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QA&A: basics for the administrator.

Quality Assessment and Assurance might seem yet another paperwork nightmare, unless you take a reasoned approach

"Just one more thing to do" seems to be the regulatory theme song heard only too often by today's long-term care administrator. OBRA's '87 and '90 turned up the volume. Among the many requirements emerging from this was the seemingly simple, but actually challenging, mandate to establish quality assessment and assurance (QA&A) programs.

For colleagues practicing in other segments of the health care field, this requirement has been around for at least a decade. In the early 1980's the Joint Commission on Accreditation of Health Care Organizations (JCAHO) formally introduced the idea and, after ten years of experience, they are still maturing it. Now nursing homes throughout the country, except those who have sought voluntary accreditation by JCAHO, are being asked to join in the journey to certifiable QA&A.

Most administrators who have been exposed to the fundamental principles of management and systems theory will find deep in their academic pasts all that is needed to comply with these new regulations. They will also find, however, that there are no "cookbook approaches" or "quick fixes" to guarantee success. However, a reasoned approach will offer many rewards (some of which, as you will see, were never anticipated even by the regulators who wrote the standards).

The Federal Regulations, although modified in some states, require the establishment of a quality assessment and assurance (QA&A) committee. They mandate specific membership to include the Director of Nursing, a physician and at least three other members of the facility staff. The committee must meet at least quarterly and develop and implement plans for corrective action.

Some states have augmented these requirements to include additional committee members, e.g., administrator, representative of the home's Governing Body and representatives of the residents. More regular meetings, as well, have been promulgated in some jurisdictions. Many of these additions, albeit not required by OBRA, have merit and can improve facility management.

The spirit of these regulations is to enhance the quality of resident life, care and treatment, and to involve staff at every level in this process. The approach should be continuous and ongoing, and viewed as a part of every staff member's daily responsibility. In short, QA&A should be a process and not a prescription.

It is really quite simple if done right -- and, more importantly, if started right! A well planned QA&A program that is fully woven into the fabric of a nursing home's administrative structure will yield incredible benefits. To that end, the steps offered in this article are intended to assure a solid foundation for such a program.

1 The First Step is establishing management's commitment to the program. All staff must clearly realize that the QA&A program will make a difference in their day-to-day work and in the quality of resident life, care and treatment. This should begin with a review of the home's mission, goals and objectives. Budget processes should clearly support the home's mission, and human resource practices fit in with its goals and objectives. In short, there should be a clear interaction between the home's QA&A program and the home's operations. Anything short of this will cause the QA&A program to be perceived as just another paper exercise, i.e. more meaningless work to meet regulatory requirements.

2 The Second Step is the creation of a quality assessment and assurance committee. The committee must have a clear purpose and its membership must be selected with great care. The administrator should, at least initially, be the chairperson of the QA&A Committee. Other members should be selected based upon their commitment to the quality of resident life, care and treatment. They should come from both clinical and support staff.

Perhaps most important, members should be chosen because of a desire to help people do well and not a desire to catch people doing something wrong. QA&A programs have failed because a "cop mentality" prevailed. The more successful efforts have been lead by QA&A staff who strive to enable other staff to do their best.

Regular committee meetings, with cancellations and postponements only for real emergencies, should be the rule. Agenda items established in advance with group input will keep the committee focused. Time limits for all meetings, usually not more than two hours, will add to productivity and acceptability.

3 The Third Step is documenting committee activities. Minute taking is critical. A format for minute taking that allows for adequate documentation of discussion, action taken and follow-up has many advantages. Besides facilitating meeting processes, minutes provides an official archive for annual evaluation of the workings and effectiveness of the nursing home's QA&A program. And, last but certainly not least, solid minute taking creates a reliable support tool for external survey processes and risk management activities.

The dynamics of the home's QA&A committee are critical to its effectiveness. The chairperson must clearly be the leader of the committee. Active participation by all members should be promoted. Because individual personalities and organizational set-ups can have a tendency to stifle open participation, it is a good idea to assign each committee member a specific responsibility. In this way, each member, regardless of influence, will be obliged to contribute and, over time, mature as valuable committee members.

The first task of the committee should be to collectively design the home's QA&A program. JCAHO's "Ten Step Process" (1989) is a useful starting point. The focus of the program should be on systemic problems, as well as on those problems of all kinds which have been resistant to management's attempt to solve them.

The QA&A program should try to compliment, not replace, the home's administrative structure. This can best be accomplished by encouraging department staff to identify and solve problems at the most appropriate level. However, the QA&A program should never become the "problem solver" for the entire home. By focusing energies on issues which require more integrated approaches, the committee will support management processes and actually serve to mature them in dealing with the more complex problems.

4 The Fourth Step is to establish a QA&A plan. This document should clearly describe what the program is and is supposed to accomplish, what its scope is and how it works. It should be clearly written and distributed widely throughout the nursing home. It must be reviewed by the QA&A committee at least annually and updated as needed. Signatures of the administrator and the chairperson of the Governing Body should be visible on the face sheet of the plan. This will publicly underscore management's commitment to the program.

Each department, service, unit and function should have a QA&A program. The program should include description of scope of services offered, aspects of care to be monitored, measurement indicators, thresholds initiating action, data collection methods, corrective action strategies and reporting mechanisms. Sharing these among committee members and management staff will promote integration.

5 The Fifth Step is designing a mechanism for reporting findings from the home's QA&A program to the QA&A Committee, the administration, medical staff and governing body. This can be accomplished in a number of ways. Individual department, service, unit and function QA&A reports can submitted to the QA&A committee for discussion. Or a QA&A coordinator can be employed to synthesize all QA&A reports into a single report that can be the basis for committee discussion. The latter approach is efficient and will allow the committee to focus its attention on the most important issues. In either case the minutes of the QA&A committee can then be used as the reporting vehicle to the administration, medical staff and the governing body.

In conclusion, the creation of the comprehensive QA&A program in a nursing home does more than afford compliance with federal and state regulations, though of course that is always a consideration. Done properly, it can become a core component of the home's ongoing management system. It can provide objective data for more reasoned decision making. It can reduce the probability of any surprises from external audits and surveys. It can create fiscal efficiencies by helping staff "do things right the first time."

The bottom line is just that, the bottom line: Quality of care is profitable. Poor quality costs money in rework, poor care and sometimes expensive litigation. In this day and age QA&A isn't just a nice idea -- it's good business.

Michael F. Amo is President of Amo Associates, a Central Valley, NY healthcare management consulting firm.


Casalou FR. Total quality management in health care. Hospital and Health Administration 1991; 36:1; 134-146.

Berwick MD. Sounding board: Continuous quality improvement as an ideal in health care. N Engl J Med 1989; 53-56.

Laffel G, Blumenthall D. The case for using industrial quality management science in health care organizations. Journal of the American Medical Association 1989; 262; 3869-3873.

Garvin D. Managing Quality, The Strategic and Competitive Edge. New York Free Press, 1988.

Meisenheimer, CG (editor): Quality Assurance: A Complete Guide to Effective Programs. Rockville, Maryland, Aspen Publication, 1985.

Troyer GT, Salman SL (editors): Handbook of Health Care Risk Management. Rockville, Maryland, Aspen Publication, 1986.

The Joint Commission Guide to Quality Assurance. Chicago, Joint Commission on Accreditation of Healthcare Organizations, 1989.
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Title Annotation:quality assessment and assurance; nursing home administrators
Author:Amo, Michael F.
Publication:Nursing Homes
Date:Sep 1, 1992
Previous Article:We're training nurses for the 21st century.
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