Q&A with Richard Lee: Quality based on what works

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Pennsylvania initiated a first-of-a-kind program to gauge nursing home quality practices in the state, and the results were striking. Outcomes in pain management, depression management, and activities of daily living in eating and drinking all showed significant improvement over the test period. Now, the nearly cost-free project is expanding to include other areas and more participants.

Lee oversees Pennsylvania's Nursing Care Facilities Best practices project, which predates the federal national quality initiative.

Q The Pennsylvania Nursing Care Facilities Best Practices Project is called "ground-breaking" and the first-of-a-kind. How so?

A Most Quality Improvement programs do not effectively measure the healthcare outcomes of residents. This project surveyed the most serious quality problems in Pennsylvania nursing facilities and based upon analysis of the results, developed sound "best practices" protocols targeted to overcome these problems.
This project not only looks at patient outcome differences between facilities, but longitudinal patient outcomes. Also, we designed a program that uses the existing Federal Minimum Data Set (MDS) reporting, which does not cost the facility additional funds to operate.
Most important, the outcomes of the project are scientifically validated and therefore we have assurance that other nursing homes that implement the protocols will achieve similar positive improvements in resident quality of care.

Q In your opinion, what have been the key findings from the first phase of the study so far?

A For all three protocols (pain, depression and ADL), we found that there were substantial improvements over non-protocol control facilities. Use of the activities of daily living protocol in test facilities slowed the rate of ADL decline 4 times more than the usual care provided by control facilities.
Use of the pain protocol in test facilities resulted in a 26% improvement in pain quality rates and decrease of inappropriate behaviors compared to an 8% decline in control facilities. For depression, use of the depression protocol in test facilities resulted in a 22% improvement in depression quality indicator rates on average, compared to a 15% decline in control facilities.

Q What was the biggest surprise about the process and/or findings?

A  The most surprising element was the determination that there was interdependence between the three protocols. As ADL capacity improved, residents became less depressed. As pain was reduced, ADL capacity was improved.
This is intuitive looking back, but it was not apparent in the early stages. To further explore this relationship, we have added several multiple protocol sites to Phase II of the project.

Q How do you quantify results for something like this? What methodology was used?

A First, we identified nursing facilities that were good solid performers in terms of their current quality indicators. These facilities were neither successful in every aspect of patient care, nor did they have any continuing problems. After we identified the eligible facilities, we asked them to volunteer and participate in the project.
We then matched the facilities that volunteered by type of facility along several demographic characteristics: size, ownership (county, profit and non-profit) and geographic location. Next, we randomly picked the test facilities and matched them with control facilities. And then we used standard MDS quality indicator data, provisional Centers for Medicare & Medicaid Services quality indicators that are risk adjusted and Minimum Data Sets data from appropriate time periods in measuring outcomes.

Q To get changes in outcomes, certain quality activities or strategies were undertaken. How was this done, and what were some of the specific actions for the three areas of focus?

A For ADLs, we focused on one area, eating or dressing, and compared what the resident does to what he or she is capable of doing. Then, by using methodical care planning and evaluation, the nursing home staff worked with the residents to assist them in performing to the best of their abilities.
Managing pain and depression included in-depth assessments paired with complementary therapies, such as aroma and pet therapies and pharmaceuticals as appropriate. Both involved consistent management of resident care plans on all shifts,