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Quality Initiatives: Are Nursing Homes Getting Better?

November 1, 2003
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Interview with Sylvia Gaudette Whitlock, AHQA's Director of Government Affairs
INTERVIEW WITH SYLVIA GAUDETTE WHITLOCK, DIRECTOR OF GOVERNMENT AFFAIRS, AMERICAN HEALTH QUALITY ASSOCIATION November marks the first anniversary of the national rollout for the federal Centers for Medicare and Medicaid Services' (CMS) Nursing Home Quality Initiative (NHQI). Nursing homes in every state are using resources they've never had before-resident data feedback, collaborative assistance from federal government healthcare quality experts-to work on upgrading their resident care performances.

Leaving aside the public reporting requirements involved-of which more later-this is the quality improvement (QI) system that nursing homes have long been asking for, as opposed to the "gotcha policing" of the OBRA survey system. Some of the results (or nonresults) of that system were taking heat at press time from the likes of Senator Charles Grassley (R-Iowa), the General Accounting Office, the House Ways and Means Committee, and the Consumers Union, with nursing homes again being pilloried in the popular press for substandard performance. Will the NHQI point to a way out? Recently, Sylvia Gaudette Whitlock, director of government affairs for the American Health Quality Association (AHQA)-the membership organization for the state Quality Improvement Organizations (QIOs) that are spearheading this effort-provided an update to Nursing Homes/Long Term Care Management Editor-in-Chief Richard L. Peck.

QIOs started 30 years ago as quality monitoring agencies for physicians and, later, hospitals. What has been their principal challenge in adjusting from physician and hospital QI to long-term care QI?

Whitlock: For the most part, the QI challenges in this setting are the same as those in the hospital setting-staffing, workload, the need for greater leadership and staff empowerment, etc. Every provider of healthcare has a system for doing so, and every system has trigger points for doing things right-or not. QIOs focus on systems, and that is no different in the long-term care setting than anywhere else.

One challenge, though, was that not many nursing homes knew who, or what, the QIOs were. Furthermore, the nursing home industry, as a whole, is not accustomed to working with entities funded by the federal government that are not regulatory in nature. So the QIOs and the nursing homes have had to get to know one another and establish a new working relationship. All the QIOs have hired people with nursing home experience, and they have all taken a very flexible approach in working with nursing homes in a collaborative relationship.

One additional barrier that the nursing home industry has faced is the lack of evidence-based best practices for their setting of care. Unlike for hospital care, there is not much research on processes and practices that yield optimal nursing home outcomes. Clinicians in this field rely largely on expert consensus and guidelines. Not only are the QIOs sharing their expertise in changing systems of care, they are compiling the available scientific information about care practices in this field to help facilities choose practices that might work best for their residents. What is the current "scorecard" in terms of number of QIOs and nursing homes directly involved in QI projects?

Whitlock: There is a QIO in every state, the District of Columbia, and the U.S. territories. Each is working with 10 to 15% of their nursing homes as "identified participants" in this initiative. The QIOs are directly responsible for helping these homes assess their systems of care and determine how they can improve, based on the Quality Measures (QMs) that the QIO and other stakeholders have determined are most appropriate for that state. In general, the participating nursing homes in each state are asked to select three to five QMs on which to work to demonstrate improvement both by the participants themselves and statewide in general. [Editor's note: For the full list of the current QMs, see sidebar.]

Which particular QMs are these projects tending to focus upon?

Whitlock: The most popular QMs (in descending order) are: pain (both chronic and post-acute), with projects underway in virtually every state; pressure ulcers, involving SNFs in 40 states; ADL decline, 17 states; and restraint use, 15 states.

How can nursing homes best work with QIOs on these initiatives?

Whitlock: Nursing homes that will be the most successful in this initiative:
  • have leadership that embraces QI principles and empowers staff to implement changes;
  • will put together a team of representatives from all aspects of care (from the janitorial staff to the administrator) to determine how care can be improved and change implemented; and

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