This report describes our review of the nursing home quality improvement programs initiated by the State of Florida. It begins with background information on the programs and how the visit and discussions were structured, and continues with a brief account of the origin and rationale for the programs. A description of the programs follows, along with the research team's findings. These findings are based on discussions with state employees, nursing facility respondents, and consumer representatives) regarding the perceived strengths and weaknesses of the programs. A discussion of the impact these programs have had on the quality of life and quality of care of Florida's nursing home residents follows. The report concludes with suggestions from program designers and participants to other states that might want to implement similar programs, a discussion of the sustainability of the various programs, and the respondents' opinions on the role of the Federal Government in quality improvement in nursing facilities.
Background
The study's Technical Advisory Group recommended that Florida be selected as a site visit state largely because of the state's Quality Monitoring program, a technical assistance program that was established in 1999. The state also has numerous other quality improvement programs, including recognition and reward programs and training/education efforts. In addition, the state has a public reporting system, risk management requirements, and mandated increases in minimum direct care staffing. All of these measures stem from two legislative mandates--the first passed in 1999 (HB 1971), and the second, SB1202, which followed in 2001. Each mandate was implemented in direct response to concerns regarding the quality of care in Florida nursing homes and the increase in the number of lawsuits filed against nursing homes.
Participants
Abt staff members Deborah Deitz and Donna Hurd accompanied by Jennie Harvell, project Task Order Officer (TOO), conducted discussions in Florida over a three-day period in September 2002, meeting with state survey agency staff, Medicaid staff and researchers, consumer advocates and provider association staff. Researchers were also able to accompany a Quality Monitor on a facility visit and speak with facility staff about the Quality Monitor program. The following individuals agreed to participate in discussions with the researchers:
Because the provider associations were unable to schedule meetings with their members while the research team was in Florida, conference calls were scheduled in late September/early October to discuss Florida quality improvement programs with Florida Health Care Association and Florida Association of Homes for the Aging members. Conference calls were also used for discussions with the Ombudsman and with staff from the Florida Policy Exchange Center on Aging at the University of South Florida.
Preparation
Prior to the on-site visit, information on the quality improvement program was gathered from a literature review, stakeholder discussions and the MyFlorida.com website. Information on the following aspects of the programs was gathered and organized in a table:
The table was forwarded to the survey agency contact, Dr. Susan Acker, prior to the on-site visit for her to review and provide additional or corrected information. The research team used the factual information in the tables as a starting point to develop interview questions that focused on more in-depth issues. Letters of endorsement explaining the project goals, state selection and interview processes were sent to prospective interviewees. Follow-up phone calls were made to arrange for convenient dates and times for interviews.
Structure
Meetings with the survey agency staff, provider associations staff members, Medicaid staff and researchers, consumer advocates and facility staff took place at their respective offices or on-site at the nursing facility and generally lasted one to two hours. The research team met with the Quality Monitoring nurse at the facility and was able to interview her prior to observing the Quality Monitor visit.
Follow-up phone calls were made to participants who were not available to meet with the researchers while on site. These were scheduled in late September/early October and conducted as conference calls with the Abt staff and the ASPE Task Order Officer.
In order to compare Florida's nursing home industry with the other study states, we present some descriptive characteristics. There are 734 facilities in Florida (AHCA web site) with 69,122 residents reported as of Spring 2001. The average number of beds per facility is 114, which is slightly higher than the national average of 108. The median occupancy rate per facility is 86.7 percent as compared to the national rate of 95.1 percent.
The percentage of for-profit homes in Florida is higher than other states, with 76 percent of homes operating for profit versus 65 percent nationally. The not-for profit-homes are lower at 23 percent vs. the national average of 28 percent. There are also fewer government-operated (2 percent vs. 7 percent) homes. The majority of homes operate as part of a chain (70 percent vs. the national average of 55 percent) and 10 percent of facilities are hospital-based, which is slightly less than the national average of 12 percent. The majority of homes are dually certified for Medicare and Medicaid (88 percent) as compared to the national average of 80 percent. There are approximately 2400 assisted living facilities and 1100 home heath agencies. (FPECA) (p. 17).
Florida's quality improvement programs are the result of legislation passed in 1999, 2000 and 2001. Prior to the passage of the legislation, respondents explained that the atmosphere in the state was unsettled with a number of issues facing nursing home providers, regulators and consumers. There was increasing concern with the quality of care in nursing facilities and how quality was to be defined and communicated to consumers.
In 1999, HB 1971 was passed, which included provisions for a technical assistance program, a quality recognition program, development of a website to post facility information for consumers, training programs and medical director standards. In 2000 a minor bill was passed that revised the measures that would be posted on the website and modified the types of documentation required for the discharge and transfer of residents.
At the same time these actions were taken, there was increasing concern about rising rates of litigation against nursing facilities and the effects of litigation on facilities' financial stability. Lawsuits had become common, affecting facilities regardless of their reputation for high or low quality care. Facilities were reportedly paying 500-fold increases in insurance rates while other facilities were unable to secure any insurance. During discussions with agency staff, it was stated that Florida ranked third in the nation for skilled nursing facility bankruptcies (behind Texas and California) and that Florida had 10 percent of the country's nursing home beds but 50 percent of the nursing home litigation. In response to these concerns, lawmakers created a 19-member Task Force to study the affordability and availability of long term care in Florida. The group was mandated to study and make recommendations on a number of issues pertaining to long-term care. Those specific to quality of care were the following:
The Florida Policy Exchange Center on Aging at the University of South Florida (FPECA) was named to provide staff support to the Task Force. FPECA's research indicated that the number of lawsuits against Florida nursing homes had in fact dramatically increased, that insurance rates had been going up, that insurance companies were writing fewer policies and that consumers were complaining of poor quality of care and violation of residents' rights. They studied risk management in hospitals and concluded that the institution of an internal risk management program in nursing facilities "could be an appropriate step…to bring about a comprehensive quality care approach. Such a step could both encourage improved quality of care and remedy the prevailing litigious climate in the industry."2
In a 700-page report, released in February 2001, the Task Force presented their findings on the major task areas including options for improving nursing home quality. SB 1202 was signed into law in May 2001 based in part on the findings from the Task Force. As part of the compromise between consumer advocates and industry representatives, consumers agreed to tort reform in the form of limiting the amount of settlements against long term care facilities on the condition that this was partnered with increased oversight on quality. The quality improvement legislation contained the following components:
The legislation was passed on May 15, 2001 and enacted immediately. There was no period for facilities to prepare or for the State to develop interpretations of the bill.
The vision of Florida's quality improvement programs, as expressed upon the passage of SB 1202, was to bring about an improvement in quality of care through a combination of risk management and internal quality assurance along with increased oversight and guidance to facilities. With liability insurance either unaffordable or not available, lawsuits affecting virtually all the long term entities in the state, and bankruptcies affecting 22 percent of skilled facilities, measures to deal with both the litigation crisis and quality of care problems in facilities were believed necessary to ensure the viability of the long term care industry in the state. FPECA staff we spoke with expressed the idea that the Task Force sought to "marry" the issues of quality of care in nursing homes, liability and insurance and home and community-based care.
During our visit, there was much discussion among stakeholders regarding the relationship between quality improvement and risk management, and the relative importance of each component. Providers stated that the quality of a nursing home had little effect on the number of lawsuits brought against it. Consumer advocates expressed the opinion that it was "embarrassing" to think that controlling litigation would bring about quality improvement. However, most participants expressed agreement with the Task Force that it was not appropriate to address the liability crisis separately from quality reforms.
Quality of Care Monitoring Program
In 1999, HB1971 established the Nursing Home Quality of Care Monitoring Program. It was designed to "create a positive partnership between the Agency and nursing homes and ultimately yield improved quality of care to residents". Initially the legislation called for yearly visits for monitoring of all facilities and quarterly for troubled facilities. The program is funded primarily by general revenue, with some matching federal funds.
SB 1202 increased the number of monitors from 13 to 19 and mandated quarterly visits to all facilities, with additional visits based on high-risk factors. Nursing homes that have been on the Nursing Home Watch List have the highest priority. Second priority facilities are those that have a combination of the following: A history of non-compliance or "yo-yo" compliance; nursing homes that upon analysis of quality indicator reports reflect potential weaknesses; nursing homes that have either changed ownership, changed administrators or changed Director of Nursing Services recently; and all new facilities.
Quality of Care Monitors must be registered nurses licensed in Florida, preferably with surveyor experience, and be Surveyor Minimum Qualifications Test (SMQT) qualified. Each monitor has a caseload of approximately 30 facilities assigned within a geographic area and each consults with other monitors on their area team who have particular areas of expertise.
Quality of Care Monitoring visits generally include touring the facility, observing residents and care providers in a variety of settings, as well as interviewing key staff, residents, and family who are present. They were originally mandated to be unannounced, but this is no longer adhered to when risk management duties require meeting with the facility risk manager. The visit may last anywhere from three hours to two days depending on the size of the facility and what a monitor finds. During visits, monitors seek to identify, at an early stage, any conditions that are potentially detrimental to the health, safety, and welfare of nursing home residents. Monitors may opt to identify a particular issue to focus on for a visit and not may discuss every triggered quality indicator. They may also opt to focus on an issue that the facility has identified as a problem.
