Hawes - Texas A&M University System Health Science Center

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Assuring Nursing Home Quality: Divining Effective

Models of Regulation

Catherine Hawes, Ph.D.

School of Rural Public Health

Texas A&M University System HSC

for the AHRQ User Liaison Conference

Indianapolis, IN: May 2002

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Retirement Research Foundation

Data from a study funded by Retirement Research Foundation

Also data and advice from colleaguesZimmerman, Harrington, Edelman,

Stegemann, Phillips Conclusions my own – not necessarily

those of RRF

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The OBRA-87 Reforms

Resident focused/outcome oriented

Addressed all three elementsStandards, Inspection, Enforcement

Elevated quality of life

Established the RAIAssessment and care planningData system – for quality indicators

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Early Results

Improvements in process qualitye.g., reduced use of physical

restraints Improvements in resident

outcomes Decreased use of hospital care

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However~Continuing Concerns About Nursing Home Quality

Representative Waxman’s report on abuse

Ombudsman reports

Research studies

CMS staffing study

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Continuing Concerns About Nursing Home Quality

Recent GAO reports

Hearings by the US Senate Special Committee on Aging

Quality problems

Failures in the regulatory system

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Five Partial Explanations

1. An industry in disarray

2. Staffing issues

3. Poor support for ombudsmen

4. A flawed regulatory system Flawed survey system Weaknesses in enforcement

5. Reimbursement policy

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Single Biggest Problem TodayTo paraphrase James Carville…

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What Are Indicators of An “Effective” Regulatory System? Ombudsman report Provider report Effective complaint investigation

Outreach, intake, type of complaints, investigations, resolution, sanctions

For allegations of abuse and neglectFor general complaints

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Indicators of An “Effective” Regulatory System, cont.

Effective Survey SystemExamples…Qualified surveyorsLow % of NFs with no

deficienciesLow % of surveys with > 18

month interval

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State Variation on Survey

State Ombud. view

% Surveys > 18 months

% NF w/ Zero Deficiences

A thorough 0.0% 1.5%

B thorough 0.0% 7.2%

C inadequate 8.6% 4.2%

D inadequate 0.0% 27.4%

E inadequate 33.5% 41.8%

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Effectiveness Indicators, cont.

Comprehensive EnforcementHas a written guidelines for which

remedies to imposeUses a range of remediesUses sanctions for deficiencies – not

just failure to correctCites deficiencies at appropriate level

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State Variation on Enforcement - 1999

State % NF cited harm or jeopardy

Range of remedies

Impose immediately

A 59.8% > 3 Many

B 47.4% > 3 Few

C 31.3% > 3 Many

D 22.6% no No

E 29.2% > 3 No

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Additional Indicators State communicates with public

State regularly communicates with providers, ombudsmen

State has and supports meaningful quality improvement program

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State With Good System

Quarterly meeting with advocates, ombudsmen, providers, public

Outreach to publicBillboards, radio and television

public service on reporting abuseNews releases on deficienciesSome states have web page w/ QI

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Description of State, cont. Toll-free hotline, 24 hours a day Written investigative protocols for

investigating complaints Most experienced surveyors used

to investigate complaints Few complaints about physical

abuse, relative to other states

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Description of State, cont.

Surveyors have Master’s in nursing

Aggressive ~ citing all deficiencies seen

Cite at appropriate level of scope and severity

Use range of federal and state remediesImmediate imposition for deficiency

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State and Quality Improvement

QUANs ~ Masters-trained nurses for voluntary quality improvement80% of facilities participateConsultation~good clinical practiceTraining on MDS and RAPsHow to implement new practicesQuarterly to monthly visits

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Genuine Partnership Among All Stakeholders

State survey agency Providers Ombudsman and aging network

Shared commitmentSupport each otherSupport good reimbursementSupport for CNAs

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Lessons from the 1990s

Regulation can improve qualityEspecially if tied to clinical quality

Quality CoalitionAdvocates + Providers

Regulation is necessary…but not sufficientQuality improvement initiativesReimbursement policy, staffing

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