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Is process hurtful or helpful?

Change needs to be from punitive to collaborative

NUMEROUS CHANGES IN NURSING HOME STANDARDS, INCLUDING a revised survey process and implementation of a standardized resident assessment instrument (RAI), were spawned by the Omnibus Budget Reconciliation Act of 1987 (OBRA). The changes were intended to ensure that each resident would attain the highest practicable level of physical, mental, and psychosocial well-being.

While the Health Care Financing Administration (HCFA) reports successes with the survey changes, not all are pleased with what is perceived as undue negative consequences. Some insist the process is more hurtful than helpful to good-performing facilities because of impact on public perception, staff morale, and finances.

The revised survey process was designed to be outcome-oriented focusing on the resident and quality of care delivered. This was a departure from the previous review system, which primarily monitored facility policies and procedures.

Federal surveys of nursing homes date back to 1965 with the start of Medicare and Medicaid programs. Over time, even though compliance requirements and external review programs existed, concern grew over widespread problems with nursing home care. An Institute of Medicine study, Improving the Quality of Care in Nursing Homes, released in 1986, confirmed these concerns and recommended strengthening federal regulations and enforcement systems. The report led to the passage of OBRA 87.

Although the revised survey process was implemented in 1990, the new enforcement procedures were not implemented until July 1, 1995. Procedures are aimed at providing intermediate sanctions, preventing nursing homes from in-and-out compliance, and shortening the interval between identification and correction of a problem. Every problem is to be considered a deficiency with a determination of scope and severity made by the survey team. The goal is to issue sanctions appropriately, timely, and relevant to the seriousness of the deficiencies.

HCFA reported to Congress in July 1998 that the new regulations had contributed to improved quality of care. There were marked decreases in use of indwelling catheters, anti-psychotics, and physical restraints. Hearing aid and anti-depressant use had increased appropriately. But other problems remained. Surveys were predictable. There was prevalence of malnutrition, bedsores, and dehydration.

Presidential Initiatives issued July 21, 1998, directed further oversight. These included swifter sanctions; civil monetary penalties for serious incidents; new survey protocols addressing malnutrition, dehydration, pressure ulcers, and abuse; educational campaigns; reducing survey predictability; more frequent inspections of problem homes; and establishing a Web site so consumers can access survey results. [1]

Why do providers feel the survey process is more hurtful than helpful? These issues are commonly mentioned during conversations. There are too many inconsistencies in the survey process. There are complaints that states are not applying the standards consistently. For example, nursing homes in Michigan have an average of 10 citations per annual survey compared to the national average of 5 (see "Michigan watch: We cannot get there from here," January 2001 CLTC, page 28). Yet other indicators of quality show that Michigan is comparable if not better than the national average. But a consumer looking at the higher number of citations might believe that care in Michigan is inferior. [2]

The inconsistency appears to be intrastate as well as interstate. Surveyors may have differing ideas about what interpretations mean because of lack of experience or training and may not give a reason for a citation. Providers are left confused because an acceptable standard for one is unacceptable for another and they are unclear about how to correct the problem.

That HCFA has identified this as a problem is evidenced in the Nursing Home Initiative Report when it states, "significant variation in state deficiency citations from the national average ... may indicate problems with the state survey process." HCFA's actions taken to improve consistency include reviewing care records more closely when picking a resident sample, increasing the sample size for some areas such as pressure sores, and scheduling federal comparative surveys closer in time to that of the original state survey. Future plans are to continue cross-regional surveys, continuing education, and periodic re-certification of surveyors and ongoing review of surveyor effectiveness. [3]

Michigan's Focus on Fairness Plan, developed by the Michigan Association of Homes and Services for the Aging, the Health Care Association of Michigan, and the Michigan County Medical Care Facilities Council, are intended to impact the system in that state. Plans to achieve greater consistency include an oversight process to monitor consistent application, and requiring the state regulatory agency to share standard interpretations of key OBRA concepts with surveyors and providers during joint training sessions. [2] The survey is too process-oriented. There is concern that the survey is not as outcome-based as it is promoted to be. Some staff complained that survey results are often based on what is documented or not documented about the resident rather than the positive achievement of an outcome. "A lot of nursing time is spent documenting staff actions and interventions. But if it is not there in adequate form, in the surveyor's eyes it didn't happen," said Lori Wething, director of Legal and Regulatory Affairs, Care Providers of Minnesota. Diane Vaughn, RN, president, Minnesota Directors of Nursing Administration in Long Term Care, questioned, "Why do I need documentation to support other documentation? Why do I have to document my entire thought process?"