Monitors are careful not to endorse a particular process--they can provide guidance and references, but the process has to be one that the facility identifies. They explained that their suggestions are very general. They are careful not to say, "Do it this way". They try "to keep the onus on the facility." They state that the facility must adapt the process to meet the needs of their residents. They offer educational resources and performance intervention models designed to improve care including materials available to share with facilities such as journal articles, websites and various protocols. They share information about good practices they have seen in other facilities. Monitors also interpret and clarify state and federal rules and regulations governing the facilities.
At the conclusion of each visit, the Quality of Care Monitor and the facility administrator meet to discuss findings. The administrator is advised that a written summary will follow, but that it's not to be construed as evidence of compliance or non-compliance. A copy is kept on file with the Agency and one is given to the nursing home so both can track progress. While the focus of the program is early detection, mandatory reporting of conditions which threaten the health or safety of a resident is required. Any such findings are officially reported to the Agency for regulatory action and, as appropriate or required by law, to law enforcement, adult protective services or other responsible agencies.
Since May 2002, monitors have also been given the responsibility to assess the operations of internal quality improvement, risk management programs and adverse incident reports. In addition, the Quality of Care Monitors collaborate and coordinate with the Field Office Managers in visiting facilities that are being financially monitored, closing, or in immediate jeopardy, to ensure the health and safety of residents. Monitors attend survey field office staff meetings and coordinate with the field office staff during a jeopardy situation. They also assist with training new surveyors.
Gold Seal Program
This program highlights facilities that provide superior care, creating a benchmark for others to strive to meet. The program was mandated by HB 1976, developed and implemented by the Governor's Panel on Excellence in Long-Term Care, and operates under the authority of the Executive Office of the Governor. The program was initiated in August 17, 2001 and the first awards were presented 7/24/02. A total of 10 "Gold Seals" have now been awarded. A nursing facility is eligible for Gold Seal consideration if it has been licensed and operated for at least 30 months, has not been rated "conditional" within that period and has had no Class I or Class II deficiencies within the previous 30 months of application. The facility must also have "financial soundness and stability" as evidenced by a financial audit. The legislation requires a Gold Seal facility to have an "outstanding record regarding the number and types of substantiated complaints reported to the State Long-Term Care Ombudsman Council within the previous 30 months." In addition, Gold Seal facilities must have a stable workforce with low turnover rates.
Early Warning/Rapid Response Teams
The Early Warning System sends surveyors on unannounced facility visits to identify facilities with financial or quality of care problems. Rapid response teams visit facilities identified by the early warning system. It is illegal for anyone to warn a facility of an unannounced inspection visit. These visits may be on nights, weekends, and holidays. They may also visit facilities that request assistance. They are not deployed for the purpose of helping a facility prepare for a regular survey. AHCA investigates serious quality of care complaints for residents still in a facility with a current conditional rating, or under special appraisal review within 72 hours from intake (previous policy--within 90 days). AHCA also changed the process for all other complaints against homes with a current conditional rating or under appraisal review by investigating within 10 days instead of within 90 days.
Risk Management/Internal Quality Assurance
SB 1202 mandated that every facility establish an internal risk management and quality assurance program with a risk manager responsible for implementation and oversight. The regulation does not require that the risk manager have particular credentials. Each facility must also form a risk management and quality assurance committee consisting of the facility risk manager, the administrator, the director of nursing, the medical director, and at least three other members of the facility staff. This committee shall meet at least monthly. The statutory language contains specific duties for this committee, including a process for reporting adverse incidents to AHCA. The goal is to identify incidents occurring in health care facilities, which have an outcome of patient injury and may reflect error in the course of the delivery of health care services.
As mandated in SB1202, each facility must also establish a grievance procedure and must respond to all grievances within a reasonable time after submission to the facility. This procedure must be available to all residents and families and must include: an explanation of how to pursue redress of a grievance; the names, job titles and telephone numbers of the employees responsible for implementing the grievance procedure; the address and toll free telephone numbers of the Ombudsman and AHCA; a simple description of how a resident may, at any time, contact the toll free numbers to report an unresolved grievance; and a procedure to assist residents who cannot prepare a written grievance without help. A facility must maintain records of all grievances and must report to AHCA annually the total number of grievances handled, a categorization of the cases underlying the grievances and the final disposition of the grievances.
Medicaid Up and Out
This was an initiative of Senator Locke Burt and was passed as part of SB1202. He was interested in replicating the Medicare HMO program Evercare for Medicaid patients in poor-performing nursing homes. The idea was to provide improved primary care for individual patients via a nurse practitioner who works with the Medical Director, the primary physician and the family to provide intensive case management.
The program has never been put into place. It was funded for $3 million dollars in 2001, but the funding was cut to $100K annually at the end of that legislative session. Evercare has provided a proposal which the State is reviewing. The proposal is in question because some are skeptical regarding whether implementation of the intervention at the individual level really will affect quality at the facility level. Evercare's reports show an improvement in some QIs, but not across the board. The State is unsure about how much latitude they have in spending the money and whether the proposal will be modified or eliminated.
Teaching Nursing Homes
Florida's Teaching Nursing Home (TNH) program was created in 1999 via State of Florida bill HB1971 and was funded in 2000 to establish an integrated long term care training curriculum for physicians and initiate an online geriatrics university. It is a statewide program coordinated by Dr. Bernie Roos, Director of the Stein Gerontological Institute of the Miami Jewish Home and administered by Richard Kelly of the Agency for Health Care Administration. SB1202 provided $700,000 for the Teaching Nursing Home Project at Miami Jewish Home and Hospital for the Aged at Douglas The 2001 Florida Legislature also allocated $100,000 to fund River Garden Hebrew Home/Wolfson Health & Aging Center in Jacksonville to develop a protocol to better identify and respond to physical pain in residents with dementia. To assist in this effort, River Garden has engaged the University of Florida Institute on Aging. To date, the TNH has produced a CD-ROM for LPNs on care of patients with Alzheimer Disease and related disorders. See Appendix E for more details on the state's Teaching Nursing Home Program.
Alzheimer Training
SB1202 required that nursing homes provide Department of Elder Affairs (DOEA) approved Alzheimer's disease training to specified employees. The Alzheimer's Association was at the table at the LTC task force and advocated strongly for this initiative. The goal is to provide a very basic understanding, information and working knowledge of how to work with Alzheimer Disease and related dementia populations. As a condition of licensure, facilities must provide to each of their employees, upon beginning employment, basic written information about interacting with persons with Alzheimer's disease or a related disorder. All employees who are expected to have direct contact with residents with Alzheimer's Disease must have one hour of training within three months of employment. All individuals who provide direct care must have an additional three hours of training within nine months of employment. If facilities are not in compliance with this, they will be cited by surveyors.
The rule published in February 2002 identifies the qualifications of the trainer They must have a Bachelor's Degree in health care, geriatrics or human services, or hold a license as an RN and possess one of the following three 1) teaching experience of caregivers or 2) have at least one year practical experience working with Alzheimer patients/related dementias or 3) have completed specialized training from a university or accredited program. A Masters Degree could substitute for the training experience. The Director of Nursing or the training coordinator usually functions as the trainer.
All nursing home Alzheimer's disease training providers and curricula must be submitted to DOEA's contractor, the University of South Florida, Florida Policy Exchange Center on Aging (FPECA). Curricula are developed by the facilities--some are based on the old state curriculum with some updates. USF/FPECA reviewed over 1,000 applications from trainers in the first 30 days of the program for approval. Many of the proposed training programs contained incorrect or out-of-date information (example: inappropriate meds) and had to be returned to facilities for correction and resubmission. The curricula must also be resubmitted every three years. Currently 130 different curricula have been approved. The website lists approved providers and curricula.
DOEA receives $100K from general funds per year to administer the program. Nursing homes were very concerned about the fiscal impact of this mandate since nursing facilities have to bear all the costs associated with training. A state official indicated funding for the initiative could be in trouble because the industry feels that the government should not be in the business of approving training and curricula. The legislature is also going to want to know whether the training is effective. Right now, the only evidence is the review of the curricula itself which showed that many of the proposed training programs contained incorrect or out-of-date information.
More information on the state's Alzheimer Training program can be found in Appendix D, which contains the Florida Steering Committee's Consensus Document of Core Competencies for Dementia Training of Licensed Practical Nurses (LPNs) in Long-Term Care.
The Nursing Home Guide
Florida's Nursing Home Guide is part of AHCA's effort to provide information to consumers and allows a search for a nursing home by geographic region or by the characteristics of the nursing homes. Descriptive information about the facility is provided, as well as the facility's performance on past inspections as represented by stars. Under the stars is a link "Inspection Details for this Facility", which links to a listing of the facility's citations over the past 45 months. Clicking on any citation links to a fuller explanation of that citation. The publication provides detailed information about each of Florida's nearly 700 licensed skilled nursing facilities, including location, ownership, number of beds, types of special services offered and the lowest daily charge. AHCA officials said they decided not to post the Quality Indicators out of concern that they were too confusing to residents and families. The web version has links to the facility inspection history and performance measures, based on geographical location. The electronic version is scheduled to be updated every quarter, although this has been difficult to accomplish. Appendix C shows the information contained in the Nursing Home Guide for a sample facility.
