Hawes - Texas A&M University System Health Science Center
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Assuring Nursing Home Quality: Divining Effective
Models of Regulation
Catherine Hawes, Ph.D.
School of Rural Public Health
Texas A&M University System HSC
for the AHRQ User Liaison Conference
Indianapolis, IN: May 2002
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Retirement Research Foundation
Data from a study funded by Retirement Research Foundation
Also data and advice from colleaguesZimmerman, Harrington, Edelman,
Stegemann, Phillips Conclusions my own – not necessarily
those of RRF
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The OBRA-87 Reforms
Resident focused/outcome oriented
Addressed all three elementsStandards, Inspection, Enforcement
Elevated quality of life
Established the RAIAssessment and care planningData system – for quality indicators
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Early Results
Improvements in process qualitye.g., reduced use of physical
restraints Improvements in resident
outcomes Decreased use of hospital care
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However~Continuing Concerns About Nursing Home Quality
Representative Waxman’s report on abuse
Ombudsman reports
Research studies
CMS staffing study
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Continuing Concerns About Nursing Home Quality
Recent GAO reports
Hearings by the US Senate Special Committee on Aging
Quality problems
Failures in the regulatory system
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Five Partial Explanations
1. An industry in disarray
2. Staffing issues
3. Poor support for ombudsmen
4. A flawed regulatory system Flawed survey system Weaknesses in enforcement
5. Reimbursement policy
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What Are Indicators of An “Effective” Regulatory System? Ombudsman report Provider report Effective complaint investigation
Outreach, intake, type of complaints, investigations, resolution, sanctions
For allegations of abuse and neglectFor general complaints
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Indicators of An “Effective” Regulatory System, cont.
Effective Survey SystemExamples…Qualified surveyorsLow % of NFs with no
deficienciesLow % of surveys with > 18
month interval
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State Variation on Survey
State Ombud. view
% Surveys > 18 months
% NF w/ Zero Deficiences
A thorough 0.0% 1.5%
B thorough 0.0% 7.2%
C inadequate 8.6% 4.2%
D inadequate 0.0% 27.4%
E inadequate 33.5% 41.8%
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Effectiveness Indicators, cont.
Comprehensive EnforcementHas a written guidelines for which
remedies to imposeUses a range of remediesUses sanctions for deficiencies – not
just failure to correctCites deficiencies at appropriate level
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State Variation on Enforcement - 1999
State % NF cited harm or jeopardy
Range of remedies
Impose immediately
A 59.8% > 3 Many
B 47.4% > 3 Few
C 31.3% > 3 Many
D 22.6% no No
E 29.2% > 3 No
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Additional Indicators State communicates with public
State regularly communicates with providers, ombudsmen
State has and supports meaningful quality improvement program
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State With Good System
Quarterly meeting with advocates, ombudsmen, providers, public
Outreach to publicBillboards, radio and television
public service on reporting abuseNews releases on deficienciesSome states have web page w/ QI
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Description of State, cont. Toll-free hotline, 24 hours a day Written investigative protocols for
investigating complaints Most experienced surveyors used
to investigate complaints Few complaints about physical
abuse, relative to other states
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Description of State, cont.
Surveyors have Master’s in nursing
Aggressive ~ citing all deficiencies seen
Cite at appropriate level of scope and severity
Use range of federal and state remediesImmediate imposition for deficiency
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State and Quality Improvement
QUANs ~ Masters-trained nurses for voluntary quality improvement80% of facilities participateConsultation~good clinical practiceTraining on MDS and RAPsHow to implement new practicesQuarterly to monthly visits
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Genuine Partnership Among All Stakeholders
State survey agency Providers Ombudsman and aging network
Shared commitmentSupport each otherSupport good reimbursementSupport for CNAs
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Lessons from the 1990s
Regulation can improve qualityEspecially if tied to clinical quality
Quality CoalitionAdvocates + Providers
Regulation is necessary…but not sufficientQuality improvement initiativesReimbursement policy, staffing
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