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OCR for page 171
6
Other Factors Affecting
Quality of Care and (duality
of Life in Nursing Homes
.
Effective regulation is essential, but regulation is not
sufficient to ensure high quality of care and quality of
life in nursing homes. Three other factors are
important: (1) active consumer involvement and effective
consumer advocacy, (2) active community interest and
involvement in nursing homes, and (3) positive motivation
on the part of the owners and managers of nursing homes,
and well-trained, well-supervised, and properly motivated
staff. The first two are needed to help improve quality
of life for residents and influence the attitudes and
performance of the government regulators and elected
officials as well as the attitudes and behavior of the
management and staff of nursing homes. The third is
essential for high-quality care. Pressures by regulators
and consumers certainly can influence management and staff
attitudes and behavior, but such pressures are not
sufficient to produce the management and staff attitudes
and to attract the quality of personnel needed to provide
high quality of care and quality of life to nursing home
residents. The desire for excellent performance and the
ability to create the climate that will attract highly
motivated and well-qualified professionals to work in
nursing homes must be nurtured by sources within the
industry and the educational and professional institutions
171
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172 / NURSING HO3lE CARE
that train and foster professional values, attitudes, and
ethical standards.
INVOLVEMENT OF CONSUMERS
AND CONSUMER ADVOCATES
Participation by residents and consumer advocates in
some aspects of resident care policy-making in nursing
homes is essential for achieving high quality of care and
quality of life. Many important decisions on care policy
rest on implicit value choices--that is, they are not
based entirely on technical or managerial imperatives.
Because quality-of-life considerations are so important in
nursing homes, systematic arrangements should be made to
determine the value preferences of the residents or those
most concerned about their well-being, both at the
individual and facility-wide levels.
Consumer Involvement
Whenever possible, facility staff and management should
honor consumer preferences. An authoritarian style of
decision-making is not appropriate in nursing homes, but
many nursing homes appear to operate in this style because
it is administratively more convenient for staff and
management. It is not appropriate for two reasons: (1)
Long-term care requires explicit recognition of the deep
psychological need of all adults to be able to exercise
some personal choice on matters involving the quality of
their daily lives--food, clothing, recreation; (2) staff
in a long-term-care facility need to obtain systematic
feedback on the care needs and desires of individual
residents to ensure that their plans of care fit the
residents' perceptions--as well as those of the staff--of
their physical and psychosocial needs. Several recommen-
dations in Chapter 3 address the issue of ensuring
resident participation in nursing home decision-making.
Another important aspect of resident and consumer
advocate participation is discussed in Chapter 4: partici-
pation in the survey process.
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OTHER FACTORS AFFECTING QUALITY / 1 73
The Role of Consumer Advocacy
Although improving state and federal regulatory
attention to residents' opinions is a fundamental
requirement for improving nursing home quality, broader
consumer protection measures are warranted for the
following reasons:
· Regulatory agencies are constrained by their limited
resources to inspecting nursing homes only once--or at
most a few times--each year, and these agencies have no
capacity to monitor the process of care or staff/resident
interactions between their infrequent inspections.
· In many nursing homes some of the care-giving staff
are undertrained, overworked, and unable to provide
sufficient attention to very dependent residents.
Moreover, there is considerable staff turnover. Under
these circumstances, staff/resident interactions may be
less than satisfactory, residents' rights may be violated
by staff, by management, or by other residents, and there
is an ever-present risk of neglect and even of abuse of
residents by staff or other residents.2
· Physical, mental, cognitive, and financial
infirmities (see data in Chapter 2) render many residents
incapable of assertion and self-protection.2 Thus,
many nursing home residents are too frail and too
vulnerable to effectively influence the attitudes and
behavior of nursing home staff in homes that are not very
sensitive to residents' needs. Without the assistance of
effective consumer advocates, such residents usually
cannot communicate complaints to outside agencies that
could help them. There is abundant evidence that the need
for strong consumer protection in nursing homes is still
essential.
