Washington State was chosen for a site visit because it has a long-standing, statewide technical assistance program, called the "Quality Assurance Nurse" (QAN) program. The QAN program evolved from an earlier UR program. Today, QAN nurses have five functions: (1) providing "information transfer" (the official name for "technical assistance") for a set of assigned nursing facilities (caseload is 8-12 facilities/QAN); (2) conducting reviews of MDS accuracy (related to the state's casemix payment system) in those facilities; (3) operating as surveyors, both conducting regular surveys and occasionally serving as complaint investigators; (4) conducting discharge reviews to determine if resident rights are maintained when discharged/transferred; and (5) serving as monitors of facilities who are in compliance trouble.
Program administrators and the experienced QANs we interviewed in a roundtable discussion at the Aging and Adult Services Administration's (AASA) central office were very upbeat about the program. These QANs said it was the best possible job because they could actually help facilities improve, while retaining the "stick" of possibly giving citations for deficiencies should that be needed. Program administrators and these QANs thought that "100 percent of facilities" were positive about the program; that the major complaint we would hear would be the diversion of QAN time to work on surveys.
Providers and others (Ombudsmen, key staff at the 2 nursing home associations, and staff and members of the Board of the Resident Councils) did in fact repeatedly emphasize problems with the diversion of QAN time from "QANing" to other duties. As predicted, most said that their main issue with the program was that "QANs don't have enough time to be QANs." Additional issues, however, were also raised. Nearly all of the providers we interviewed (including those generally very positive about the program) said that the technical assistance functions and the survey functions were a conflict and advised other states not to adopt the "multiple hats" approach. All agreed that the success of the relationship between a facility and a QAN was very dependent on the particular situation…the skills of the QAN and a facility's own circumstances. Several of the providers we interviewed had had less than optimal experiences and believed that the program should be substantially changed to be far more objective (i.e., less discretion for the QAN nurse, more reliance on protocols); one firmly believed it should be discontinued. Both of the consumer groups with whom we held discussions were somewhat skeptical about the effect of the QAN program on quality and suggested alternatives.
In the absence of a formal evaluation (including interviews with a scientifically representative sample of providers), it is difficult to know the actual effect of the program or the true extent of provider satisfaction/dissatisfaction. However, the fact that the program--in operation for over 20 years--has withstood the test of time is itself an indication of some success.