State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Sustainability and Lessons Learned


Since Texas, like most states, has substantial budget problems, virtually all programs are theoretically at greater risk now than in better economic times. Most of the programs are relatively inexpensive and during our visit, the only program that was said to be potentially vulnerable in the short term was the new Quality Monitor Program. Among those we spoke with, there was some discussion about the possibility of pressure being exerted on the legislature for repeal of the program, stimulated by one or more providers who are unhappy with the program's operation.

Program staff and providers were asked what advice they might give to another state considering implementing programs similar to those in Texas. General lessons learned by program staff from their experience in implementing the Quality Monitoring Program included the following:

  • It was easier to train nurses for Quality Monitoring positions if they had not had prior surveyor experience. Training former surveyors was difficult because they initially tended to "act like surveyors", sending a message that is counter to the intent of the new program.

  • Better coordination with respect to scheduling visits between the survey managers and the Quality Monitor staff would have been helpful. Unintended overlaps meant that Quality Monitors had to leave and return some other time, leading to some waste of time and effort.

  • Complete and well-executed training was found to be important to the success of the program. The monitors in the field are the most important ambassadors of the program. Selecting the right personnel who share the philosophy and goals of the program was crucial.

  • Salaries for the professional degree positions that will be needed to perform the quality monitoring duties need to be realistic. If there is a huge gap between state and private sector salaries, and/or there is a staffing shortage such as the case with pharmacists nationwide and nursing regionally, then this issue should be addressed upfront.

As noted above, providers had little experience with the program at the time of the site visit. A few we spoke to saw little benefit and advised other states not to implement a similar program. Others thought the program should be given a chance but thought a key lesson from the earliest days of the Texas program was the need for better information about the program's design and goals as well as greater collaboration between providers and DHS on key details. At the end of our site visit, one of the issues that most concerned providers--the wording of the Quality Monitor reports--was being addressed by program leadership.

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