7

Building Organizational Capacity

In the past decade, much time, money, and effort has been spent on improving care in nursing homes, with less than adequate results. Measurement tools, quality standards, and external oversight mechanisms all are important for providing quality care, but they do not ensure a capacity to use the measures correctly, implement the standards effectively, or respond to oversight as intended.

This chapter discusses the organizational capacity of a provider to manage information and personnel, the technology and resources needed to translate knowledge into improved long-term care, and the management needed for meeting policy makers' demands for accountability. Specifically, it discusses the needed technology and resources that are generally not present in long-term care settings, ways to improve organizational capacity, and the effectiveness of the guidelines and quality management initiatives in long-term care. Although this chapter focuses mostly on nursing homes, many of the issues discussed are applicable directly or with some adaptation to those providing services in other long-term care settings, such as residential care facilities and home health care.

RECENT INITIATIVES TO IMPROVE CAREGIVING CAPACITY IN LONG-TERM CARE

A number of initiatives have been put in place in recent years to facilitate the ability of nursing homes to produce better outcomes for people using long-term care. These initiatives include the following:



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Improving the Quality of Long-Term Care 7 Building Organizational Capacity In the past decade, much time, money, and effort has been spent on improving care in nursing homes, with less than adequate results. Measurement tools, quality standards, and external oversight mechanisms all are important for providing quality care, but they do not ensure a capacity to use the measures correctly, implement the standards effectively, or respond to oversight as intended. This chapter discusses the organizational capacity of a provider to manage information and personnel, the technology and resources needed to translate knowledge into improved long-term care, and the management needed for meeting policy makers' demands for accountability. Specifically, it discusses the needed technology and resources that are generally not present in long-term care settings, ways to improve organizational capacity, and the effectiveness of the guidelines and quality management initiatives in long-term care. Although this chapter focuses mostly on nursing homes, many of the issues discussed are applicable directly or with some adaptation to those providing services in other long-term care settings, such as residential care facilities and home health care. RECENT INITIATIVES TO IMPROVE CAREGIVING CAPACITY IN LONG-TERM CARE A number of initiatives have been put in place in recent years to facilitate the ability of nursing homes to produce better outcomes for people using long-term care. These initiatives include the following:

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Improving the Quality of Long-Term Care Omnibus Budget Reconciliation Act of 1987 (OBRA 87) Regulations. Regulatory standards articulated in OBRA 87 have provided nursing homes with a specific definition of quality (e.g., considering quality of life as well as quality of care). One effect was to focus nursing homes on their residents and on achievable quality. Minimum Data Set (MDS). Standardized clinical information systems have been developed in the form of the MDS. This data set is designed to help nursing homes organize their clinical activities to meet regulatory expectations for quality of care. Practice Guidelines. Evidence-based practice guidelines, which provide the best scientific advice available on how to treat common health problems, have been developed for some long-term care settings and common geriatric conditions (e.g., incontinence, behavioral agitation, depression, and pain). These guidelines bridge the gap between the clinical research literature and the providers, often in algorithms or steps to guide assessment and treatment and thus lead to better outcomes. Quality Improvement Systems. Some nursing homes have embraced improvement philosophies and methods that have primarily been successful in settings outside of health care. These quality improvement systems focus on consumer perspectives and preferences, organize staff efforts and care processes, and guide management activities. Taken together, these four initiatives logically begin with policies to define goals for better nursing home care and they help providers meet these goals. The logic of this approach tempts a generalization to other long-term care settings. However, there is no strong evidence that these approaches have solved major quality problems in nursing home care. FROM RULES, DATA, AND GUIDELINES TO EFFECTIVE PRACTICE A review of the research literature and testimony presented to the committee generated insufficient evidence to conclude that the four initiatives to improve nursing home care have improved quality to the levels expected. Previous chapters have addressed issues related to OBRA 87 and MDS initiatives. This chapter focuses on the evidence about the effectiveness of practice guidelines, initiatives in quality management systems in long-term care, and the limitations of organizational capacity to translate knowledge into improved care. Practice guidelines were developed with the hope that they would improve health outcomes and, often more importantly, contain costs (see, e.g., PPRC, 1988, 1989; IOM, 1990, 1992). They try to make user-friendly