The Nursing Home Watch List
The Florida Nursing Home Watch List is published by the AHCA to assist consumers in evaluating the quality of nursing home care in Florida (see Appendix C for an excerpt of the most recent Watch List). The Watch List reflects facilities that met the criteria for a conditional status, on any day, on a quarterly basis. A conditional status indicates that a facility did not meet, or correct upon follow-up, minimum standards at the time of an annual or complaint inspection. The Watch List also lists all facilities that are in bankruptcy. AHCA mails a copy to each nursing facility where it must be posted in a prominent place accessible to all residents and to the general public. It is also mailed to assisted living facilities, hospital discharge planners, Ombudsmen, legislators and others upon request. All copies are also maintained on the AHCA website. The Watch List is also posted on-line at http://www.fdhc.state.fl.us/Nursing_Home_Guide/pdf/nhup0403.pdf.
The Quality of Care monitor program is funded through a Quality of Long-Term Care Facility Improvement Trust Fund that, in 2001, was created within the state's Agency for Health Care Administration. The trust fund supports activities and programs directly related to the care of nursing home and assisted living facility residents, and is funded through a combination of general revenues and 50 percent of any punitive damages awarded as part of a lawsuit against nursing homes or related health care facilities (Florida law 400.0238). Monies in the fund come from a percentage of punitive awards in nursing home and ALF court awards, gifts, endowments and other legal charitable contributions, along with specific appropriations by the Legislature.
According to the legislation that created the trust fund, expenditures from the trust fund can be made for direct support of the following:
Development and operation of a mentoring program for increasing the competence, professionalism, and career preparation of long-term care facility direct care staff, including nurses, nursing assistants, and social service and dietary personnel.
Development and implementation of specialized training programs for long-term care facility personnel who provide direct care for residents with Alzheimer's Disease and other dementias, residents at risk of developing pressure sores, and residents with special nutrition and hydration needs.
Provision of economic and other incentives to enhance the stability and career development of the nursing home direct care workforce, including paid sabbaticals for exemplary direct care career staff to visit facilities throughout the state to train and motivate younger workers to commit to careers in long-term care.
Promotion and support for the formation and active involvement of resident and family councils in the improvement of nursing home care.
For FY 2001-2003, the total cost of the state's Quality Monitoring program is about $1.65 million--this includes $1,395,911 for the quality monitors and $261,000 for other expenses. The legislation authorizing the quality monitor program also increased licensing fees for facilities (from $35 to $50 per bed), and this increase covered part of the costs of the TA program.3
Costs for other Florida quality improvement programs that were funded under Senate Bill 1202 (2001) are as follows: nursing home risk management and quality assurance program: $2.1 million in FY 2001-02 and $1.54 million in FY 2002-03. (This includes costs of about $450,000 for data system development) and staff costs; Nursing Home Care Alzheimer's training: $10.5 million in FY 2001-02 and $6.8 million in FY 2002-03; surveyor training: $66,000 (in both FY 2001-02 and FY 2002-03). The risk management program is paid for entirely by state funds, but federal funds cover more than 50 percent of the funding for the state's Alzheimer's Training Program, under which dementia-specific training is provided to staff who care for residents with Alzheimer's Disease.4
Some provider representatives asserted that the Quality Monitors, Gold Seal and Risk Management are programs that have impacted the quality of care in their facilities. Although opinion on the value of the Quality Monitor program was mixed, some provider representatives expressed that they found the visits to be very helpful, describing them as providing objective non-punitive advice. Providers also appreciate the Quality Monitors sharing information on best practices, recommending educational materials and offering interpretation and clarification of state and Federal rules and regulations.
The Gold Seal program was seen by some as a good marketing device that potentially can decrease the cost of liability insurance and drive up revenues. Consumer advocates praised the fact that it requires a financial audit. Participants reported that the Risk Management requirement had forced them to investigate incidents and accidents in greater detail, examine their facility processes for flawed practices, and make changes with the goal to prevent future problems.
Educational training programs including the Teaching Nursing Homes and Alzheimer Training were described as useful by several of the provider representatives with whom we spoke. Providers felt that the Alzheimer Training was most useful for non-nursing staff and for facilities that did not have a designated ADRD unit. The approval process for trainers and curricula for the Alzheimer Training program is considered innovative. Each submitted curricula is reviewed by a doctoral-level staff member at the Florida Policy Exchange Center on Aging at the University of South Florida. Many of the curricula as initially submitted, contained incorrect or out-of-date information and had to be returned to facilities for correction and resubmission. Although providers were aware of the compact disc developed for LPNs on Alzheimer's disease as part of the Teaching Nursing Homes program, and were pleased that it would be web disseminated, most indicated that they had not personally reviewed it.
Some discussion participants approved of the state's web-based Nursing Home Guide, particularly the star assessment system. FAHA staff and providers expressed that the star system does a reasonable job with some expressing the opinion that it does a better job of evaluating quality than the CMS Nursing Home Compare site.
Discussants also commented on the mandated staffing increases, noting that the gradual mandated nursing assistant staffing increases were seen as more reasonable than one large increase. Advocates were pleased that SB1202 created language to link facilities in large chains so that a staffing problem in one facility of a chain is viewed by the State as non-compliance across all the homes in the chain.
Although some discussion participants praised the Quality Monitoring program, consumer advocates voiced some concerns, primarily because of the changes that were made to the original role and responsibilities as laid out in HB 1971 in 1999. The program as initially enacted was seen as separate from the survey agency and allowed the monitors to focus on the more problematic facilities. In SB1202, the quality monitors' roles and responsibilities were expanded. It required the Quality Monitors to provide quarterly visits to each facility in his/her region, oversee the risk management program, verify that facilities were meeting the minimum staffing requirements and perform various surveyor activities as needed. Quality monitors are now responsible for monitoring facilities that were closing or in immediate jeopardy and provide orientation for new surveyors. By taking on surveyor tasks, the separation between quality monitoring and enforcement became less distinct. Provider association members reported that since the Quality Monitors are seen more as part of the risk management effort now, providers rarely think anymore about how they can use them for quality improvement.
Consumer advocates were concerned that the close ties between Quality Monitors and surveyors would lead to one group putting pressure on the other so that the information they presented about facilities was consistent between them. For example, a poor survey outcome could lead to the conclusion that the Quality Monitor was not providing effective oversight.
There was some concern expressed that Quality Monitors hired as a result of SB 1202 were not as qualified as the former surveyors hired in the first round, and that there was great variability in the quality of quality monitoring depending on region of the state. Providers noted that often they were asked to provide information for the Quality Monitors who did not necessarily have a background in long term care. They also stated that a problem existed with inconsistency between information being disseminated by Quality Monitors and surveyors. Some providers complained that visits were not occurring on a quarterly basis because of Quality Monitors being overwhelmed and the position experiencing high turnover rates. They also noted that often a survey followed a quality monitoring visit, focusing on the same issues that the monitor had raised, causing them to question whether the Quality Monitors were maintaining confidentiality of the visits.
Consumer advocates objected to the promotion of the best surveyors out of the enforcement agency, saying it weakened survey. They also stated that they did not agree that taxpayer funds should be used to provide advice to multi-facility chains on how to deliver care, likening it to the government providing training to Fed-Ex on how to deliver packages on time. They agreed that small, independent facilities often needed and should be entitled to such support, but it made more sense to shut down large for-profit chains if they provided poor quality care to residents. Concern was also expressed that because Quality Monitors must now oversee the risk management programs, visits are no longer always unannounced, since the Quality Monitor must meet with the facility's designated risk manager.
Respondents were critical of the Gold Seal program because the strict criteria eliminated the majority of facilities. The expense of a financial audit, which is required, was also a negative. Providers noted that there was not much incentive to seek a Gold Seal, as there was no change to the survey cycle, no immunity from lawsuits and no change in reimbursement.
Although some facilities praised the risk management process as teaching them how to critically evaluate their protocols, the reporting of adverse incidents and the confusion around the reporting requirements has put providers in a difficult situation. Facilities have been over reporting adverse incidents because they have trouble identifying incidents that are in their control and because the stakes for not reporting are so high. The failure to report an adverse incident to the survey agency can result in a G-level deficiency. A G-level deficiency citation results in placement on the Watch list. Two G-level deficiency citations may result in a six-month survey cycle and imposition of fines. Reporting of adverse incidents was intended to distinguish better performing facilities from problem facilities, thus encouraging insurance companies to come back into the state. In part because of the over-reporting issue, however, no progress has been made in improving the insurance situation. Participants also noted that no credentials or qualifications were mandated for the facility risk manager. Requiring credentialing was seen as one way to improve the program.
Both the Nursing Home Watch List and Nursing Home Guide are based on survey outcomes and were thus criticized because of the recognized inconsistency of survey results. Participants noted that information in both areas was often not available in a timely manner. The website star system is based on 45 months of data and participants noted that, "a lot can happen in 45 months." Consumer advocates did not agree with the star system, maintaining that giving the worst facilities in the state even a one-star rating was misleading. They also did not agree with the agency's practice of not posting information until appeals had been resolved. Advocates also recommended that the website should contain information on lawsuits and fines. Providers also noted that Florida consumers now have access to three types of sites with nursing home quality of care information--the CMS site, the proprietary sites and the AHCA site. Since information varies from site to site, they use different ratings, and show different levels of compliance, they question how this helps consumers.
