3

Current Quality Assurance and Improvement Strategies

Quality assurance strategies seek to prevent, detect, and correct problems in the quality of services provided to individuals and populations. Quality improvement strategies attempt to improve quality through continuous study and modification of the services being provided. Although these approaches tend to have different quantitative techniques and philosophical perspectives, they are inextricably linked (IOM, 1990). Put another way, an effective quality assurance program is not an end in itself; rather, it is a means of maintaining and improving care (O'Leary, 1988).

This chapter introduces elements of quality to be assessed and improved, briefly describes different types of quality assurance or improvement programs, and offers some of the committee's ideas about the appropriateness, effectiveness, and adequacy of existing strategies in the home and community-based context. It is intended to provide a conceptual background for the issues and study questions posed in Chapter 4, but it does not purport to be an exhaustive review of this field.

QUALITY MEASURES

To assess the quality of service, three elements or types of measures need to be considered: structure, process, and outcomes (Donabedian, 1966, 1980). Structural measures refer to the organization and elements of the system of care. Process measures examine how the care is provided. Outcomes relate to the ultimate effects or results of the care rendered.



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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings 3 Current Quality Assurance and Improvement Strategies Quality assurance strategies seek to prevent, detect, and correct problems in the quality of services provided to individuals and populations. Quality improvement strategies attempt to improve quality through continuous study and modification of the services being provided. Although these approaches tend to have different quantitative techniques and philosophical perspectives, they are inextricably linked (IOM, 1990). Put another way, an effective quality assurance program is not an end in itself; rather, it is a means of maintaining and improving care (O'Leary, 1988). This chapter introduces elements of quality to be assessed and improved, briefly describes different types of quality assurance or improvement programs, and offers some of the committee's ideas about the appropriateness, effectiveness, and adequacy of existing strategies in the home and community-based context. It is intended to provide a conceptual background for the issues and study questions posed in Chapter 4, but it does not purport to be an exhaustive review of this field. QUALITY MEASURES To assess the quality of service, three elements or types of measures need to be considered: structure, process, and outcomes (Donabedian, 1966, 1980). Structural measures refer to the organization and elements of the system of care. Process measures examine how the care is provided. Outcomes relate to the ultimate effects or results of the care rendered.

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings Although choosing which criteria to examine can be difficult, assessing structural elements tends to be fairly straightforward. With respect to structure, one can ask the following: Does the facility meet appropriate fire, safety, and sanitation codes? Do staff have relevant or legally required professional credentials? Are adequate records kept? In home care and residential care, process elements are slightly more difficult to assess than is true for care rendered in hospitals or physicians' offices because the actual processes of care are invisible and cannot always be inferred from records. Moreover, the more socially oriented aspects of care concerning the way personnel relate to consumers are difficult to observe and measure. Nonetheless, regarding the processes of care, questions such as the following arise: Did a nurse visit the consumer in a timely manner? Was her assessment accurate and comprehensive? Did she follow the correct procedures for treating the consumer's condition? Did she inform the consumer about his or her condition? Did she treat the consumer with respect and involve him or her in the decisionmaking process? Outcomes can be viewed from the perspective of consumers and their families, care providers, and the community. Outcomes are somewhat more elusive to measure than is the case for structural or process variables, but arguably they are the most important aspect of quality. Outcomes measures prompt questions such as: Did the provision of care achieve the goals intended and expected? Was the patient, resident, or consumer satisfied with the services rendered and the results achieved? Recently, the emphasis of regulation at all levels of government and industry has shifted to improving performance based on outcomes measurement. Although structure and process measures are still considered valuable, greater importance has been placed on ensuring that a regulated entity achieves a desired goal, instead of merely complying with basic capacity standards and procedural steps that presumably lead to the achievement of that goal. This shift can be seen in the Clinton administration's initiation of a far-ranging series of regulatory reforms and in Congress' passage of the Government Performance and Results Act of 1993, which requires federal agencies to develop clear statements of what their regulations are intended to accomplish (GAO, 1995d). The shift to outcomes measurement has recently picked up momentum in the field of home and community-based care. The Health Care Financing Administration (HCFA) is sponsoring work on the development of an outcomes-based quality improvement approach, which has the capability to examine specific patient-level outcomes, for use by Medicare home health agencies and the Medicare system (Peter Shaughnessy, University of Colorado, personal communication, September 22, 1995). Similarly, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recently restructured its survey and accreditation procedures for home health agencies to be much more focused on outcomes measurement (JCAHO, 1994). Many residential care