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Improving the Quality of Long-Term Care synthesis of evidence available to providers who are unable to evaluate broad scientific and clinical literature. Over time, despite charges about “cookbook medicine” and controversy over government-sponsored guidelines, the practice guidelines fulfill a need. Accordingly, health care organizations are using careful evidence-based processes to develop guidelines. In the long-term care area, both the American Medical Directors Association and the American Geriatrics Society support practice guidelines (AMDA, 1996; AGS, 1997, 1998). Unfortunately, studies of acute and primary care report limited implementation of guidelines, although they have also begun to identify barriers to their use and propose ways of overcoming them (see, e.g., Chassin, 1993; James, 1993; Pestornik et al., 1996; Davis and Taylor-Vaisey, 1997; Cameron and Naylor, 1999; Guyatt et al., 1999; Katz, 1999). Although long-term care is less studied than acute care, guidelines appear neither routinely nor effectively implemented by nursing home providers, nor widely known by direct care nursing home staff. QUALITY MANAGEMENT SYSTEMS Many nursing homes report that they have made significant investments and progress in the quality improvement area. However, like practice guidelines, it is difficult to demonstrate objectively that quality management systems have significantly improved nursing home care. Even though originally developed for the industrial sector, they are being increasingly adopted by health care organizations (Berwick, 1989; Laffel and Blumenthal, 1989; IOM, 1990; Blumenthal and Kilo, 1998; Shortell et al., 1998). Quality management principles include the following: a focus on consumer needs and consumers' perceptions of how well their needs are met; an understanding that a system is composed of processes, all of which must work together to meet consumers' needs; a management responsible for process design and quality management; a focus on those processes needed to meet consumers' needs; a focus primarily on how the processes work, not on individual performance; a data-driven quality management system that is based on objective measurements, not on guesses, intuition, or anecdotes; quality management measures of consumers' values and perceptions, consumers' health and well-being, and resource use and costs, as they actually occur, not as they are intended to occur; and measures to identify improvement opportunities, set priorities, reduce

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Improving the Quality of Long-Term Care variation in processes (including errors) and outcomes (including adverse events) such as improved health and resource efficiency. Two major nursing home provider organizations—the American Health Care Association and the American Association for Homes and Services for the Aging—and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) support the quality management systems approach. However, there are only anecdotal reports by nursing home providers that quality improvement systems have been implemented or that implementation has resulted in improved outcomes. Moreover, this anecdotal evidence is contradicted by two studies that used controlled designs to evaluate the effectiveness of continuous quality improvement interventions (McKenna et al., 1998; Schnelle et al., 1998). The Ohio pressure ulcer project reported no improvement in pressure ulcers (McKenna et al., 1998). The incontinence study (Schnelle et al., 1998) showed improved outcomes, but only while incontinence care was provided or monitored by research staff. The researchers concluded that although practice guidelines could be implemented to improve outcomes, such improved outcomes did not in themselves provide sufficient incentive for nursing homes to maintain the program without the external monitoring and consultation provided by research staff. Limited trained staff time and organizational capacity are a barrier to improved performance in nursing homes. The improvement principles mentioned above are demanding to implement, even in organizations that are relatively rich in resources and expertise, which most long-term care organizations are not. Most applications and most research on quality management have focused on hospitals. A recent review of the literature by Shortell and colleagues (1998) revealed some evidence of improved outcomes and reduced costs in clinical care from quality improvement techniques. It did not find evidence of organization-wide improvements in clinical performance. Another recent review suggested that in studied hospitals, the techniques had little impact on organizational culture (Gerowitz, 1998). ORGANIZATIONAL CAPACITY TO TRANSLATE KNOWLEDGE INTO PRACTICE Defining expectations for quality care and extending the knowledge base needed to meet these expectations will lead to improvement only if nursing homes have the capacity to translate this knowledge into practice. Unfortunately, a large gap exists between current knowledge and the industry's capacity to implement that knowledge. The missing compo-