Providers were very concerned that the mandated increase in nurse aide staffing to 2.9 ppd (due in January 2004) is going to be virtually impossible to attain. They are concerned that it will force facilities to compete with one another by offering bonuses and incentives. There was disagreement as to the adequacy of the workforce needed to meet the future requirements. Consumer advocates stated that there were plenty of nurse aides available in the state, with 250,000 on the registry and 10,000 new grads each year. They saw nurse aide shortages as the result of the poor conditions, benefit and pay provided by facilities and stated that improving working conditions and giving nurse aides 40 hour work weeks would go a long way to remedying the situation. Provider representatives, however, said that there was not an adequate supply to meet the demand "without significant wage pressure." Two-thirds of Florida's nursing homes are paid for by Medicaid and they will not be able to increase wages to engage in competition for employees.
Provider representatives also noted that they would like the State to relax the requirement that facilities self-impose an admission moratorium when unable to meet the staffing minimums. They would also like to see the staffing requirement relaxed for smaller facilities. Facilities are being forced to use temporary agency staff to meet the requirements. The cost is prohibitive and providers complain that they are not being reimbursed for it. They also fear that the legislature will not pass the funding necessary to increase the nurse aide hours, but that facilities will still be expected to meet the required staffing minimums.
Consumer advocates noted that they would prefer that staffing minimums be designated by shift rather than for a 24 hour period. They are also concerned that the industry circumvents the staffing requirements by shifting tasks and duties to nursing assistants. Provider association staff also expressed concern that some facilities were eliminating housekeeping positions and shifting housekeeping duties to nursing assistants.
No formal evaluation of Florida's quality improvement programs has been performed to date. AHCA staff reported that they are interested in evaluating the success of the programs, particularly the TA component. However, because the programs have been operating only a short time, it is not yet possible to evaluate their impact. Because many of the programs were implemented simultaneously, it will be difficult to measure improvement or to attribute improvement solely to any one program. Uncertainty about appropriate measures also makes the evaluation complicated. A decrease in the number of deficiencies cited, a decrease in overall scope and severity, or a decrease in the number of citations have been considered as possible measures by AHCA, but none is yet considered to be reliable. AHCA has been tracking liability claims and reported that they have been tapering off since they peaked in October 2001 (which was the deadline for all claims). They produce an annual report on adverse events and survey citations, which was due to be published in December 2002. They stated that they have not seen big changes in the aggregate of deficiencies, but that it is too early to see changes especially those that would be related to the passage of SB1202. Agency staff are also aware of the impact staff turnover both at facilities and within the TA program has had on program effectiveness and sustainability, making them hesitant to begin an evaluation that does not take turnover into account. Facility staff turnover was described as being particularly concerning, with some QMs reporting that they were seeing a new Director of Nursing at each facility visit, and finding that QM reports and recommendations were often lost in the transition.
Dr. Acker stated that anecdotal evidence indicates the TA program is having positive effects, however. As described in the previous section, many providers we spoke to noted that they felt that the quality of care in their facilities had improved as a direct result of the visits. AHCA also has received positive feedback from surveys and feedback forms used to gauge the success of the Quality Monitoring program. They have conducted two surveys--one with field office managers on the relationship between monitors and field office staff, and one with providers on the value of the monitor program. AHCA also receives feedback from facility staff in the form of a paper questionnaire given to facility staff at the end of a visit, asking facilities to provide information rating the performance of the TA staff and how helpful the visit had been. Most comments have been complimentary, with observations such as the visits were helpful and that staff at facilities were pleased to have someone to ask when questions arose. However, at the time of our visit, AHCA was revising the form and hadn't used it for six months. Some providers we spoke with also said that they are reluctant to offer criticism on the questionnaire for fear that there could be negative repercussions from a Quality Monitoring staff that increasingly has ties with the survey process.
Regarding the Gold Seal Program, many comments we heard from providers and consumer advocates indicated they thought the program probably was unlikely to affect quality. Some stakeholders voiced the opinion that the award was primarily a marketing tool which may become increasingly relevant when bed occupancy is lower. They felt that the greatest impact may be on those facilities on the cusp of providing higher quality care which are deciding whether to make the investments that quality improvement requires. For those facilities, the Gold Seal program could make a positive difference.
Assessing the value of the Alzheimer training program, most stakeholders said they thought it provides good information, and that it is was most likely to have a positive impact for nursing aides and for facilities that do not have a specific dementia care unit. But some expressed the opinion that facilities would benefit more from being able to choose for themselves the training that would most benefit their facility. And some said mandatory training felt more like a "big brother is watching" regulatory approach than a valuable educational program that improved quality of care.
Florida's web-based public reporting program was considered sufficiently valuable by consumer representatives that they said they thought that every state should have one. But a number of stakeholders stated their belief that a several factors were currently limiting its impact on quality improvement. They thought that consumers frequently do not know that the Guides and Watch List exist, may not have internet access, or may not be proficient in navigating the internet. Some provider representatives also noted that some facilities have been on the Watch List many times, and that this does not appear to have provided sufficient motivation for those facilities to do a better job. Stakeholders said that they believe public reporting of deficiencies can improve quality of care provided by stimulating competition and sparking change in facility culture. However, one provider representative stated that since 90 percent of admissions come from the hospital, the discharge planner has the greatest influence on where patients go, rather than a family member who had taken the opportunity to review quality ratings. He posited that as consumers become more computer savvy, interest and impact will increase--and that would make facilities be more concerned about how they look on the public reporting website.
Opinions varied about whether the mandated increases in staffing had impacted quality. Some providers said they spent a huge amount of time and money on this issue and it had not made any impact on quality. Another said the belief that by increasing staffing, turnover will be decreased, and that increased staffing creates more flexibility, increases the ratio of staff to residents and improves the quality of life for the residents by allowing staff able to spend more time with them.
As with all of Florida's quality initiatives, the impact of the risk management program has not yet been formally evaluated. AHCA staff and provider representatives reported that the number of lawsuits has declined, but it is impossible to know whether this is due to improved quality processes, or whether the number of facilities "going bare" (operating without liability insurance) has made the state's facilities less attractive targets for litigation. Regardless, several providers expressed the belief that the risk management program had been one of the quality initiatives that had the greatest impact on nursing home quality of care. They reported that at first there was resistance to changes such as monthly meetings of the risk management committee, but they now see it as very useful. "It forces us to keep focused." One provider reported that they now do a lot of education around risk management with staff. When staff understand the goals, they stated that their participation and openness increases and they are less defensive. Another provider said that the way that they investigate bruises has changed dramatically since the risk management program was instituted and that how they do their investigation has impacted quality on each nursing unit in their facility.
Currently, funding for Florida's quality improvement programs comes from general revenue and licensure fees with some federal funding. AHCA staff noted that there is general support for quality initiatives among members of the legislature. Other state agency officials offered that there has been a focus on seniors, primarily because of the large elderly population, and that the governor and the legislature are committed to seniors' issues. State agency staff also noted that the programs are up for review every year and that the funding for the both the Medicaid Up and Out program and for the Consumer Satisfaction survey have been cut, and that continued support may be tied to demonstration of positive outcomes in the future.
We asked providers, state program administrators, and consumer representatives we spoke with in Florida for lessons they have learned and any recommendations they wished to offer other states considering quality improvement programs. Nearly all we spoke to would recommend the Quality Monitor program, which was generally characterized as having a positive impact on facility quality of care. Quality Monitors have been able to establish a more collaborative, less adversarial relationship with nursing facilities than is typical for surveyors, and this relationship allows providers the opportunity to have an open dialogue with TA staff about problems and issues in resident's care, to obtain information on good clinical care practices, and to receive feedback on how they can improve their care processes. Some stakeholders felt the intervention should be targeted either to the smaller free-standing facilities with no corporate support, or to facilities that were having more problems. Most providers said they wanted to see the program continue, remain confidential and separate from survey. They especially wanted the content of the visits not to be shared with surveyors or to be available for litigation. Most said they would prefer that the QM staff not overlap with survey staff--they should be kept entirely separate. However, some providers said that surveyors and Quality Monitors should be trained to provide consistent guidance, and felt that TA staff with past survey experience were most valuable in helping them interpret applicable regulations. All agreed that Quality Monitors needed to be well qualified and experienced in long-term care.
Discussants also had recommendations on several of the other quality improvement programs Florida has initiated. Consumer advocates supported the public reporting website as important for consumer decision-making. They believed that the algorithm for ranking facilities is good, but they don't like the fact that every facility gets a star regardless of how low its quality rating is, and would prefer a numeric ranking. Provider representatives recommended that the website resolve problems associated with the reporting of 45 months of survey and deficiency information by showing current performance alongside historical performance. They also thought that regular updating was critical for accurate representation of facilities.
Regarding the Gold Seal program, participants thought it important to ensure that there is a well-defined consumer advocate position on the selection panel and that the panel performs an on-site inspection of any facility being considered for an award. They also stated that the awards should be reserved for facilities that were truly doing something special for residents and not merely meeting minimum criteria. Provider representatives noted that there is a need for rewards beyond public recognition that make the Gold Seal worth pursuing and that in order to have an impact, it had to be more attainable for more facilities.
Finally, numerous stakeholders reported that the risk management program has real potential for prevention, managing losses and minimizing litigation and that it was helping facilities focus on how best to prevent adverse incidents.
Much of the feedback aimed at the Federal Government concerned the issue of reimbursement. One provider representative summed it up by saying that "You cannot separate money from care," and that Medicare and Medicaid programs have to pay reasonably for reasonable care. There has to be more emphasis on alternative care (home care, assisted living) to really decrease the financial pressure on nursing homes.
