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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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180 / NURSING HOME CARE 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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184 / NURSING HO3lE CARE 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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186 / NURSING HOME CARE 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.