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Improving the Quality of Long-Term Care nents are the number and competence of staff and the amount and type of needed resources. OBRA 87 regulations, practice guidelines, and quality management systems fail to emphasize these critical capacity issues, perhaps because the technical expertise of long-term care providers and the necessary tangible resources are assumed. Practice guidelines, for example, provide specific recommendations about how to treat nursing home residents based on the best knowledge available in the clinical research literature. None of the guidelines, however, include a description either of the personnel necessary to implement recommended treatment steps or of the implementation costs (Schnelle et al., 1998). Moreover, because implementation issues are not a major focus of controlled clinical trials, they also are not a major focus of the practice guidelines. Schnelle and colleagues (1998) recommended that guidelines should be evaluated to show how they apply to long-term care settings. The lack of emphasis on such basic implementation barriers as staffing adequacy and cost is common in efforts to improve long-term care. Long-term care providers have deemphasized the importance of organizational capacity by failing to document systematically the costs or problems associated with delivering care consistent with OBRA 87 or other regulations. Instead, these providers suggest that existing resources are adequate not only to provide care consistent with regulations, but also to implement sophisticated improvement programs—all this without a significant increase in the direct care nursing home work force since OBRA 87 was enacted. Furthermore, most nursing homes, even highly motivated ones, lack the technical expertise and tangible resource capacity necessary to translate OBRA 87 regulations, practice guidelines, and quality improvement systems into practice. The rest of this chapter discusses two broad issues relevant to improving quality of care: (1) collecting and analyzing information and (2) translating this information into care processes that address quality problems. Collecting and Analyzing Information Regulations, data, guidelines, and quality improvement initiatives identified above all include information collection requirements. As Johnson and Kramer (1998) point out, improving quality requires identifying problems accurately. But an information system to measure the broad array of problems experienced by nursing home residents is difficult to design and even more difficult to implement. Nursing home residents suffer from multiple clinical and functional disabilities as well as quality-of-life problems. Unfortunately, nursing homes have little experience using informa-

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Improving the Quality of Long-Term Care tion either to evaluate the quality of care or to manage staff activities; they traditionally have not employed floor supervisors with training or expertise in information management. Even today, computers typically are not found at nurses' stations or otherwise accessible to direct care staff. Some of the issues relevant to collecting the clinical information involved in the MDS and information on quality of life or satisfaction through resident or family interviews are discussed in Chapter 4. One of the primary barriers to accurate data collection in nursing homes is the absence of standardized clinical or life quality assessment protocols. Without standardized protocols nursing homes cannot plan or budget accurate quality assessments. The MDS is generated from the perception of a nursing home workforce that is largely paraprofessional, temporary, and in need of more professional supervision. Such staff is not competent to provide the precise ratings in multiple areas of the MDS. Furthermore, accurately completing the annual or quarterly MDS reports is only part of the challenge. There are 18 resident assessment protocols (RAPs), which are triggered by problems noted in the MDS items. For example, a series of additional assessments are recommended for residents rated on the MDS as showing low oral food intake. Two separate studies reported that over 60 percent of nursing home residents would be triggered for these follow-up assessments (Pokrywka et al., 1997; Simmons and Reuben, 2000). 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. Translating Information into Practice Assuming that accurate information can be collected, the result is not quality improvement unless it is translated into practice. Two major aspects of translating clinical or quality-of-life information into practice require organizing information to identify quality problems; and implementing, managing, and evaluating care processes to resolve quality problems. Automated information-processing technologies help providers use

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Improving the Quality of Long-Term Care MDS information to evaluate outcomes. The barriers to using this information to improve care are due primarily to obsolete information technologies and the ability of staff to interpret the information. Mechanisms exist to organize MDS information either at the resident or at the aggregated level (e.g., facility or region). The resident assessment protocol (RAP) is a brief version of a practice guideline that makes recommendations about further assessment and treatment after a problem or potential problem has been identified (e.g., How do you assess and treat a resident whom you suspect is dehydrated?). This triggering system can be managed manually or with specially designed software. This triggering software may automatically generate care plans that are not appropriately individualized, This problem suggests that nursing home staff will need education in how to use information-processing technologies (Harrington et al., 1996). Recently, software has been designed that aggregates MDS data into risk-adjusted quality indicators (e.g., number of residents with pressure ulcers who have high or low risk factors for that condition) (Zimmerman et al., 1995). The primary purpose of this is to identify facilities with unusual quality indicator scores. Quality indicators are now also incorporated in the survey process. Presumably, state survey staff can target problem facilities and motivate nursing homes that score poorly to correct problems. Whether this approach will achieve its purposes is unclear because it is based on the following three untested assumptions: survey staff will know which processes to assess in nursing homes that have scored poorly on quality indicators; nursing homes that score poorly do, in fact, implement different care processes than nursing homes that score well; and significant and stable variation in the quality indicator performance scores will allow identification of both “good” and “bad” nursing homes. One study reported that stable differences between nursing homes in Massachusetts were not evident on nine different indicators monitored over a three-year period (Porell et al., 1998). The authors concluded that it might not be possible to identify “good” nursing homes using clinical quality indicator data. Other studies have concluded that indicators are stable over a short time (Karon et al., 1999). Clearly, further research is needed on all three assumptions. As mentioned, quality indicator software produces summary scores which do not provide caregivers with the specific information necessary to influence the care of an individual resident, even though it might allow nursing homes to identify groups of residents with a common problem and monitor their progress over a