Another recalled a situation where a nurse mistakenly referred to constipation as a fecal impaction. It was evident from the record that this definitely was not a case of impaction; however the facility was cited for harming a resident because it did not treat a fecal impaction, according to Sandra J. Kilde, president and CEO, Michigan Association of Homes and Services for the Aging.

Michael Tripple, assistant director for policy at the Minnesota Department of Health and chair, Association of Health Facility Survey Agencies (a forum for discussing issues related to the federal certification programs), says this perception may be related to the commonly cited physical plant deficiencies and situations where care-plans didn't connect with assessments. But he believes that the survey process still emphasizes outcomes; clarification of protocols for such things as malnutrition and pressure ulcers has helped make surveyors more outcome-oriented because it requires them to look at residents and observe their care. There is a negative impact on staffing and morale. Nursing home staff members frequently complain that the survey process is too demoralizing. A director of nursing said that staff members got the impression that surveyors didn't believe what they said; they felt they weren't trusted.

Wething believes a survey process focusing on what's wrong sets up a culture of blame, which drives people out of the industry.

A nurse writing about her exodus from long term care lamented that "every state survey was the same: demeaning, demoralizing, and at times downright rude and disrespectful to staff members who loved their residents and who were doing just about anything to promote their well-being." She complained that there was "no room for humanness, and no praise for effort." And she was bothered that along with identification of errors was the implication of intentional motives. [4]

A director of nursing and vice president of NADONA/LTC addressed a serious subject humorously when she described the stress levels of her colleagues. "Many would trigger all of the QIs having depression, weight gain or loss of more than 5 percent, 9 or more medications, psychotropic drugs, sleeping pills, constipation, little or no activities, and they are chair bound, writing their plans of correction! Many are seeking relief elsewhere as in 'retirement,' 'resignation,' or not by choice being 'relieved' from their duties."

Tripple is aware of concerns about staff turnover and morale. He says that some persons, including legislators, place blame for staff turnover and low morale on the survey process, telling him that if it weren't for that process, nursing homes would be fine. He believes, however, that low reimbursement, difficulty in hiring, frequent admissions, and workload associated with short resident stays are all factors. [6] There is a negative impact on the public's perception of nursing home care. The image of nursing homes, already negative because of media exposure, may be deteriorating further. Kilde believes the public impression of nursing homes is that they are suspect and lacking in quality. But she says that Michigan residents or their families tend to be very positive about their care as evidenced in consumer satisfaction surveys.

Some wonder if the Nursing Home Compare found on a HCFA Web site may be limited and misleading. In spite of attempts to define terms such as potential for or actual harm, consumers may have difficulty discerning the difference, and may assume that homes are harming and injuring residents.

Know what the figures mean

The Nursing Home Compare report shows the number of a home's deficiencies in comparison to both state and national averages. Tripple feels that most persons have a mind-set that a specific number of deficiencies means bad quality. He says people must understand that because a survey covers many facets, it isn't out of the ordinary to have deficiencies, and that a facility with one or two high-level deficiencies differs in quality from one with several low-severity ones. But a consumer who doesn't understand the terminology and is simply looking at numbers may not interpret it that way.

The fact that the numbers are getting higher may influence the public's perception that provider performance is getting worse. According to the Nursing Home Initiative Implementation report, the proportion of nursing homes with deficiencies and the mean number of deficiencies per home began to increase in 1998. Possible reasons for this, according to the report, are changes in facility quality, changes in resident acuity, changes in state survey agency practice, or just random variation. But HCFA believes that more likely reasons are more attention to and funding of the survey process, and heightened HCFA oversight of the states' work. [3]

Can the process be helpful?

