The project team was impressed with the level of support that most QIPs received from the various providers that participated in our discussions. The general attitude expressed was that most of the QIPs introduced in the Nursing Home Reform package were feasible, appropriately directed, and able to be implemented by most (if not all) nursing facilities. Some areas for improvement were noted, of course, but by and large those we spoke to were supportive of the programs. Areas noted for improvement were an increase in communication about QIPs between OHCQ and the Ombudsmen and between facilities and the Ombudsmen, and a greater degree of accessibility among providers to special funds for quality improvement projects.
This is not to say that all nursing facility representatives with whom we met in Maryland believed strongly in the ability of the programs to improve resident outcomes. To the contrary, providers were skeptical that these QIPs were sufficient to solve the quality of care problem in nursing homes. They named issues of staffing and of the long-term care survey and certification process as barriers to high quality performance. Providers attributed the biggest problems to promoting or increasing nursing home quality to:
- Nursing staff turnover and the nursing shortage;
- Mid-level nursing staff lacking critical management skills; and
- The pervasive use of contract nursing staff.
Provider representatives met with also stated that the long-term care survey and certification requirements must be changed, as the process and penalties are so severe that it is impossible for facilities to ever feel positive about performance when the best result that can stem from the long-term care survey is a "zero" deficiency.
Another opinion expressed in general about the quality initiatives was with regard to quality indicators used for measuring facility performance. The opinion was expressed that quality indicators should focus on positive outcomes, rather than just on negative measures. An example of a positive indicator of quality cited was the number of hours the Medical Director is in the facility.
From this project's point of view, it is difficult to say with certainty what will work in Maryland and what may not work to improve nursing home quality. There are a multitude of initiatives underway, all enacted during the same timeframe, all enacted in a climate of decreases in nurse staffing and other changes affecting the nursing home industry (e.g., declines in occupancy, Medicare skilled nursing facility prospective payment, public reporting MDS-based quality indicators). No formal evaluation is currently underway to examine the affect of any of these programs on resident outcomes. Such an evaluation would assist the state in refining and improving upon the current set of quality initiatives.