It's time to fix the skilled nursing survey process

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It's time to fix the skilled nursing survey process
It's time to fix the skilled nursing survey process
While having dinner with a few of my peers one night, I suggested that the annual survey process for skilled nursing facilities be eliminated. It does nothing to assure "quality" in nursing facilities and is a profoundly flawed and disruptive effort that distracts from truly important issues ...

Although we all knew this to be true, nonetheless, they looked at me with a combination of incredulity and concern, as though I had completely lost all touch with reality. And I probably had. As someone told me not long ago, "It is hard to get regulators not to regulate." Even the National Commission For Quality Long-Term Care's recent report was largely silent on the subject of the survey process.

The Survey Process

The current process, as defined in 1987 Omnibus Budget Reconciliation Act legislation, presumably stemmed from gaps or shortcomings identified in the way services were being delivered up to that point. But the solution was misguided, equivalent to what the manufacturing industry refers to as "inspecting quality in."

Decades ago, any manufacturer interested in improving quality would put inspectors at the end of the assembly line to ensure that all finished products were free from defects prior to being delivered to the marketplace. What the world ultimately learned was that there were a great deal of defects that had gone undetected, and that no matter how much inspection was performed, the product never got any better coming off the line.

Over the last 50 years, under the philosophy of quality icon Dr. W. Edwards Deming, and others, manufacturers have come to understand that inspection is largely irrelevant. Instead, quality must be "built in," meaning that any defects would need to be avoided during the manufacturing process rather than caught at the end. I would argue that we are trying, through the survey process, to "inspect quality in" rather than "build it in."

That doesn't mean providers should be let off the hook. I believe the answer lies in defining expected outcomes and measuring performance against them. First, we must define what constitutes appropriate measures of quality in aging services across the board. The technology is there to define and measure desired outcomes and establish standards of performance. These indicators should be widely published.

Second, we must have the temerity to shut down providers who cannot or will not achieve those standards (unlike the current system where unscrupulous providers can continue substandard operations for months, even years). Finally, I propose that all of the money currently spent on the survey infrastructure should, instead, be allocated to defining and measuring standards of quality.

Nursing facility quality indicators derived from the MDS process are a good start but need to include a wider service platform than just skilled nursing, and be less focused in narrow clinical measures, encompassing more comprehensive health indicators and quality of life measures.

Innovation: The American Way

This country was founded on innovation. It is about building a better mousetrap. Driven by competition, innovation results in better products offered at lower costs. If there is a better way to do something, someone will find it.

Current funding mechanisms for aging services in this country are unsustainable. We must find better ways to deliver services, ways that significantly reduce costs. Otherwise, services will need to be severely curtailed or taxes substantially increased, or both.

So, in light of the issues discussed above, coupled with the need to dramatically reduce costs, why don't aging services providers revolutionize service delivery models by wringing inefficiencies out of the system, thereby improving overall quality? Isn't that the American way? Unfortunately, the answer is not that easy. Providers are largely proscribed from developing innovative solutions because the regulatory environment mandates much of the process and required inputs.

Again, I would argue that we should rely on outcomes rather than inputs. If all of the outcomes that are deemed important are achieved, does it really matter if you stood on your head to get there? Conversely, if you religiously adhere to all the regulations, but the end result is substandard, do you feel better that at least you followed the rules?

Can you argue that the width of the corridors, the number of feet from the nurses' station to a room, or what a call light over a door looks like, are truly relevant to providing superior results for residents?
The flaw with regulations is that good ideas have nowhere to go, rendering the field stagnant. What if we made the decision to allow the innovation that has made this country great to solve our problems in aging services--by eliminating surveys and regulations and instead setting forth performance goals and allow the best and brightest of the field find the solutions?

I realize this can never happen, but as someone used to say to me, "I know we can't do this, but if we could, how would we start?"

Jeff A. Petty is president and chief executive officer of Wesley Enhanced Living, a multi-site CCRC organization based in suburban Philadelphia.

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