Quality Improvement in Nursing Homes: The Elephants in the Room

As long as there have been nursing homes (NHs), it seems, there has been controversy about the quality of care they provide. In fact, over the past 30 years, we have settled into a disturbingly familiar cycle. Some event—often a media exposé—creates a public furor, prompting a regulatory “crackdown,” to which providers respond by scurrying to correct the identified problem, after which everyone returns to business as usual until the next exposé. The focal issues have varied over the years, from physical restraints to chemical restraints to pressure ulcers to, most recently, pain management. Specific venues for debate have shifted, from the newspapers to the legislative floor to civil and criminal courts, but the basics remain much the same. From a safe and cynical distance, one might well conclude that little progress has been made in understanding how to improve quality of NH care. The article by Baier et al. in this issue demonstrates how wrong that conclusion would be.1 Their intervention to improve pain management in Rhode Island NHs is a sterling illustration of how quality improvement (QI) ought to be practiced. The issue is important and timely; inadequate assessment and treatment of pain in NHs are well documented,2-6 and pain management has become a priority for accrediting and regulatory agencies.7 Moreover, Baier et al. used state-of-the-art methods. To promote the transition from quality assurance to QI, they focused on proven QI methods and models. Recognizing the challenges of changing care processes, they assembled an assortment of strategies, including education, data analysis, and benchmarking. When they encountered skill or knowledge deficits, they provided additional training and mentoring. In short, the Rhode Island intervention is a textbook example of how to use QI principles to improve NH care. Despite some points of intractability (primarily pharmacological management), the study exemplifies what can be accomplished when an ardent and integrated effort to change clinical processes is made. It demonstrates clearly what can work. Unfortunately, as is often the case with textbook examples, this intervention simply will not work in the real world of NH care as it is currently provided. Baier et al. are to be commended for the effort they put into implementation and for openly discussing the many and varied barriers they encountered. Some of these barriers—for example, physicians' and nurses' attitudes about pain and analgesic medications—are relatively specific to pain management, but others, because they are intrinsic to the NH industry as it exists today, work to hinder QI efforts in all areas of care. These latter, systemic obstacles are by far more important, because they preclude translating what is known can work into large-scale, systemwide improvements that will work. Anyone familiar with NHs knows that they exist, yet too often, the impediments they present fail to be acknowledged. For those trying to improve quality of NH care, these factors are the proverbial elephants in the room. We know they are there, we recognize the problems they cause, but rather than taking them on directly, we simply do our best to ignore them. Three elephants are particularly strong barriers to effective QI in NHs today: staffing levels and staff skills, the role of the Minimum Data Set (MDS), and the regulatory environment. The nursing shortage has hit NHs especially hard. On any given day in the average NH, 8.5% of nursing assistant positions and as many as 15% of professional nursing slots are unfilled.8 Similarly, turnover among registered nurses and licensed practical nurses approaches 50% annually and is much higher for unlicensed personnel.7 What this means is that, on any given day, there may not be enough “hands on deck” to meet residents' most basic care needs. Given that state of affairs, is it any wonder that a director of nursing services told Baier et al. that her staff were “too busy … to worry about pain management”? No QI intervention will work unless direct-care staff and facility management understand and support it. Achieving adequate staffing levels is a crucial first step toward garnering that understanding and support—and perhaps improving overall quality of care as well,9 but simply having enough staff will not, of itself, ensure that QI efforts succeed. Baier et al. found that many NH staff lack the specific knowledge and skills needed to implement and maintain a quality-management program. Providing ongoing, hands-on assistance by a QI specialist can, as those investigators also demonstrated, help nursing staff develop the needed perspective and skills to implement effective QI projects, but is it realistic to expect that, in this day of decreasing reimbursement and competition from other long-term care options, providers will be willing or able to provide that kind of addition staff support on an ongoing basis? The answer is “No.” Thus, although multifaceted, resource-intensive interventions based in classical QI principles may produce improved quality of care, they are not feasible for large-scale use. What works in the academic laboratory cannot realistically be translated to the field. Nor does the solution lie simply in adding more staff. Yes, it is imperative to increase number and retention of