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Improving He Quality of J C. - are in ~ urging OCommittee on Nursing Home Regulation Institute of Medicine NATIONAL ACADEMY PRESS Washington, D.C. 1986

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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, NW Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an advisor to the federal government, and its own initiative in identifying issues of medical care, research, and education. This volume is the final report of a study conducted under Contract No. 500-83-0054 with the Health Care Financing Administration. Publication IOM-85-10 Library of Congress Catalog Card Number 86-70373 International Standard Book Number 0-309-03646-1 First Printing, March 1986 Second Printing, February 1987 Third Printing, March 1988 Fourth Printing, September 1989 Printed in the United States of America

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Committee on Nursing Home Regulation SIDNEY KATZ (Chair), Associate Dean of Medicine, Brown University, Providence, Rhode Island CARL E. ADAMS, Director, National Health Corporation, Murfreesboro, Tennessee ALLAN BEIGEL, Professor of Psychiatry and Vice President for University Relations and Development, University of Arizona, Tucson JUDITH F. BROWN, Vice President of Professional Services, ARA Living Centers, Houston, Texas PATRICIA A. BUTLER, Attorney, Boulder, Colorado IRIS FREEMAN, Director, Nursing Home Residents' Advocates, Minneapolis, Minnesota BARRY J. GURLAND, Director, Columbia University Center for Geriatrics and Gerontology, New York City CHARLENE A. HARRINGTON, Associate Professor, School of Nursing, University of California, San Francisco CATHERINE HAWKS, Research Triangle Institute, Research Triangle Park, North Carolina ROSALIE ANN KANE, Center for Health Services Research, University of Minnesota, at Minneapolis St. Paul JUDITH R. LAVE, Professor of Health Economics, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, Pennsylvania MAURICE I. MAY, Chief Executive Officer, Hebrew Rehabilitation Center for Aged, Roslindale, Massachusetts ~

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DANA L. PETROWSKY, Chief, Division of Health Facilities, Iowa State Department of Health, Des Moines SAM SHAPIRO, Professor, Department of Health Services Administration, The Johns Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland PETER W. SHAUGHNESSY, Director, Center for Health Services Research, University of Colorado, Health Sciences Center, Denver JUNE L. SIDES, Consultant, Regency Health Centers, Inc., Clemmons, North Carolina HELEN L. SMITS, Associate Vice President for Health Affairs, University of Connecticut Health Center, Farmington DAVID ALAN WAGNER, Vice President for Planning and Marketing, Trimark Corporation, West Orange, New Jersey BRUCE C. VLADECK, President, United Hospital Fund of New York, New York City MAY LOUISE WYKLE, Associate Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio Staff David Tilson, Staff Director Jane Takeuchi, Staff Officer Robert E. Burke, Staff Officer Michael G. H. McGeary, Staff Officer Susan E. Sherman, Research Associate Peter Reinecke, Research Assistant H. D. Tiller, Administrative Secretary 1V

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Preface The Institute of Medicine Committee on Nursing Home Regulation was given a complex and controversial task: to recommend ways to improve nursing home regulation. The regulation of nursing homes is a matter on which many knowledgeable people in all parts of the country have very strong and by no means unanimous views. I was privileged to serve as chairman of the committee appointed by the president of the Institute of Medicine to conduct the study. The committee consisted of 20 individuals with substantial knowledge of and experience in nursing homes and with the perspectives of ownership, management, consumer advocacy, state regulation, and professional staff in both for-profit and not-for-profit nursing homes. Members of the committee have had substantial training and practical experience in medicine, health law, nursing, social work, public administration, public policy analysis, economics, statistics, sociology, health services research, and health care management. They come from 15 states and are familiar with the nursing homes in most parts of the country. v

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The study was prompted by controversy over changes in nursing home certification procedures, proposed by the Health Care Financing Administration (HCFA) in 1982. When the committee commenced its work it agreed that a serious look at many factors bearing on nursing home regulation was necessary if the study was to contribute significantly toward enhancing the quality of care and of life in nursing homes by improving the regulatory system. The range of relevant issues is large and the relationships are complex. Not all could be addressed by the committee, but an effort was made to at least recognize and discuss them and to point some directional arrows for future policy development. To address its charge properly, the committee decided that the study should collect and analyze data and other information as follows: 1. Views of interested parties. Knowledgeable, interested parties in various parts of the country-- residents and their families, long-term-care ombudsmen, nursing home owners and administrators, professional and other staff who work in nursing homes, and state and federal regulatory agency officials--were asked to give their views of the problems. This information was obtained in several ways. First, the staff conducted semistructured interviews with state and federal regulatory officials, nursing home administrators, professional staff, and consumer advocates, and they visited nursing homes in several states. Second, they reviewed the voluminous hearings conducted by the HCFA in 1978 and the congressional hearings on, and the written responses to, the HCFA's proposed changes in the federal certification regulations (the action that led, ultimately, to this study). Third, the committee held five public meetings during September 1984, in Philadelphia, Atlanta, Dallas, Minneapolis, and Los Angeles. The meetings were announced and publicized well in advance and all interested parties were invited to offer oral and/or written statements to the committee. Over 200 persons spoke at the meetings and V1