Some providers expressed concerns about some of CMS' policies on quality measures. For example, Florida has low restraint use, but high fall rates. Providers believe that CMS is not looking at how one area of care impacts another and about interdependencies like the relationship between restraint use and falls. They also described problems with CMS classifying resident-to-resident altercations and that special considerations needed to be made for special populations like dementia and head injury patients where they have no alternatives for placement.
State agency staff attempting to look at disease management outcomes and measure resource use said they wish that is was easier to access MDS data and resource use for dually eligible patients. Providers also expressed a need for the Federal Government to take a stronger role in the development of best practice recommendations. "We wish we still had AHCPR to do best practices. They were impartial and the information came from researchers and evaluators--not surveyors." Similar direction was sought on end of life care issues, unavoidable decline and the management of expectations of patients and families about realistic outcomes of nursing home care.
Since 1999, Florida has established and implemented a number of quality improvement programs including a technical assistance program, public reporting measures, recognition programs, training/education efforts, risk management requirements and mandated increases in minimum direct care staffing. All of these measures stem from legislative mandates implemented in direct response to concerns regarding the quality of care in Florida nursing homes and the liability insurance crisis.
The centerpiece of the quality improvement efforts is the Quality Monitor program first established in 1999. The monitors visit all facilities quarterly, providing education and monitoring for facility staff. They also seek to identify any conditions that are potentially detrimental to the health, safety, and welfare of nursing home residents. The role of the quality monitor has recently expanded to include providing support to field office staff during a closure or immediate jeopardy situation, reviewing the risk management program and records of adverse incidents, and ensuring that staffing requirements are being met. The majority of participants stated that they found the QM visits to be very helpful, describing them as providing objective, non-threatening advice. They particularly appreciated the Quality Monitors sharing information on best practices, recommending educational materials and offering interpretation and clarification of state and Federal rules and regulations. However, many were concerned about the increased blurring of monitor and surveyor roles and the negative impact this could potentially have on the willingness of facilities to openly discuss problems they were experiencing.
The risk management program implemented in 2001 is designed to identify incidents occurring in health care facilities, which have an outcome of patient injury and may reflect error in the course of the delivery of health care services. Providers reported that the risk management requirement had improved the quality of care by requiring them to investigate incidents and accidents in greater detail, examine their facility processes for flawed practices, and make changes with the goal to prevent future problems. Although the number of liability claims filed in the state has reportedly been tapering off since it peaked in October 2001, there has not yet been an easing in the liability insurance crisis.
Consumer advocates and provider representatives we spoke with had mixed reviews of the quality improvement programs. While nearly all stakeholders would recommend the Quality Monitor and risk management programs, not all believed strongly in the ability of any of the implemented programs to improve quality of care or resident outcomes. In fact, many stakeholders were skeptical that these efforts were sufficient to solve the quality of care problem in nursing homes. They named issues such as the pervasive problem of high staff turnover and inadequate reimbursement as barriers to high quality performance.
We are unable to draw conclusions as to what effect any of Florida's quality improvement programs will have on nursing home quality. First, the programs have been in operation for only a short period of time. Second, the state is not performing the type of evaluation necessary for a rigorous impact analysis. Furthermore, there are a multitude of initiatives underway, all enacted during the same timeframe and during a time of changes within the nursing home industry (e.g., declines in occupancy, Medicare skilled nursing facility prospective payment, public reporting of MDS-based quality indicators). Even so, by reviewing the experiences of Florida, we believe some important lessons can be learned that might be applicable to other states considering quality improvement programs. In addition to those described in the Lessons Learned section above, we would add that states planning to implement quality improvement programs should consider the potential need to evaluate these programs--which is being demanded increasingly by program funders in the current fiscal environment--and do their best to design the programs in a manner that will allow their evaluation needs to be met.
This report describes our exploration of the various quality improvement programs initiated by the State of Iowa. It begins with background information on the programs and how the visit and discussions were structured and continues with a brief history and rationale for how the various quality improvement programs were selected and implemented. A description of the programs follows along with the research team's findings (from discussions with state employees and nursing facility providers) regarding the overall strengths and weaknesses of the programs as well as a discussion on the impact that these programs have had on the quality of life and quality of care of Iowa nursing home residents. It concludes with lessons learned by the state, the sustainability of the various programs and the participants' opinions on the role of the Federal Government in quality improvement in nursing facilities.
Background
Although it does not have a technical assistance program, Iowa has a large number of innovative programs intended to improve nursing home quality. Despite the absence of a technical assistance program, the project's Technical Advisory Group believed that the study should include Iowa, as its programs may be substitutes for a technical assistance program and may include quality improvement models that other states may wish to replicate, potentially improving our study's ability to provide guidance to states considering implementing quality improvement projects. Iowa's quality improvement programs involve a wide variety of efforts including an Internet web-based Nursing Home Report Card, recognition programs for innovative practices and outstanding performance on licensure and certification surveys, training for providers and surveyors, feedback on surveys/surveyors and an alternative survey process for state-only licensed facilities meeting certain criteria.
Participants
Abt staff members Alan White and Donna Hurd met with individuals involved in the development, management and implementation of Iowa's programs, as well as representatives from two of the state's provider groups, the State's Long Term Care Ombudsmen, and others familiar with the state's programs. Over a three-day visit in June 2002, the research team met with individuals and groups associated with the following organizations:
Marvin Tooman, Ed.D., the HFD Administrator, was the primary contact for the Iowa site visit. He has been in this position for about two years and previously was a facility administrator (at On With Life, a non-profit post-acute rehabilitation facility that specializes in brain injury/neurological and pulmonary rehabilitation). Dr. Tooman leads the division responsible for many of the state's quality initiatives. The division has made an effort to recognize facilities doing exemplary work, to improve relations between providers and surveyors (i.e., through the joint surveyor-provider training), and to encourage facilities to engage in resident-centered care. Dr. Tooman was an excellent resource for us, and the work of him and his staff in helping to plan our visit is greatly appreciated. We found that everyone with whom we spoke were willing to speak freely on their impressions of the State's programs, and found a great deal of consistency in their responses.
Preparation
Prior to the on-site visit, factual information on the quality improvement programs was gathered based on our discussions with Dr. Tooman, stakeholder discussions, DIA's web site, and Insight, the department's quarterly newsletter for nursing facilities. Insight was a particularly valuable resource-- it had information on most of the state's quality improvement programs that gave the site visit team valuable background information. Information on the following aspects of the programs was gathered and organized in a table:
The table was forwarded to Marvin Tooman, prior to the on-site visit. He reviewed the table and added some additional details. The research team used the factual information in the table as a starting point to develop discussion questions that focused on more in-depth issues.
Structure
Discussions with everyone but the IAHSA representative took place at their office. (For logistical reasons, we met with the IAHSA representative at DIA's offices.) Meetings lasted from one to two hours.
In order to put Iowa in context with the other study states, we have included some descriptive characteristics of the State's nursing home environment. Comparative data presented are from the American Health Care Association (AHCA) web site (AHCA, 2002). There are 470 facilities in Iowa, with 29,535 residents reported as of Spring 2001. The average number of beds per facility is 96, which is slightly lower than the national average of 108. Iowa's median occupancy rate per facility is 84 percent as compared to the national rate of 95 percent.
The percentage of for-profit homes is lower than the national average, (52 percent vs. 65 percent) while the percentage of not-for-profit homes is higher (43 percent vs. 28 percent nationally) with few government-operated facilities (4.7 percent vs. 6.5 percent). Fewer of Iowa's facilities are hospital-based (11 percent vs. 12 percent nationally) and dually certified for Medicare and Medicaid (60 percent vs. 80 percent nationally).
No single event or series of events or situations within Iowa or outside the state were reported by participants as being the impetus for the Iowa quality improvement programs. The development of the programs appears to stem from the vision of several key contributors. First, Iowa Governor Tom Vilsack has long been a vocal supporter of nursing home issues, both as governor and while serving in the Iowa Senate. The appointment of Marvin Tooman, a former nursing facility provider, to the position of administrator of the Health Facilities Division greatly aided in promoting the issue of quality. The current programs are the result of a uniform vision within the restraints of the current state budget crisis.
The first quality improvement program, the nursing home report card, was initially the idea of bureau chief, Larry Lindblom back in 1996 or 1997. It started as a web page to provide information to the public, news, and links to CMS (formerly HCFA). He later thought that it could be improved by adding survey results. At the time the Report Card section of the web site was developed, only one other state (Arizona) had done any work in this area and the Federal Government's site was still under development. In 1999, during his first year in office, Governor Vilsack included among his legislative proposals the creation of the Governor's Award for Quality Care in Health Care Facilities.
The selection of Marvin Tooman in February 2000, as HFD administrator made him, reportedly, the first person outside the Department of Inspections and Appeals to hold that position. His background and education make him uniquely qualified for the position. Prior to his appointment, Tooman had been CEO and president of his own company, "On With Life," a non-profit post acute care program specializing in brain injury/neurological and pulmonary rehabilitation. Prior to starting "On With Life," Tooman spent 11 years as a resource manager for the Iowa Department of Education's Division of Vocational Rehabilitation. He holds a Bachelor's degree in Education, a Master's Degree in Counseling, and a Doctorate in Administration and he is an Adjunct Assistant Professor in the University of Iowa's College of Education. He received his quality improvement training in the military, having been trained on the Baldrige self-assessment process. He is also a Commission on Accreditation for Rehabilitation Facilities (CARF) surveyor. Toomam explained that CARF standards are very similar to the Baldrige criteria. At the time of our interviews, he was the president-elect of the Association of Health Facility Survey Agencies.
