1 the basis for improving and reforming long-term care part 4: identifying meaningful improvement...
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The Basis For Improving and Reforming Long-Term Care
Part 4: Identifying Meaningful Improvement Approaches
Steven A. Levenson MD, CMD
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Objectives of This Segment
Previous segments have identified key conceptual foundations For providing high-quality care For overseeing and trying to improve care
quality This final segment
Applies earlier discussions to assess current and prospective efforts to improve and reform nursing home care
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Recommended Approaches A number of specific approaches
herein Based on the foregoing discussions
Correctly define the problems Identify their diverse causes Present a cohesive strategy
Many of them differ from the conventional wisdom
Should be taken seriously
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Ongoing Criticism of Nursing Home Performance Continuing allegations
Significant improvement still needed Many important issues and conditions
remain inadequately recognized and managed or, conversely, overtreated
Nursing home industry response In past decade, significant improvement Competent care despite challenges
More sophisticated postacute care more than in other settings
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What is the Truth?
Is care as good as some claim? If so, why so many more reform efforts? If not, why would more of the same be
any more beneficial? Which approaches are likely to
produce dramatic improvements? Just how good are the current
improvement and reform efforts?
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Important Historical Context
Important to understand history of attempts to reform nursing homes Just as patient history helps us
understand his or her current condition
Attempts to reform long-term care have succeeded to some extent
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Important Historical Context
Previously, much of criticism of nursing homes and their care has been warranted
Challenge for nursing home staff, practitioners, and management to identify which of the numerous alleged solutions are viable and worth pursuing
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Important Historical Context Some good intentions have gone
astray Inconsistent and incomplete
implementation of pertinent ideas Inaccurate and inappropriate advice Questionable agendas of various interest
groups Considerable resistance or sabotage Abundant and problematic political
opportunism
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Foundation For Subsequent Reforms
Further tinkering is inadequate because Resources are limited Waste is problematic Results count more than ever
Important to consider reasons for success or failure of previous efforts
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Recommendations to Improve & Reform Long-Term: Summary
Reconsider current improvement and reform efforts
Challenge the conventional wisdom Vigorously subdue “political
correctness” Rethink the research agenda Focus attention on basic care
principles and processes
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Recommendations to Improve & Reform Long-Term: Summary
Suppress reductionism and jurisdiction over care
Reconsider notions of competency and expertise
Change approaches to assessing and trying to improve quality
Develop biologically sound reimbursement
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Reconsider Current Improvement and Reform Efforts
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Sources of Efforts to Improve and Reform Long-Term Care
Governmental Industry groups, associations, and
coalitions Public and consumer initiatives Physician initiatives Insurance initiatives Non-industry organizations and
associations
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Types of Efforts Targeting Reform
Laws and regulations Assessment tools Workforce initiatives Quality-improvement strategies Work groups Campaigns Consumer initiatives (e.g., “culture
change”)
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Categories of Approaches Targeting Reform: Examples
Improve information systems for quality monitoring
Strengthen the regulatory process Strengthen the care giving
workforce Provide consumers with more
information
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Categories of Approaches Targeting Reform
Strengthen consumer advocacy Increase Medicare and Medicaid
reimbursement Develop and implement practice
guidelines Change the culture of nursing
facilities
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Problems and Solutions
Current reform initiatives A potpourri of approaches Still lacks a comprehensive problem
statement and cohesive strategies Inadequate to just aggregate
multiple “solutions” and reform agendas, e.g. [Agenda A] + [Idea B] + [Campaign C] +
[Proposal D] + [Notion E]
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Reform Misconceptions
Easy to identify that something is amiss May not = having appropriate solutions
Analogous to care planning for a complex patient Consequences may have multiple causes Various causes may have multiple
consequences
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Reform Misconceptions
Before trying to “fix” the problems Define issues and identify root causes
More interventions are not necessarily better
Some proposed approaches are pertinent and meaningful Others may exacerbate situation or
just circumvent underlying causes
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Reform Efforts: Desirable and Problematic