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Improving the Quality of Long-Term Care period of time. Effective clinical practice requires constant adjustments in the resident's treatment. With this in mind, and because the health of nursing home residents can generally be expected to decline, a technology is needed to track the expected rate of decline for both individuals and for groups of residents in the same risk-adjusted categories (Kane et al., 1998b). Lack of such automated information organization systems is a resource barrier to organizing MDS information for better care and regulation. Labor resources are less of a barrier to data organization than they are to accurate data collection. However, the time and intellectual resources required to prepare primary MDS data collection forms for computer entry are significant. In summary, better automated information systems to organize MDS data are essential to improve care in nursing homes. IDENTIFYING EFFECTIVE INTERVENTIONS The initiatives for improving care processes and outcomes include recommendations for assessment and treatment. Although the costs of implementing the assessment recommendations are unknown, they are likely to exceed nursing home resources. If the resources needed to implement treatments are factored in, nursing home resources are likely to be overwhelmed. As was discussed earlier in this chapter, practice guidelines and RAPs are two initiatives designed to help nursing home staff identify processes that will improve outcomes. Two contradictory criticisms have been made about these initiatives. First, guidelines are too “prescriptive” and the nursing home work force (presumably mostly nurse assistants) should be able to design their own interventions to improve quality. This position puts significant pressure on an overworked, underpaid, and unstable paraprofessional work force. It also contradicts the basic assumption underlying practice guidelines that even highly paid professionals need advice and assistance. In fact, most guideline recommendations are intended to influence physician practice. Furthermore, as one reads the guidelines or RAPs with an eye toward implementing them, the argument that they are overly prescriptive loses force. Indeed, the second criticism is that these initiatives lack sufficient specificity for providers who are not expert in any one particular content area (e.g., depression) and who are consumed with the simple demands of daily care (Schnelle et al., 1998). Clearly no guidelines have been tested under realistic field conditions for the purpose of answering the following questions: Can the guideline recommendations be implemented by staff who are not specifically trained in the guideline content area?

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Improving the Quality of Long-Term Care How time-consuming is it to implement the guidelines? What skills are needed to do so? How do these time and skill requirements match those typically available in nursing homes? What are the effects of implementing the guidelines? A great deal of clinical expertise, creativity, and time is needed to fully implement the assessment and treatment recommendations contained in the 12 practice guidelines available pertaining to nursing home residents and the 18 RAPs. At present, there is little reason to believe that nursing home staff will have either the technical expertise or reimbursed time necessary to implement even the assessment recommendations in the RAPs and practice guidelines. At the same time, many low-tech, common sense interventions can improve nursing home quality outcomes. For example, multiple controlled clinical trials have demonstrated that urinary incontinence in most nursing home residents can be improved with simple toileting assistance programs (Creason et al., 1989; Schnelle, 1990; Colling et al., 1992; Hu et al., 1995). Although simple, these interventions are often more time-consuming to implement than the usual care processes conducted in nursing homes. Also, the labor costs associated with implementing care processes may be even more than those associated with conducting assessments. The above discussion shows that practice guidelines and RAPs rarely have been developed with an eye towards getting providers to understand what personnel would most appropriately implement them and what are the costs associated with them. CARE PROCESS IMPLEMENTATION AND IMPROVEMENT Simple (i.e., not technically complicated) interventions can improve nursing home resident outcomes, but it is doubtful that there is enough staff to implement these simple but time-intensive interventions. Furthermore, improvement management models designed to facilitate the implementation of validated care processes require a significant expenditure of time for measurement and analysis. These expenses increase the total cost of implementing the processes. The care patterns of nursing home staff have been described in observational studies by multiple research teams starting with the classic study by Baltes and her colleagues in 1983. This study documented that caregivers were more likely to reinforce resident behaviors characterized as dependent as opposed to independent (e.g., providing excessive physical assistance with movement instead of reinforcing residents for independent efforts to move). Not much has changed in 20 years. More recent