In the first nine months following his selection, the department introduced the Quality-Based inspections program in May 2000, the Joint Surveyor/Provider Training in June 2000; the Deficiency-Free certificates in October 2000 and Best Practices program in November 2000. Later in June 2001, the survey questionnaire was introduced.
The goal of quality improvement programs is viewed as promoting the "culture of quality." Tooman has expressed the department's vision for nursing home quality by writing regularly in DIA's quarterly newsletter, Insight. In the June 2001 issue, Tooman wrote about the department changing the HFD mission statement. He wrote:
"Assuredly, within this experience, we are accountable to the state and federal rules that provide a "baseline" for the quality of care that our residents and clients receive. However, we should not be satisfied with merely maintaining the minimum standard of state and federal rules. To that extent the HFD has changed it's mission statement.--"The mission of the HFD is to promote the quality and optimal outcomes of services through a survey process that centers on enhancing the lives of the people served."
Tooman puts the responsibility for success on the facilities that are able to introduce and maintain a "culture" of quality care. He went on to state that, "we need to insure compliance with state and federal rules. But rule compliance is a by-product of a quality improvement effort. …First, it is safe to say that the facility is not immune from the problems that nursing homes face on a daily basis. And there may be occasions where they may be deficient with a rule or two. …[T]hey have established a way of operation that speaks to quality services. Some may say that they have a "Quality Culture."
Bureau chiefs echoed Tooman's belief in a quality culture, noting that they recognize quality through mechanisms presented in the Baldrige criteria and that they had moved in that direction via a culture change. They explained that they saw themselves as a team "all pointing in the same direction" and that changes had been "strategized and well implemented."
This section includes a brief description of each of Iowa's quality improvement programs followed by a discussion of program funding, governance and the management and staffing structure. The following quality improvement programs were reviewed:
Nursing Home Report Card
The Nursing Home Report Card is an Internet web site that contains information on all federally certified nursing facilities and skilled nursing facilities in the state. The Report Card allows users to search for facilities by name or location. It includes "quality indicators" (Note: These are F-tags and not the CMS quality indicators) based on survey results. The web site includes the full inspection report, including detailed write-ups of deficiencies and the facility responses/Plans of Correction. All survey/complaint investigations since June 1999 are listed, including those under appeal, with the appeal noted (see Appendix C for a sample facility Report Card). The Report Card also includes information on facility best practices. The legislation that created the Report Cards was passed in late 1997. At that point in time, the CMS Nursing Home Compare site was still under development, and there was little consumer information on nursing homes available on the Internet. The Iowa Nursing Home Report Card went on-line on November 5, 1999.
A goal of the Report Card is to provide consumers with information on nursing home quality so that they can make informed nursing home choices. It is believed that provision of this information will motivate facilities to improve quality. The department strongly believes in making information available to consumers, believing, according to Dr. Tooman, that the availability of public information is "sacrosanct" (except when it is necessary to protect confidentiality). Iowa is the only state that researchers are aware of that posts complete survey results on the Internet. The survey findings are posted to the Report Card web site two days after the survey is mailed to the facility.
According to an article in Insight, the Report Card website was designed over an 18-month period as DIA worked in collaboration with resident advocates and nursing home industry leaders. DIA met with stakeholders twice as they developed the report card. The group included representatives from the four provider groups, the Iowa Partners group, advocacy groups, ombudsmen, state legislators, and representatives from the Departments of Elder Affairs and Public Health. In the facilitated meetings, DIA presented a shell and asked for input from stakeholders.
Quality-Based Inspections
Under the Quality-Based Inspection Program, facilities that are state-only licensed may be surveyed every six to 30 months, depending on facility performance. The program was intended to allow DIA to maximize its resources and concentrate more fully on the facilities in the state needing the greatest attention. Legislation authorizing the program was signed on May 11, 2000 (Senate Bill 2144). The quality based inspection program is reported to have originated from provider groups requesting the state to make changes in the survey process. Facilities opting to participate must complete a detailed application process based on the Malcolm Baldrige National Quality Program. The Baldrige Award is given by the President of the United States to businesses and education and health care organizations that apply and are judged to be outstanding in seven areas: leadership, strategic planning, customer and market focus, information and analysis, human resource focus, process management, and business results. Nationwide, there were five winners in 2001. DIA modified the Baldrige application process by shortening the application and broadening the categories to accommodate the limited resources of most nursing facilities.
The program, however, has not been truly successful. Very few facilities have opted to participate. There are ten nursing facilities statewide that do not participate in the Medicare or Medicaid programs, and are thus eligible for the program. Three facilities were invited to participate in a pilot program, but only one nursing facility has completed the self-assessment necessary to participate in the quality-based inspections program.
Furthermore, the potential benefits from participating (in terms of a less frequent survey cycle) are probably outweighed by the time and effort required to apply. A major component of the Baldrige National Quality Program is the feedback report, which is a written assessment of an organization's strengths and opportunities for improvement based on its application. Due largely to limited staff availability and budgetary restrictions, the Iowa-modified program does not provide any type of feedback report to its applicants. This feedback report had been envisioned as one way, among others, that the department could provide a type of technical assistance to facilities.
Best Practices
Begun in November 2000, the Best Practices Program aims to recognize and disseminate new and innovative approaches to providing nursing home care. Shortly after assuming the Division Administrator duties, Dr. Tooman observed a surveyor congratulating a director of nursing on a uniquely successful nursing procedure. He believed that the details on this practice should be shared with other facilities and that at the time there were no means to accomplish that. The goal for the program as described by DIA is to close the gap between knowledge and practice and point to positive approaches to integrating new knowledge and practices.
Facilities that believe they have developed an innovative practice report it to the surveyor during the annual inspection. The surveyors review the practice on site with the team leader, making the decision as to whether it qualifies as a Best Practice. Those practices deemed to be among the best in the state are recognized and posted on the division's Report Cards and in a separate listing on the web site. Best Practices are sought and recognized in nine categories--community integration, dietary, resident rights, nursing practices, human resource management, environmental, quality of life, habilitation/rehabilitation and end-of-life experiences.
Currently, there are 300 Best Practices listed on the web site (note that fewer than 300 facilities are represented since some facilities are recognized for more than one best practice.) Originally, the department's web site denoted best practices with a trophy icon, but this was later changed to a light bulb, as the department wanted to emphasize that the Best Practice program was designed to recognize a facility's practice, not the facility itself. Also, the practice of sending facilities Certificates of Recognition was later changed to the sending of a letter, because of confusion related to certain facilities receiving recognition and then later having problems with survey inspections and/or complaints. Appendix D includes the state's principles and procedures of Best Practices.
Joint Surveyor Provider Training
Beginning in June 2000, the DIA and the provider associations have collaborated to present four joint surveyor/provider training sessions, with another session scheduled in October 2002. Training sessions have been held on elopement, activity-focused care, dental needs of long term care residents and resident-centered living. The October 2002 session will address pain-related issues. The department initiated the joint training sessions in an effort to provide a common knowledge base for surveyors and providers and to enhance the quality of care and quality of life of the state's residents. The department utilizes local community colleges to assist with the organization of the training with experts in the topic recruited to conduct the actual training sessions. For example, two professors from the University of Iowa College of Dentistry led the training sessions on oral health and Eric Haider, from the Crestview Nursing Home in Bethany, Missouri spoke about his philosophy on resident-centered care. Nearly all of the state's 60 surveyors and 200- 350 providers have participated.
Governor's Quality Awards
The Governor's Award for Quality Care in Health Care Facilities recognizes quality services provided by long term care facilities, residential care facilities and intermediate care facilities for the mentally retarded or mentally ill. The award is based on the uniqueness of the services provided by the facilities to its residents, and any activities undertaken by the facility to enhance the quality of care or quality of life for its residents. The program was signed into law on May 11, 2000 with the first awards given in 2001 to eight health care facilities.
Nominations may be made by residents, family members, advocates and staff at other nursing homes. A stakeholder committee selected by the Director of the Department of Inspections and Appeals reviews nominations. Committee members evaluate each nomination and recommend facilities for further consideration. Prior to the selection of finalists, onsite reviews are made by DIA personnel to verify the accuracy of the information in the nomination. There can be up to two winners in each of the state's five Congressional districts. In 2001, there were 29 nominations and five winners. In the first year of the program, the awards were mailed to seven of the award-winning facilities, with the Governor making a personal presentation at one location. This past year, Governor Vilsack presented the awards at the Governor's Annual Conference on Aging.
Deficiency-Free Certificates of Recognition
Beginning in September 2000, DIA provides certificates of recognition to facilities that are deficiency-free in their annual inspection. The certificate is the department's way of acknowledging the "hard work and dedication" of the facility's staff in meeting the established standards of care. During the fiscal year that ended in September 2000, nearly 15 percent of the state's 800 long-term care, intermediate and residential care facilities had achieved deficiency free surveys. In March 2001, it was reported that 55 nursing facilities had received certificates.