Access to Information
Consumer advocates require access to certain information
to be effective in their roles of advising and helping
consumers. In the case of individual residents, access to
a resident's medical records (with the resident's
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174 / NURSING HOME CARE
permission) may be necessary for an ombudsman concerned
with investigating a complaint about an individual's
care. Recommendation 3-7F in Chapter 3 addresses this
issue. More broadly, it is important for local and other
substate ombudsmen, as well as other consumer advocacy
organizations, to have access routinely and easily to
government inspection and cost reports on individual
nursing homes. Although these are public documents, many
states do not routinely make the information publicly
available and it is often difficult for consumer advocates
to obtain copies.3 The HCFA has no explicit policy
on this matter. In the survey of state licensure and
certification agencies conducted by the committee, 30 of
47 state agencies expressed support for the policy of
making the results of nursing home inspections
public. A few states already do so. The committee
is convinced it would be desirable to make this practice
universal.
Recommendation 6-1: The [ICFA s1'ouIc! require states to
make public all nursing home inspection and cost reports.
These documents should be required to be readily
accessible at nominal cost to consumers and consumer
advocates, including state and local ombudsmen.
The O mbudsman Program
The ombudsman program emerged in the early 1970s in
response to growing public awareness of the need for
stronger consumer protection activities in nursing homes
to supplement government regulation. Eight pilot programs
were funded by HEW in 1972 and 1973. In a program
instruction dated May 1975, and issued to all state
agencies on aging, the Commissioner of the Administration
on Aging (AoA) explained the necessity for establishing
the ombudsman program:
Our nation has been conducting investigations,
passing new laws, and issuing new regulations
relative to nursing homes at a rapid rate during the
past few years. All of this activity will be of
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OTHER FACTORS AFFECTING QUALITY / 175
little avail unless our communities are organized in
such a manner that new laws and regulations are
utilized to deal with the individual complaints of
older people who are living in nursing homes. The
individual in the nursing home is powerless. If the
laws and regulations are not being applied to her or
to him, they might just as well not have been passed
or issued.4
The statutory authority for the ombudsman program dates
from 1978 (minor amendments were added in 1984) when the
Older Americans Act was amended to require that every
state agency on aging include in its multiyear plan of
proposed activities assurances that each state plan will
(A) establish and operate, either directly or by
contract or other arrangement with any public agency
or other appropriate private non-profit organization
not responsible for licensing or certifying long-term
care services in the State or which is an association
(or an affiliate of such an association) of long-term
facilities (including any other residential facility
for other individuals), a long-term-care ombudsman
program which provides an individual who will, on a
full-time basis:
(i) investigate and resolve complaints made by or
on behalf of older individuals who are residents of
long-term care facilities relating to administrative
action which may adversely affect the health, safety,
welfare, and rights of such residents;
(ii) monitor the development and implementation
of Federal, State and local laws, regulations, and
policies with respect to long-term care facilities in
that state;
(iii) provide information as appropriate to
public agencies regarding the problems of older
individuals residing in long-term care facilities;
(iv) provide for the training of staff and
volunteers and promote the development of citizen
organizations to participate in the ombudsman
program; and
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176 / NURSING I:IOME CARE
(v) carry out such other activities as the
Commissioner deems appropriate;
(B) establish procedures for appropriate access
by the ombudsman to long-term care facilities and
patients' records, including procedures to protect
the confidentiality of such records and ensure that
the identity of any complainant or resilient will not
be disclosed without the written consent of such
complainant or resident? or upon court order;
(C) establish a statewide uniform reporting
system to collect and analyze data relating to
complaints and conditions in long-term care
facilities for the purpose of identifying and
resolving significant problems, with provision or
submission of such data to the agency of the State
responsible for licensing or certifying long-term
care facilities in the State and to the Commissioner
on a regular basis;
(D) establish procedures to assure that any files
maintained by the ombudsman program shall be
disclosed only at the discretion of the ombudsman
having authority over the disposition of such files,
except that the identity of any complainant or
resident of a long-term care facility shall not be
disclosed by such ombudsman unless
(i) such complainant or resident, or his legal
representative, consents in writing to such
disclosure; or
(ii) such disclosure is required by court order;
(E) in planning and operating the ombudsman
program, consider the views of area agencies on
aging, older individuals and provider
agencies.5
Several aspects of this authority are particularly
significant:
· The responsibilities of the state ombudsman programs
are defined in very broad and general terms. Their
interpretation and implementation are left entirely to
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OTHER FACTORS AFFECTING QUALITY / 177
the states. (The implementing regulations issued by AoA do
not eliminate the vagueness.)
