The Basis For Improving and Reforming Long-Term Care

1
The Basis For Improving and Reforming Long-Term
Care

• Part 4 Identifying Meaningful Improvement
  Approaches
• Steven A. Levenson MD, CMD

2
Objectives of This Segment

• Previous segments have identified key conceptual
  foundations
• For providing high-quality care
• For overseeing and trying to improve care quality
• This final segment
• Applies earlier discussions to assess current and
  prospective efforts to improve and reform nursing
  home care

3
Recommended Approaches

• A number of specific approaches herein
• Based on the foregoing discussions
• Correctly define the problems
• Identify their diverse causes
• Present a cohesive strategy
• Many of them differ from the conventional wisdom
• Should be taken seriously

4
Ongoing Criticism of Nursing Home Performance

• Continuing allegations
• Significant improvement still needed
• Many important issues and conditions remain
  inadequately recognized and managed or,
  conversely, overtreated
• Nursing home industry response
• In past decade, significant improvement
• Competent care despite challenges
• More sophisticated postacute care more than in
  other settings

5
What is the Truth?

• Is care as good as some claim?
• If so, why so many more reform efforts?
• If not, why would more of the same be any more
  beneficial?
• Which approaches are likely to produce dramatic
  improvements?
• Just how good are the current improvement and
  reform efforts?

6
Important Historical Context

• Important to understand history of attempts to
  reform nursing homes
• Just as patient history helps us understand his
  or her current condition
• Attempts to reform long-term care have succeeded
  to some extent

7
Important Historical Context

• Previously, much of criticism of nursing homes
  and their care has been warranted
• Challenge for nursing home staff, practitioners,
  and management to identify which of the numerous
  alleged solutions are viable and worth pursuing

8
Important Historical Context

• Some good intentions have gone astray
• Inconsistent and incomplete implementation of
  pertinent ideas
• Inaccurate and inappropriate advice
• Questionable agendas of various interest groups
• Considerable resistance or sabotage
• Abundant and problematic political opportunism

9
Foundation For Subsequent Reforms

• Further tinkering is inadequate because
• Resources are limited
• Waste is problematic
• Results count more than ever
• Important to consider reasons for success or
  failure of previous efforts

10
Recommendations to Improve Reform Long-Term
Summary

• Reconsider current improvement and reform efforts
• Challenge the conventional wisdom
• Vigorously subdue political correctness
• Rethink the research agenda
• Focus attention on basic care principles and
  processes

11
Recommendations to Improve Reform Long-Term
Summary

• Suppress reductionism and jurisdiction over care
• Reconsider notions of competency and expertise
• Change approaches to assessing and trying to
  improve quality
• Develop biologically sound reimbursement

12
Reconsider Current Improvement and Reform Efforts
13
Sources of Efforts to Improve and Reform
Long-Term Care

• Governmental
• Industry groups, associations, and coalitions
• Public and consumer initiatives
• Physician initiatives
• Insurance initiatives
• Non-industry organizations and associations

14
Types of Efforts Targeting Reform

• Laws and regulations
• Assessment tools
• Workforce initiatives
• Quality-improvement strategies
• Work groups
• Campaigns
• Consumer initiatives (e.g., culture change)

15
Categories of Approaches Targeting Reform
Examples

• Improve information systems for quality
  monitoring
• Strengthen the regulatory process
• Strengthen the care giving workforce
• Provide consumers with more information

16
Categories of Approaches Targeting Reform

• Strengthen consumer advocacy
• Increase Medicare and Medicaid reimbursement
• Develop and implement practice guidelines
• Change the culture of nursing facilities

17
Problems and Solutions

• Current reform initiatives
• A potpourri of approaches
• Still lacks a comprehensive problem statement and
  cohesive strategies
• Inadequate to just aggregate multiple solutions
  and reform agendas, e.g.
• Agenda A Idea B Campaign C Proposal
  D Notion E

18
Reform Misconceptions

• Easy to identify that something is amiss
• May not having appropriate solutions
• Analogous to care planning for a complex patient
• Consequences may have multiple causes
• Various causes may have multiple consequences

19
Reform Misconceptions

• Before trying to fix the problems
• Define issues and identify root causes
• More interventions are not necessarily better
• Some proposed approaches are pertinent and
  meaningful
• Others may exacerbate situation or just
  circumvent underlying causes