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings facilities are also reviewing their practices to place a greater focus on achieving better resident outcomes (MAHA, 1994). TYPES OF QUALITY ASSURANCE AND IMPROVEMENT PROGRAMS Although the division is somewhat arbitrary and the lines are sometimes blurred, quality assurance and improvement strategies and programs can be classified in two ways: external programs and internal programs. Both types of programs are needed; neither is sufficient on its own to ensure that the highest quality of care is provided (IOM, 1990). Thus, in understanding how issues of measuring and assuring high-quality care in home and community-based environments might best be addressed, all parties (from patients and residents to providers and clinicians, researchers, payers, and policymakers) will need to take both external and internal quality assurance strategies into account. External Quality Assurance Programs External quality assurance programs are, in general, those implemented by outside agencies and entities such as the federal government or private accreditation organizations. They attempt to define and maintain at least minimum standards for quality; often, they can serve as a catalyst for provider organizations to establish or enhance their own quality improvement efforts. External programs typically follow a variety of approaches to establish criteria, set quality standards (structure, process, and/or outcome), assess quality, and correct problems. These approaches classically involve regulation—various kinds of licensure, certification, and accreditation; inspection and audit functions—and a focus on poor performance. In this context, external programs might be directed at home care agencies, at individually employed home care providers, or at occupations. In the public sector, they might be carried out on the federal, state, or local level, but the private, voluntary role is not insignificant. Other external strategies may involve structuring or financing care in ways believed to promote quality of care; such steps might involve the use of case management or managed care procedures of many sorts. Finally, an array of consumer advocacy or complaint resolution programs exists to offer some protection against poor care, fraud, and abuse.

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings Federal and State Regulation Generally, home care and residential care are regulated separately. Some overlap occurs, however, because certain of the same types of services can be furnished in either setting. For example, home health care services are often provided in residential care settings. Home care. Both federal and state governments have enacted a number of laws and regulations regarding home care services. Some of the most far-reaching involve the conditions that agencies and providers must meet to become certified to participate in Medicare and Medicaid. Many states have also imposed their own licensure requirements on agencies and providers. As part of their licensing and certification duties, states conduct inspections and surveys. They can impose civil fines, order the suspension of payments, or decertify providers giving substandard care. The regulation of home care services varies tremendously from state to state. One indication of this can be seen in state licensure laws; in 1992, 39 states required compliance with their own licensure requirements in addition to federal requirements for Medicare-certified home health agencies, 35 states applied such licensure requirements to non-Medicare-certified agencies, and 20 required individual providers of home care (home care aides, homemakers, personal care assistants) to obtain a license from the state (NAHC, 1993). For example, Massachusetts and Ohio do not license home care agencies at all, whereas California licenses only those agencies that are certified to provide services to Medicare beneficiaries. Regulation also varies within states; for example, home health agencies in Minnesota are classified into one of five separate categories, each with its own set of standards. Residential care. Unlike home care, which receives a fair degree of federal oversight as a result of Medicare and Medicaid's role as a major purchaser of care, the regulation of residential care is primarily a state responsibility. In fact, federal regulation is limited to oversight of the Keys Amendments mentioned in Chapter 1, which simply require states to certify that board and care (B&C) facilities (as defined by the state) meet appropriate standards (as defined by the state). As a result, no uniform regulations and no single definition of what constitutes a B&C facility—let alone a residential care setting—exist. Even within a single state, multiple classes of facilities can exist, each with its own target population and its own set of rates and regulations concerning staffing, admissions, and standards of care (Hawes et al., 1993). A recent survey of assisted living entities (again, defined differently by each state) by the National Academy of State Health Policy revealed that 22 states had passed or issued regulations or otherwise implemented assisted living regulatory programs through Medicaid home and community-based waiver programs