Desirable Efforts Problematic Efforts- Cohesive and compatible - Fragmented, piecemeal,
uncoordinated, inconsistent, incompatible
- Arise from thoughtful discourse
- Based on inadequate understanding of problems and underlying causes
- Respect precedent - Tend to reinvent the wheel
- Biologically sound - Biologically unsound
- Promote all essential elements
- Overly complicated; missing key elements
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Reform Efforts: Desirable and Problematic
Desirable Efforts Problematic Efforts- Promote full care delivery process
- Do not emphasize all care delivery process components
- Emphasize empirical methods for clinical problem solving
- Underemphasize rational clinical problem solving
- Emphasize good outcomes
- Emphasize good intentions
- Assess both results and related processes
- Unbalanced emphases
- Valid approaches to identifying care quality
- Inadequate approaches to identify care quality
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Reform Efforts: Desirable and Problematic
Desirable Efforts Problematic Efforts- Focus on underlying care as well as treating specific conditions
- Overemphasize treatment of specific conditions at expense of underlying concepts
- Promote balanced care and treatment in “context”
- Promote unbalanced or superficial care
- Avoid false “medical / social” model dichotomies
- Unbalanced emphasis on “medical” or “social” models
- Balanced approaches to regulatory compliance
- Excessive preoccupation with regulatory compliance
- Promote vital management role in effective care
- Downplay or overlook key management role
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Strategies: Reconsider Current Improvement & Reform Efforts
Evaluate compatibility of various reform efforts with key philosophical and scientific principles Including evidence-based care and full
care delivery process Focus more on defining issues
correctly and identifying root causes
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Challenge the Conventional Wisdom
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Challenge the Conventional Wisdom
“Conventional wisdom” “A belief or set of beliefs that is widely
accepted, especially one which may be questionable on close examination”
Susceptibility of reform to the conventional wisdom Only some of it is accurate and
pertinent
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Challenge the Conventional Wisdom CW can impede genuine
improvement and reform if it Fails to identify issues correctly Diverts attention and resources Leads to inadequate or inappropriate
interventions Both political and clinical CW Diverse sources of CW
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Political CW Political CW
Refers to platitudes about nursing homes, their staff, and quality of care, as well as to alleged solutions
Clinical CW Refers to habitual and widespread
approaches to aspects of care Often inconsistent with evidence or fail closer
scrutiny May be so widespread that it becomes a
false “standard of care”
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Political CW Example: RAI and High-Quality Care
Resident Assessment Instrument (RAI) Including Minimum Data Set (MDS) Meant to improve on previously haphazard
and inadequate assessment Can be helpful if used as originally
intended A minimum data set with basic functional,
behavioral, and psychosocial information
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Conventional Wisdom: The Other Side
Conventional Wisdom Unconventional Viewpoint
- Reformers are above reproach
- Reformers deserve scrutiny- Reformers may be blocking legitimate solutions
- More laws and regulations are needed
- Laws and regulations need a biologically sound basis
- Nursing homes need to measure performance
- Measurement has limits in improving performance
- Nursing homes need minimum staffing levels
- Numbers are just one part of a much bigger picture
- Stronger enforcement is needed
- Accountability needs to be consistent and evidence-based
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Conventional Wisdom: The Other Side
Conventional Wisdom Unconventional Viewpoint
- More research is needed to solve these big issues
- Implementation of existing knowledge is vital
- Interdisciplinary teams are essential
- IDTs must function properly and know their limits
- The more care that is given, the better the quality
- More care may simply be irrelevant or hazardous
- There are only a few poor performing facilities
- Performance varies widely in and among facilities
- Quality measurement measures care quality
- Relevance of some current quality measurement is unclear
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CW Example: RAI Misinterpretation and Misuse
Regrettably, RAI has a life of its own Often serves as primary or sole
informational basis for care MDS has spawned new job
description (MDS coordinator) and many consultants Many efforts to validate assessments
and conclusions that are based on it
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RAI Use and Misuse
RAI serves a purpose However, a limited guide to effective
clinical decision making MDS does not consider detailed,
chronological patient history RAI provides only a limited basis
for more complex care planning
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RAI CW: Basis for Meaningful Reform More realistic and balanced view
needed of the RAI and MDS Intended for specific purposes
Excessive reliance on assessment instruments has become problematic
Limits to how much it can improve care or give basis for sound reimbursement
Responses to concerns have not necessarily been substantive