· The ombudsmen are to be available to help all
residents of nursing homes and other long-term-care
facilities, not only those funded by Medicare and
Medicaid.
· The ombudsman program was evidently conceived as a
bridge between the state government and the nongovern-
mental consumer advocacy groups. An ombudsman (according
to Webster's New Collegiate Dictionary) is a
government official appointed to receive and investigate
complaints made by individuals against abuses or
capricious acts of public officials; also one who
investigates reported complaints from consumers and helps
to achieve equitable settlements. But the ombudsman's
role, as defined in the Older Americans Act, goes beyond
the dictionary definition in that it mandates a consumer
advocacy role for the ombudsman programs. It also
explicitly authorizes contracting with "appropriate
non-profit" organizations. In practice, most such
organizations are consumer advocacy organizations
concerned with nursing home residents because the local or
area-wide ombudsman role fits comfortably within the
purposes and capabilities of such organizations. Many,
though by no means all, states have thus merged the ombuds-
man and the voluntary consumer advocacy functions at the
local level.
· The law makes state ombudsmen responsible for the
collection and analysis of data and other information
about complaints, about conditions in long-term-care
facilities, and about other matters required to carry out
their statutory responsibilities, and makes them respon-
sible for submitting such data to the state licensure and
certification agencies.
· The statute does not refer to substate ombudsmen--
only to "the ombudsman" who is, presumably, the state
ombudsman. Thus, for example, in paragraph B concerning
access to facilities and patients' records, the reference
is to "the ombudsman," although it is the local ombudsman
program representatives (who may be volunteers) who do
most of the complaint investigations.
There are ombudsman programs in virtually every state
and territory, with more than 1,000 paid staff and more
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1 7 8 / NURSING HO3lE CARE
than 5,000 volunteers,6 but the programs vary widely
in their effectiveness. Moreover, there are many
communities that are not adequately served. Successful
programs tend to have the following factors in common:
budget continuity, some professional staff, a qualified
supervisor, organizational sponsorship but independence in
operation, standard methods of intervening and
representing residents, consistent documentation of
findings and actions, and standard methods of correcting
problems and coordinating with regulatory and community
services agencies.2~6~9
Ombudsmen help individual residents and their families
negotiate with nursing homes and regulatory agencies.
They deal with individuals and their orientation is
problem-solving rather than regulatory. They frequently
deal with problems that are beyond the scope of
regulation. And they are available to help all residents
of long-term-care facilities, not just those supported by
Medicare or Medicaid.7
Because of their orientation, the scope of their
responsibilities, and because they see residents regularly
and are acquainted with individual resident views and
difficulties, ombudsmen in the effective programs have
demonstrated their ability to serve as consumer
representatives in dealing with nursing home staff and
management and with government agencies. They can aid
individuals and they can help residents obtain more formal
assistance when it is needed.
Ombudsmen have a range of legitimate and necessary roles
in consumer protection. They can serve as a resident's
ally in a negotiation or serve as a third-party mediator.
They can educate family groups in self-advocacy or help a
community planning group develop a service for the elderly
and handicapped. They can be a conduit of consumer
information to nursing home professionals and to
regulatory agencies. Whereas state government surveyors
are responsible only for determining whether facilities
are in compliance with licensure and certification
regulations, an ombudsman addresses any problems faced by
residents, ranging from unsatisfactory food to unexplained
extra charges to personal worries. Because ombudsmen are
not regulators, they can mediate between and among
consumers, providers, and regulators.7~9
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OTHER FACTORS AFFECTING QUALITY / 179
Despite the breadth of the statutory authority provided
to the ombudsman program, Congress implicitly accorded the
program low priority within the Older Americans Act
because (1) it is authorized in Title III, where it is
juxtaposed with the service programs for the
non-institutionalized elderly, that is, with AoA's major
program responsibilities; and (2) each state program is
authorized to use not more than 1 percent of its AoA Title
III federal funding or $20,000, whichever is larger, and
to match federal funding at 15 percent of the
total.7~0 States may opt to fund their programs at
higher levels, but few do.33~ The scope and
responsibilities of the state ombudsman programs are
defined by the act in very broad and general terms.