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings (Mollica et al., 1995). An additional six states have issued draft regulations or have legislation pending that would establish such a regulatory program. Throughout the country, many local officials such as county fire marshals, health inspectors, and building inspectors also exert considerable influence on and regulation of residential care facilities. The abovementioned survey also revealed that states have typically chosen one of three approaches in their regulation of residential care: institutional, housing and services, and services. Institutional approaches focus on the facility's physical structure and generally maintain strict admission and retention standards to exclude individuals who could qualify for care in a nursing facility. Housing and services approaches are designed for two purposes: (1) to address the needs of individuals who receive care comparable to that of a nursing facility in a residential care setting, and (2) to examine both the physical structure and the services provided. Services approaches require that the provider of services be licensed and certified, rather than the setting in which those services are provided. Voluntary Accreditation Two private national accreditation organizations have been granted deeming status for home health agencies by HCFA: JCAHO and the National League of Nursing. Agencies that receive accreditation through these organizations are deemed to have met, and in some places, to have exceeded the federal conditions for participation in the Medicare program. No similar accrediting organizations currently exist for residential care settings. Several groups, however, including the Assisted Living Facilities Association of America, the Association of Homes and Services for the Aging, and JCAHO, are considering implementing an accreditation program for such settings. Agencies and providers seek such accreditation for several reasons. First, it can provide important marketing benefits; consumers view it as a type of “Good Housekeeping Seal of Approval” by which they might distinguish better from poorer agencies and providers. Second, in some states, deemed status allows providers to bypass the state survey process, which they may regard as more intrusive, onerous, or unenlightening than the professional accreditation effort. Finally, many payers, such as managed care organizations, are now requiring private accreditation as a condition of participation in their own programs. As these market forces gain more power, agencies across the quality spectrum are increasingly seeking accreditation in an effort to remain competitive. According to JCAHO, the profile of agencies that it now accredits (which exceeds 4,100 organizations) is changing. Whereas a group in the past often achieved accreditation with commendations, agencies seeking and receiving

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings accreditation now are increasingly accredited with some known deficiencies (about two-thirds of home care organizations in 1995; Dennis O'Leary, President, JCAHO, personal communication, October 17, 1995). Other Quality-Related Mechanisms Various mechanisms are available for advocacy and complaint resolution in both home and residential care settings. The long-term-care (LTC) ombudsman program is mandated to investigate complaints made by residents of B&C facilities and to advocate on their behalf. In a few states ombudsmen also investigate home care complaints, but the implementation of such programs has been extremely limited to date (IOM, 1994). Protection and advocacy agencies are more broadly charged with advocating for the rights of individuals with disabilities. In addition, many states operate consumer complaint hotlines, hold public hearings, and utilize appeals processes to detect and resolve consumer complaints. Under home and community-based waivers and state-funded programs, most states have developed well-articulated case management programs separate from the internal case management programs sometimes offered by home care providers (Justice, 1993). Such case managers (usually social workers, nurses, or teams of both) typically act as the consumer 's advocate by assessing the client's need for service, developing a service plan, and monitoring the cost and quality of care given by providers, as well as client outcomes. Thus, case managers have the potential to assess and influence quality. Some programs consciously expect their case managers to perform this function (Kane and Degenholtz, 1995). A few states have developed computerized information systems used by their case managers to inform a quality assessment and improvement effort (Kinney et al., 1994.) Yet other efforts may be directed more specifically at certain types of caregivers. For example, the 1987 Omnibus Budget Reconciliation Act (OBRA 87) requires states to maintain a registry of nursing aides who have been found to have been abusive to patients. Internal Quality Assurance Programs Internal quality assurance and improvement programs are developed and used by provider organizations of their own accord as a way to improve the systems and processes that help them realize the goal of providing excellent care that continues to improve over time (JCAHO, 1994). Embodied in many of these internal programs are the principles of “total quality management” and “continuous quality improvement.” The procedures followed by organizations

