Washington's QAN program has evolved over time. The state traces its origins to a program in the 1970s in which a "Nursing Care Consultant" from the state was in each facility about once a month to perform utilization review. Transformation of this role to include additional aspects of quality was spurred by Congressional passage of OBRA '87--the Nursing Home Reform Act. Implementing regulations for this law were delayed at the national level and Washington adopted the OBRA reforms in state law prior to full federal implementation. Washington adopted implementing regulations in 1989.
In the 1980s there were totally separate functions for the QAN nurses and the Survey staff. State program officials with whom we spoke noted, "There was a yellow line down the center of the office to separate the two staffs." Conducting surveys was added to the role of the QAN staff in the early 1990s. QAN nurses, however, generally do not act as surveyors in the same facilities where they provide special quality assistance. Two factors contributed to the decision to merge these roles. First, a stakeholder's task force on quality had concluded that it was important for all to "be on the same page" with respect to understanding the regulations. Second, the state had fallen behind in its surveys and needed additional trained staff available to help. Today, QAN nurses have five functions: (1) providing "information transfer" (described below) for a set of assigned facilities; (2) conducting reviews of MDS accuracy (related to the state's casemix payment system) in those facilities; (3) conducting discharge reviews; (4) operating as surveyors both conducting regular surveys and occasionally serving as complaint investigators; and (5) serving as monitors of facilities that are in compliance trouble.
Washington program officials with whom we spoke reported that in the early days of the QAN program federal officials frequently questioned the state about the appropriateness of the QAN program in the context of the survey, but that over time this concern had apparently lessened. Program officials noted the design of the QAN program has been influenced by a desire to "try to capitalize on federal funds." Thus, as the QAN nurses added surveys to their roles, the state was careful to keep the program in line with federal rules regarding appropriate roles for survey staff. For example, by state law the particular type of technical assistance provided by QAN nurses is called "information transfer." That term comes from federal procedures for the survey. According to a 1998 Report to Congress prepared by the Health Care Financing Administration (now CMS), "If some kind of activities [by survey staff] that could be construed as technical assistance are prohibited, it appears that other kinds of similar activities are permitted. Task IX in the [state Operations Manuel] Survey Procedures for Long Term Care Facilities states that:
'…the state should provide information to the facility about care and regulatory topics that would be useful to the facility for understanding and applying the best practices in the care and treatment of long term care residents.
This information exchange [italics added] is not a consultation with the facility, but is a means of disseminating information that may be of assistance to the facility in meeting long term care requirements. …
Performance of the function is at the discretion of the state and can be performed at various times, including during the standard survey, during follow-up or complaint surveys, during other conferences or workshops or at another time mutually agreeable to the survey agency and the facility…'13
The Report to Congress goes on to say, "…[T]he State of Washington may resolve, or at least balance, the inherent conflict between the traditional surveyor role of determining compliance and an expanded information transfer role by separating these two functions. The two functions are not performed at the same time, and generally not performed by the same person.14
HCFA, Report to Congress: Study of Private Accreditation (Deeming) of Nursing Homes, Regulatory Incentives and Non-Regulatory Incentives, and Effectiveness of the Survey and Certification System, 1998; Section 18.104.22.168 9 (downloaded version, no pagination).
Ibid. Section 13.5.6 (downloaded version, no pagination).