Interpretation and implementation are left entirely to the
states.
Local programs vary widely within and among states in
their organizational arrangements and the training and
qualifications of ombudsmen. Most ombudsman programs rely
heavily upon volunteers to carry out the day-to-day work
in nursing homes. Volunteers vary in background,
experience, and aptitude. Local programs lack resources,
staff, legal support, and training.7~8 Yet between
FY 1982 and FY 1984, there was a 56 percent increase
(29,699 to 46,325) in the complaints processed by these
offices.6 Increased service requests are expected.
Concern has been expressed by state and substate
ombudsmen about the lack of adequate professional staff
support at the federal level for the ombudsman
program.6 Concern has also been expressed about the
adequacy of federal guidelines for structuring state
ombudsman programs. There needs to be stronger national
leadership to foster development of effective training and
other necessary materials to assist state programs. No
national clearinghouse has been established to facilitate
exchange of information and experience among state
programs. Inadequate information is being collected on
the comparative effectiveness of different programs.8
The complex issue of standardizing data collection and
analysis in the various state programs has not been
solved.
Consistency and accountability would be enhanced by the
statutory establishment of a National Advisory Council
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whose members are appointed by the Secretary of HHS and
who would not only advise the Secretary on the development
and operation of the program but would submit an annual
report to Congress on the status, progress, problems, and
future plans of the ombudsman program.
Vague statutory language is responsible in part for
problems of access to nursing homes experienced by local
ombudsmen in some states. The law specifies that only
"the ombudsman" has authorized access to facilities,
residents, and documents. In many states, this is
interpreted to mean that only the state ombudsman has this
authority. Yet it is the local ombudsman who is most
likely to visit residents and assist in resolving their
individual problems. Substate and volunteer ombudsmen,
who deal directly with the majority of residents, do not
always have official access to residents and facilities.
Some states have statutes addressing this issue. Many do
not.8
Further, the ombudsman programs need legal advice and
support to ensure careful interpretation of laws and
regulations, and to withstand the occasional legal
challenges with which they are confronted as a result of
actions taken in carrying out their authorized
responsibilities. Statutory language should authorize
such support.
Another pressure constraining ombudsmen stems from a
recent circular of the Office of Management and Budget.
In April 1984 the Office of Management and Budget issued a
revision of OMB Circular A-122, "Cost Principles for
Non-Profit Organizations." Among other provisions, the
circular prohibits federally funded programs from
lobbying. The Older Americans Act makes ombudsmen
responsible for monitoring legislative and regulatory
events to advise public officials on the perceived effects
of particular laws and regulations on nursing home
residents. This statutory responsibility can be
interpreted as conflicting with Circular A-22. Federal
funds are usually the major portion of an ombudsman's
budget. If federal auditors were to disallow use of
ombudsman program funds on the ground that ombudsmen were
violating the lobbying provisions of Circular A-122, they
could destroy the program. To safeguard the continuance
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OTHER FACTORS AFFECTING QUALIFY / 181
of individual client services, many programs have ceased
speaking publicly about nursing home issues. Although
requested to do so, the OMB has declined to exempt the
ombudsman program from compliance with the relevant
portions of this circular. Most substate ombudsmen
believe that advocacy involving such activities as
testimony before state legislative committees will be
challenged by federal auditors because of OMB Circular
A-122, despite their statutory authority to act as
advocates for long-term-care residents at the state policy
level.7~8 Congress should resolve this conflict by
statutory action that confirms the legislative and
regulatory advisory roles of ombudsmen. With the
increases in resources and authorities recommended below,
state and local programs should be obligated to screen,
train, and monitor their professional and volunteer staff;
set service standards and evaluate results; and coordinate
services with other community and professional groups and
with regulatory agencies.
The successful ombudsman programs have demonstrated the
considerable value these programs have for nursing home
residents, but there are too few successful programs.
These circumstances are not likely to change without
increased funding and stronger federal direction for the
program.