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Political CW: The Virtues of Interdisciplinary Teams
Interdisciplinary team Use individuals of multiple disciplines
to provide care Key tenet of geriatrics and long-term care
Also referred to as interdisciplinary care, interdisciplinary care teams, and interdisciplinary collaboration
Approach has proven beneficial
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Interdisciplinary Team: Implications and Limitations Teams are a means to an end
Not an end in themselves Benefit of teams depends heavily on
training, knowledge, qualifications, and performance of team members
Improper realization of IDT team approach may Distort purpose Impede care quality improvement
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Team Approach: Misconceptions Team approach can be redundant,
inefficient, or hazardous If team members exceed scope of
knowledge and skills Having more participants does not
necessarily improve the care For example, separate “teams” for issues such
as weight loss, skin care, falling, and pain A single comprehensive collaborative review
may be more biologically sound
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Amount of Care as a Reflection of Quality More interventions do not necessarily
produce better results A single intervention targeted at a root cause
may be preferable For example, hypothyroidism or medication-
related adverse consequences Evidence: more care may result in more
unnecessary treatment or complications Amount of care not a reliable measure of
quality
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Team Approach: Basis For Meaningful Reform
Need to reexamine how nursing homes actually implement true IDT approach Such scrutiny is likely to show significant
variability and deficits Ineffective or inappropriate team
approach can contribute to redundant, irrelevant, or problematic care
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Clinical CW: Alleged Virtues of Antibiotics
Many long-term care residents/patients have infections Colonization is also very common
Antibiotics are commonly prescribed for diverse symptoms and test results
For several decades, concerns about use of antibiotics in various situations
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Clinical CW: Alleged Virtues of Antibiotics
Specific criteria for antibiotics use exist Generally inadvisable to treat
colonization Misdiagnosis and inappropriate
antibiotic treatment are common Routine use of antibiotics for behavior
symptoms is largely unwarranted
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Clinical CW: Alleged Evils of Antipsychotic Medications
Concerns about antipsychotic medications a major driving force behind nursing home reform efforts
Concern about inappropriate use of all medications is warranted However, issues are far broader than any
one category of medications Including correct assessment and management
of behavioral and psychiatric issues
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Clinical CW: The Alleged Evils of Antipsychotic Medications Nursing home staff and practitioners
often bypass the care process Including meaningful details about behavior
Frequent push for psychiatric consultations for changed or problematic behavior
Inadequate search for underlying causes may lead to Poor outcomes Unnecessary or problematic treatment
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Clinical CW: The Alleged Evils of Antipsychotic Medications Drug treatment of behavior and mood
disturbances often based on guesswork
New generation of medication-related issues compared with traditional ones
Genuine reform requires attention to issues underlying medication use Including related clinical problem-solving
and decision-making activities
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Clinical CW: Pressure Ulcer Prevention and Treatment Pressure ulcers arouse strong emotions
and fervent efforts at reform Prevention and management of
pressure-related wounds has improved overall in nursing homes It remains problematic in other settings,
and still in some nursing homes Topic still influenced by mythology and
misinformation
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Clinical CW: Pressure Ulcer Prevention and Treatment
CW heavily promotes nutrition to prevent and heal pressure ulcers
CW promotes the idea that pressure ulcers cause increased energy expenditure
However, evidence often does not support the CW Despite evidence, pressure ulcer care still
haunted by myths and dogma
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Clinical CW: Pressure Ulcer Prevention and Treatment Poor personal, medical, and skin care
still common in diverse settings, including hospitals
Continuing need for initiatives says much about widespread and longstanding inconsistent care
Genuine reform requires addressing basic care failures in all settings Including failure to care for all relevant
concerns and risks
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Clinical CW: The Alleged Role of Rehabilitation
Rehabilitation is a central tenet of geriatrics and long-term care
Medical stability and illness have a major impact on function Patients allegedly sent “for rehabilitation”
commonly have multiple active medical comorbidities and risk factors
Rehabilitation therapies mostly address impairments, not underlying causes
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Rehabilitation Concepts and Misconceptions
In long-term care, rehabilitation commonly equated with provision of therapy services Physical, occupational, and speech
Rehabilitation has become erroneously equated with function and functional improvement More discipline-centered than patient-