20
Reform Efforts Desirable and Problematic

Desirable Efforts Problematic Efforts
- Cohesive and compatible - Fragmented, piecemeal, uncoordinated, inconsistent, incompatible
- Arise from thoughtful discourse - Based on inadequate understanding of problems and underlying causes
- Respect precedent - Tend to reinvent the wheel
- Biologically sound - Biologically unsound
- Promote all essential elements - Overly complicated missing key elements
21
Reform Efforts Desirable and Problematic

Desirable Efforts Problematic Efforts
- Promote full care delivery process - Do not emphasize all care delivery process components
- Emphasize empirical methods for clinical problem solving - Underemphasize rational clinical problem solving
- Emphasize good outcomes - Emphasize good intentions
- Assess both results and related processes - Unbalanced emphases
- Valid approaches to identifying care quality - Inadequate approaches to identify care quality
22
Reform Efforts Desirable and Problematic

Desirable Efforts Problematic Efforts
- Focus on underlying care as well as treating specific conditions - Overemphasize treatment of specific conditions at expense of underlying concepts
- Promote balanced care and treatment in context - Promote unbalanced or superficial care
- Avoid false medical / social model dichotomies - Unbalanced emphasis on medical or social models
- Balanced approaches to regulatory compliance - Excessive preoccupation with regulatory compliance
- Promote vital management role in effective care - Downplay or overlook key management role
23
Strategies Reconsider Current Improvement
Reform Efforts

• Evaluate compatibility of various reform efforts
  with key philosophical and scientific principles
• Including evidence-based care and full care
  delivery process
• Focus more on defining issues correctly and
  identifying root causes

24
Challenge the Conventional Wisdom
25
Challenge the Conventional Wisdom

• Conventional wisdom
• A belief or set of beliefs that is widely
  accepted, especially one which may be
  questionable on close examination
• Susceptibility of reform to the conventional
  wisdom
• Only some of it is accurate and pertinent

26
Challenge the Conventional Wisdom

• CW can impede genuine improvement and reform if
  it
• Fails to identify issues correctly
• Diverts attention and resources
• Leads to inadequate or inappropriate
  interventions
• Both political and clinical CW
• Diverse sources of CW

27
Political CW

• Political CW
• Refers to platitudes about nursing homes, their
  staff, and quality of care, as well as to alleged
  solutions
• Clinical CW
• Refers to habitual and widespread approaches to
  aspects of care
• Often inconsistent with evidence or fail closer
  scrutiny
• May be so widespread that it becomes a false
  standard of care

28
Political CW Example RAI and High-Quality Care

• Resident Assessment Instrument (RAI)
• Including Minimum Data Set (MDS)
• Meant to improve on previously haphazard and
  inadequate assessment
• Can be helpful if used as originally intended
• A minimum data set with basic functional,
  behavioral, and psychosocial information

29
Conventional Wisdom The Other Side

Conventional Wisdom Unconventional Viewpoint
- Reformers are above reproach - Reformers deserve scrutiny - Reformers may be blocking legitimate solutions
- More laws and regulations are needed - Laws and regulations need a biologically sound basis
- Nursing homes need to measure performance - Measurement has limits in improving performance
- Nursing homes need minimum staffing levels - Numbers are just one part of a much bigger picture
- Stronger enforcement is needed - Accountability needs to be consistent and evidence-based
30
Conventional Wisdom The Other Side

Conventional Wisdom Unconventional Viewpoint
- More research is needed to solve these big issues - Implementation of existing knowledge is vital
- Interdisciplinary teams are essential - IDTs must function properly and know their limits
- The more care that is given, the better the quality - More care may simply be irrelevant or hazardous
- There are only a few poor performing facilities - Performance varies widely in and among facilities
- Quality measurement measures care quality - Relevance of some current quality measurement is unclear
31
CW Example RAI Misinterpretation and Misuse

• Regrettably, RAI has a life of its own
• Often serves as primary or sole informational
  basis for care
• MDS has spawned new job description (MDS
  coordinator) and many consultants
• Many efforts to validate assessments and
  conclusions that are based on it

32
RAI Use and Misuse

• RAI serves a purpose
• However, a limited guide to effective clinical
  decision making
• MDS does not consider detailed, chronological
  patient history
• RAI provides only a limited basis for more
  complex care planning

33
RAI CW Basis for Meaningful Reform

• More realistic and balanced view needed of the
  RAI and MDS
• Intended for specific purposes
• Excessive reliance on assessment instruments has
  become problematic
• Limits to how much it can improve care or give
  basis for sound reimbursement
• Responses to concerns have not necessarily been
  substantive

