Adverse events and the culture of fear in long-term care
The government report on adverse events in post-acute care that was released yesterday shines a light on issues of real concern. However, as long-term care stakeholders and regulators consider the implications of the report and ways to reduce the number of adverse events, I'd suggest a companion report to be read alongside it: “Is Excessive Paperwork in Care Homes Undermining Care for Older People?”
The “Excessive Paperwork” report was released last week by the Joseph Rowntree Foundation, a British organization working toward social change. The investigators conducted research in two nursing homes in the United Kingdom, where they looked at how paperwork is prepared and interviewed a variety of stakeholders, including staff, residents and regulators.
While the report focuses on how documentation is done in British nursing homes, the issues it raises — and some of the conclusions it draws — most certainly apply to providers in the United States. Caregivers here have not been shy in protesting increasingly burdensome documentation requirements, and for good reason. For example, U.S. nurses are spending about five hours per comprehensive assessment, which is eating into the time they have to actually interact with residents, according to a recent survey.
The U.K. findings were similar. There, care home managers are spending 20% of their time on paperwork, according to the report. This not only can erode the quality of care by diverting staff energies toward paperwork, it can lead caregivers to lose their “sense of vocation,” if they feel they're being judged more on their documentation than their caregiving skills.
But the report identified another troubling aspect of long-term care paperwork: It is “fueled by fear and insecurity.” In other words, LTC professionals see documentation as a way of covering themselves from being blamed for adverse events, rather than as a useful tool to boost care quality. Documentation requirements are tied to regulations meant to ensure that residents are in good hands, but these requirements have led providers to focus more on preventing poor care than providing good care, according to the report.
Take risk assessments. The focus here is on identifying potential risks to resident safety and mitigating these risks. This sounds like a laudable goal, but it can easily lead to caregivers unreasonably saying “no” to residents. The report terms this “the path of least resistance,” because it is easier to document that a risk has been identified and a resident kept out of harm's way than to explain that a risk may exist, but the caregiver has judged that taking the risk might be in the resident's best interests. A staff member telling a resident that she couldn't make her own tea was listed as one instance in which an overly cautious caregiver limited resident autonomy. Another example was not allowing a physically unsteady resident to go into a garden:
“I think risk assessments do need to be changed by putting in something that shows it's not just about the risk if they do it but the risk to the whole person if they don't do it,” said one care home manager. “So saying someone can't go into the garden anymore because they can't stand up, what risk is there to their emotional and psychological self?”
Faced with the scrutiny of tough surveyors and the threat of litigation, providers “tend to play it safe” by avoiding even “tolerable risk,” the report concluded.
I think these findings from across the pond could helpfully inform the response here to the report from the inspector general's office. The OIG report should prompt a “national discussion on the care of frail elders and how it can be improved,” stated AMDA-Dedicated to Long-Term Care. No doubt, this discussion will include calls for providers to report even more information to watchdogs. The Office of the Inspector General's report itself recommended that CMS and partner agencies compile a list of potential events leading to resident harm, and it called for nursing homes to voluntarily report these events to patient safety organizations.
It certainly is important that adverse events are brought to light. But it seems that sending nursing homes a list of a hundred potential adverse events and moving toward a systemized reporting system for these events could compound documentation woes and exacerbate the tendency to hedge against risk rather than empower residents. I can't pretend I have a better recommendation than the inspector general. But I would point toward the British report's larger point, which is that residents and caregivers could benefit from a big shift in the oversight process. Specifically, it needs to be more observational in nature and less tied to paperwork.
“The ability to capture on paper the transactions between carers and residents that make for high-quality relational care is limited, and much more needs to be done in the inspection and judgment process to increase the weight given to observed high-quality care relationships in homes,” the Rowntree Foundation authors wrote.
The OIG report spurred one of the top voices at LeadingAge to make a similar point about the need for large-scale change. The recommendation for voluntary reporting to patient safety organizations might make sense, but the survey and certification process writ large is too punitive and is not a good vehicle for reducing adverse events, according to LeadingAge Senior Vice President for Public Policy and Advocacy Cheryl Phillips, M.D.
“We need surveys to ensure compliance with regulations,” she wrote. “We need a safety culture to transform care.”
What would be the hallmarks of this “safety culture?” There's a lot packed into that pithy phrase, but I imagine it certainly is not a culture defined by fear and insecurity. And I think the report from Britain provides some helpful ideas about moving toward this culture — one that supports courageous and confident caregiving.
Tim Mullaney is Senior Staff Writer at McKnight's. Follow him @TimMullaneyLTC.