centered
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Rehabilitation Concepts and Misconceptions Inappropriate labeling of being “sent for
rehab” Excessive jurisdiction and domination of
utilization review Diversion from seeking underlying
medical causes of impaired function Knowledge about therapy modalities not
same as knowing how to identify underlying causes of impaired function
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Challenging the Conventional Wisdom
Genuine reform and improvement requires rethinking and undoing much of the conventional wisdom Many common practices in long-term
care are unfounded Many beliefs about long-term care are
incorrect or misleading Current CW often prevails because it
serves diverse agendas
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Strategy: Challenge the Conventional Wisdom
Seek and use available evidence to assess conventional wisdom Regardless of its source
Identify and contest common practices that have questionable basis Including undesirable de facto
“standards” of care, despite incompatibility with evidence
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Vigorously Subdue Political Correctness
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Vigorously Subdue Political Correctness
Politics The means by which societies try to
accommodate and reconcile diverse needs, desires, and perspectives.
Politics can be constructive or problematic
Presently, some serious imbalances
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Political Correctness “Political correctness” (PC)
Promote or expect certain beliefs, words, attitudes, or actions
Avoid, sanction, or fail to even consider others Operates at all levels
Within social institutions, facilities, organizations
Often merely a rationalization for Maintaining the status quo Gaining personal advantage
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Political Correctness
Commonly used tactic to restrict open discussion, inhibit accountability, or fail to identify and resolve problems
In nursing homes Failure to allow open discussion about
the root causes of facility care problems Failure to identify or restrict those
practicing beyond scope of their knowledge and training
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Political Correctness
Critics and reformers may get disproportionate attention and credibility Includes scapegoating to divert
attention from others’ shortcomings Political interventions, laws, and
regulations can be helpful, irrelevant, or problematic
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Genuine Reform: Subdue Political Correctness Genuine improvement and reform
require more open and balanced public dialogue about Long-term care's virtues and
weaknesses Appropriateness of proposed
“solutions” from diverse sources Alleged “expertise” Staff and practitioners who do
inappropriate and problematic things
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Strategies: Subdue “Political Correctness” Broaden dialogue about
Strengths and weaknesses of long-term care Proposals to improve and reform it
Reinforce accountability at all levels Contest incorrect and misleading advice
and instructions about care practices and performance improvement Regardless of the sources
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Strategies: Subdue “Political Correctness”
Focus on identifying and incorporating valid existing evidence into practices of all disciplines
Contest efforts to rationalize inappropriate practice and performance
Promote vital critical scrutiny of all alleged reformers and their recommendations
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Rethink the Research Agenda
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Knowledge and Its Effective Implementation
Many contributions from decades of research
Huge gap between knowledge and its effective application
Research is a means to an end Not an end in itself
An evidence basis for care does not necessarily improve that care
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Knowledge and Its Effective Implementation
Billions of dollars spent on medical research Billions of dollars pay for care that fails to
apply relevant evidence Newest or latest research is not
necessarily more valid Current geriatric and gerontologic
research is often redundant and esoteric
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Knowledge and Its Effective Implementation Many published studies comment on
need for more research May not consider how to improve
application of existing knowledge Already known how to provide, oversee,
and maintain high quality care Some highly competent nursing homes,
staff and practitioners exist It is possible to identify why some succeed
while others do not
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Respecting Precedent
Desirable improvement and reform activities respect existing knowledge Consider effectiveness of applying
existing knowledge Emphasize enduring and universal
clinical and management principles For example, problem solving and linking
causes and consequences
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Example: Medications
For example, issues related to medications have been identified for decades
Researchers keep studying the topic Conclusions not remarkably different from
the past Problem of adverse medication
consequences remains widespread Perhaps worse than ever
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Studying the Right Things Instead of continuing to study what is
overtreated and undertreated Real issue: is there optimal medication
intervention based on effective clinical problem solving and decision making?