34
Political CW The Virtues of Interdisciplinary
Teams

• Interdisciplinary team
• Use individuals of multiple disciplines to
  provide care
• Key tenet of geriatrics and long-term care
• Also referred to as interdisciplinary care,
  interdisciplinary care teams, and
  interdisciplinary collaboration
• Approach has proven beneficial

35
Interdisciplinary Team Implications and
Limitations

• Teams are a means to an end
• Not an end in themselves
• Benefit of teams depends heavily on training,
  knowledge, qualifications, and performance of
  team members
• Improper realization of IDT team approach may
• Distort purpose
• Impede care quality improvement

36
Team Approach Misconceptions

• Team approach can be redundant, inefficient, or
  hazardous
• If team members exceed scope of knowledge and
  skills
• Having more participants does not necessarily
  improve the care
• For example, separate teams for issues such as
  weight loss, skin care, falling, and pain
• A single comprehensive collaborative review may
  be more biologically sound

37
Amount of Care as a Reflection of Quality

• More interventions do not necessarily produce
  better results
• A single intervention targeted at a root cause
  may be preferable
• For example, hypothyroidism or medication-related
  adverse consequences
• Evidence more care may result in more
  unnecessary treatment or complications
• Amount of care not a reliable measure of quality

38
Team Approach Basis For Meaningful Reform

• Need to reexamine how nursing homes actually
  implement true IDT approach
• Such scrutiny is likely to show significant
  variability and deficits
• Ineffective or inappropriate team approach can
  contribute to redundant, irrelevant, or
  problematic care

39
Clinical CW Alleged Virtues of Antibiotics

• Many long-term care residents/patients have
  infections
• Colonization is also very common
• Antibiotics are commonly prescribed for diverse
  symptoms and test results
• For several decades, concerns about use of
  antibiotics in various situations

40
Clinical CW Alleged Virtues of Antibiotics

• Specific criteria for antibiotics use exist
• Generally inadvisable to treat colonization
• Misdiagnosis and inappropriate antibiotic
  treatment are common
• Routine use of antibiotics for behavior symptoms
  is largely unwarranted

41
Clinical CW Alleged Evils of Antipsychotic
Medications

• Concerns about antipsychotic medications a major
  driving force behind nursing home reform efforts
• Concern about inappropriate use of all
  medications is warranted
• However, issues are far broader than any one
  category of medications
• Including correct assessment and management of
  behavioral and psychiatric issues

42
Clinical CW The Alleged Evils of Antipsychotic
Medications

• Nursing home staff and practitioners often bypass
  the care process
• Including meaningful details about behavior
• Frequent push for psychiatric consultations for
  changed or problematic behavior
• Inadequate search for underlying causes may lead
  to
• Poor outcomes
• Unnecessary or problematic treatment

43
Clinical CW The Alleged Evils of Antipsychotic
Medications

• Drug treatment of behavior and mood disturbances
  often based on guesswork
• New generation of medication-related issues
  compared with traditional ones
• Genuine reform requires attention to issues
  underlying medication use
• Including related clinical problem-solving and
  decision-making activities

44
Clinical CW Pressure Ulcer Prevention and
Treatment

• Pressure ulcers arouse strong emotions and
  fervent efforts at reform
• Prevention and management of pressure-related
  wounds has improved overall in nursing homes
• It remains problematic in other settings, and
  still in some nursing homes
• Topic still influenced by mythology and
  misinformation

45
Clinical CW Pressure Ulcer Prevention and
Treatment

• CW heavily promotes nutrition to prevent and heal
  pressure ulcers
• CW promotes the idea that pressure ulcers cause
  increased energy expenditure
• However, evidence often does not support the CW
• Despite evidence, pressure ulcer care still
  haunted by myths and dogma

46
Clinical CW Pressure Ulcer Prevention and
Treatment

• Poor personal, medical, and skin care still
  common in diverse settings, including hospitals
• Continuing need for initiatives says much about
  widespread and longstanding inconsistent care
• Genuine reform requires addressing basic care
  failures in all settings
• Including failure to care for all relevant
  concerns and risks

47
Clinical CW The Alleged Role of Rehabilitation

• Rehabilitation is a central tenet of geriatrics
  and long-term care
• Medical stability and illness have a major impact
  on function
• Patients allegedly sent for rehabilitation
  commonly have multiple active medical
  comorbidities and risk factors
• Rehabilitation therapies mostly address
  impairments, not underlying causes

48
Rehabilitation Concepts and Misconceptions

• In long-term care, rehabilitation commonly
  equated with provision of therapy services
• Physical, occupational, and speech
• Rehabilitation has become erroneously equated
  with function and functional improvement
• More discipline-centered than patient-centered