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had informal discussions with committee members and staff. Many others submitted written statements. The discussions at the public meetings and the written materials were reviewed, analyzed, and summarized in a working paper used by the committee in shaping some parts of the study and. as a basis for some statements made in this report. Finally, in the course of conducting the case studies in six states (discussed below), there was an opportunity to discuss in depth the perceptions of state regulatory officials, state agency staff, federal regional office staff, consumer advocates, nursing home operators, and professional staff. 2. How states actually regulate nursing homes. Information was obtained in four ways. First, case studies of nursing home regulation were conducted in six states. The states (Connecticut, Maryland, Georgia, Texas, Minnesota, and California) were chosen because they represented widely varying local circumstances, different regions of the country, and different approaches to regulating nursing homes. In each state, three staff members conducted semistructured interviews with state regulatory agency officials, with state surveyors and those who conducted inspection-of-care reviews in nursing homes, with representatives of the state nursing home operators' associations, with for-profit and nonprofit nursing home administrators and professional staff, with state and local ombudsmen and other consumer representatives, with state legislative committee staff, and with representatives of the attorney generals' and governors' offices. They also talked to federal regional office staff. Second, a mail survey of all 51 (including the District of Columbia) state licensure and certification directors was conducted. Its purpose was to get information on the resources being used by the states in carrying out their nursing home survey and certification responsibilities, on the intermediate sanctions they had available, the extent to which the sanctions were used, and the directors' opinions on several aspects of regulatory policy. Responses were received from 47 directors, although not all items were answered by all respondents. vat

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Third, staff reviewed and analyzed the contents of 15 state nursing home investigatory commission reports issued in the last 10 years, to determine the kinds of regulatory problems that prompted these investigations. Fourth, a workshop was conducted to examine problems of enforcing the certification regulations and to formulate recommendations to improve enforcement. Several papers by experts were commissioned, and a group of over 30 enforcement experts from state and federal government agencies (including attorney generals' offices), lawyers who represented providers and their associations, and consumer advocacy (including legal service) groups, discussed the issues for 2 days. 3. Quality and quality assessment. The work consisted mainly of a review of the published literature, some unpublished studies including evaluations of HCFA-sponsored demonstration projects, plus commissioned papers. A great deal of research has been conducted and published on these subjects in the past 10 years or so, and this was digested by a subcommittee of the full committee. 4. 31eclicaid reimbursement policies. A conference was convened to explore what is known about the relationships between various types of state Medicaid reimbursement policies and both quality of care of, and access to nursing homes by, Medicaid-financed residents and those requiring extensive care. A paper was commissioned that reviewed the published literature on this subject, and extensive discussions were held by knowledgeable participants representing all pertinent perspectives. Additional literature was also reviewed by staff and committee members. The committee believes this to be an important subject that merits deeper exploration, but it was beyond the scope of this study. 5. Demand for and supply of nursing home beds. In addition to a literature review conducted by staff, two papers were commissioned to examine this question. One projected population and morbidity and disability trends by age category. The other reviewed the published and unpublished information and analyses on the effects of nursing home loed supply on regulation, enforcement, and quality of care. ~ vail

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6. Staffing. A paper was commissioned to address the issues of training and accreditation (including licensure and/or certification) of four categories of nursing home staff: administrators, registered nurses, licensed practical nurses, and nurse's aides or nursing assistants. Another paper was commissioned on the role of physicians in nursing homes, and HCFA data on current staffing of nursing homes were analyzed. 7. Consumer role and con~rn~'nity relations. A workshop was organized to explore the role of consumers (residents) and their advocates in quality assurance and to determine how this role should be enhanced by public policy changes. The same workshop also addressed the issue of nursing home/community relations. Several papers were commissioned that reviewed the ombudsman program, the development of nursing home residents' advocacy organiza- tions, the development of residents' councils and family councils, and nursing home/community interactions. 8. Management incentives. The committee organized a workshop to explore the feasibility of introducing positive incentives into the regulatory system. The regulatory system now works almost entirely on negative incentives: There is punishment for inadequate performance, but no recognition or rewards for good or excellent performance. Nine papers were commissioned for the workshop. I would like to call attention to two important considerations that affect the content of the report. First, although we used data and objective evidence as much as possible, many conclusions and recommendations rest largely on professional judgment. The committee was made up of people with diverse backgrounds and experience. Achieving consensus within this group after extensive discussion of the available evidence clearly is an appropriate and responsible way to recommend necessary adjustments in public policy. Of course, individual members did not agree in all cases with every conclusion and recommendation. But they all support the report as a whole. 1X

