A systematic approach to quality

The Pennsylvania Department of Military and Veterans Affairs operates six facilities that provide long-term care to eligible veterans and their spouses. Pennsylvania’s state veterans homes have implemented a quality assurance/quality improvement (QA/QI) program that uses a systematic approach to identify areas for improvement throughout the system.

The QA/QI program relies on several databases, such as QI/QM, resident and family surveys, mock survey, Centers for Medicare & Medicaid Services (CMS) Nursing Home Compare, and Departments of Health and Veterans Affairs survey reports to help guide and measure improvement initiatives. The QA/QI program is designed to be both proactive and reactive in distinct and measurable ways.


Quality measures are routinely compiled and tracked. Each facility in the system is measured against the others, along with state and national averages. Because of the unique population of residents served in a veterans home, it is valuable to measure each home against every other home. Measuring performance against state and national measures gives the homes benchmarking ability and guides the development of many quality improvement initiatives.

The archives of national and state quality measure values can be found on the CMS website at www.cms.gov/MDSPubQIandResRep/02_qmreport.asp. As the homes have begun to rely on the quality measure database, it has become more accurate and is a statistical representation of the condition of the residents on the nursing floors.


The Pennsylvania Veterans Homes System uses the CMS Nursing Home Compare Five-Star Quality Rating System to benchmark against state and national ratings. The homes also use this site to compare themselves to other homes in their zip codes and counties. CMS chose seven long-term stay quality measures to determine the quality measure portion of the rating system, and Pennsylvania state veterans homes treat those as indicators of quality within its system of homes. When the homes identify one area where they are below state or national averages, the QA/QI program performs a root-cause analysis and may choose that area for a QI initiative. This database is used as another tool to help measure their success.


The homes routinely measure satisfaction and the survey results are used for many purposes. Residents and families are considered valuable resources in providing feedback regarding the care provided. While typically the results are positive overall, the real value of the satisfaction survey program is in identifying opportunities for improvement. If the survey process identifies any area a resident or family member is dissatisfied with, the facility works to resolve the problem identified on a case-by-case basis. The results of the satisfaction surveys are compiled and used to identify collective issues that might require a system-wide approach to correct.


The Pennsylvania Veterans Homes System has developed a mock survey program called peer reviews. Each home has a team from other homes come annually to identify what that particular home is doing right and identify areas where it could do better. By routinely bringing staff together from the various homes, the sharing and development of best practices is encouraged. The program’s goals are to identify the best way to complete a task and replicate it throughout the system, and to assist the homes in preparation for actual licensure and certification surveys.


Throughout the year, the homes receive unannounced annual and issue-/complaint-driven regulatory inspections from various licensing agencies. If a home receives any deficiencies as a result of those inspections, the QA staff assists or performs a root-cause analysis to identify the reason for the deficiency. QA staff monitors the plans of correction to ensure compliance and avoid repeat violations. The program’s goals are not merely to correct the item out of compliance, but to identify any system breakdown that led to the problem.


Each home in the system has a monthly interdisciplinary QA/QI team meeting that guides the process. While the homes operate as a system, each facility has unique approaches to address individual issues that arise there. The QA staff and team help develop and review QI initiatives throughout the home. The team uses data and observations to target areas for improvement. The team sets a baseline with measurable goals and objectives to determine if the targeted improvements were met. If the desired changes are not reached within the allotted time frame, which is usually measured monthly and set on a three-month cycle, the initiative is reviewed and may be modified and continued.

An integral part of the Pennsylvania State Veterans Home QI program is constant oversight and measurement of performance. Interdisciplinary environmental rounds have been found to be a useful tool for locating and correcting items that might go unnoticed. The rounds have identified and helped to correct areas ranging from minor maintenance/housekeeping issues such as chipped paint or built-up dirt, to infection control issues and potentially unsafe practices.

The process involves scheduling managers from different departments of the home to perform routine inspections on other departments using an established inspection checklist. When a deficiency is found during environmental rounds, for example, the corrective action may be as simple as an on-the-spot correction, but it is not uncommon to perform a root-cause analysis to identify a systemic problem that needs to be addressed.


Systematic chart audits have evolved into a very useful tool for the QI program. Routinely reviewing a sample of charts ensures individual chart compliance. Having a fresh set of eyes review helps to identify patterns to use for more accurate and efficient charting procedures. Audits can be focused on a specific area that needs improvement or to identify potential areas that need to be included in future quality improvement efforts. Chart audits can be both a proactive or reactive tool in the QA/QI process.


The QA/QI program relies on data and processes that identify areas for improvement and determines those initiatives that were successful. Building accurate and reliable sources of data is the core of a successful QA/QI program. Recognizing the importance of residents’ and families’ voices, quantifying clinical data, and spending time doing routine inspections enable continual improvement within the Pennsylvania system of homes. The program’s number one goal is to ensure the best possible resident care.

Jeffrey Backer, MBA, is the Quality Assurance/Risk Management Director for the Pennsylvania Department of Military and Veterans Affairs, Bureau of Veterans Homes. He can be reached at

jbacker@state.pa.us. Long-Term Living 2011 May;60(5):38-39

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