Cannot overlook existing information that already bridges research and clinical practice
It may be time to think differently about Utility of research Effective translation of findings into practice
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Studying the Right Things Important issues concern ability to
identify and apply existing knowledge to specific circumstances For example, applying topical
knowledge to patient care More pragmatic approaches outside
of the research arena may be useful Successful implementation of these
approaches has varied
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Questions and Answers In all aspects of life, answers we get
depend on the questions we ask In research, overlooking hypotheses likely
gives results reflecting limited alternatives Could depression be overdiagnosed or
overtreated? Could issues concerning end-of-life care
relate to failed processes and practices?
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The Need for Context
Research-related interventions may be developed and tested under optimal conditions Often differ from real-world conditions Often highly standardized, intensive,
implemented by trained research staff Disease-specific guidelines must be
applied in the proper context
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The Need for Context
Too much information and advice can be confusing
Need to rethink current research approaches
Need to expand scope of issues for funding Reconsider funding endless reiteration
of the same topics and hypotheses
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Refining Research Community Rethinking
Expand research hypotheses to include meaningful but largely overlooked issues
Focus on basic challenges of implementation
Seek more basic real-world solutions Reveal predispositions and conflicts of
that taint current dialogue and inquiry
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Meaningful Research Hypotheses: Examples What is impact of proper and improper
care process and clinical problem solving and decision making on outcomes? Proper care delivery process task
performance essential to high-quality care Lapses in care delivery process-related task
performance underlie care / quality issues Failures of cause identification are major
source of avoidable negative outcomes
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Meaningful Research Hypotheses: Examples How well do nursing home staff and
practitioners apply the care delivery process? Only some of them understand and apply the
full care delivery process How much can nursing homes
compensate for knowledge and skill deficits? There are significant limits Need more individuals who already have
certain basic knowledge and skills
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Meaningful Research Hypotheses: Examples
Are certain vital issues being overlooked or downplayed? For example, medication-related issues
have major impact on function and quality of life
Is reliable current knowledge about care process being used? Nursing homes often advised incorrectly Current evidence often not applied
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Meaningful Research Questions: Examples
Do nursing homes hold staff and licensed professionals accountable for their performance and practice? Accountability is inconsistent,
leading to problematic care and outcomes
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Meaningful Research Hypotheses: Examples
Do treatment and care decisions have a valid clinical rationale? Valid rationale often missing or
incompatible with patient-specific evidence
Too much care is based on guesswork and rote interventions
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Meaningful Research Hypotheses: Examples
How do practices and care in other settings affect outcomes of patients who are sent to nursing homes? Many patients come after inadequate
or inappropriate care prior to transfer Inadequate or inappropriate previous care
has major impact on Achieving specific results Avoiding complications
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Meaningful Research Hypotheses: Examples
To what extent do organizational and operational issues impact care quality and outcomes? Facility management and care
systems profoundly influence Care delivery process Provision of appropriate, safe, and
effective care
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Strategies: Rethink the Research Agenda Shift balance towards implementing
existing knowledge Analyze failures in implementation
Recognize precedents, including existing knowledge
Consider more pragmatic approaches to influencing and improving performance
Broaden scope of research hypotheses and questions
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Strategies: Rethink the Research Agenda
Redirect funding more towards rethinking traditional approaches Reduce repetition of conventional
wisdom Reexamine conflicts of interest that
impede free inquiry and dialogue Focus much more attention on
basic care principles and processes
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Focus Attention on Basic Care Principles and Processes
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Focus Attention on Basic Care Principles and Processes
Good care results from painstaking detective work
Nursing homes need more individuals with basic generic competencies
Need a return to the roots of primary care medicine and nursing
Need faithful adherence to the care delivery process
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Strategies: Focus on Basic Care Principles and Processes Move away from prescriptions and
procedures as surrogates for real health care and real dialogue
Diagnostic inadequacies are recognized as a basic patient safety issue
Nursing homes may not need highly complex diagnostic capabilities But, they must improve on basic cause
identification
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Strategies: Focus on Basic Care Principles and Processes