Survey Questionnaire
Since June 2001, facilities have had the opportunity to complete a survey questionnaire that is presented at the conclusion of the regular survey. Completed surveys are returned to the Iowa Foundation for Medical Care (IFMC) for tabulation. IFMC estimates that 40-50 surveys are returned each month. The goal of the questionnaire is to improve the survey process in the state, ultimately improving the provision of health care services in the state. The survey includes information on surveyor conduct; facility opportunity to provide information and survey-related data; clarity of exit conference information; and whether the facility received information on the Best Practices program. Providers are also given the opportunity to provide general comments on the survey process, including suggestions on how to improve it.
IFMC produces a report for DIA in an Excel spreadsheet, which DIA in turn shares with their staff. In May 2002, the state average was 4.62 (on a one to five scale with five representing the most favorable rating). Data are stratified for each program coordinator so that specific areas for improvement can be identified and addressed.
Program Funding
The Nursing Home Report Card, Best Practices Program, Joint Surveyor/Provider Training, Deficiency-Free Certificates and Survey Questionnaires are funded through a combination of federal and state dollars, with 73 percent of budgeted costs paid by federal funds. Only the costs for the Governor's Award for Quality Care ($5,000) and the Quality-Based Inspections ($7,000) are funded entirely through state funds.
Current annual programming costs for the Nursing Home Report Cards are approximately $25,000 per year, with 73 percent paid by federal funds. In the 2002 budget, costs related to the division's web site were about $105,000, which included $31,500 for web maintenance, $10,800 for web hosting, $41,000 for electronic licensing, and $21,000 for scheduling software. The Best Practices program costs an estimated $15,000 per year, 73 percent of which is paid by the Federal Government. The cost associated with the Joint Surveyor/Provider Training sessions is approximately $50,000 per year, with 73 percent (approximately $36,500) paid by federal funds. The Deficiency-Free Certificates ($500 per year), and the Survey Questionnaire ($50,000 per year) each receive 73 percent of program costs from the Federal Government.
Governance of Programs
Each of the quality improvement programs is administered through the Iowa Department of Inspections and Appeals' Health Facilities Division.
Management and Staffing
Staff within the Department of Inspections and Appeals, Health Facilities Division, is involved in the management as well as the day-to-day operation of the various quality improvement programs. One Bureau Chief is responsible for routing of any questions (2-6 questions per day) that come through the web site to the appropriate person for a response. A clerical person scans the survey reports so that they can be posted to the web after the reports have been reviewed for removal of any confidential information.
Although participation in the Quality Based Inspections Program is very low, DIA staff is responsible for reviewing applications and determining the appropriate frequency of surveys based on facility applications. Joint Surveyor/Provider training is coordinated by two DIA trainers who are responsible for the planning, organization and recruitment of experts to conduct the sessions. Potential Best Practices are verified by the survey team leader during the survey process. Once verified, the HFD administrator and other staff further consider the identified practice. A stakeholder committee, chosen annually by the department Director, reviews the Governor's Award nominations.
The Deficiency-Free Certificate program does not require any additional staff, as it is handled as part of the normal survey process. The state's QIO (the Iowa Foundation for Medical Care) handles data entry of responses on the Survey Questionnaires. No analysis of the data is generated. However, a summary report is forwarded to the department on a regular basis.
Provider representatives overwhelmingly agreed that recognition programs (Deficiency Free Certificates, Governor's Quality Award, and Best Practices) did much to boost nursing facilities' morale. Over and over, participants stated that in the heavily regulated and scrutinized nursing home environment, facilities were grateful for positive recognition. Stakeholders told us that receipt of such awards was sometimes publicized in community newspapers and local media. Both provider associations agreed that the Best Practices program was a good informational resource for facilities as well as providing recognition for exemplary programs.
The Nursing Home Report Card was generally recognized as reporting current, accurate information, although there is considerable controversy regarding the posting of survey results that are under appeal (see further discussion below). Bureau chiefs reported that it had cut down on telephone requests for survey information and had saved considerable staff time sending out paper copies of survey results. Bureau chiefs and the Ombudsman agreed that the report card had done a good job improving consumer access to public information. According to division web site statistics, the web site is widely used with 14,664 sessions recorded in June 2002 (this does not represent unique users since some individuals may have accessed the web site multiple times). The Report Card pages are among the most accessed on the division's web site, with 7,050 hits to the report card result summaries, 5,945 hits on the detailed facility results, almost 5,000 hits to the report card search page and 2,292 viewings of the detailed survey findings. Although it is not possible to determine the identity of web site users, they do represent nearly every state, as well as Europe and Asia.
According to one of the Bureau Chiefs, report card utilization had gone up 50 percent in the last six months. In September 2000, GovNetworks and eGovernment magazine recognized the division web site with their Digital Award of Excellence, which is intended for deserving web sites that benefit the public.
Joint Surveyor/Provider trainings have been well attended--600 attended the first programs (elopement prevention), 200 attended the programs on creative care giving, 300 attended the oral health training, and 300 participated in the programs on resident centered care. Joint trainings may have helped improve relations between facilities and surveyors. Based on feedback forms, providers find these sessions very informative and useful.
The Survey Questionnaire reportedly has increased surveyor accountability, and has encouraged them to be more courteous, communicative, professional and approachable. Provider associations were pleased to have had input in the development of the questionnaire.
Although there was agreement that nursing facilities appreciated recognition for good performance, there was concern expressed by the Ombudsman that these awards gave consumers a false sense of security. In their experience, they noted that consumers seeing a Best Practice icon on the website or a Deficiency Free Certificate assumed that the facility was performing well in all care areas on a consistent basis. In fact, as they pointed out, a Deficiency Free Certificate only attested to the facilities' ability to meet minimal standards for the days that the surveyors were in the building. Likewise, recognition of one good area of practice did not mean that all practice areas were exemplary. HFD surveyor trainers noted that advocacy groups had been critical that these award programs were seen as bringing the regulatory agency too close to the entity they were supposed to be regulating.
The Ombudsman also noted that the requirement that the Best Practice be reported and evaluated during the survey was burdensome for facilities. They recommended that the recognition of Best Practices not be tied to a particular facility, but listed separately on the website.
One of the most difficult situations for all parties to contend with concerned those facilities that had received recognition for a practice or deficiency free survey and then later had compliance problems. These situations had been widely reported in the news media by an individual reporter who focused on long-term care issues. Initial praise and recognition of a facility that subsequently falls into disfavor was reported by participants as making the whole process look suspect. Another very controversial issue concerned the posting of all deficiencies on the web site, including those that were under appeal. The HFD policy is to post them two days after they are mailed to facilities and if appealed by the facility to mark them as such on the website. Both provider associations had unsuccessfully attempted to block the posting of deficiencies under appeal. Provider associations stated that even when deficiencies were later overturned, the damage from the initial posting and subsequent publication in the media was not readily reversed. Appealed postings are noted as pending appeal. The third most widely expressed concern with the Nursing Home Report Card posting of deficiencies is that it is claimed by some industry representatives to have had an impact on nursing home liability insurance rates. According to the AHCA representative, based on the number of deficiencies, some insurance companies were not writing policies and others had increased rates to the point that they were unaffordable by facilities. According to the department's Deputy Director, the governor convened a task force to examine insurance issues generally. The Task Force report does not note any connection between rates/availability of insurance and the web site report card postings.
Other more minor issues with the Nursing Home Report Card concerned the ease of consumer use. The Ombudsman pointed out that consumers were confused by the listing of complaints that were found unsubstantiated. Complaints that are not substantiated are not written out in their entirety. They recommended that all complaints be posted so that trends over time could be evaluated. The provider associations also felt that more collateral materials should be included on the website to aide consumer understanding of the information posted. They also disagreed with the inclusion of the names of directors of nursing and administrators in several years worth of data, noting that if these individuals are no longer employed because of poor performance their information remains on the web site.
Participants were mixed in their impressions as to how widely the Report Card was used by consumers. Consumer advocates noted that many consumers do not know that it is out there and that especially in many rural situations, there may only be one facility within a reasonable distance of family members and in this situation there could be little benefit to using the report card for facility selection.
There was widespread agreement from all participants that the Quality-Based Inspections program had not been successful as the application process was generally too burdensome for the majority of facilities to complete. Only ten nursing facilities are state-only licensed and even though the program had been modified in an attempt to streamline the process, only one had applied to participate in the program. Additionally, the benefits from applying for the quality-based inspections were reported as, "not worth the effort." The potential benefit is that the survey cycle could be extended to as long as 30 months. And, even for facilities that qualify for an extended survey cycle, some type of annual follow-up (a validation review) is required to make sure that the facility is still performing at the high level required to justify the longer survey cycle. The validation review involves one or two surveyors on site for no more than two days and involves a quality assessment based on the program's criteria. The State's Ombudsman reported that the philosophy of the quality-based inspection program "scared them." They believed that there could be large changes in provider quality after the inspection (i.e., in the case of "yo-yo compliance") and are opposed to any program that would increase the length of time between inspections.
Provider representatives reported that facilities were not convinced that responses on the survey questionnaire were completely anonymous. Even though the forms are sent to the Iowa Foundation for Medical Care for tabulation, providers are fearful that surveyors have access to the survey feedback information. Provider associations reported that comments they received from facilities regarding surveys were not consistent with the survey results that they had received from HFD. Either facilities were not completing the survey or were being overly generous to HFD in their rankings. The provider association also believed that individual surveyors should be named on the questionnaire rather than be reported at the coordinator/supervisor level. In their opinion, the naming of individual surveyors would lead to individual employment counseling where indicated. IHCA has developed and begun distributing its own questionnaire, which is similar to that used by DIA (except that it includes surveyor-specific questions) so that the association may compare its results with those obtained from the department questionnaires.