How could the process be made more helpful? Ideas range from modifications in the current process to drastic overhauls. Desired are changes moving a perceived punitive system to one truly focused on quality of care for residents by being collaborative, recognizing facilities with good quality-improvement programs, and providing incentives for innovation.

Alternative surveys in a variety of forms have been suggested. Tripple suggests having different levels of survey activities based on compliance history. Abbreviated annual monitoring of good facilities would allow regulatory agencies to focus more resources on below-standard homes. Darrell Shreve, director of Research and Regulation, Minnesota Health and Housing Association suggested deferring surveys for three years for facilities with two consecutive years of low-severity deficiencies.

Rick E. Carter, president and CEO, Care Providers of Minnesota, would prefer to see a process not only consistent with the latest management theories but more relevant in a milieu where residents, technology, care needs, and lengths of stay are dramatically different from 20 years ago. He feels that facilities should be allowed to be more self-regulatory using their own internal standards.

Proposals to HCFA to make survey modifications generally haven't received a positive reception; the reason given is that HCFA doesn't have the authority to approve waivers for Medicare survey and certification.

Saying it had no authority to waive the current survey process and that it viewed the proposal as lacking in objectivity, HCFA declined approval of an innovative South Dakota Quality Initiative Project to assign survey teams to facilities for quarterly contact and annual quality improvement activities. The proposal would be approved only if it operated concurrently with the regular survey process. But having neither the money nor staff to do both, South Dakota dropped the proposal. [6]

State power

However, some changes can be made effectively at the state level. Michigan's Focus on Fairness Plan is one example. Minnesota has a task force looking at documentation. And in Ohio a law was passed allowing the Department of Health to develop a technical-assistance program for consultation in the area of best practices. The unit will look at survey results for pervasive problems and advise ways to address them while also responding to questions and requests from facilities. But it is not a part of the survey process, according to Clark Law, president and CEO, Association of Ohio Philanthropic Homes, Housing and Services for the Aging.

Providers have a goal of quality care for residents. So do regulatory agencies. Consumers seek it. Obviously there is a common goal. But the atmosphere that often prevails is an adversarial one resulting in blame, anger, and suspicion. Breaking down these barriers is an essential step in progressing toward the common goal.

Woodbury, Minn.-based Janice K. Olson, RN, MS. MEd. is a regular contributor to CLTC.


(1.) History of Nursing Home Enforcement.

(2.) Focus on Fairness Plan. Document of Michigan Association of Homes and Services for the Aging, the Health Care Association of Michigan, and the Michigan County Medical Care Facilities Council. 2000.

(3.) Measures of NHI Implementation.

(4.) Bradbury S. The Exodus. The Director. Fall 2000. Volume 8(4):127.

(5.) Dornberger S. It Could Happen to You or Me. The Director. Spring 2000. Volume 8(2):62.

(6.) South Dakota Quality Initiative Document. 1996.

How to promote a more helpful survey process for your facility

Structure. Ensure there are effective systems in place including organizational structure and quality-improvement processes. Clearly identity and communicate roles and responsibilities. Build in flexibility and backup so important responsibilities aren't overlooked in the event of a key person's absence.

Accurate record-keeping. Documentation is an important system. Periodically review it for the whole picture. Does it address assessment, diagnoses, planning, and evaluation? Discharge planning? Resident education? Avoid creating a patchwork system--it may lead to duplication in some areas and overlook others.

Protocol awareness. Staff should be familiar with care protocols, policies, and procedures. Enlist staff development to carry out a regular, systematic education program.

Know the survey process. Teach staff about the survey process. Encourage them to ask for clarification from surveyors. Promote an attitude of friendliness and cooperation. Instruct staff to report irregularities. Under the present system, accept that deficiencies are likely inevitable.

Communication. Inform residents and families about the survey process. Explain changes in the process, including deficiencies and terminology.

Get involved. There is strength in numbers. Work through your professional group to effect changes in the system. Discuss concerns with legislators.
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Publication:Contemporary Long Term Care
Date:Feb 1, 2001
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