Working the Web.

Wendy L. Bonifazi, RN, is a contributing writer to Contemporary Long Term Care.

Massachusetts providers lobby for better online survey

WHEN HCFA UNVEILED ITS NATIONAL NURSING HOME Database Web site last September, consumers welcomed instant access to survey results in every state. But many providers objected to the site's confusing inclusion of health and safety code violations (dropped this March after the pilot) and the continuing emphasis on fault-finding, frightening scope and severity definitions (now simplified). Although HCFA has also agreed to refine information about staffing and residents' conditions, they were concerned about the impact this data might have on consumers unfamiliar with the survey process.

Those skeptics might be surprised to learn that HCFA's Web site was the brainchild of a group of providers, who envisioned an online "report card" as a way of interpreting and softening the impact of negative survey results.

It all started in 1995, after new enforcement regulations took effect. The new survey process was a tough adjustment for Massachusetts nursing homes. "Something had to be done quickly because good homes were receiving horrendous surveys," says Ann Turner, RN, director of clinical services and education for the Massachusetts Extended Care Federation.

The "something" proposed by the MECF was the first of its kind: an online quality rating tool, geared to consumers, that would show a broader picture of facilities' strengths. In 1996 the association asked the state department of public health to put this interpretation of its results online. "HCFA thought it was a good idea and, one year later, developed their site," says Turner.

"I think [MECF's] impetus was a way to assess facilities independent of the 'substandard' term, and to highlight the positives," says Paul Dreyer, director of the division of health care quality, Massachusetts' designated state survey agency. To develop the Survey Performance Tool for Nursing Homes, the division formed a committee of providers, industry associations, and consumer representatives, then tested the tool with consumers.

Committee members established five categories--administration, nursing, resident rights, kitchen/food services, and environment. After negotiation, they hammered out the tags pertinent to each category. The tool evaluates 44 selected items reviewed during surveys.

The Web site (www.state.ma.us./dph/qtool/qthome.htm) maintains information on the state's Medicare- and Medicaid-certified nursing homes. Non-participating licensed facilities aren't included, nor are new facilities until completion of multiple surveys.

Users can search facilities by name and geographic location and compare nursing homes' performances to statewide averages in each category. The site now averages 1,300 to 1,500 hits monthly.

Provider representatives say the original tool had several weaknesses. "You couldn't tell if a deficiency was from the first or second survey," says Elissa Sherman, PhD, director of Public Policy at the Massachusetts Aging Services Association. "Most importantly, it didn't consider scope and severity. Each category was weighted the same, so a facility with one severe actual harm tag looked better than another facility with three small, isolated deficiencies." What's more, the tool didn't include complaint investigations, and reports were based only on a facility's last two surveys.

On May 13, Massachusetts unveiled a new system. Reports are now based on the three most recent standard surveys after January 1, 1996, as well as information from all complaint surveys after January 1, 1998, or within a year of the most recent standard survey, whichever is later.

The site reports the number of requirements in each of the 44 items that are in compliance, awarding a point for each one that is not assigned a deficiency. Deficiencies cited as a result of complaint or serious incident investigations conducted within one year of the most recent standard survey are scored, but investigations not resulting in a citation are not reflected. The maximum score is then mathematically adjusted to reflect the scope and severity of all deficiencies cited.

The new tool also lists standard survey dates and reports complaint investigation(s), enforcement actions, jeopardy findings, substandard quality of care, payment denial, and admission freezes. In addition, the site includes a description of each rating. Shaded boxes highlight deficiency ratings designated as constituting substandard quality of care.

"It's a wonderful tool for consumers," says Dreyer, who has seen similar sites adopted by New Jersey and Rhode Island.

It may seem less wonderful to providers. But now that HCFA has put every state's survey results online, it's clearly in the industry's interest to help decide how states display and explain that information.