49
Rehabilitation Concepts and Misconceptions

• Inappropriate labeling of being sent for rehab
• Excessive jurisdiction and domination of
  utilization review
• Diversion from seeking underlying medical causes
  of impaired function
• Knowledge about therapy modalities not same as
  knowing how to identify underlying causes of
  impaired function

50
Challenging the Conventional Wisdom

• Genuine reform and improvement requires
  rethinking and undoing much of the conventional
  wisdom
• Many common practices in long-term care are
  unfounded
• Many beliefs about long-term care are incorrect
  or misleading
• Current CW often prevails because it serves
  diverse agendas

51
Strategy Challenge the Conventional Wisdom

• Seek and use available evidence to assess
  conventional wisdom
• Regardless of its source
• Identify and contest common practices that have
  questionable basis
• Including undesirable de facto standards of
  care, despite incompatibility with evidence

52
Vigorously Subdue Political Correctness
53
Vigorously Subdue Political Correctness

• Politics
• The means by which societies try to accommodate
  and reconcile diverse needs, desires, and
  perspectives.
• Politics can be constructive or problematic
• Presently, some serious imbalances

54
Political Correctness

• Political correctness (PC)
• Promote or expect certain beliefs, words,
  attitudes, or actions
• Avoid, sanction, or fail to even consider others
• Operates at all levels
• Within social institutions, facilities,
  organizations
• Often merely a rationalization for
• Maintaining the status quo
• Gaining personal advantage

55
Political Correctness

• Commonly used tactic to restrict open discussion,
  inhibit accountability, or fail to identify and
  resolve problems
• In nursing homes
• Failure to allow open discussion about the root
  causes of facility care problems
• Failure to identify or restrict those practicing
  beyond scope of their knowledge and training

56
Political Correctness

• Critics and reformers may get disproportionate
  attention and credibility
• Includes scapegoating to divert attention from
  others shortcomings
• Political interventions, laws, and regulations
  can be helpful, irrelevant, or problematic

57
Genuine Reform Subdue Political Correctness

• Genuine improvement and reform require more open
  and balanced public dialogue about
• Long-term care's virtues and weaknesses
• Appropriateness of proposed solutions from
  diverse sources
• Alleged expertise
• Staff and practitioners who do inappropriate and
  problematic things

58
Strategies Subdue Political Correctness

• Broaden dialogue about
• Strengths and weaknesses of long-term care
• Proposals to improve and reform it
• Reinforce accountability at all levels
• Contest incorrect and misleading advice and
  instructions about care practices and performance
  improvement
• Regardless of the sources

59
Strategies Subdue Political Correctness

• Focus on identifying and incorporating valid
  existing evidence into practices of all
  disciplines
• Contest efforts to rationalize inappropriate
  practice and performance
• Promote vital critical scrutiny of all alleged
  reformers and their recommendations

60
Rethink the Research Agenda
61
Knowledge and Its Effective Implementation

• Many contributions from decades of research
• Huge gap between knowledge and its effective
  application
• Research is a means to an end
• Not an end in itself
• An evidence basis for care does not necessarily
  improve that care

62
Knowledge and Its Effective Implementation

• Billions of dollars spent on medical research
• Billions of dollars pay for care that fails to
  apply relevant evidence
• Newest or latest research is not necessarily more
  valid
• Current geriatric and gerontologic research is
  often redundant and esoteric

63
Knowledge and Its Effective Implementation

• Many published studies comment on need for more
  research
• May not consider how to improve application of
  existing knowledge
• Already known how to provide, oversee, and
  maintain high quality care
• Some highly competent nursing homes, staff and
  practitioners exist
• It is possible to identify why some succeed while
  others do not

64
Respecting Precedent

• Desirable improvement and reform activities
  respect existing knowledge
• Consider effectiveness of applying existing
  knowledge
• Emphasize enduring and universal clinical and
  management principles
• For example, problem solving and linking causes
  and consequences

65
Example Medications

• For example, issues related to medications have
  been identified for decades
• Researchers keep studying the topic
• Conclusions not remarkably different from the
  past
• Problem of adverse medication consequences
  remains widespread
• Perhaps worse than ever

66
Studying the Right Things

• Instead of continuing to study what is
  overtreated and undertreated
• Real issue is there optimal medication
  intervention based on effective clinical problem
  solving and decision making?
• Cannot overlook existing information that already
  bridges research and clinical practice
• It may be time to think differently about
• Utility of research
• Effective translation of findings into practice

67
Studying the Right Things

• Important issues concern ability to identify and
  apply existing knowledge to specific
  circumstances
• For example, applying topical knowledge to
  patient care
• More pragmatic approaches outside of the research
  arena may be useful
• Successful implementation of these approaches has
  varied

68
Questions and Answers

• In all aspects of life, answers we get depend on
  the questions we ask
• In research, overlooking hypotheses likely gives
  results reflecting limited alternatives
• Could depression be overdiagnosed or overtreated?
• Could issues concerning end-of-life care relate
  to failed processes and practices?