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Second, for a number of reasons we did not address every issue that might be considered relevant. Two are of particular importance: Medicaid reimbursement policy and policy governing bed supply (that is, the administration of certificate-of-need for nursing homes). Both are state-administered policies and both clearly affect nursing home operations. Some members of the committee believed we should have addressed these issues directly, but the majority believed--for the reasons explained in Chapters 1 and 7 of the report--that we should not. The results of our efforts are contained in this report. We hope they will contribute to achievement of the goals of improving the quality of care and the quality of life for nursing home residents and of producing a more efficient and effective regulatory environment. Sidney Katz, Chairman Committee on Nursing Home Regulation x

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Acknowledgments The committee wishes to express appreciation for the excellent cooperation and assistance it has received from hundreds of individuals and dozens of organizations throughout the country. The staffs of the Health Care Financing Administration, the American Health Care Association, the National Citizens' Coalition for Nursing Home Reform, the National Senior Citizens Law Center, the American Association of Homes for the Aging, the Association of Health Facility Licensure and Certification Directors, and the American College of Health Care Administrators were especially helpful. They received numerous requests from us for various types of information and documents. They always responded promptly and courteously. Other organizations, including the American Association of Retired Persons, the National Council of Senior Citizens, and the National Council on Aging, also were helpful. Government officials in the six states in which we conducted case studies were generous in allotting time for interviews with our staff. The same was true of representatives of provider associations, consumer groups, ombudsmen, and staff in federal regional offices. We particularly appreciate the cooperation of the 47 state licensure and survey agencies who responded to our survey x. .

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questionnaire. For many, a major effort was entailed to obtain the information needed to respond to our questions. A study as complex and technically demanding as this requires competent professional staff. The committee was singularly fortunate in being supported by such a staff, effectively organized and directed by David Tilson. In addition to its deep appreciation for Mr. Tilson's leadership, the committee gratefully acknowledges the work of the other members of the professional staff: Robert Burke, Michael McGeary, Susan Sherman, Jane Takeuchi, and Peter Reinecke (who worked on the staff through January 1985~. Don Tiller provided exceptionally effective administrative support. Staff members organized and coordinated conferences and workshops. They reviewed and abstracted hundreds of publications and technical documents. They carried out the survey of state licensure and certification agencies and analyzed the data. They prepared staff papers and drafted this report. In addition to long hours, the IOM professional staff displayed a sensitive commitment to nursing home residents. They never lost sight of the study's principal focus on residents as human beings with special needs for living and for care. x~

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Contents PREFACE 1 INTRODUCTION AND SUMMARY Purpose of the Study The Public Policy Context of the Study Perspective on the Issues Conclusions Summary of Recommendations 2 CONCEPTS OF QUALITY, QUALITY ASSESSMENT, AND QUALITY ASSURANCE Quality of Care in Nursing Homes Quality of Life Quality Assessment Criteria Assessing Quality of Care Perspective on Quality Assurance Interpreting and Using Information for Quality Assurance Quality Assurance and the Regulatory System x~ 2 8 21 25 45 45 51 53 56 60 61 67

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3 REGULATORY CRITERIA The Issues Consolidating the Two Sets of Criteria Resident Assessment Revising and Strengthening the Conditions and Standards Note on Staffing Standards 4 MONITORING NURSING HOME PERFORMANCE The Issues Problems with the Survey Process Redesigning the Survey Process PaCS: A New HCFA Survey Protocol Increasing State Regulatory Capacity Organizational Changes 5 ENFORCING COMPLIANCE WITH FEDERAL STANDARDS The Issues Enforcement Attitudes Federal Rules and Procedures State Rules and Procedures Enforcement Resources 6 OTHER FACTORS AFFECTING QUALITY OF CARE AND QUALITY OF LIFE IN NURSING HOMES Involvement of Consumers and Consumer Advocates Community Involvement Management and Staff Motivation 7 ISSUES REQUIRING FURTHER STUDY Information Systems Medicaid Payment Policies Demand for and Supply of Nursing Home Beds Staffing of Nursing Homes Single- Versus Multiple-Occupancy Rooms x~v 69 69 71 74 77 98 104 104 106 109 130 132 140 146 146 147 150 162 169 171 172 184 185 190 191 193 196 200 201

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8 ACTIONS REQUIRED AND COST IMPLICATIONS OF THE RECOMMENDATIONS Legislative Actions Required Revision and Addition of Survey and Certification Regulations Design and Testing Activities Cost Implications of the Recommendations NOTES APPENDIX A History of Federal Nursing Home Regulation APPENDIX B Existing SNF Conditions of Participation and ICE Standards APPENDIX C Report of Survey of State Health Facility Licensure and Certification Agencies APPENDIX D Selected Data on Nursing Homes and Residents APPENDIX E Key Indicators of Quality of Care GLOSSARY ACRONYMS AND INITIALISMS INDEX xv 203 204 206 207 210 213 238 254 315 351 378 389 405 407

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