There was no discussion among those we spoke to of any of the nursing home reform legislation being repealed, or any quality initiatives being at risk of termination due to budget cuts or other reasons. This lack of discussion or concern, combined with a generally positive attitude among the provider community about the quality initiatives, indicate that most Maryland QIPs appear quite sustainable. Carol Benner reported that most programs are of cost to providers (vs. the state), and that the Second Survey is likely to continue. "The Second Survey people are protected…they aren't federally funded…".
There were many lessons learned cited by the state staff, and a couple of comments made regarding how the quality initiatives could have been better implemented. A provider stated that the state could have moved more slowly in implementing regulations, as facilities were not adequately prepared for newly required QA activities.
General lessons learned by OHCQ staff in Maryland include:
States need to have creative ways to look for balance between punitive and non-punitive programs.
It is important to obtain industry (and legislative) buy-in. According to Carol Benner, "A lot of the program success is attributable to public relations--getting your ideas out there and promoting them".
States should disclose their goals and be very upfront with facilities when launching such programs.
States should take a multi-faceted approach, since it's unclear what exactly works in improving nursing home quality.
States should conduct intensive training for program staffs on newly enacted regulations before implementation (surveyors thought Maryland might have done this better).
States should take the time to study other quality improvement models, as Maryland did, prior to designing and implementing any new programs.
Program-specific comments had to do with the Medical Director requirement and the implementation of the Second Survey. In terms of the Medical Director requirement, the state reported that, if they had to do this all again, they probably would have engaged in more collaboration with the industry and physician groups to get buy-in from these groups before the Medical Director regulation went into effect. They would, however, advise other states to follow their lead and pass strong regulations to make physicians accountable.
Lessons learned regarding the Second Survey included that, since a process like this is a dramatic departure from the usual "surveyor" mindset, the personality of the technical assistance surveyors is the key to success. The surveyors themselves commented that it is very important early in implementation to assure that everyone involved in the program "be on the same page." They found that, early on in the process, they were not always consistent in their message to facilities. This has improved over time, but could have been dealt with more effectively by more thorough communication.
The Second Survey is evolving with time and as lessons are learned by the surveyors. For example, a standardized tool has been developed for the Second Survey that examines the facility's ability to internally monitor falls, malnutrition and dehydration, pressure ulcers, medication administration, accidents and injuries, changes in physical/mental status, quality indicators, and other important aspects of care. At the time of our visit, all nursing homes had been surveyed once and baseline data had been collected. The Technical Assistance Unit is in the process of reviewing lessons learned from the first year and establishing the focus for the second round of surveys.