69
The Need for Context

• Research-related interventions may be developed
  and tested under optimal conditions
• Often differ from real-world conditions
• Often highly standardized, intensive, implemented
  by trained research staff
• Disease-specific guidelines must be applied in
  the proper context

70
The Need for Context

• Too much information and advice can be confusing
• Need to rethink current research approaches
• Need to expand scope of issues for funding
• Reconsider funding endless reiteration of the
  same topics and hypotheses

71
Refining Research Community Rethinking

• Expand research hypotheses to include meaningful
  but largely overlooked issues
• Focus on basic challenges of implementation
• Seek more basic real-world solutions
• Reveal predispositions and conflicts of that
  taint current dialogue and inquiry

72
Meaningful Research Hypotheses Examples

• What is impact of proper and improper care
  process and clinical problem solving and decision
  making on outcomes?
• Proper care delivery process task performance
  essential to high-quality care
• Lapses in care delivery process-related task
  performance underlie care / quality issues
• Failures of cause identification are major source
  of avoidable negative outcomes

73
Meaningful Research Hypotheses Examples

• How well do nursing home staff and practitioners
  apply the care delivery process?
• Only some of them understand and apply the full
  care delivery process
• How much can nursing homes compensate for
  knowledge and skill deficits?
• There are significant limits
• Need more individuals who already have certain
  basic knowledge and skills

74
Meaningful Research Hypotheses Examples

• Are certain vital issues being overlooked or
  downplayed?
• For example, medication-related issues have major
  impact on function and quality of life
• Is reliable current knowledge about care process
  being used?
• Nursing homes often advised incorrectly
• Current evidence often not applied

75
Meaningful Research Questions Examples

• Do nursing homes hold staff and licensed
  professionals accountable for their performance
  and practice?
• Accountability is inconsistent, leading to
  problematic care and outcomes

76
Meaningful Research Hypotheses Examples

• Do treatment and care decisions have a valid
  clinical rationale?
• Valid rationale often missing or incompatible
  with patient-specific evidence
• Too much care is based on guesswork and rote
  interventions

77
Meaningful Research Hypotheses Examples

• How do practices and care in other settings
  affect outcomes of patients who are sent to
  nursing homes?
• Many patients come after inadequate or
  inappropriate care prior to transfer
• Inadequate or inappropriate previous care has
  major impact on
• Achieving specific results
• Avoiding complications

78
Meaningful Research Hypotheses Examples

• To what extent do organizational and operational
  issues impact care quality and outcomes?
• Facility management and care systems profoundly
  influence
• Care delivery process
• Provision of appropriate, safe, and effective care

79
Strategies Rethink the Research Agenda

• Shift balance towards implementing existing
  knowledge
• Analyze failures in implementation
• Recognize precedents, including existing
  knowledge
• Consider more pragmatic approaches to influencing
  and improving performance
• Broaden scope of research hypotheses and
  questions

80
Strategies Rethink the Research Agenda

• Redirect funding more towards rethinking
  traditional approaches
• Reduce repetition of conventional wisdom
• Reexamine conflicts of interest that impede free
  inquiry and dialogue
• Focus much more attention on basic care
  principles and processes

81
Focus Attention on Basic Care Principles and
Processes
82
Focus Attention on Basic Care Principles and
Processes

• Good care results from painstaking detective work
• Nursing homes need more individuals with basic
  generic competencies
• Need a return to the roots of primary care
  medicine and nursing
• Need faithful adherence to the care delivery
  process

83
Strategies Focus on Basic Care Principles and
Processes

• Move away from prescriptions and procedures as
  surrogates for real health care and real dialogue
• Diagnostic inadequacies are recognized as a basic
  patient safety issue
• Nursing homes may not need highly complex
  diagnostic capabilities
• But, they must improve on basic cause
  identification

84
Strategies Focus on Basic Care Principles and
Processes

• Focus on
• Strengthening care delivery process
• Minimizing diagnostic fallacies and avoid
  treating the chief complaint
• Addressing challenges to providing safe and
  effective care
• Strengthening clinical problem solving and
  decision making to help compensate for these
  challenges