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings with stable quality improvement programs include development of internal procedures and information systems, ongoing data gathering and analysis, staffing policies, case management, and consumer feedback mechanisms. Hospitals, hospital systems, and various types of managed care organizations tend to be in the forefront of implementing quality improvement programs. Little if any progress has been made in adapting these approaches fully to providers such as home care agencies or to settings such as homes or residential care settings, although some providers (primarily Medicare-certified or privately accredited home care agencies) have developed and begun implementing elements that are critical to successful quality improvement efforts. Many agencies and residential care settings develop internal guidelines or standard operating procedures to guide the way in which services are to be provided by their organizations. These steps increase the consistency of services and provide a benchmark against which to gauge the quality of service provision. Although the actual procedures followed may vary according to the needs and desires of the individual consumer, many organizations with good internal quality improvement programs develop individualized care plans for consumers that are based on input from the consumers, their families, and the various professionals and paraprofessionals involved with the consumers' care. Care plans are then monitored, through ongoing involvement as well as retrospective record reviews, to ensure that the plan remains suitable for the consumer's needs. Having a highly trained and motivated staff is one way for an organization to ensure that it has the basic capacity to provide quality services. Therefore, many organizations expend a sizable effort on such issues as staff recruitment, training, placement, and supervision. Nevertheless, in certain settings (e.g., hospitals and nursing facilities), the training of the nursing staff continues to be an obstacle to high-quality care (IOM, in press). For settings and providers in which organized quality assurance programs or staff development efforts are less well established, this situation doubtless is also an appreciable issue. Training in quality assurance and improvement is an important element of long-term staff development. Internally provided case management or utilization management typically plays a very different role from externally provided case management. In this situation, case management is used to coordinate and control the services given to a consumer. Although greater coordination is generally seen as beneficial, concerns arise when the dominant function of a case manager is to limit costs or find alternatives to costly services, rather than to fill the breadth of services that the consumer needs. The degree to which services are limited by a case manager may have a negative impact on the consumer's overall well-being. Conversely, internal case managers may want to maximize service use if they are being paid on a fee-for-service basis and might arrange unnecessary services.

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings ASSESSMENT OF QUALITY ASSURANCE AND IMPROVEMENT STRATEGIES The original legislative charge for the studies of the quality of B&C facilities and home care services called for an examination of whether existing quality, health, and safety requirements and their enforcement are (1) appropriate, (2) effective, and (3) adequate. Put another way, in terms of assuring and improving quality, the questions could be posed as follows: (1) Are the right things being done (appropriateness)? (2) Are those things being done well (effectiveness)? and (3) Are enough of those things being done (adequacy)? This committee could not and did not seek to answer those questions definitively. Rather, it has identified several problem areas in regard to the overall appropriateness, effectiveness, and adequacy of existing quality assurance and improvement strategies as they might be directed at services rendered in home and community-based settings. In identifying these issues, the committee noted, with concern, how little information is presently available that would permit a quantitative examination of these topics. Are Quality Assurance and Improvement Strategies Appropriate? To answer the question of whether the “right” strategies for measuring and managing the quality of resident or patient services are in place, one ought first to have a clear view of what quality is. In the broad area of home and community-based care, this is often a more difficult issue to come to terms with than it might be in the general area of inpatient and outpatient medical care rendered in traditional settings. For one thing, in this broader arena, the services stretch beyond well-known medical, nursing, or rehabilitation care to a variety of other personal assistance and social services that have not traditionally been the focus of organized quality assurance programs. Thus, what exactly constitutes a set of appropriate quality assurance or improvement procedures for this growing area of care cannot be answered definitively by this committee. Moreover, as is true in health care as a whole, consumers, caregivers, providers, and purchasers all have differing views of what constitutes quality. One consumer may consider a service to be of high quality; another may regard it as poor. Differences between consumers or residents (on the one hand) and providers or purchasers (on the other) may be even greater, because of differences in preferences, in the kind of information brought to bear on the question, or in the criteria used to evaluate quality. Some programs have begun to develop frameworks and practical tools to help reconcile these differences, but much work remains to be done in this arena (New England SERVE, 1989). Apart from how judgments about quality may differ depending on who is doing the evaluation, there is the issue of differences between intended and