Joint provider/surveyor training was praised for providing access for both groups to up-to-date clinical information although progress toward its secondary goal of opening up communication between the two groups was seen as marginal. Participants noted reluctance on the part of both groups to asking questions in the group setting, as providers did not want to share areas of facility weakness and surveyors did not want to look uninformed in front of providers. Surveyor trainers also noted that by providing these joint training sessions, they necessarily had to cut back on the number of surveyor-only meetings for budgetary reasons. Also, provider associations initially objected to the issuing of continuing education units for these programs, as the income from offering educational programs has traditionally made up a major part of their revenue.
No evaluation of the impact of these programs has been made to date. Some decrease in the number of deficiencies has been noted in recent years, but it is not clear that there is any connection between the quality improvement programs and the number of deficiencies cited. Although there are statistics available on how many people access the website, there is no information as to whether these users are consumers, policymakers, researchers, or others. It is not known how the Report Cards affect consumer choices or facility quality. With only one nursing home in the state having applied to participate in the Quality-Based Inspections program, it is clear that this program, as implemented, has not had any impact on the quality of care or the quality of life for Iowa nursing home residents. Based on informal polling of providers, Dr. Tooman reported that the majority of providers have at least looked at the best practices, and he has anecdotal evidence that some facilities have adopted the best practices of other facilities.
Ombudsman did not note any significant improvement in care since the implementation of the quality improvement programs. They explained that, for example, the Governor's Award program, "It's nice and warm and fuzzy, but we don't really know that it improves care." They went on to say that these programs have focused on the average and above average facilities and have not raised the standards or done enough to deal with the poor performers. They believe that many of the best practices just represent activities that the facility should be performing routinely and do not represent exceptional care. They also believe that many facilities do not nominate themselves for a Best Practice Award believing that these practices are simply, "part of their job."
One provider representative stated that, "nothing improves quality more than reimbursement." She went on to say that although award programs are going in the right direction--the number one and two issues for facilities are reimbursement and consultative assistance and that these are the issues that facilities would like addressed--the "rest of this is just window dressing."
Except for the Quality-Based Inspections program, discussion participants did not identify any programs noted as unsuccessful or at risk of discontinuation. The department places great importance on making information available to consumers. There were no plans to add additional items (e.g., staffing information or MDS quality indicators) to the Nursing Home Report Cards. When CMS begins posting the quality indicators, the department will include a link to this site.
AHCA representatives advised other states to carefully consider all aspects of a report card and to have as much detail on the description, development and implementation as possible written into the legislation. They advised other states to consider what information will be seen by the public, how it will be displayed, timeframes for display, and how much collaboration there will be in the development process as examples of the types of topics that should be clearly defined prior to enactment. They noted that when the legislation to develop the Iowa report card was passed, it sounded acceptable, but later they found that DIA's interpretation of the legislation varied significantly from their interpretation, which led to the current problems regarding the posting of deficiencies prior to the resolution of appeals. Ombudsmen stated that they would like to see all complaints posted, including those that are not substantiated. They also advised that more advertising is needed to let consumers know that the report card is available.
There was general agreement that the application for the Quality-Based Inspections program needs to be simplified and the benefits for eligible facilities enhanced. Until CMS is willing to consider an alternative survey process which differentiates between good and poor performers, programs designed to make it possible for good facilities to be surveyed less often will not work if they can only be applied to state-licensed only nursing homes, given that most homes participate in Medicaid and/or Medicare.
Participants believed that programs rewarding best practices and deficiency-free surveys were valuable, despite the potential fall-out if those facilities later run into problems. They pointed out that it was important to have an objective process by which facilities are judged, so that the award is seen as truly recognizing outstanding quality and not based on other factors such as politics.
Both provider groups and the department indicated that they were pleased with the joint training programs and would recommend these to other states. High attendance at the sessions is indicative of the value that providers place on the training. DIA trainers suggest that states collaborate with community colleges and universities in the development of curriculum and presentation of materials. They also suggested that since provider associations usually have had more experience in planning and presenting educational programs, the states use them as resources. States should also consult with provider associations so as not to duplicate topics. DIA trainers also noted that states should avoid controversial topics, such as regulatory issues, and select "safer" topics, such as clinical issues.
The survey questionnaire was reported to be a relatively inexpensive way of improving the survey process, increasing surveyor accountability, and allowing facilities to provide feedback to the department. DIA recommends it to other states interested in these outcomes.
Dr. Tooman explained that he prefers that the Federal Government take the lead on providing "technical advisement" to states and facilities on quality-based cultures and organizational processes. Although the Quality-Based Inspections program, based on the Baldrige criteria was less than successful in Iowa because of its complexity and the limited resources available to most nursing homes, he remains a strong proponent of the process, having been a trainer prior to joining HFD. He believes that through technical assistance, facilities can be "equipped to do a better job.
Budgetary issues emerged as having a significant impact on the department's current programs and plans for future quality improvement programs. Iowa had experienced a 4.6 percent cut in last year's budget, plus additional cuts that amount to about 4.6 percent for this year. Despite the Governor's support for long-term care issues (he introduced a bill that would have allowed the state to shift resources so that budget cuts would not need to be as large) the general assembly rejected this proposal. Due to the budget cuts and expanded responsibilities (DIA recently assumed the responsibility for regulating assisted living programs), the concern for DIA has been to maintain current QI programs, as it is currently not feasible to implement new programs.
Provider group representatives expressed their desire for a consultative component to the survey process. They appreciate the recognition programs and awards, but identify the lack of "someone they could call for help," as a problem. Other than higher reimbursement, some type of technical assistance is what facilities want most from the state. Dr. Tooman noted that he has interest in implementing a technical assistance program, but the lack of available state funding in combination with additional DIA responsibilities make such an undertaking not feasible at this time. Funding remains a difficult issue.
Another significant influence on quality improvement programs in Iowa comes from the media. The State's major newspaper, the Des Moines Register, has focused a great deal of attention on long-term care issues, raising public awareness of quality in nursing homes and assisted living programs. The Nursing Home Report Cards are a major source of information for these articles and attention has been given to homes that receive awards, but are later cited for major deficiencies. During the site visit, the Register began a major series on assisted living programs. The attention generated from previous articles on these programs reportedly led to the change in oversight responsibility from the Department of Elder Affairs to DIA.
Finally, Dr. Tooman's background as a former facility chief executive officer and administrator and his sensitivity to facility issues appear to have contributed to the direction that DIA has taken in developing and implementing its quality improvement programs. DIA has made an effort to recognize facilities doing exemplary work, to improve relations between providers and surveyors, and to encourage facilities to engage in continuous quality improvement.
AHCA. State Summaries of Nursing Facilities, 2001/www.ahca.org/research/keynotes/statefactsheets-2001.pdf.
Iowa Department of Inspections and Appeals. Governor Unveils Nursing Home Report Card Site. Insight, February 2000.
Tooman, M.L., Department, Health Care Providers Share Common Responsibilities. Iowa Department of Inspections and Appeals. Insight, June 2001.
Tooman, M.L., Presentation Sparks Motivation for Quality Care. Iowa Department of Inspections and Appeals. Insight, September 2001.
Maine was selected for a site visit because it met the criteria established by the research team and Technical Advisory Group in that it has established and funded quality improvement programs, which are not reimbursement related. Researchers were particularly interested in Maine because of the unique technical assistance component within the quality improvement programs. Maine's technical assistance program, in existence since 1994, consists of one nurse who provides consultation and educational inservices statewide to any long term care facility on problem resident behaviors. The Technical Advisory Group believed that Maine's small technical assistance program might serve as a model to other states that were interested in providing technical assistance to nursing facilities but not able to implement a large-scale program. The State also recently enacted legislation that mandated a Best Practices Program, a consumer satisfaction survey and measures to significantly increase their minimum nurse staffing ratios.
Participants
Abt staff members Donna Hurd and Leighna Kim spent one day in Augusta, Maine on September 12, 2002. The following individuals agreed to participate in in-person and telephone discussions with the researchers:
Laura Cote and Brenda Gallant were the primary contacts for our Maine visit. Ms. Cote and her supervisor, Diane Jones participated in both in-person and telephone discussions. Ms. Cote also provided written information about the behavioral consulting program and a list of directors of nursing who would be willing to speak with us about her services. Ms. Gallant and Ms. Grasso were helpful in providing information on the quality improvement programs enacted as part of the April 2000 omnibus legislation. Ms. Gallant provided copies of the final legislation. Dr. Kane provided valuable information on the development of the legislation.
Preparation
Prior to the on-site visit, factual information on the quality improvement program was gathered from a literature review, stakeholder discussions and Maine Department of Human Services web site. Information on the following aspects of the programs was gathered and organized in a table:
The research team used the factual information in the tables as a starting point to develop discussion questions that focused on more in-depth issues. Letters of endorsement explaining the project goals, state selection and discussion processes were formulated and sent to prospective participants. Follow-up phone calls were made to arrange for convenient dates and times for meetings.
Structure
Discussions with Ms. Jones and Ms. Gallant took place at their offices. Ms. Cote, who works from her home, met with the researchers at the Division of Licensing and Certification offices. These meetings lasted from one to two hours. Discussions were generally loosely structured with researchers presenting