85
Strategies Focus on Basic Care Principles and
Processes

• Scrutinize impact of reform and improvement
  initiatives on care delivery process
• At least, these activities must not inhibit or
  contradict key principles
• More accountability and consequences needed for
  those who give inadequate and incorrect
  instruction and advice

86
Suppress Reductionism and Jurisdiction
87
Suppress Reductionism and Jurisdiction Over Care

• Time to reverse the trend to excessive
  reductionism and jurisdiction over aspects of
  long-term care
• Reductionism
• Misconception that aggregating pieces of care
  managing the whole patient
• Jurisdiction
• Giving various disciplines or settings rights of
  supremacy to diagnose and treat

88
Suppress Reductionism and Jurisdiction Over Care

• Every conclusion and patient intervention needs a
  proper context
• Excessive jurisdiction
• Is biologically unsound
• Undermines proper clinical problem solving and
  decision making
• Need proper interdisciplinary application of care
  delivery process
• Including appropriate individual roles

89
Suppress Reductionism and Jurisdiction

• Capable staff and practitioners
• Willingly explain evidence basis for their
  conclusions and decisions
• Take responsibility for results
• Can analyze and recover from unexpected or
  avoidable complications
• Less capable individuals do not
• Offer a valid basis for conclusions
• Accept appropriate responsibility

90
Suppress Reductionism and Jurisdiction

• Shortages of qualified staff and practitioners do
  not justify inappropriate practices with adverse
  consequences
• Political correctness must not inhibit
  accountability for performance and practices
• Including setting appropriate limits on clinical
  decision making prerogatives

91
Strategies Suppress Reductionism and Jurisdiction

• Apply evidence and manage issues in the proper
  context (phronesis)
• Ensure that care is consistent with basic
  physiological principles
• Inhibit claims of primary or exclusive rights to
  diagnose and treat specific problems and body
  parts
• Faithfully implement correct interdisciplinary
  team approach

92
Reconsider Notions of Competency and Expertise
93
Reconsider Notions of Competency and Expertise

• Nursing homes need direct care staff and
  practitioners who can do basic tasks well
• Shortage of both direct care work force and
  professionals and practitioners
• Could take many years to educate and train enough
  additional staff and practitioners
• Meanwhile, much more could be done to improve
  current capabilities and performance

94
Critical Generic Workforce Competencies

• Make, report, document observations
• Collect and organize information
• Examine evidence
• Provide a chronological story of events
• Reason inductively and deductively
• Formulate hypotheses
• Draw conclusions
• Providing rationale for those conclusions

95
Critical Generic Workforce Competencies

• Solve problems
• Seek and identify causation
• Give detailed answers to questions
• Deal with multiple simultaneous causes and
  consequences
• Follow instructions and procedures
• Abide by limits of personal knowledge and skills

96
Reasons For Variable Performance

• Diverse reasons for desirable and inadequate
  performance for example
• Inadequate knowledge
• Failure to apply knowledge
• Deficient clinical problem solving and decision
  making skills
• Effective reform efforts must address these
  diverse issues and root causes

97
Strategies Workforce Functions and Competencies

• Rethink key strategies about what constitutes
  competency and expertise
• Topical knowledge is important
• Each topic must be applied in the proper context
• Knowledge about a topic does not guarantee
  expertise in clinical problem solving and patient
  management

98
Workforce Functions and Competencies

• Limited impact of knowing regulations and survey
  issues on teaching key care-related competencies
• Vital to
• Clarify individual staff and practitioner
  functions
• Emphasize competent performance of tasks related
  to the care delivery process

99
Workforce Functions and Competencies

• Example
• Observers and information gatherers should be
  able to do capable job regardless of the issue
• Higher skill levels involve more extensive
  capabilities in performing more complex tasks
  for example
• Perform a detailed physical exam
• Identify multiple causes of symptoms

100
The Cascade of Competent Performance and Practice

• Collect and analyze information
• in order to perform
• - Accurate problem definition cause
  identification
• resulting in
• - Effective clinical problem solving and
  decision making
• leading to
• - Evidence-based, individualized care

101
Workforce Training and Preparation

• Emphasize training in approaches and philosophies
  that geriatrics represents
• For example, managing syndromes, not just
  symptoms and diseases
• Derive competencies from understanding roles,
  functions, and tasks related to
• Care delivery process
• Clinical problem solving and decision making