direct-care staff, but it is equally imperative to design interventions that are not intrinsically prohibitively time consuming or demanding of staff who may have no formal QI training. Rather, approaches that are feasible and user-friendly in NHs as they normally function need to be developed. What is feasible? What does work? At this point, we don't know. It is clear, though, that we need to begin to dissect the full-scale QI process to identify those elements and subprocesses that are meaningful and useful to NH staff and translatable to the environments in which they currently work. This may mean settling for small, incremental improvements rather than rapid and dramatic change, but real, sustainable increments, however small, are at this point far more desirable than further demonstrations of what sweeping changes could be made—if only NHs could implement the programs that have been designed. There is no doubt that the MDS, the federally mandated assessment instrument for Medicare- and Medicaid-certified skilled nursing facilities, is here to stay. In addition to its function as an assessment and care-planning tool, the MDS now drives federal reimbursement, measurement, and public reporting of quality of care and the annual inspection and certification process. And as Baier et al.'s use of the tool for sample selection and outcome measurement illustrates, the research community, too, has embraced the MDS as an empiric tool for assessing and comparing NHs and the care the provide. Unfortunately, in doing so, a substantial literature indicating that the MDS may not be a valid or reliable instrument for any of these functions is being ignored. Data supporting its psychometric adequacy have almost universally come from studies in which NH staff received special, intensive training in its use (e.g.,10-12)—training that far exceeds the real-world norm.13 Studies conducted under more usual circumstances have generally yielded far less favorable results regarding the robustness of MDS data themselves2, 14-16 and the quality indicators based on them.17-20 Despite this evidence, researchers seem to have much more faith in the MDS than do those who actually use it in clinical context. There has been little systematic study of NH staff's views and uses of the MDS. Anecdotal evidence suggests that many regard it as a necessary evil, yet another requirement to be met. My own work in the NH industry convinced me that direct care staff do not understand computation, risk adjustment, and use of quality indicators well; the emphasis tends to be not on coherent QI process but on getting the numbers to look good any way one can. Given these considerations, the MDS as it is currently used may pose more problems than solutions for QI in NHs. Rather than blindly forging ahead with measures known to be problematic, the geriatric research community would do well to continue study of what does and does not work about the MDS and associated quality indicators. Similarly, before launching many more content-specific interventions, it would be helpful to document how NH staff currently use the MDS and associated indicators, and how we can help prepare them better to use those tools to improve quality of care. It was refreshing to see Baier et al. directly acknowledge nursing staff's preoccupation with the annual (or more frequent) state inspection and certification survey. They are not the first to discover that quality assurance—more specifically, meeting the standards of surveyors—takes precedence over QI in NHs today. One study21 has cogently summarized both problems with the existing survey-based regulatory process and reasons why it is unlikely to be replaced in the foreseeable future. Yet in its current adversarial and often punitive form, the survey process poses a tremendous barrier at attempts to translate from quality assurance to a true QI model for NH care. Change in the regulatory system will be slow at best. In the meantime, instead of competing with it for NH staff's attention, QI interventions need to be tailored specifically to coordinate with the survey process. The quotes offered by Baier et al. bolstered my conviction that NH staff do not automatically or easily make the connection between classically conducted QI and improved survey performance. It is incumbent on interveners, then, to demonstrate that connection and hence to make the QI process a more salient priority for direct-care staff. In summary, it is clear that the same factors that hinder attempts at intervention to improve quality of NH care are those that impede delivery of best practice care in the first place. The barriers to intervention that Baier et al. cited are not unique to Rhode Island or to the problem of pain management. Rather, they are hallmarks of NH care as it exists today, and they stand in the way of any systematic attempt to improve the way that that care is delivered, yet daunting as they may seem, these obstacles are not insurmountable. It behooves us, as academicians and providers, to acknowledge the elephants in the room, to make these endemic, systemwide barriers to QI a research and intervention priority. In effecting system change, efficacy must be given no more weight than effectiveness. Our first concern must be the feasibility and sustainability of interventions in the everyday contexts for which they are intended.