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings achieved effects. Some strategies to ensure quality may have the opposite effect in practice. For example, Florida requires that any resident of an adult congregate living facility who remains bedfast for longer than 14 days has to move to a facility that can provide a higher—and presumably more appropriate—level of care. For many residents who are then forced out their “homes,” however, this represents a significant decrease in quality. An approach that allowed more flexibility so that consumers could remain in the least restrictive setting could, in fact, prevent some individuals from receiving care in an institution. Some strategies to protect the health and safety of residents may, even with all good intent, go too far and deny some individuals certain rights established under the Americans with Disabilities Act and other laws. As a case in point, a recent study sponsored by the American Association of Retired Persons found that some residents of group residences for frail and disabled older persons have had their “ housing choices and personal autonomy limited by overt acts of discrimination or by rules and regulations regarding health, safety, and land use ” (Edelstein, 1995, p. iv). Thus, what on paper may appear appropriate as a quality assurance mechanism may, in the event of its implementation or enforcement, have entirely unintended consequences. How actually to implement quality assurance and improvement strategies can be a complicated proposition, particularly given the remarkable diversity of the population receiving home and community-based care. Substantive evaluation never relies on only one type of measure or approach. A variety of flexible strategies needs to be developed to deal with a variety of situations; one predetermined strategy may well not be appropriate for all circumstances. For instance, an approach that relies heavily on consumer input and feedback to monitor the quality of care may not be suitable when consumers are cognitively impaired, even if surrogates or proxies for those individuals are available. Similarly, functional assessment is different for children, adults, and the elderly (NRC/IOM, 1994), and this variation must be considered when developing appropriate outcomes measures to be used in quality improvement programs. Finally, assessing and improving care involve costs. Decisions and trade-offs have and will continue to be made about how much we as a society are willing to invest to achieve and sustain high-quality services, especially in these newer settings for services. We will need to look particularly at the trade-off between the quantity of service that an individual may receive and the formal credentials demanded of those who provide the care. For example, to the extent that licensed nursing personnel are used to provide care (often considered a structural characteristic of high-quality care), the services will almost certainly be more expensive and the individual will have less flexible coverage at irregular hours (as is feasible with some unlicensed workers, including the self-employed). Another trade-off concerns the cost of quality assurance versus the cost of care itself. A perennial debate, worth revisiting particularly in the home care context,

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings is how best to invest resources in quality assurance activities in an arena widely believed to have limited resources for actual service provision.1 Are Quality Assurance and Improvement Strategies Effective? The legislation authorizing these studies directed the IOM to determine whether existing quality assurance and improvement strategies are effective in promoting good personal care. Again, a distinction between external (or regulatory) and internal quality management programs is relevant, and the committee found both encouraging and discouraging indications about this matter. For example, a recent study of B&C facilities by the Research Triangle Institute found that in states rated as having extensive regulation, several quality indicators were higher than in states rated as being less regulated (Hawes et al., 1995). These indicators include lower use of psychotropic drugs, lower use of medications contraindicated for the elderly, more provider training, and greater availability of social aids and supportive devices thought to improve overall quality. Recent studies about the effects of nursing home regulations enacted in OBRA 87 (based in part on the recommendations of the IOM study [1986] on reforming nursing home care) also suggest that these steps have improved the situation for residents of nursing facilities in terms of lower use of physical or chemical restraints, for example, and better attention to residents' rights (Phillips et al., 1993). Conversely, little evidence exists to show that using the common structural measures of professional credentials and minimum training has an impact on quality outcome measures in home and community-based care (Perrin et al., 1   An example from Minnesota illustrates the dilemma. A state-licensed residential care facility provides home care services, but it is not certified to receive reimbursement from Medicare or Medicaid. Therefore, whereas private pay residents can receive services directly from the residential care facility, Medicare and Medicaid beneficiaries must receive services from a Medicare-certified home health agency in order to have the costs reimbursed. The facility charges are much lower than those of the agency. For example, a bath provided through the facility costs a resident $12 compared to $40 charged by the certified agency. Similarly, the facility charges residents $25 a month for medication supervision and management; the same services provided through the agency cost $50 a month. The additional charges for baths and medication supervision and management alone equal about $200 a month per resident on Medicaid or Medicare, or about $72,000 a year on a facility-wide basis (Michael Demmer, Executive Vice President, Kensington Management Group, Inc., personal communication, September 29, 1995).

