Surveyors stymied by survey criteria, researchers find.

The survey process administered by states to certify nursing homes for Medicaid reimbursement is flawed, according to a multiyear research effort completed recently by a consultant to the federal Health Care Financing Administration (HCFA). The report noted that items cited as deficiencies may not, in fact, reflect the real concerns of the survey teams. Meanwhile, the real quality-of-life needs of residents may not be addressed adequately.

Representatives of HCFA and Abt Associates, the contractor that conducted the research in collaboration with the Center for Health Policy Research of Colorado, presented preliminary findings of the complex study at a March meeting of the American Association of Homes for the Aging (AAHA). The Abt researchers suggested that many of the problems they documented in the survey process result from surveyors' difficulties in meeting sophisticated survey guidelines developed in the mid-1980s by the Institute of Medicine (IOM) of the National Academy of Sciences. These guidelines recommended that surveys be outcome-oriented and resident-centered.

According to Margo Cella of Abt Associates, the IOM guidelines serve as the basis for current two-stage survey process, even though outcome-oriented assessment requires statistical sophistication and knowledge of outcome projection techniques that are lacking among most survey personnel. In effect, the process expects surveyors to respond to two difficult questions: Given resident status at admission, is the resident receiving appropriate care? What will be the outcome of that care? Michelle Teitelbaum, also of Abt Associates, noted that, in evaluating these questions, current practice assumes survey personnel will employ over 300 evaluation criteria. By comparison, a similar nursing home certification process in Australia requires evaluators to look at no more than 31 criteria.

The Abt Associates research disclosed that many nurses conducting the survey may remain very uncomfortable with trying to base judgements of nursing home performance on projected outcome of patient care. To compensate, they either fail to cite potential problems or substitute easily-documented minor deficiencies for more substantial concerns. For example, the researchers found that documentation of food storage problems or discrepancies in paperwork may, in fact, reflect the survey team's belief that more serious, but less easily-documented, threats exist. This may occur most frequently when the surveyors find only one or two cases indicating a serious deficiency based on outcome assessments.

In addition to discomfort in citing outcome deficiencies, the Abt Associates study revealed that nurses involved in the survey process may have problems performing "quality-of-life" assessments. In some cases, the Abt researchers found that survey teams collapsed incidents from several quality-of-life areas into a single category to present a strong case for one type of deficiency, rather than provide weaker documentation for several quality-of-life deficiencies.

Some states have attempted to address this narrowed focus by adding a social worker to the nursing home survey team. The Abt Associate researchers found that this practice doesn't always improve the situation. Too often, the nurse-led team decisions override the input of the lone social worker.

In summary, the Abt Associates review of the survey decisionmaking process suggests that survey teams are not "out to get" nursing homes when citing minor deficiencies. Rather, according to a member of the AAHA panel, "If surveyors were more confident about investigating serious problems, they would spend less effort citing minor, easily-documented problems."

The HFCA officials attending the panel agreed that new training and assessment tools could make the survey process less stressful for both the nursing homes and the survey teams. As the first results emerged from the Abt Associates research this spring, HCFA had already invited states to recommend suggestions and changes in the survey process. Twenty-four states responded, and HCFA is amenable to trying many of the suggestions for pilot tests of limited scope and duration. Commenting on the tinkering that lies ahead, one HCFA official remarked. "There's going to be some funny-looking things going on in nursing homes during the spring and summer."