Recommendation 6-2: The Older Americans Act should be
amend ed to
· establish the or''budsman program uncler a separate
title in the Act;
· increase funds for state programs by authorizing
fecleral-state matching formula grants for state ombudsman
programs. The formula should provide each state with a
minimum annual budget in the range of $100,000 (1985
dollars) plus an additional amount based on the number of
elderly residents in the state. The federal-state
matching ratio should be two-thirds federal to one-thirc!
state funds. (Although the committee did not study in
any depth the budget requirement, this minimum amount is
intended to provide the ombudsman program with, for
example, the capability to support, at a minimum, a
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182 / NURSING HOME CARE
full-time professional and secretary and sufficient travel
and training funds to recruit, train, and certify
volunteers as local ombudsmen.)
· establish a statutory National Advisory Council
composed of state ombudsmen, state and local aging
agencies, provider and consumer representatives, state
regulators, health care professionals (physicians, nurses,
administrators, social workersJ, anc! members of the
general public to advise on administration, training,
program priorities, alevelopment, research, and evaluation;
· authorize state-certified substate and local
ombudsmen, including trained, unpaid! volunteers, access to
nursing homes and, with the permission of the resident, to
a resident's medical and social records;
· authorize public legal representation for ombudsman
programs;
· exempt the ombudsman programs, including substate
ombudsmen who are supported by funds from the state
ombudsman program, front the antilobbying provisions of OMB
Circular A-122.
Recommendation 6-3. The Secretary of HHS shouic! direct
the Administration on Aging (AoAJ to take steps to provide
effective national leadership for the Ombudsman Program.
At a n~inimur'' the Con~r''issioner of AoA should designate a
senior full-tir''e professional arid some supporting staff to
assur''e res possibility f or ad n~i,~isteri'~g the program.
Priority should be given to establishing a nations!
resource center for the progran' tent would develop, in
consultation with state programs, an i'~forn~ation
cleari'~gho'~se, trig arid other materials to assist
states, a''d guidance to states on data collection and
analysis. The center should advise on establishing
program priorities, a''d sponsor research and evaluation
studies.
One other major issue requires attention: the
relationships between state licensure and certification
agencies and ombudsmen. Although reasonably good working
relationships exist in some states, relationships are
unfriendly in many states. The key issues are mutual
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OTHER FACTORS AFFECTING QUALITY / 183
understanding of, and agreement on, roles, operational
relationships, and access to information. These can be
complex issues, and there are few states where they have
been worked out fully. Obtaining copies of state nursing
home survey reports is sometimes difficult and expensive
for ombudsmen. In many states, surveyors seldom make an
effort to contact local ombudsmen either before or after
they survey a facility.7~8 About one-quarter of the
states regularly inform ombudsmen of survey findings; less
than half receive information from ombudsmen.3
Survey agencies are often concerned that ombudsmen are
assuming a quasi-regulatory role, or that they are
ill-equipped to render beneficial services to nursing home
residents. Only a few state regulatory agencies routinely
share information with ombudsmen and receive and refer
cases to ombudsmen.~° On the other side, ombudsmen
often are suspicious of regulators and their findings.7
Conceptually, of course, the two roles are comple-
mentary: the state surveyor is concerned with legal
compliance with regulatory standards by the nursing home,
the ombudsman with ensuring that the individual residents'
rights are observed and that they receive reasonable
treatment by facility staff and management. In places
where ombudsmen and state surveyors understand each
others' roles, seek and offer each other advice and
services, and cooperate on problems of mutual concern
(whether the problem is a specific facility or a state
policy), nursing home residents and their families
benefit. A few states have developed formal, written
agreements between state regulatory agencies and the state
ombudsman program that cover information-sharing,
training, and case referral between surveyors and
ombudsmen. The committee is convinced that this is a
desirable arrangement that all states should follow.
Recommendation 6-4: The HCFA should require state
long-term-care regulatory agencies to develop written
agreements with state ombudsman programs covering
information-sharing, training, and case referral.
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COMMUNITY INVOLVEMENT
In the last 20 years or so, research studies have
explored issues of the effects on nursing home residents
and staff of varying degrees of involvement with community
groups. These studies have found that residents benefit
and the quality of nursing home performance is likely to
be higher than in homes with few outside visitors.~3~~5
Residents who were able to maintain family relationships
or create new relationships with others from the community
were more likely to have more amenities for living,
including favorite foods to supplement the institutional
`diet. Clothing and toiletries, which are difficult to
obtain because most nursing home residents have a very
small monthly personal allowance and are unable to shop
outside the home, may be supplied by visitors. Moreover,
the frequent presence of visitors encourages staff
attention to the resident, and often roommates and others
in the unit.
