Measuring Quality in Nursing Homes

David J. Farrell, MSW, LNHADirector of Organizational DevelopmentSnF Management

Omnibus Budget Reconciliation Act (OBRA)

1987 – OBRAStandardize regulationsStep-up enforcementIntended to improve the Quality of Life

“Provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.”

OBRA Twenty Years Later

Good news:Physical restraint use declinedPsychotropic medications declined RN hours, total staffing hours increasedCertification of nursing assistantsDecline in immediate jeopardy and actual harm

Wiener, J. et al. 2007

OBRA Twenty Years Later“…improvements appear to have reached a

plateau.”93% of all facilities receive deficiencies20% are cited for actual harm or immediate jeopardy230,000 complaints to Ombudsman in 2005

Significant increase in complaints about staffingMany facilities are chronically understaffed

Wiener, J. et al. 2007

Measurement Components

Structural measures – the capacity to provide quality careProcess measures – performance necessary to achieve quality of careOutcome measures – the result

Institute of MedicineQuality of care depends on the performance of the workforceStaffing levels are necessary Other key factors:

EducationSupervisionJob satisfactionTurnoverLeadershipOrganizational culture

Wunderlich G. S., “Improving the Quality of Long Term Care,” IOM, 2000

Structural Measure of Quality

Staffing levelTotal nursing hours per patient day (PPD)RN hours PPD

Evidence-basedAvailability – OSCAR database, cost reportsRecommendation – quarterly updates

Staffing Measures

Staff turnoverCollected annually by OSHPDTotal departures/average number of staff

Staff retentionStaff with one year of service/avg. number of staff

Evidence-basedAvailability – OSHPD, cost reports

High Turnover = Low Quality

Physical restraintsCatheter useContracturesPressure ulcersPsychoactive drug useQuality-of-Care deficiencies

Castle et al., 2005Castle, 2007

Structural Measure of Quality

Staff SatisfactionOverall satisfactionRecommendation to others

Evidence-basedAvailability – limitedRecommendation – quarterly updates

Power of Staff Satisfaction

InfluencesStaff turnoverQuality of life

Relationships - co-workers, residents, familiesQuality of careRegulatory compliance

Castle et al., 2007

Higher Employee Satisfaction

Fewer resident fallsFewer pressure ulcersFewer cathetersLess nurse turnover and absenteeismLess CNA absenteeismHigher occupancy rates

MyInnerView, Inc. 2005

Staff Satisfaction = Family SatisfactionSatisfied employees report:

Better supervisionBetter trainingBetter work environments

Satisfied families report:Quality of lifeQuality of careQuality of service

Grant, L., “Organizational Predictors of Family Satisfaction in Nursing Homes.” Seniors Housing & Care Journal. 2004.

Drivers of Workforce Satisfaction

Management cares about employeesManagement listens to employeesHelp with job stressFair evaluationsStaff respect for residentsWorkplace is safeSupervisor cares about you as a person

MyInnerView, Inc. 2008

Process Measure of Quality

Consistent AssignmentEvidence-basedAvailability – noneRecommendation – quarterly updates

Staffing Models

Consistent Assignment = Consistently assigning the same caregivers to the same nursing home residents every day

Rotating Assignment = Rotating caregivers from one group of residents to the next after a period of time

Support for Consistent AssignmentResults from 13 research studies:

Improve teamworkEnhance relationshipsImprove attendanceImprove staff, resident, family satisfactionLower turnoverImprove screening and assessmentsImprove clinical outcomesImprove quality of life

Facilitates person-centered care

Outcome Measures of QualityMeasures –

State survey complianceClinical outcomes of careQuality of life - resident and family satisfaction scores

Evidence-basedAvailability – all but satisfaction scoresRecommendation – quarterly updates

State Survey ResultsMeasure –

Escalating weighted scale based on F-tags and scope and severity for each deficiency cited provides a performance scoreCurrently utilized by CMS

Represent the minimum federal standardsAnnual inspectionsSnap shot of quality at the time of survey

Availability - OSCAR database

Quality MeasuresMeasures -19 clinical outcome measures

Posted by CMS NH Compare14 long-stay measures, 5 short-stay

Driven from MDS assessments of residentsSome measure change, most measure prevalenceMDS data is readily available

Restraints QMNUMERATOR

Residents who were physically restrained daily on the target assessment

Used on a daily basis in last 7 daysP4c = Trunk restraintP4d = Limb restraint P4e = Chair prevents rising

DENOMINATOR All residents with a valid target assessment

Exclusions - the target assessment is an admission assessment

Quality of Life Measures

Family member and resident satisfaction Overall satisfactionRecommendation to others

Meaningful information for consumersCritical component of quality is quality of life

Availability - limitedNot a widespread practice in CA

Drivers of Consumer SatisfactionCompetency of staffCare (concern) of staffNursing careRespectfulness of staffNursing assistant careSafety of facilityMeeting choices/preferences

MyInnerView, Inc. 2008

Limitations of Satisfaction Surveys

All providers need to use one toolMy InnerView being used by 7,000 in U.S.

250 providers in CA

Integrity of dataAdministrationResponse rates

High Performing Nursing HomesThree Common Elements -

Culture – person-directed careWorkforce commitment

Clinical systemsEquipment

Leadership practices

All three are interdependentGrant, L. 2008

Results are InterrelatedImplement principles of culture change

Enhanced leadership practicesEmployee SatisfactionWorkforce performance

Low turnover, high retention, low absenteeismConsumer satisfactionClinical outcomesRegulatory compliance

Grant, L. 2008

Better Policy/Better PerformanceTying payment to workforce measures and family and residents satisfaction could be profoundFoster sustained change and continuous improvement

Drive evidenced-based practices that enhance quality of care and quality of life

Validate superior performance

Contact Information

David Farrell, MSW, NHADirector of Organizational DevelopmentSnF Management(510) 725-7409

Summary

Element and SourceStaffing level (OSCAR and cost rep[orts)Staff turnover (OSHPD and cost reports)Staff satisfaction (limited availability) Consistent assignment (not available)State Survey results (OSCAR)

ChangeQuarterly update

Quarterly update

Select uniform tool; quarterly updateDevelop method; quarterly update

Summary

Element and SourceClinical Outcomes (Minimum Data Set)Quality of life – patient and family satisfaction

Changes?

MDS 3.0?