John F. Schnelle, John F. Schnelle, PhDPhD

Vanderbilt Center for Quality Vanderbilt Center for Quality AgingAging

ProfessorProfessor

School of MedicineSchool of Medicine

Point 1Point 1

Quality can be improved with care Quality can be improved with care identified in practice and regulatory identified in practice and regulatory guidelines.guidelines.

Care is labor intensive and hard to Care is labor intensive and hard to manage.manage.

Point 2Point 2

Nursing Homes can or do not Nursing Homes can or do not implement recommended care for implement recommended care for three major reasonsthree major reasons

Staffing :numbers and poor information for Staffing :numbers and poor information for management.management.

Motivation: regulatory system does not Motivation: regulatory system does not reinforce improvement in direct care.reinforce improvement in direct care.

Knowledge: Required care is not described Knowledge: Required care is not described with adequate specificity to implement.with adequate specificity to implement.

Point 3Point 3

There are immediate and realistic There are immediate and realistic solutions if we think differently.solutions if we think differently.

Solutions are outlined in the last Solutions are outlined in the last slide.slide.

Point 1: Quality can be Point 1: Quality can be improved with simple but improved with simple but

labor intense carelabor intense care

Functional incidental training controlled Functional incidental training controlled clinical trial.clinical trial.

Incontinent Nursing Home Residents Incontinent Nursing Home Residents (60% +)(60% +)

Care every 2 hours.Care every 2 hours. Resident offered toileting assistance (choice).Resident offered toileting assistance (choice). Resident assisted with incidental exercise Resident assisted with incidental exercise

standing; transfer; movement.standing; transfer; movement.

OutcomesOutcomes

Intervention group significantly Intervention group significantly better than control group.better than control group.

Urinary IncontinenceUrinary Incontinence One constipation measureOne constipation measure ADL declineADL decline Resident family report of met needsResident family report of met needs Family report of positive communication with Family report of positive communication with

staffstaff

Labor costs and Labor costs and ManagementManagement

21 minutes aide time per resident ever 2 21 minutes aide time per resident ever 2 hours.hours.

30 minutes of supervisory time per day.30 minutes of supervisory time per day. Staffing projection- Ratio 5 residents to 1 Staffing projection- Ratio 5 residents to 1

aide.aide. 90% Nursing homes are staffed below this 90% Nursing homes are staffed below this

level.level. Staffing ratios are only part of the problem.Staffing ratios are only part of the problem.

Schnelle et al. Journal of American Geriatric Society.2002.Schnelle et al. Journal of American Geriatric Society.2002.

ManagementManagement

Homes staffed at high levels (5-1 Homes staffed at high levels (5-1 ratio) did better but still did not ratio) did better but still did not implement consistent care in some implement consistent care in some areas.areas.

Schnelle et al. Health Services Research.2004.Schnelle et al. Health Services Research.2004.

Barriers to ManagementBarriers to Management

Inaccurate information about care.Inaccurate information about care. Unrealistic expectations given Unrealistic expectations given

resources.resources. No objective method to target care No objective method to target care

given suboptimal staffing.given suboptimal staffing.

Regulatory IssuesRegulatory Issues

Nursing homes highly sensitive to Nursing homes highly sensitive to regulatory feedback.regulatory feedback.

Regulatory feedback does not Regulatory feedback does not reinforce improvement.reinforce improvement.

External regulation works bestExternal regulation works bestif… if…

provider/regulator consensusprovider/regulator consensus

Definition of Quality MeasuresDefinition of Quality Measures Methods of measurement.Methods of measurement. Rules to link measures to deficiency Rules to link measures to deficiency

statements.statements.

Current regulatory system Current regulatory system meets none of these criteriameets none of these criteria Unrealistic expectations about how many Unrealistic expectations about how many

recommended care processes can be measured.recommended care processes can be measured. Poor definition of measures and methods of Poor definition of measures and methods of

measurementmeasurement (e.g.) observe quality of assistance at meal (e.g.) observe quality of assistance at meal

times.times.

Confusing rules linking measures to deficiency Confusing rules linking measures to deficiency statements.statements.

Failure to provide realistic Failure to provide realistic survey task and standardized survey task and standardized

protocolsprotocols Survey culture that depends on Survey culture that depends on

expert judgment.expert judgment. InconsistencyInconsistency Confused providers who do not know Confused providers who do not know

how to improve care.how to improve care.

Solutions for improving Solutions for improving qualityquality

More active bedside research as More active bedside research as opposed to statistical opposed to statistical manipulation of secondary data.manipulation of secondary data.

Labor costs and management Labor costs and management Outcomes (Quality of Life and Outcomes (Quality of Life and Clinical)Clinical)

Staffing and Management Staffing and Management Issues:Issues:

Best practice Best practice demonstration sitedemonstration site Develop consensus about important Develop consensus about important

care.care. Implement care and document labor Implement care and document labor

costs and outcomes.costs and outcomes. Improve efficiency (alternative Improve efficiency (alternative

staffing models, alternative staffing models, alternative environments).environments).

Match staffing levels to care Match staffing levels to care expectations.expectations.

Regulatory SystemRegulatory System

Develop and test standardized Develop and test standardized investigation protocols based on investigation protocols based on existing survey guidelines.existing survey guidelines.

Determine resources to implement Determine resources to implement protocols.protocols.

Focus on realistic set of quality Focus on realistic set of quality measures.measures.

Make procedures known to Nursing Make procedures known to Nursing Home Staff and obtain consensus. Home Staff and obtain consensus.