informal interviews with residents, family members, facility staff, resident guests, volunteers, other regulatory staff, and representatives of a human rights advocacy committee.
Finding from monitoring visits, both positive and negative, should be provided orally and in writing to the facility administrator or director of nursing.
Quality monitors may recommend to the long-term care facility administrator procedural and policy changes and staff training to improve the care or quality of life of facility residents.
Conditions observed by the quality monitor that create an immediate threat to the health or safety of a resident must reported immediately to the regional survey and certification office for appropriate action and, as appropriate or as required by law, to law enforcement, adult protective services, other divisions of the department, or other responsible agencies.
Building on this legislative framework, DHS (with input from two stakeholder meetings) crafted an innovative program that complements other departmental quality improvement efforts. The mission of the Quality Monitoring Program is "to promote the consistent use of evidence-based resident care planning and resident care practices that offer residents the highest possible quality of care and life." A core feature of the program is a set of highly structured protocols and assessment instruments that Quality Monitors use during their visits to determine if care is being provided in accordance with evidence-based best practices. These best practices were determined by DHS through a systematic review of the literature and assistance from selected outside clinical experts.
The initial focus of the Quality Monitoring program is three specific clinical care issues. These are the use of psychoactive medications, the promotion of continence, and the use of restraints. The state selected these issues for special emphasis because they are areas that offer real opportunities for improving the care of the state's nursing facility residents. Each of these is objectively defined. Quality Monitors provide information regarding best practices and how to achieve them, give feedback to facilities regarding the degree to which the facility is providing care consistent with DHS best practice protocols, and help the facility identify system changes that could result in greater use of best practices.
Every nursing facility in Texas has been assigned a Quality Monitor. Caseloads (dictated by available resources) are approximately 30-40 facilities per registered nurse. The plan is for all facilities to have at least one monitor visit a year and for priority facilities to receive as many as are required to address identified problems. Visits are unannounced, and are prioritized based on a variety of factors including a troubled history of regulatory compliance, a history of poor resident outcomes, a DHS assessment of high risk for a poor survey outcome on the next survey visit, a high frequency of serious complaints, and other factors. This prioritization is intended to send monitors to the facilities where they may be able "to do the most good" in terms of helping the facility to improve resident care. Visits occur during work days, nights, evenings, weekends, and holidays.
Given the program's goal of making technical assistance available to nursing facilities, the state believes that it is important that the Quality Monitors develop stable collaborative relationships with individual providers similar to the relationships between facilities and Ombudsmen. To attempt to develop these types of stable relationships, each monitor is assigned a defined group of facilities.
The overall focus of this program is technical assistance, and as Dr. Cortes commented, an initial task can sometimes include getting facilities to recognize that they need the type of technical assistance the program provides. The goal of the Quality Monitor visit is to establish a relationship with the facility, identify system problems and trends in selected areas, and work to help facility staff make improvements as needed. The Quality Monitors are specifically instructed to refrain from telling a facility how to solve a particular problem with a particular resident. During the exit conference, the Quality Monitor is to brainstorm with facility staff regarding potential solutions to identified system problems. Rather than acting as surveyors, the Quality Monitor's job is to be a facilitator of a solution that the facility will "own".
Quality Monitor visits include a variety of activities that are intended to help the monitor and the facility staff to identify quality improvement opportunities. A visit includes an entrance conference, which gives facility staff the opportunity to provide information to the monitor about challenges and issues at the facility. The monitor uses resident assessment and record review to construct an objective picture of the quality of care concerning specific clinical issues. During the visit, facilities also can share their Quality Improvement progress and Quality Assurance Committee activities with the monitor. The monitor spends time time working with the staff to assess the effectiveness of its quality management activities. During the exit conference, the monitor will identify areas where progress has occurred as well as areas where improvement is needed.
After completing a visit, the Quality Monitor prepares a Visit Summary Report. This is a written report that is sent to the facility, typically by email, within ten working days of a monitoring visit. The facility has the opportunity to provide electronic feedback to program managers regarding the visit, the report, and the program in general. This provider feedback is part of the Quality Monitor Program's critical self-evaluation process.
10. The text of this bill is available on-line at http://www.capitol.state.tx.us/cgi-bin/tlo/textframe.cmd?LEG=77&SESS=R&CHAMBER=S&BILLTYPE= B&BILLSUFFIX=01839&VERSION=5&TYPE=B.