Focus on Strengthening care delivery process Minimizing diagnostic fallacies and
avoid treating the chief complaint Addressing challenges to providing
safe and effective care Strengthening clinical problem solving
and decision making to help compensate for these challenges
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Strategies: Focus on Basic Care Principles and Processes
Scrutinize impact of reform and improvement initiatives on care delivery process At least, these activities must not inhibit
or contradict key principles More accountability and
consequences needed for those who give inadequate and incorrect instruction and advice
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Suppress Reductionism and Jurisdiction
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Suppress Reductionism and Jurisdiction Over Care
Time to reverse the trend to excessive reductionism and jurisdiction over aspects of long-term care
Reductionism Misconception that aggregating pieces of
care = managing the whole patient Jurisdiction
Giving various disciplines or settings rights of supremacy to diagnose and treat
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Suppress Reductionism and Jurisdiction Over Care
Every conclusion and patient intervention needs a proper context
Excessive jurisdiction Is biologically unsound Undermines proper clinical problem solving
and decision making Need proper interdisciplinary
application of care delivery process Including appropriate individual roles
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Suppress Reductionism and Jurisdiction
Capable staff and practitioners Willingly explain evidence basis for their
conclusions and decisions Take responsibility for results Can analyze and recover from unexpected
or avoidable complications Less capable individuals do not
Offer a valid basis for conclusions Accept appropriate responsibility
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Suppress Reductionism and Jurisdiction
Shortages of qualified staff and practitioners do not justify inappropriate practices with adverse consequences
“Political correctness” must not inhibit accountability for performance and practices Including setting appropriate limits on
clinical decision making prerogatives
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Strategies: Suppress Reductionism and Jurisdiction Apply evidence and manage issues in
the proper context (phronesis) Ensure that care is consistent with basic
physiological principles Inhibit claims of primary or exclusive
rights to diagnose and treat specific problems and body parts
Faithfully implement correct interdisciplinary team approach
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Reconsider Notions of Competency and Expertise
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Reconsider Notions of Competency and Expertise Nursing homes need direct care staff and
practitioners who can do basic tasks well Shortage of both direct care work force and
professionals and practitioners Could take many years to educate and train
enough additional staff and practitioners Meanwhile, much more could be done to
improve current capabilities and performance
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Critical Generic Workforce Competencies
Make, report, document observations Collect and organize information Examine evidence Provide a chronological story of events Reason inductively and deductively Formulate hypotheses Draw conclusions
Providing rationale for those conclusions
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Critical Generic Workforce Competencies
Solve problems Seek and identify causation Give detailed answers to questions Deal with multiple simultaneous
causes and consequences Follow instructions and procedures Abide by limits of personal knowledge
and skills
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Reasons For Variable Performance
Diverse reasons for desirable and inadequate performance; for example Inadequate knowledge Failure to apply knowledge Deficient clinical problem solving and
decision making skills Effective reform efforts must address
these diverse issues and root causes
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Strategies: Workforce Functions and Competencies
Rethink key strategies about what constitutes competency and “expertise” Topical knowledge is important Each topic must be applied in the proper
context Knowledge about a topic does not
guarantee expertise in clinical problem solving and patient management
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Workforce Functions and Competencies
Limited impact of knowing regulations and survey issues on teaching key care-related competencies
Vital to Clarify individual staff and practitioner
functions Emphasize competent performance of
tasks related to the care delivery process
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Workforce Functions and Competencies
Example Observers and information gatherers
should be able to do capable job regardless of the issue
Higher skill levels involve more extensive capabilities in performing more complex tasks; for example Perform a detailed physical exam Identify multiple causes of symptoms
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The Cascade of Competent Performance and Practice Collect and analyze information
in order to perform
- Accurate problem definition & cause identification
resulting in
- Effective clinical problem solving and decision making
leading to
- Evidence-based, individualized care
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Workforce Training and Preparation Emphasize training in approaches and
philosophies that geriatrics represents For example, managing syndromes, not just
symptoms and diseases Derive competencies from understanding
roles, functions, and tasks related to Care delivery process Clinical problem solving and decision making
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Workforce Training and Preparation Only so much can be done to