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Improving the Quality of Long-Term Care observational studies in the areas of incontinence, mobility and exercise, dressing, and nutrition show that caregivers still tend to provide care that is time-efficient but is inconsistent with maintaining residents' highest level of functioning. For example, nursing aides (NAs) prefer to change wet residents because this takes significantly less time than toileting, even though toileting promotes continence (Schnelle et al., 1988a). Nursing assistants employ time-efficient care practices that incidentally reinforce dependence and functional decline. Their workloads are inconsistent with the labor-intensive care processes to promote independence. However, no study has yet documented how many residents a nurse assistant can effectively care for, suggesting a large gap in this area. Multiple studies indicate that staffing in nursing homes is inadequate to provide care that meets consumer expectations or is consistent with maximizing residents' independence. For example, families and residents interviewed in three different projects consistently identified staffing as their primary problem with nursing home care (VA, 1994; Gustafson and Gustafson, 1996; Norton et al., 1996). Inadequate staffing also was repeatedly identified as a problem in testimony both before this committee and before the Senate committee that commissioned the General Accounting Office to report on nursing home care (U.S. Special Committee on Aging, 1998, 1999). In addition, nursing aides themselves have reported in three separate studies that they have insufficient time to implement toileting programs or interventions designed to improve food intake among residents, and to individualize care (Kayser-Jones and Schell, 1997; Lekan-Rutledge et al., 1998; Walker et al., 1999). Finally, observational studies contrast the actual time spent providing usual care to the increased time required to implement care processes that promote better outcomes. Controlled intervention studies by different research teams show that incontinence can be improved within one to three days using a toileting assistance program (Creason et al., 1989; Schnelle, 1990; Colling et al., 1992; Hu et al., 1995); but perhaps because of the increased staff time costs involved with a continence program, nursing home staff did not maintain improved continence by consistently providing the requested toileting assistance in even the most responsive residents after research staff left the facility (Schnelle et al., 1990; Schnelle et al., 1993, 1995b). Similarly, other studies of ambulatory residents with high risk of functional decline show that mobility declines with inactivity, use of restraints, and fear of falling (Schnelle, 1992a; Schnelle et al., 1995b; MacRae et al., 1996). These residents need guidance and physical assistance with walking, which requires time- and attention-consuming care. An integrated protocol, called Functional Incidental Training (FIT) combines continence care with ambulation exercise. FIT implemented every two hours, four times a day for eight weeks, significantly increases walking endurance,

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Improving the Quality of Long-Term Care physical activity levels and standing ability (Schnelle et al., 1995b), while contributing to continence training. Time cost analysis shows that staff time and cost differentials are high, but there is no apparent way to reduce the time needed to implement the intervention protocols (Schnelle et al., 1995a). Supervised exercise is necessary to prevent mobility declines and physically dependent residents need labor-intensive toileting assistance to be continent. Also, the frequency of walking assistance and incontinence care in these studies are consistent with resident and family preferences for such assistance (Schnelle et al., 1988a, 1995b; Simmons and Schnelle, 1999). As in continence and mobility, the activity of daily living of dressing can be improved with slower, but greater resident involvement. Excessive assistance in dressing saves staff time but produces dependence (Beck et al., 1997; Rogers et al., 1999). However, the time needed to promote independent dressing exceeds the time that staff usually devote to assistance with dressing. One dressing intervention study reported that nursing staff failed to maintain residents' independence levels once research staff stopped implementing the prompting protocol (Beck et al., 1997). Similarly, nutrition may be enhanced with labor intensive prompting strategies. Nursing home staff do not spend sufficient time assisting residents at risk for under-nourishment (Backstrom et al., 1987; Kayser-Jones et al., 1997; Steele et al., 1997). In addition, staff often either provide excessive physical assistance with feeding or pressure residents to eat quickly, apparently because of work-related time pressures (Kayser-Jones et al., 1997). Even residents who are physically capable of feeding themselves are at-risk for under-nutrition if they are regarded as “slow eaters” by nursing home staff. Two sudies reported that increased staff attention may be effective with nutrition (Lange-Alberts and Shott, 1994; Van Ort and Phillips, 1995) and an expert consensus group has reported that a staffing level of two to three residents per one aide is needed at mealtimes (Harrington et al., 2000c); the usual ratios are 10 to 1 or higher. In summary, the various intervention studies reviewed here pertaining to four different domains—continence training, mobility, dressing, and nutrition—have reported consistent results. They provide strong evidence that simple interventions that use prompting and graduated physical assistance will produce better outcomes in nursing home residents. The interventions produce comparatively better results during the research period, in part because usual care processes are done too infrequently to promote better outcomes, or provide excessive physical assistance, which undermines the resident's ability to perform independently. Unfortunately, usual care practices are less time-consuming and less costly than promoting strategies that lead to more independence and better outcomes. The available time-based estimates of the staffing needed to implement