102
Workforce Training and Preparation

• Only so much can be done to compensate for
  workforce deficits
• Genuine reform requires a combined approach
• Need to expand teaching generic competencies in
  public and health professional education for
  example
• Organize and present complex information
• Make and document observations

103
Workforce

• Changes approaches to on-the-job education and
  training
• Limited proven effectiveness of many current
  education practices
• For example, in-services
• More case-based training and learning
• Including direct oversight of actual performance
  on the job

104
Strategies Reconsider Notions of Competency and
Expertise

• Reconsider notion of expertise and criteria for
  determining who is an expert
• Distinguish genuine clinical and management
  expertise
• Rethink strategies and core competencies for
  training work force

105
Strategies Reconsider Notions of Competency and
Expertise

• Focus public education on improving key generic
  competencies
• Shift health care professional education to
  include key concepts
• Shift approaches to training and educating
  nursing home staff

106
Change Approaches to Assessing and Improving
Quality
107
Change Approaches to Trying to Improve Quality

• Rethink current approaches to assessing and
  improving quality
• Some current approaches are pertinent and
  meaningful
• Others may actually impede definitive improvement

108
High Quality Care

• High quality care has certain attributes
• Safe, effective, efficient, person-centered,
  equitable, timely
• Attained by consistently doing the right things
  in the right way
• This approach may be most likely to attain
  desirable results

109
Path to Quality Care
How Done ? What Is Done Right Way Wrong Way
Right Thing / / -
Wrong Thing - / - / -
110
Quality Improvement

• Quality improvement principles and practices are
  universal and enduring
• Quality improvement activities try to influence
  human performance by
• Identifying and measuring performance
• Giving feedback over time
• Nursing homes vary widely in adopting basic
  quality improvement approaches

111
Trying to Improve Quality

• All facilities receive at least some external
  data
• Some facilities also routinely collect and
  analyze their own data
• Others do little of either
• Genuine improvement and reform require facilities
  to have successful quality improvement activities
  
• With balance between internal and external
  sources of data and feedback

112
Limits of Measurement

• Numerous efforts to improve quality by collecting
  and analyzing data
• Not everything being measured is meaningful
• Only some meaningful things are being measured
• Quality measurement and quality indicators are a
  means to an end

113
Potential Complications From Measuring Quality

• Harm related to diagnostic fallacies
• Overlooking other important issues not covered by
  quality measures
• Overemphasis on interventions
• In contrast to full care process
• Goal attainment at expense of method
• What is done becomes too important relative to
  why

114
Balancing Outcome and Process Emphasis

• Nursing home reform efforts driven by concern
  about paper compliance
• Institute of Medicine 1986 report
• Recommended quality indicators based on
  resident-centered measures of process AND outcome
  quality
• Unfortunate misunderstandings about process

115
Balancing Outcome and Process Emphasis

• Care process compliance is not paper compliance
• Effective clinical problem solving and decision
  making are vital for outcomes
• Genuine reform requires better balance between
  outcomes and care processes as basis for
  assessing care quality

116
Divide and Combine

• OBRA regulations and surveyor guidance divide
  care by topic
• Currently quality measures aggregated and
  reported by facility
• Then compare each facility to composites

117
Divide and Combine

• However, these approaches have limits
• Human physiological processes are closely linked
• Often, multiple simultaneous causes and
  consequences
• Limited value to outcomes data without seeking
• Common causes of diverse clinical and operational
  outcomes
• Diverse causes of individual outcomes
• Context and links among various areas of concern
  are all important

118
Divide and Combine

• Facility outcomes cannot be judged just by
  comparing to other facilities
• Patient characteristics and other factors often
  influence results
• Unsound practices may sometimes produce desirable
  results but cause potentially avoidable
  complications
• For example, address pain but cause anorexia,
  depression, or delirium

119
Divide and Combine

• Must aggregate diverse outcomes per patient
• Cannot just look at rates of unplanned weight
  loss, depression, and pain as separate entities
• Better balance needed between
• Identifying aggregate outcomes and
• Evaluating underlying processes and practices in
  individual cases

120
Taking the Measure of Measures

• Some pertinent care process-based quality
  measures exist
• Must identify limitations as well as attributes
  of alleged quality measures
• Including those based on MDS
• For example, a facility's scores on diverse
  measures
• Do not necessarily correlate
• May fluctuate significantly over time, despite
  consistent processes and practices

121
Taking the Measure of Measures

• Questionable clinical validity of some quality
  measures
• Results on specific measures may vary over time
• Improving on specific measure does not
  necessarily improve care overall
• Must acknowledged limits of information derived
  from fixed data sets
• Need broader, more balanced approach