compensate for workforce deficits Genuine reform requires a combined
approach Need to expand teaching generic
competencies in public and health professional education; for example Organize and present complex information Make and document observations
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Workforce
Changes approaches to on-the-job education and training
Limited proven effectiveness of many current education practices For example, in-services
More case-based training and learning Including direct oversight of actual
performance on the job
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Strategies: Reconsider Notions of Competency and Expertise
Reconsider notion of expertise and criteria for determining who is an expert
Distinguish genuine clinical and management expertise
Rethink strategies and core competencies for training work force
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Strategies: Reconsider Notions of Competency and Expertise
Focus public education on improving key generic competencies
Shift health care professional education to include key concepts
Shift approaches to training and educating nursing home staff
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Change Approaches to Assessing and Improving Quality
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Change Approaches to Trying to Improve Quality
Rethink current approaches to assessing and improving quality
Some current approaches are pertinent and meaningful Others may actually impede definitive
improvement
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High Quality Care
High quality care has certain attributes Safe, effective, efficient, person-
centered, equitable, timely Attained by consistently doing the
right things in the right way This approach may be most likely to
attain desirable results
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Path to Quality Care
How Done
What Is Done
Right Way Wrong Way
Right Thing + / + + / -
Wrong Thing - / + - / -
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Quality Improvement
Quality improvement principles and practices are universal and enduring
Quality improvement activities try to influence human performance by Identifying and measuring performance Giving feedback over time
Nursing homes vary widely in adopting basic quality improvement approaches
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Trying to Improve Quality All facilities receive at least some
external data Some facilities also routinely collect and
analyze their own data Others do little of either
Genuine improvement and reform require facilities to have successful quality improvement activities With balance between internal and external
sources of data and feedback
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Limits of Measurement
Numerous efforts to improve quality by collecting and analyzing data
Not everything being measured is meaningful
Only some meaningful things are being measured
Quality measurement and quality indicators are a means to an end
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Potential Complications From Measuring Quality Harm related to diagnostic fallacies Overlooking other important issues
not covered by quality measures Overemphasis on interventions
In contrast to full care process Goal attainment at expense of
method “What” is done becomes too important
relative to “why”
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Balancing Outcome and Process Emphasis
Nursing home reform efforts driven by concern about “paper compliance”
Institute of Medicine 1986 report Recommended quality indicators based
on resident-centered measures of process AND outcome quality
Unfortunate misunderstandings about “process”
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Balancing Outcome and Process Emphasis
Care process compliance is not “paper” compliance
Effective clinical problem solving and decision making are vital for outcomes
Genuine reform requires better balance between outcomes and care processes as basis for assessing care quality
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Divide and Combine
OBRA regulations and surveyor guidance divide care by topic
Currently quality measures aggregated and reported by facility Then compare each facility to
composites
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Divide and Combine However, these approaches have limits
Human physiological processes are closely linked
Often, multiple simultaneous causes and consequences
Limited value to outcomes data without seeking Common causes of diverse clinical and
operational outcomes Diverse causes of individual outcomes
Context and links among various areas of concern are all important
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Divide and Combine Facility outcomes cannot be judged just
by comparing to other facilities Patient characteristics and other factors
often influence results Unsound practices may sometimes
produce desirable results but cause potentially avoidable complications For example, address pain but cause
anorexia, depression, or delirium
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Divide and Combine
Must aggregate diverse outcomes per patient Cannot just look at rates of unplanned
weight loss, depression, and pain as separate entities
Better balance needed between Identifying aggregate outcomes and Evaluating underlying processes and
practices in individual cases
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Taking the Measure of Measures Some pertinent care process-based
quality measures exist Must identify limitations as well as
attributes of alleged quality measures Including those based on MDS
For example, a facility's scores on diverse measures Do not necessarily correlate May fluctuate significantly over time,
despite consistent processes and practices
121
Taking the Measure of Measures Questionable clinical validity of some
quality measures Results on specific measures may vary