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Improving the Quality of Long-Term Care better care processes indicate that nursing homes are inadequately staffed to provide care that maximizes residents' independence and, by implication, their quality of life. These labor resource barriers become more daunting when requirements of improvement management models are added. Such improvement management models involve their own intellectual and labor resource costs, which go beyond those just discussed. MEASUREMENT ISSUES The core components of an improvement management model, described earlier in this chapter, have been embraced by both nursing home providers and others in the health care industry in part because the model is intuitively appealing and has worked well in other settings, primarily industrial settings. However, the model may be more difficult to replicate successfully in health care settings due in part to measurement costs and related issues, although there is some evidence that continuous improvement models have been implemented successfully in acute care settings (Berwick and Bisognano, 1998).1 An improvement model focuses on work processes that are both under the control of providers and causally related to outcomes. The strategy is to frequently monitor these processes so as to identify and control the factors that interfere with their successful implementation. This should lead to continuous process improvements and thus, to improved outcomes. With this strategy, it would be inefficient to wait until outcomes are reported to conclude that care is either good or bad. In most cases, care processes have to be conducted poorly for extended periods to produce bad outcomes. Instead, the improvement model continuously analyzes work processes to prevent bad outcomes from ever occurring. Implementing an improvement model successfully entails adding further to the already high measurement burden incurred by nursing homes. In industrial and service settings, where the improvement management model is most successful, very frequent and even continuous records of work processes are available. For example, continuous measures of assembly-line work processes are generated with computerized measurement technologies. In most health care settings there are few, if any, process-monitoring technologies analogous to those in industrial settings. In nursing homes, nursing staff record some data relevant to processes on work flow-sheets (e.g., reposition every two hours, ambulate one time). However, these 1   A more complete discussion of the barriers to implementing improvement models in nursing homes (e.g., unstable staff) has been published (Schnelle et al., 1993).

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Improving the Quality of Long-Term Care self-reported data are of suspect accuracy and in some cases are too non-descriptive (e.g., change wet residents as needed) to be useful for improvement management purposes. Cost-efficient methods for measuring work processes in health care settings are largely unavailable at this time, and considerable creativity is needed to develop such methods. Recent research, for example, shows that approximately 48 percent of nursing home residents can accurately describe the care they receive (Simmons et al., 1997). Thus, it is possible that accurate reporters could be targeted and systematically interviewed as a means of determining whether care processes are being implemented (e.g., “Were you given walking assistance today?”). This system could work, but whether it is affordable and whether nursing home residents will cooperate is unknown. Other innovative monitoring systems have used hand-held computers to facilitate frequent records of care activities and microchips to continuously record resident movements, wetness levels, and staff contact with residents (Holmes, 1996). The microchip technology potentially permits continuous monitoring, similar to the continuous process data collection that occurs in industrial improvement models. These high-tech solutions to process-monitoring have been criticized by some as dehumanizing care. At the same time, a counter-argument has been made that these methods provide the missing information needed to effectively manage consumer-centered care, and that nursing aides need the feedback provided by such information to sustain high motivation for their job. Clearly, more research is needed in this area, including studies that assess resident, family, and staff perceptions of these new technologies. Given the potential of automated process-monitoring systems to resolve both accuracy problems that have been reported with nursing home data recording systems and given their obvious usefulness for improvement management purposes, these research programs should receive a high priority. Nonetheless, long-term care is years away from having a cost-effective process and information monitoring technology that is acceptable to all stakeholders and is as useful as the systems used in industrial settings. In the absence of such a technology, it is not surprising that nursing homes and other healthcare settings have experienced difficulty in implementing successful improvement models. Research is needed to test feasibility and cost effectiveness of implementing clinical practice guidelines and proven care interventions in long-term care settings. As stated earlier, there is an increasing number of guidelines and interventions that require rigorous testing to determine the costs of training, implementation, and maintenance, as well as the impact on key resident outcomes.