There are many examples of the involvement and
commitment of local community groups such as churches and
service organizations to some nursing homes in their
communities, but--although data are not available--such
involvement appears to be much less common than would be
desirable.
Many nursing homes, despite their status as public
facilities, generally receive little or no community
support or attention. Increasing community involvement
with nursing homes on a regular, sustained basis is
important for three reasons: (1) to enhance the quality
of life of nursing home residents by reducing their sense
of isolation from the community and providing
opportunities for stimulating social interactions, (2) to
help improve the quality of care in nursing homes by
making staff-resident interactions more visible to members
of the community, (3) to increase the level of
understanding in the community about the issues and
complexities of long-term care so as to facilitate the
development of more appropriate public policies in this
area.
Serious exploration of ways to stimulate and foster such
community involvement merits the attention of the
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OTHER FACTORS AFFECTING QUALITY / 185
Administration on Aging. The possibility of enlisting the
interest of one or more national service organizations to
undertake a demonstration project should be considered.
MANAGEMENT AND STAFF MOTIVATION
The motivation, attitudes, qualifications, and skills of
management and staff in nursing homes are among the most
critical factors affecting quality of care and quality of
life in nursing homes. Professionals in all fields are
responsive to peer judgment. A professional's ethical and
performance standards and associated values and attitudes
are acquired as a concomitant of his/her education and
training. They are sustained through interactions with
peers in various settings and circumstances, both formal
and informal.
Development of Professionalism
The emergence of professionalism in the nursing home
industry is a recent phenomenon. There was very little
professionalism in this field 30 to 35 years ago, but this
has been changing. A number of professional organizations
and institutions have contributed to this growth of
professionalism.
Although the committee does not believe it would be
sound public policy to allow JCAH accreditation to
serve--in lieu of a state survey--as a basis for certify-
ing a nursing home, it does believe that the accreditation
process is an important and very desirable way for the
industry to raise its own standards of performance using
the techniques of peer judgment and consultation.
The Joint Commission on Accreditation of Hospitals
(JCAH) has had an accreditation program for nursing homes
since 1966. Voluntary accreditation by JCAH has been the
standard form of quality assurance used by hospitals for
many years. The JCAH accreditation process emphasizes
voluntary participation, independent peer review, and
professional responsibility. Individualized and ongoing
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educational and consultation activities are key aspects of
the program. About 1,400 nursing homes are now
accredited. The JCAH publishes a Long-Term Care Standards
Manual that is revised and updated periodically.
The health professional schools, particularly schools of
nursing and schools of medicine, have begun to develop
active research and educational ties with nursing homes.
Both the Robert Wood Johnson Foundation and the National
Institute on Aging sponsor teaching nursing home
programs.~7~8 These are recent developments--the
programs have been under way for a few years--but in the
long run they are likely to exert a powerful effect on
professional values, on care practices, on training, and
on quality of care in nursing homes.
The professionalism of nursing home administrators also
is being strengthened. All states license nursing home
administrators, although requirements for state licensure
vary widely. Nursing home administrators have formed an
active professional association--the American College of
Health Care Administrators--to raise qualifications and to
enhance the professionalism and skills of its members.
Although physicians' roles in nursing homes are much
more limited than they are in hospitals, there is
substantial concern that in many nursing homes physicians
perform in only a perfunctory or pro forma manner.
But this may be changing. There is growing interest in
geriatric medicine among physicians and in medical
schools. This has been stimulated by the programs of the
National Institute on Aging, the Veterans Administration,
and the Bureau of Health Professions in the U.S. Public
Health Service. It seems probable that the growing numbers
of elderly and the rapid growth in the number of
practicing physicians in the l980s also may be
contributing.~7~9 In the long run, these trends
are likely to result in better-motivated physicians, with
some formal training in geriatric medicine, providing
better medical care to nursing home residents.
The leadership of organized nursing has recognized for
almost 20 years a specialty of "gerontological nursing."
It emphasizes health promotion, health maintenance,
disease prevention, self-care, and self-help.