over time Improving on specific measure does not
necessarily improve care overall Must acknowledged limits of information
derived from fixed data sets Need broader, more balanced approach
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Efforts to Improve Performance: Examples Diverse efforts to try to improve results
by influencing performance and practice Modified OBRA survey process and related
surveyor guidance National campaign has focused on
improving performance through Quality measures Quality Improvement Organizations (QIOs) Local coalitions
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Limits of Impact of Measuring Quality
Ultimately, quality measurement can only improve performance somewhat For example, giving more statistics to an
athlete does not necessarily produce additional improvement
Also need capacity to improve and proper guidance
Addressing root causes may improve multiple performance aspects
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Root Causes Are Vital
Nursing home reform requires recognizing and addressing root causes Not just finding more things to measure For example
Identifying deficits in clinical problem solving and decision making
Identifying inadequate accountability for ineffective performance and clinical decision making
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Strategies: Change Approaches to Assessing & Improving Quality
Balance assessing outcomes and underlying processes and practices
Emphasize internal systems for identifying and addressing quality issues
Recognize limits of measurement in improving performance
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Strategies: Change Approaches to Assessing & Improving Quality
Find a balance between measuring things and improving processes and practices
Recognize limits of using aggregate outcomes to judge care quality for individuals
Recognize limits of fixed data sets as basis to evaluate quality
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Develop Biologically Sound Reimbursement
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Develop Biologically Sound Reimbursement Incentives ultimately are a major
influence on human behavior Money is a major incentive in many societies
Reimbursement must be compatible with—and not inhibit—desirable care
Physiology does not obey payment rules Payment must be biologically sound At present, it is only partially sound
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Develop Biologically Sound Reimbursement
Payment for care is often based on providers and treatments Instead of patient characteristics and
needs Evidence that combinations of patient
characteristics influence multiple outcomes Both causes and consequences are
relevant
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Develop Biologically Sound Reimbursement
Care is often reimbursed despite incompatibility with key concepts, practices, and processes
Payment sources still unduly influenced by less significant things Primary diagnoses / DRGs Facility licensure or category Treatments and services rendered
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Develop Biologically Sound Reimbursement Insurers may pay for treatment
Without adequate problem definition and cause identification in one setting
Additionally required because of earlier process failures
MDS-based Prospective Payment System (PPS) as an example
Payment must consider impact of both causes and consequences
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Root Causes of Wasteful Care
Much concern expressed about waste and inefficiency in health care
“Reform” must identify and tackle key root causes For example, failures of the care delivery
process in diverse settings Reimbursement must not distort care
approaches; for example, Labeling patients based on treatment
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Strategies: Develop Biologically Sound Reimbursement
Recognize how reimbursement influences care practices and quality
Modify reimbursement to Promote biologically sound clinical problem
solving and decision making Inhibit biologically unsound approaches
Limit expectations for pay-for-performance to help correct quality, performance, or cost issues
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Summary
Enduring improvement and reform require focus on things not commonly considered
Essential biological, medical, and philosophical principles
Consider whether reform efforts Reflect and promote desirable approaches Avoid and inhibit undesirable approaches
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Summary: General Responsibilities For Reform
Better understanding by overseers and reformers of What they are trying to oversee and
improve Their appropriate roles
Impact of social institutions and culture on identifying and solving problems
Need for improvement in every component of health care system
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Summary: Reforming the Reform Efforts
History of efforts to improve long-term care reflects American society and culture in general
Respecting essential, enduring, and universal concepts and approaches typically brings desirable results Defying them brings perilous
consequences for health and well-being
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Summary: Reforming the Reform Efforts Need much more attention to the basics
Not inadequate workaround “solutions” Need universal accountability Need to stop scapegoating nursing
homes for more universal failures Politics of scapegoating are never
constructive For example, hospitals and their
practitioners
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Summary: Applying the Lessons Lessons of efforts to reform long-term
care apply to all facets of the health care system
Reform and improvement are entirely possible Only by respecting and applying key concepts
and approaches Law of gravity is universal
Either respect it to our advantage or defy it at our own risk