Hi rags500-ga,
Anyone who has been in a situation with responsibility for regulatory
compliance, but no control over the departments that feed into the
audit findings can appreciate your frustration.
Each department focuses on their primary concern. Often, too often,
compliance with lots of paperwork and confusing regulations, is not
high on anyone's list -- except for the administrator who must face
reviews by external agencies.
The common goal is to provide quality care for the patient, but that
is often lost in the paperwork. Getting cooperation is difficult at
best. With "report cards" being made available to the public based
solely on these findings, the reputation of the intitution and the
staff is dependent on the paperwork getting done. Quality care does
not exist unless it can be documented. Government and insurance
reimbursements depend on these reports. Liability is going to be an
issue in any legal proceedings if your facility is consistently not
meeting regulatory standards. It may seem like silly p[aperwork, but
it means the continued existence of the place where you work. You know
that.
The reality is that it may be more difficult than you realize for the
staff to meet these standards. The government regulations do not take
into account the lack of training, the lack of staff and the lack of
time that make taking care of patients needs a marathon. Meeting
report deadlines just may not seem relevant to the staff member who is
trying to make sure that all of the population is receiving quality
care.
"Improving the Quality Of Long Term Care" (available online) puts it
into these words...
"Given the number of residents who need to have MDS and RAP
assessments completed, it is surprising that there is no information
about what staff time, supervisory oversight, or training mechanisms
are necessary to collect these data accurately. Apparently, nursing
homes are assumed to have both the tangible resources and the
technical expertise necessary for accurate MDS and RAP assessments.
The assumption of "adequate resources" seems particularly tenuous when
the additional resource requirements of assessing resident or family
perceptions of quality are considered. The latter measures are not
covered in the MDS and involve significant technical challenges and
resources that are different from those involved in completing the
MDS, and assessment is only the first step in improving quality and
not even the most labor-intensive step."
http://books.nap.edu/html/improving_long_term/ch7.html
The staff barely has time to provide care - adding reams of paperwork
is just increasing their burden. Getting everyone to feelthat they are
a part of the quality asuurance team is the best way to improve state
inspections. To do that you need to educate them to the reality of
what not meeting standards - on paper - means in the industry today.
No matter how fine the care is, if it's not properly documented it
looks bad.
The Centers for Medicare & Medicaid Services, Nursing Home Quality
Initiative,
http://cms.hhs.gov/providers/nursinghomes/nhi/ has a good overview of
the regulations. The Frequently Asked Questions section may help you
to get others to understand why you are asking for some of the reports
and procedures.
http://www.medqic.org/nursinghomes/measures/index.shtml is another
very good resource for putting the quality measures into terms that
everyone can see as beneficial to both the patient and the
institution.
The American Nurses Association has a very nice continuing ed module
that focuses on the nurses responsibilty under PPS which may also be
helpful in helping staff to understand why the compiance issues are
important to them and the patients - as well as you.
http://www.nursingworld.org/mods/mod90/ltcabs.htm
But even in the event that you do manage to communicate the necessity
for compliance, the staff is overburdened with activities relating to
patient care and forms that need to be completed with specific
information can be left undone or completed improperly.
That brings us to your request for a change in the organizational
structure to allow you to have some formal authority to bring your
facility up to standard before reviewers are knocking on the door.
The answer for many long term care facilities has been to institute a
compliance program with an institutional compliance officer. The
compliance officer normally reports directly to the CEO. The arguments
for doing this before you are compelled to are well stated in
"Introduction to Compliance Programs"
http://www.ppsv.com/issues/intro.htm.
http://www.wsha.org/GoverningBoardManual/qualitymanagement.html is
written for a hospital setting, but the implications of the legal
liability of the Board of Directors for lapses in quality management
apply to your situation as well. This may be your strongest argument
in getting support to strengthen your authority.
Monitoring the Quality of Hospital Care produced by the Center for
Human Services provides a guideline for implementing a successful
quality assurance program.
The model they use is to have the quality assurance administrator
rectuit a team from the relevant departments. The team becomes
responsible for gathering the data and reporting on implementation
issues. The concept is to spread ownership of the monitoring process
to all of the areas involved.
That way, you are not a fussy administrator making unreasonable
demands, you are the team leader who sends your motivated team into
their departments and the quality assurance demands come from internal
sources. As the team leader you would need to have authority to insist
on compliance, but if the team works well, the need to use the
authority should not arise.
"Finding ways to inform and involve staff is also key to success,
since monitoring quality is not the work of a single individual. The
output of quality monitoring may prove useless if staff do not “buy
into” the need for quality measurement. The need to keep all
stakeholders informed cannot be over-emphasized (see the section
'Developing and Implementing a Communication Plan')."
http://www.qaproject.org/PDF/hspcarebook501.pdf
Another approach is described in OASIS and Outcome-Based Quality
Improvement in Home Health Care: Research and Demonstration Findings,
Policy Implications, and Considerations for Future Change for the
three interrelated studies:
The National Medicare Quality Assurance and Improvement Demonstration
The New York State Outcome-Based Quality Improvement Demonstration
A Project to Assist Home Care Providers to Effectively Use Patient
Outcomes
(February 2002):
"...agencies were encouraged to establish two teams: one to select the
target outcomes (possibly titled the Target Outcome Selection Team)
and another to conduct the other activities (possibly titled the Care
Process Action Team). The Target Outcome Selection Team analyzed the
outcome report and selected the specific outcomes to be investigated.
This team usually included agency administrative and quality
improvement staff. The Care Process Action Team conducted the
investigation and planned implementation activities (with leadership
often provided by a member of the Target Outcome Selection Team).
Agencies were advised to have some staff common to both teams to
ensure continuity of process.
In general, it is desirable for the Care Process Action Team to
include staff directly involved in providing care related to the
target outcome. In small agencies, the Target Outcome Selection Team
and Care Process Action Team may include primarily the same
individuals. In large agencies, there may be one Target Outcome
Selection Team, a Care Process Action Team for the first target
outcome, and another Care Process Action Team for a second target
outcome."
http://cms.hhs.gov/providers/hha/Volume3-SuppDoc7thru9-Feb2002.pdf
Using this double team concept worked well in the demonstration
facilities during the study.
There are plenty of other studies, reports and books on this topic.
You are not alone in the struggle to implement quality management
procedures with an overworked and trimmed down staff who just don't
get why they need to add this to their list of things to do. It's a
tough job, and you do need the support of top management to succeed.
Just don't forget that you also need the support of the staff or it
will just be more frustration for you.
search terms used:
1.nursing home quality control officer
2.problems with compliance quality control issues nursing homes
3.PPS compliance assistance
4.Director of Quality Management nursing home organizational structure
sample diagram
5.Nursing Home Quality Initiative
6.State Surveys to evaluate SNF performance
If you need additional resources, plese post a clarification and I
will respond.
Enjoy your holiday and good luck with compliance. Just hope that the
New Year doesn't bring new regs to add to the paperwork!
bcguide-ga |
