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The Basis For Improving and Reforming Long-Term Care


Title (F501) 483.75(i) Medical Director Author: Steven Levenson Last modified by: Steven Levenson Created Date: 6/15/2005 2:10:34 AM Document presentation format – PowerPoint PPT presentation

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Title: The Basis For Improving and Reforming Long-Term Care

The Basis For Improving and Reforming Long-Term
  • Part 4 Identifying Meaningful Improvement
  • Steven A. Levenson MD, CMD

Objectives of This Segment
  • Previous segments have identified key conceptual
  • 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

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

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

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
  • Which approaches are likely to produce dramatic
  • Just how good are the current improvement and
    reform efforts?

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

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

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

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

Recommendations to Improve Reform Long-Term
  • 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

Recommendations to Improve Reform Long-Term
  • 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

Reconsider Current Improvement and Reform Efforts
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

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

Categories of Approaches Targeting Reform
  • Improve information systems for quality
  • Strengthen the regulatory process
  • Strengthen the care giving workforce
  • Provide consumers with more information

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

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

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

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
  • Others may exacerbate situation or just
    circumvent underlying causes

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
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
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
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

Challenge the Conventional Wisdom
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
  • Only some of it is accurate and pertinent

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

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

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

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
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
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

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

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

Political CW The Virtues of Interdisciplinary
  • 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

Interdisciplinary Team Implications and
  • 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

Team Approach Misconceptions
  • Team approach can be redundant, inefficient, or
  • If team members exceed scope of knowledge and
  • 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

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

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

Clinical CW Alleged Virtues of Antibiotics
  • Many long-term care residents/patients have
  • 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

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

Clinical CW Alleged Evils of Antipsychotic
  • 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

Clinical CW The Alleged Evils of Antipsychotic
  • 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
  • Poor outcomes
  • Unnecessary or problematic treatment

Clinical CW The Alleged Evils of Antipsychotic
  • 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

Clinical CW Pressure Ulcer Prevention and
  • 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

Clinical CW Pressure Ulcer Prevention and
  • 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

Clinical CW Pressure Ulcer Prevention and
  • 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

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

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

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

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

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

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

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,
  • Often merely a rationalization for
  • Maintaining the status quo
  • Gaining personal advantage

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

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

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

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
  • Regardless of the sources

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

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

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
  • Current geriatric and gerontologic research is
    often redundant and esoteric

Knowledge and Its Effective Implementation
  • Many published studies comment on need for more
  • 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

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

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

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

Studying the Right Things
  • Important issues concern ability to identify and
    apply existing knowledge to specific
  • 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

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?

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

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

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

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

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

Meaningful Research Hypotheses Examples
  • Are certain vital issues being overlooked or
  • 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

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

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

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

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

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

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

Focus Attention on Basic Care Principles and
Focus Attention on Basic Care Principles and
  • 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

Strategies Focus on Basic Care Principles and
  • 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

Strategies Focus on Basic Care Principles and
  • 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

Strategies Focus on Basic Care Principles and
  • 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

Suppress Reductionism and Jurisdiction
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

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

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

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

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
  • Faithfully implement correct interdisciplinary
    team approach

Reconsider Notions of Competency and Expertise
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

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

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

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

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

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
  • Emphasize competent performance of tasks related
    to the care delivery process

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

The Cascade of Competent Performance and Practice
  • Collect and analyze information
  • in order to perform
  • - Accurate problem definition cause
  • resulting in
  • - Effective clinical problem solving and
    decision making
  • leading to
  • - Evidence-based, individualized care

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

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
  • Organize and present complex information
  • Make and document observations

  • Changes approaches to on-the-job education and
  • 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

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

Strategies Reconsider Notions of Competency and
  • Focus public education on improving key generic
  • Shift health care professional education to
    include key concepts
  • Shift approaches to training and educating
    nursing home staff

Change Approaches to Assessing and Improving
Change Approaches to Trying to Improve Quality
  • Rethink current approaches to assessing and
    improving quality
  • Some current approaches are pertinent and
  • Others may actually impede definitive improvement

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

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

Trying to Improve Quality
  • All facilities receive at least some external
  • 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

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

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

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
  • Unfortunate misunderstandings about process

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

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

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

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
  • For example, address pain but cause anorexia,
    depression, or delirium

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

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
  • Do not necessarily correlate
  • May fluctuate significantly over time, despite
    consistent processes and practices

Taking the Measure of Measures
  • Questionable clinical validity of some quality
  • 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

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

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
  • Also need capacity to improve and proper guidance
  • Addressing root causes may improve multiple
    performance aspects

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

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

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

Develop Biologically Sound Reimbursement
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

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

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

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
  • MDS-based Prospective Payment System (PPS) as an
  • Payment must consider impact of both causes and

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

Strategies Develop Biologically Sound
  • 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

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

Summary General Responsibilities For Reform
  • Better understanding by overseers and reformers
  • 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

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

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

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
  • Law of gravity is universal
  • Either respect it to our advantage or defy it at
    our own risk