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Improving the Quality of Long-Term Care IMPROVING ORGANIZATIONAL CAPACITY The high expectations for improved care created by post-OBRA 87 requirements, such as the MDS, suggest objective analyses of the resources needed to operationalize and implement the initiatives. Pressuring nursing homes to document care consistent with the regulatory requirements may be counterproductive in the absence of sound estimates of resource requirements and the match between these requirements and those actually available (Schnelle et al., 1997). Certainly, current nursing home resources can be used more effectively and efficiently to improve care. But lack of a more realistic analysis of the resources needed and currently available to fulfill the intent of OBRA 87 prevents more objective resolution of these financially focused arguments. In addition, simply spending more money on nursing home care without improvements in other factors associated with quality care will not result in significant improvement (see Chapter 8 for a review of evidence linking payment to quality). This report emphaizes the inadequacy of staffing levels in nursing homes and the consequent deficiency in long-term care services. However, increasing staffing levels without simultaneously improving their education and training, and management systems will most certainly result in less-than-expected improvement. The management problems related to accurate measurement of staff performance as well as numerous other management issues must be resolved to fully realize the benefits of increased staffing. The committee has made several recommendations throughout the report that could resolve organizational capacity problems that have been raised in this chapter. For example, recommendations made in Chapter 6 regarding staffing are necessary ingredients for significantly improving organizational capacity (see Recommendations 6.1, 6.2, and 6.3). In addition, the committee offers the following recommendations to resolve the primary organizational capacity problems that have been discussed in this chapter related to both technical (e.g., how to manage staff) and tangible resources (e.g., how many staff and with what education and training levels are needed, and what are the costs associated with them?). Recommendation 7.1: The committee recommends that the Department of Health and Human Services fund research to examine the actual time and staff mix required in different long-term care settings to provide adequate processes and outcomes of care consistent with the needs and variability of consumers in these settings, and the fit between these needs and other existing staffing patterns. The Committee further recommends

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Improving the Quality of Long-Term Care that the Department of Health and Human Services, by establishing Centers for the Advancement of Quality in Long-Term Care, initiate research, demonstration, and training programs for long-term care providers to redesign care processes consistent with best practices and improvements in quality of life. The committee believes that the Centers for the Advancement of Quality in Long-Term Care could be research, development, and teaching sites. Their functions could be partially listed as follows: Implement and develop clinical or quality-of-life assessment protocols for all long-term care settings as described in Recommendation 4.1. Implement and evaluate care processes that are demonstrated to improve measures of clinical or life quality. Demonstrate the resource requirements for implementing all assessment and care processes including the costs of training and managing staff in the provision of care. Serve as training sites for long-term care providers who are willing to invest in improving capacity. Serve as test sites for policy makers who need a realistic appraisal of the cost and feasibility of implementing regulatory standards being considered for legislative approval. CONCLUSION This chapter argues that most nursing homes, even highly motivated ones, may lack the technical expertise and resources—including but not limited to staffing levels—necessary to translate OBRA 87 regulations, practice guidelines, and quality improvement systems into practice. A strong case is made in this and the previous chapter that nursing home staffing levels are inadequate and that there will be little improvement until this issue is addressed. However, increasing staffing without simultaneously improving management systems will most certainly result in less-than-expected improvement. The management problems related to accurate measurement described in this chapter, as well as numerous other management issues, will have to be addressed to realize fully the benefit of increased staffing. These problems should not be used by any stakeholders to justify abandoning efforts to improve care. The discussions in this chapter support realistic directions for improvement that should take long-term care to the next level of quality.