122
Efforts to Improve Performance Examples

• Diverse efforts to try to improve results by
  influencing performance and practice
• Modified OBRA survey process and related surveyor
  guidance
• National campaign has focused on improving
  performance through
• Quality measures
• Quality Improvement Organizations (QIOs)
• Local coalitions

123
Limits of Impact of Measuring Quality

• Ultimately, quality measurement can only improve
  performance somewhat
• For example, giving more statistics to an athlete
  does not necessarily produce additional
  improvement
• Also need capacity to improve and proper guidance
• Addressing root causes may improve multiple
  performance aspects

124
Root Causes Are Vital

• Nursing home reform requires recognizing and
  addressing root causes
• Not just finding more things to measure
• For example
• Identifying deficits in clinical problem solving
  and decision making
• Identifying inadequate accountability for
  ineffective performance and clinical decision
  making

125
Strategies Change Approaches to Assessing
Improving Quality

• Balance assessing outcomes and underlying
  processes and practices
• Emphasize internal systems for identifying and
  addressing quality issues
• Recognize limits of measurement in improving
  performance

126
Strategies Change Approaches to Assessing
Improving Quality

• Find a balance between measuring things and
  improving processes and practices
• Recognize limits of using aggregate outcomes to
  judge care quality for individuals
• Recognize limits of fixed data sets as basis to
  evaluate quality

127
Develop Biologically Sound Reimbursement
128
Develop Biologically Sound Reimbursement

• Incentives ultimately are a major influence on
  human behavior
• Money is a major incentive in many societies
• Reimbursement must be compatible withand not
  inhibitdesirable care
• Physiology does not obey payment rules
• Payment must be biologically sound
• At present, it is only partially sound

129
Develop Biologically Sound Reimbursement

• Payment for care is often based on providers and
  treatments
• Instead of patient characteristics and needs
• Evidence that combinations of patient
  characteristics influence multiple outcomes
• Both causes and consequences are relevant

130
Develop Biologically Sound Reimbursement

• Care is often reimbursed despite incompatibility
  with key concepts, practices, and processes
• Payment sources still unduly influenced by less
  significant things
• Primary diagnoses / DRGs
• Facility licensure or category
• Treatments and services rendered

131
Develop Biologically Sound Reimbursement

• Insurers may pay for treatment
• Without adequate problem definition and cause
  identification in one setting
• Additionally required because of earlier process
  failures
• MDS-based Prospective Payment System (PPS) as an
  example
• Payment must consider impact of both causes and
  consequences

132
Root Causes of Wasteful Care

• Much concern expressed about waste and
  inefficiency in health care
• Reform must identify and tackle key root causes
  
• For example, failures of the care delivery
  process in diverse settings
• Reimbursement must not distort care approaches
  for example,
• Labeling patients based on treatment

133
Strategies Develop Biologically Sound
Reimbursement

• Recognize how reimbursement influences care
  practices and quality
• Modify reimbursement to
• Promote biologically sound clinical problem
  solving and decision making
• Inhibit biologically unsound approaches
• Limit expectations for pay-for-performance to
  help correct quality, performance, or cost issues

134
Summary

• Enduring improvement and reform require focus on
  things not commonly considered
• Essential biological, medical, and philosophical
  principles
• Consider whether reform efforts
• Reflect and promote desirable approaches
• Avoid and inhibit undesirable approaches

135
Summary General Responsibilities For Reform

• Better understanding by overseers and reformers
  of
• What they are trying to oversee and improve
• Their appropriate roles
• Impact of social institutions and culture on
  identifying and solving problems
• Need for improvement in every component of health
  care system

136
Summary Reforming the Reform Efforts

• History of efforts to improve long-term care
  reflects American society and culture in general
• Respecting essential, enduring, and universal
  concepts and approaches typically brings
  desirable results
• Defying them brings perilous consequences for
  health and well-being

137
Summary Reforming the Reform Efforts

• Need much more attention to the basics
• Not inadequate workaround solutions
• Need universal accountability
• Need to stop scapegoating nursing homes for more
  universal failures
• Politics of scapegoating are never constructive
• For example, hospitals and their practitioners

138
Summary Applying the Lessons

• Lessons of efforts to reform long-term care apply
  to all facets of the health care system
• Reform and improvement are entirely possible
• Only by respecting and applying key concepts and
  approaches
• Law of gravity is universal
• Either respect it to our advantage or defy it at
  our own risk