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings 1993).2 Part of the problem here is methodologic: Structural measures are proxies for actual assessments of process and outcome, and they are notoriously difficult to link directly to process and outcome variables with reliable, valid empirical data. It is clear, however, that requiring these standards to be met does raise costs and reduce the availability of services (Kane, 1995). Additionally, several studies have shown that consumers place greater value on the characteristics, rather than credentials, of their care providers; that is, they want people who are honest, reliable, and caring and who do a good job, not simply those who have a professional degree or have completed a training course (Eustis et al., 1993; Kane et al., 1994). In general, however, the traditional focus of much externally imposed regulation has been primarily on identifying and dealing with “outliers, ” the small percentage of providers who give extremely bad service. Experts can argue about the extent to which such programs are effective in removing such practitioners or providers from practice. For example, considerable experience with the Medicare program (through both the Professional Standards Review Organization program and the Peer Review Organization [PRO] program) suggests an uneven pattern of success with respect to hospital care (IOM, 1990). There is little if any empirical evidence on the question for outpatient medical care or (especially) for home and community-based care. Problems have also been noted in the effectiveness of existing complaint resolution mechanisms. A recent study by the IOM (1994) noted barriers to the effectiveness of LTC ombudsmen working in B&C facilities, including limited access: It found that in most states ombudsmen are not a major presence in such facilities.3 As noted earlier, ombudsan involvement with home care consumers is extremely rare; given the likelihood of federal cuts to the ombudsman program, it is not expected to expand significantly. Sabatino (1992) found a low utilization of Medicare complaint hotlines and questioned their effectiveness as a complaint resolution strategy. The effectiveness of provider registries has also been questioned (IOM, in press). Although required by law, many are not updated regularly, include information only on cases that are resolved, and may not be utilized by employers who fear litigation from former employees. Most importantly, these registries cannot prevent abuse from happening in the first place. 2   More research on this subject has been done in settings such as hospitals and nursing facilities where clearer links between these structure and outcome measures have been determined (IOM, in press). 3   Ombudsmen had similar problems gaining access to nursing facilities until federal legislation was enacted guaranteeing them access. These same provisions also cover access to B&C homes, but because states regulate these homes independently, access has varied tremendously from state to state.