Gerontological nurses are expected to help older patients
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O THER FA CTOR S A FFECTI NO Q UA L I TY / 1 8 7
reach their maximum potential level of physical, mental,
and social functioning. Both the National League for
Nursing and the American Nurses Association Division of
Gerontological nursing have been promulgating national
standards for long-term nursing care. As the regulatory
system becomes more sensitive to the presence and
importance of directors of nursing in nursing homes, the
professional nursing organizations are responding by
formulating standards, career development courses, and
facility-based procedures that support the nursing
director's role in the organization and management of care
in nursing homes. Facilities should recruit
and employ specialty-trained gerontological nurses and
encourage currently employed nurses to seek training in
gerontological nursing.
Another step toward professionalism is indicated by the
large interstate proprietary nursing home chains that have
started internal corporate quality assurance programs.
For example, the National Health Corporation introduced a
computerized resident assessment system about 12 years ago
in its eight-state chain of 50 nursing homes.20 The
system has multiple purposes, but among them is
outcome-oriented quality assurance by means of
longitudinal analysis of changes in resident status. The
availability of the data makes it possible for corporate
headquarters to determine whether specific nursing homes
are having quality problems and to take steps to deal with
them promptly. The Hillhaven Corporation, one of the
largest chains, is in the process of installing a similar
system. Beverly Enterprises, the largest of the chains,
has developed an internal quality assurance program with a
full-time executive in charge of it.
It is clear that both private efforts and government
regulation are needed to improve quality of care for and
well-being of nursing home residents. Private efforts to
increase knowledge, to improve training, to enhance
professionalism in the industry, to increase efficiency
and effectiveness in providing care, and to strengthen
commitments to self-regulation are essential. But the
vulnerability of the residents and the widespread
perceptions that current levels of performance still leave
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188 / NURSING HO3lE CARE
much to be desired also make effective government
regulation essential.
Incentive Systems for High-Quality Care
Modern management theory holds that excellent results
are more likely to be achieved when the members of an
organization are motivated not by fear of sanctions for
inadequate performance, but by pride, accountability,
cooperation, and loyalty. The HCFA and state
governments can apply this concept in their dealings with
nursing homes. The current federal regulatory system is
structured only to punish poor behavior. Good behavior
goes unrecognized. Only a few states have developed
systems for rewarding good or outstanding facilities.3
In part, this is attributable to the crudeness of the
survey instruments. After the HCFA has implemented the
new survey process recommended in Chapter 4, and after
some statistically derived outcome standards are
developed, it should be possible to reliably distinguish
the very good from the poor or merely acceptable
performers. It will then be possible to reward facilities
for excellent performance and thus to encourage continued
excellent performance.
The new survey process recommended in Chapter 4
ultimately can facilitate development of an incentive
system. Facilities with proven records of good behavior
would be praised by surveyors and would be surveyed in
full less frequently. Extended surveys would be applied
only to facilities whose outcomes of care indicate that
further investigation is warranted. More reliance on
outcome-oriented standards would enable the survey agency
to allow facilities with records of good care to experi-
ment with better procedures for delivering care. Methods
that continue to produce good results, even though not
strictly in keeping with structural or process regula-
tions, such as the use of a geriatric nurse practitioner
for a medical director, should be allowed in facilities
that consistently demonstrate excellent performance on th
standard survey.
be
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OTHER FACTORS AFFECTING QUALITY / 189
The certificate-of-need (CON) process also can be used
as part of an incentive system. Certificates of need are
documents issued by the state to authorize health
facilities to build or expand. States set criteria by
which they judge whether the services proposed by a
provider are needed, and whether the provider is qualified
to provide services in the state. Currently, 46 states
require nursing homes to obtain certificates of need
before expanding services.23
In 25 states, the
agency granting a CON first reviews the facility's
licensure and certification record. These states use the
procedure as a sanction against poor providers, denying
certificates of need to providers with records of poor
care. (Ten states refused certificates of need to poor
providers in 1983.3) Awarding a certificate of need
also could be used as an incentive to provide superior
care. Only facilities with records of providing superior
care should be eligible to receive CONs.
Systematic use of rewards for superior performance would
not only motivate providers who currently give superior
care to continue to do so, but would encourage
above-average and average facilities to try to improve so
as to reap the benefits of this status.
Representative terms from entire chapter:
nursing home
