Quality pursuit taken to a new level

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Providers join critics in coalition to show they can improve over the next two years.

Sept. 29, 2008, is going to be a very interesting day for the nursing home profession.
That might be putting it a bit too simply for some – especially providers – but whether they like it or not, the date is going to be a closely watched milepost.
It will occur exactly two years after the formal kick-off of providers' latest push into a new "quality" campaign. This quality charge has measurable goals and, not coincidentally, a two-year target.
Keeping providers' feet to the fire will be their own coalition "teammates," some of them nursing homes' harshest critics in the past.
But making new history is part of what the Advancing Excellence in America's Nursing Homes campaign is partly about. Participants hail it as a historic coalition of interested stakeholders. The goal is to use finely honed criteria to improve quality of care in nursing homes.
This campaign enters an already crowded "quality" field. It borrows goals from the federal government's Nursing Home Quality Initiative and providers' other major, voluntary quality push, the Quality First covenant.
With so many high-profile players involved, some of the deepest intrigue will be to see if providers can keep their hand firmly on the mixing spoon of the potluck gathering. One way or another, they have turned up the heat on themselves.
The Advancing Excellence campaign formally kicked off Sept. 29 in Washington. Previously, representatives of key long-term care professional, consumer and governmental groups met for more than six months to carve out goals.
They include four clinical measures and four quantifiable processes (see figure, page 28). While resident care and satisfaction get the most focus, a notable new twist also puts staff satisfaction into the limelight.
Providers must volunteer for the program. They choose at least three of the eight goals to pursue, no more than two from either the clinical or processes group.
Although it's not a government-sponsored initiative, the Centers for Medicare & Medicaid Services will help monitor progress.

Who goes there?
It's not clear which side of the "providers vs. the rest of the world" relationship might be most strongly heeding the mantra "keep your friends close and your enemies closer." But there's a strong feeling it's at play here.
"We're working our way toward a more robust set of quality measures," says John Rother, director of public policy for the gigantic consumer advocacy group AARP. "I think we're making progress, but are we where we want to be? No way."
He says he needs to let "a little more time go by" before trying to definitively answer whether the various "quality" efforts have made a significant difference. But the clock is ticking.
"I'm from Missouri, so I say, 'Show me,'" Rother says. "Obviously, if some homes are doing well with certain resources, others ought to be able to, too. I'm hoping it won't take five to 10 years to find out. I'm hoping for two. If we're going to have measures, people ought to see changes by then."
Perhaps the biggest non-governmental thorn in the nursing profession's side has been the National Citizens' Coalition for Nursing Home Reform. It also is taking part in the Advancing Excellence campaign.
Its overarching concern – staffing levels – has notably been addressed. Increasing staff retention and more consistent staff assignments are two of the eight goals in play.
But that doesn't mean the watchdogs are becoming lap dogs.
"We don't know how successful this will be," says Janet Wells, NCCNHR's director of public policy. "We're putting some faith into it."
Some faith.
"We're still concerned about the GAO and OIG reports saying enforcement still needs to be improved," Wells adds. "(And) we have mixed feelings about the quality measures and the way they've been used. We don't think all the data's accurate. But we think it's a start. For Quality First, we haven't seen any analysis of it other than some numbers of facilities participating."
She sounds more optimistic when she says there is "no question" a lot of nursing homes "are doing a better job or really good job" pursuing quality goals. Yet she's more cautious again when discussing her constituents.
"Our members have been (providers') adversaries so there's some risk for us. If they're still having bad experiences, they'll question why we're working so closely with the industry," she says. "One test is in two years: Will there be better relations between consumers and providers?"

Setting the table
Providers have wisely caught on. While they are hopeful, they also are already trying to temper expectations – and timetables.
"This is an ongoing process. It doesn't have an end goal," says Bruce Rosenthal, vice president of AAHSA Quality First. "From providers' standpoint, the benchmarks would be continuous quality improvement. You never get there."
Rosenthal's very title is evidence of the recent quality wave. Before January 2004, it didn't exist.
Under his guidance, about three-fourths of all American Association of Homes and Services for the Aging's members have undertaken at least part of the Quality First pledge. Most have fully signed on. That's a far cry from the abysmal numbers recorded a year after the initiative was introduced.
Quality First numbers at the American Health Care Association also have risen dramatically, to just over 50%, in recent years. But both organizations realize they still have a little more persuading to do.

Powerful group
Participants say one of the strengths of the new Advancing Excellence campaign is that more than 30 individuals from virtually every key interest group are taking part. The list includes medical directors, administrators, regulators, consumer watchdogs, nursing aides and others.
That means some hard looks in the mirror in the future for scrutinized nursing home operators. After all, this program aims to drive services from providers. Sometimes the benchmarks will be hard to measure, all good intentions aside.
"We're looking to shape a different paradigm for quality," says Chris Condeelis, senior director, quality and professional development for AHCA. "That's not to say the old paradigm is useless, but that paradigm, with all its resources and focus, still has not generated quality."
She sees it as a good sign that 7,000 of her 11,000 members have undertaken some sort of customer satisfaction information gathering. That number is up from nearly zero just a few years ago. However, the number of members assessing staff satisfaction is still less than 1,400, she adds with disappointment.
"A part of what this is about is ensuring providers are focusing on the things that are most important to the families and residents, and staff," she reminds, a bit subdued before turning determined again.
"This two-year campaign will do a lot for us. It will give us a chance to see what we can really accomplish when we focus our resources. For the next two years, we're going to do everything in our power to drive resources and support to these eight goals. We're pretty sure we're going to make more progress in the first four years of this than either of the other campaigns."
Rest assured, the country will be watching.

Excellent goals
Participants in the Advancing Excellence in America's Nursing Homes campaign must pick at least three of the following eight measurable goals to work on. One must be from the clinical group, a second must be from the processes group and the third can be from either group.

1. Reduce high-risk pressure ulcers
2. Reduce the use of daily physical restraints
3. Improve pain management for long-term residents
4. Improve pain management for short stay, post-acute home residents

5. Establish individual targets for improving quality
6. Assess resident and family satisfaction with care
7. Increase staff retention
8. More consistently assign staff members to the same residents

Source: www.nhqualitycampaign.org, 2006