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings A more significant issue, however, is that typical external quality assurance efforts are not established or conducted with the aim of steadily improving the average performance of providers over time —that is, of “shifting the curve upward.” In this regard, traditional approaches may or may not be effective in weeding out poor performance and ensuring that practitioners or others meet some minimal standards, but they are rarely effective in promoting sustained efforts at continual improvement within organizations or agencies. Most programs are “not in a position to identify exemplary providers or to offer assistance in reaching higher levels of quality of care” (IOM, 1990, p. 48). This is one reason that, in recent years, quality-of-care experts, organizations such as the JCAHO, and government agencies such as HCFA have all advocated and facilitated the adoption and implementation of rigorous quality improvement programs by provider organizations and facilities. Such programs cannot be regarded a priori as the answer to effective quality management, however. Apart from the usual barriers to effective quality improvement, internal programs may be of limited effectiveness because “conflict over authority, lack of commitment or expertise, concern about financial repercussions for individuals or of financial stress in the organization may result in inaction despite well-known and well-documented problems” (IOM, 1990, p. 48). However, health care providers in recent years have begun to develop far more sophisticated quality improvement and quality management programs than were known even a decade ago, and some are beginning to demonstrate real improvements in quality of care (Lohr, 1995). For example, nursing staff interventions in a continuous quality improvement context at an Intermountain Health Care hospital dramatically lowered the rate of decubitus ulcers among inpatients (Susan Horn, Ph.D., Senior Scientist, Institute for Clinical Outcomes Research, personal communication, July 10, 1995). Consumer satisfaction surveys are a well-known adjunct to quality improvement efforts by provider organizations, but their record with respect to effectiveness is not conclusive. In particular, the validity and utility of these surveys have been questioned for use with such a vulnerable and service-dependent population as consumers of LTC, who may be hesitant to provide potentially negative feedback about services on which they depend (Davies and Ware, 1988). Promising strategies to deal with this and other problems include assuring anonymity, rewording questions, and using in-person and telephone interviews rather than written surveys (Capitman et al., 1994a). Nonetheless, although consumer input is critically necessary, it is probably insufficient to judge the technical aspects of care.

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings Are Quality Assurance and Improvement Strategies Adequate? As noted earlier, whether quality assurance and improvement programs are adequate should be judged in terms of whether enough of them are being conducted, recognizing that prior questions of appropriateness and effectiveness also need to be answered. Moreover, the issue of adequacy has to be evaluated in terms of the levels of quality problems (i.e., frequency, severity) that must be tackled. Thus, this question will be difficult to answer, because knowledge of the extent or seriousness of quality problems is extremely limited. A fundamental problem is that many home and community-based services are provided in isolated settings such as individuals' homes and apartments. Public and peer oversight is extremely limited or nonexistent for these environments and services, and virtually no systematic data have been collected about quality of care apart from those amassed through research projects. Even federal regulatory efforts that have had formal legislative mandates to collect and use quality-related information in the home health care arena, such as the PRO program for Medicare, have not developed as clear a picture of the types, frequency, and seriousness of quality problems in these settings as would be either desirable or necessary to comment on the adequacy of quality assurance efforts. As a general proposition, the adequacy of quality-of-care programs in this area can probably be called into serious question. Concluding Thoughts What seems clear to this committee is that achieving good quality of home and community-based services will require a variety of both external and internal programs. For example, given the infrequency of licensure and accreditation surveys, these programs on their own have little capacity to oversee how well care fits the needs of consumers who age in place or who have a change of status. Conversely, reliance solely on putative quality improvement efforts undertaken by provider groups or agencies with little formal training in quality measurement or little history of successful implementation of such programs would be foolhardy. Taken together, however, well-founded regulatory requirements, sensible outside monitoring of performance, and solid internal programs that capitalize on such steps as periodic reassessment of the consumer 's individualized care plans and appropriate use of data can increase the likelyhood that consumers and residents receive the highest quality services possible. The challenge will be to develop means by which the appropriateness, effectiveness, and adequacy of these efforts can be defined and evaluated.

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Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings SUMMARY This chapter has commented on the structure, process, and outcomes variables important to a full conceptualization of quality of care; it has also briefly discussed different types of quality assurance or improvement programs that can be mounted externally by regulatory agencies or by private voluntary entities, as well as those that can be implemented by provider organizations themselves. Given the original legislation's emphasis on the appropriateness, effectiveness, and adequacy of existing quality-of-care strategies in the home and community-based context, the committee has also offered its ideas on how these aspects of quality improvement programs might be considered and assessed. These points lay the groundwork for the conceptual framework, empirical questions, and recommendations about a further study that are taken up in Chapter 4.