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Best-Practices Protocols Can Improve Quality

June 1, 2004
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Through a state-sponsored program, Pennsylvania nursing homes identify new paths to quality care by Malcolm H. Morrison, PhD; Ruth A. Cheng, MBA; and Richard H. Lee, MPA

Best-practices protocols can improve quality

Pennsylvania nursing homes got results with a program sponsored by their state health department Pennsylvania, which has the third largest senior population in the United States, is in a unique position to lead in setting the standard of long-term care quality. Overseeing more than 90,000 residents in more than 700 nursing facilities, the Pennsylvania Department of Health sought to go beyond its survey and regulatory functions by initiating, in April 2001, the Nursing Care Facilities Best Practices Project. The two-year project, the first of its kind in the nation, identified quality-of-care areas to be improved and tested best practices aimed at achieving these improvements. Using scientifically based research methods and measurable outcomes, the project's data analysis plan was based on evaluating facility-level Quality Indicator (QI) rates. The result: significant improvements in quality and sufficient success to extend the project another two years.

After the project was announced, nursing care facilities across the state responded with immediate interest and support. More than 100 nursing facilities volunteered to participate. Twenty were selected, based on the QI results from their MDS reports and stated ability to support the project. Ten facilities were designated as test sites and ten as control sites.

The Department of Health conducted one public information meeting and two workshops, with the December 2001 public information meeting serving as the project kickoff. A February 2002 workshop was held for nursing home facilities not participating in the project but interested in presenting information on current practices they found were producing quality outcomes. At the June 2003 workshop, the project team (see "Project Team," below) and participating facilities shared their experiences and project outcomes. How the project developed is described below.

In Phase I of the project, the team assessed patterns of care that could be targeted for quality improvement. Three of the most prevalent quality concerns were selected for best-practices pilot protocols: improvement in eating and dressing ADLs, improved pain management, and improved treatment of depression. Pennsylvania MDS data from all nursing homes were reviewed to assess baseline nursing home performance.

Each of the ten test facilities implemented one of the best-practices protocols over a 12-month period, from March 2002 to March 2003. A nurse educator was assigned to each test facility to provide ongoing training and support. The nurse educators also helped facilities implementing a quality assurance process to monitor consistency in protocol implementation and resident enrollment, and to ensure that care was provided in accordance with protocol guidelines. Types of support included, but were not limited to: providing detailed instruction on the protocol, developing systems for organizing data, presenting examples of completed documentation forms, and recommending methods to instill staff confidence through reassurance and positive feedback. Once the initial training of facility staff was complete, weekly on-site scheduled visits by nurse educators were gradually decreased to once or twice a month, as the protocol became more integrated into care processes at the nursing home.

Protocols were designed to generally replace current practices and did not require any additional staff for implementation, although they did require commitment of initial time and resources from administrative, nursing, clinical, therapy, and housekeeping staff. At each test site, staff attended training aimed at producing an in-depth understanding of the protocol area and the use of assessment and evaluation tools. All residents of the test facilities were screened using the protocol assessment tools, and care plans were implemented based on the best-practices protocol. The length of the assessment process varied by facility-from three to six months.

The nurse educator met with the administrator and director of nursing to discuss the selected protocol in general, and to decide which staff members would comprise a facility advisory panel. The advisory panel consisted of department heads or their representatives from physical or occupational therapy, recreation, social services, and dietary services, as well as supervisory and frontline nursing staff (usually nursing assistants) and, if appropriate, housekeeping staff. Appropriate staff members from each facility's evening shift were included to stress the importance of follow-through on all shifts. This panel became, in effect, a steering committee to oversee the interdisciplinary implementation of the protocol, to problem-solve facility-specific challenges in implementation, and to review significant resident care issues that arose and for which the facility requested help in care planning.

Throughout the year, all disciplines became more knowledgeable about how other departments functioned and, as a group, became more cohesive. This strengthened communications, which resulted in a stronger interdisciplinary team.