Best-Practices Protocols Can Improve Quality


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.

Facility-level, MDS-adjusted MegaQIs being used by CMS were used to evaluate project outcomes. Developed by the Hebrew Rehabilitation Center for Aged to assist CMS in developing QIs reflective of clinical and other important resident care outcomes, the MegaQIs adjust for multiple risks encountered by residents and facilities and therefore more thoroughly measure quality improvement. Facility QI rates from the first quarter of 2002-before the protocols were in place-were compared to facility QI rates from the first quarter of 2003-the first 12 months the protocols were in place.

During the 12-month Phase I period, test facilities slowed the rate of decline in ADL QIs by 30 to 40% compared with control facilities. The test facilities also experienced a significant improvement in pain management results, including a 20 to 40% improvement in the behavior indicator of pain management (one of six pain-management-related QIs measured) compared to controls. In depression management, test facilities showed a 22% improvement in combined QI rates (i.e., combined depressed/anxious mood worsening, little or no activities, cognition worsening, communication worsening, new/persistent delirium, weight loss, and inadequate pain management), versus a 15% decline experienced by control facilities. Results from the project also showed that best practices can be coordinated and lead to quality improvement in multiple areas simultaneously.

In addition to the residents benefiting, test facility staff also experienced benefits from the project. Test facilities reported increased consistency of internal systems, strengthened interdisciplinary approaches and communications, and improved staff satisfaction.

Generally, as a result of the facilities’ participation in the project, more referrals of residents were made to physicians, dietitians, therapists, and social workers. This produced more comprehensive use of appropriate services and was reflected in more sensitive care planning. Satisfaction grew as staff witnessed their efforts resulting in better care, increased levels of independence, more positive self-esteem, and enhanced quality of life for residents.

Within the categories studied, more specific investigations and results included:

Activities of daily living. One ADL area, either dressing or eating, was selected for each resident. Using the MDS data, the “ADL late-loss worsening” QI was analyzed. Late-loss ADLs include loss of bed mobility and difficulties with transfer, eating, and toilet use. The results:

  • During the 12-month period, both the test and control groups improved their ADL late-loss worsening rates.
  • Test sites using this protocol slowed the rates of ADL decline four times more than the control facilities providing usual care.
  • Each test site improved by 30 to 40%, whereas control sites experienced a lower rate of improvement or stayed the same.
For a summary, see figure 1.

Pain management. Pain affects 50 to 60% of residents in long-term care facilities and influences many quality-of-life factors, such as mobility, sleep, appetite, and cognition. Six QIs were examined under this protocol: inadequate pain management, pain worsening, behavior problems, behavior problem-high-risk, behavior problem-low-risk, and depressed/anxious mood worsening. The results:

  • All sites improved significantly after the preintervention assessment.
  • Pain-protocol test facilities experienced a 26% improvement in QI rates for inappropriate behaviors, compared to an 8% decline at the control sites.
  • Test sites improved significantly in the area of behavior QIs, while control sites’ indicator rates declined or stayed the same.
  • Test sites also improved in depressed/anxious mood QI rates, while these declined at control sites.
For a summary, see figure 2.

Depression. The QIs examined included: depressed/anxious mood worsening, little or no activities, cognition worsening, communication worsening, new/persistent delirium, weight loss, and inadequate pain management. The results:

  • Test sites showed a 22% improvement in combined QI rates versus a 15% decline among control sites.
  • For each QI outcome, test sites started at a lower quality-performance level than the control sites but, after implementation, test sites improved in each area.
  • The most dramatic areas of improvement for the test sites occurred in resident involvement in activities programs, with a 69% improvement, and pain management, with a 61% improvement rate.
For a summary, see figure 3.

Conclusions and Next Steps
Through measurable indicators, the Nursing Care Facilities Best Practices Project has provided the Pennsylvania Department of Health with replicable protocols that improve the quality of care of nursing home residents. In addition, the department gained key insights concerning the impact of best-practices protocols on nursing homes, their staff, and residents. Among specific conclusions:

  • Through a systematic and consistent implementation of best-practices protocols, the quality of care can be improved for nursing home residents.
  • Successful implementation of best-practices protocols requires a commitment by administration and all staff at every level, every shift.
  • Key to improving quality of care is having knowledgeable nurse clinicians and offering staff continuing education.
  • Best practices in one quality-of-care area can lead to improvement in other areas.
  • Implementation of best practices empowers facility staff and increases staff satisfaction.
  • There is a demand for additional best-practices protocols and a need for further study.
Regarding the latter, as a result of the positive outcomes of Phase I, in June 2003 the Pennsylvania Department of Health extended the Nursing Care Facilities Best Practices Project demonstration for two additional years, through 2005. The scope of work for Phase II includes continuing the nurse educator support for the initial test facilities using the three original protocols, public release of the pain protocol, development of two new best-practices protocols for pressure ulcers and urinary incontinence, and implementation of the two new protocols in additional nursing facilities. The project will be investigating the stability of quality improvement results over time, the benefits to facilities of using multiple protocols, and the effectiveness of the new best-practices protocols for pressure ulcers and incontinence.

Malcolm H. Morrison, PhD, is President and CEO of Morrison Informatics, Inc., a Mechanicsburg, Pennsylvania-based healthcare consulting company, and was assisted in the project by Ruth A. Cheng, MBA, the firm’s Director of Special Projects.

Richard H. Lee, MPA, is the Deputy Secretary for Quality Assurance at the Commonwealth of Pennsylvania Department of Health.

This project is funded, in part, under a contract with the Pennsylvania Department of Health. Basic data for use in this study were supplied by the Pennsylvania Department of Health, Harrisburg. The department specifically disclaims responsibility for any analyses, interpretations, or conclusions.

For more information, contact Dr. Morrison at (717) 795-8410 or e-mail To comment on this article, please e-mail For reprints in quantities of 100 or more, call (866) 377-6454.

Project Team
The project team is led by Morrison Informatics, Inc., a Mechanicsburg, Pa., healthcare consulting company with long-term and post-acute care clients nationwide. Other members of the team include nationally recognized experts in long-term care services and quality improvement. Best-practices protocol development, data analysis, and evaluation are being conducted by John Morris, PhD; Sue Nonemaker, RN, MS; and the staff of the Research and Training Institute of the Hebrew Rehabilitation Center for Aged, Roslindale, Mass. Brant Fries, PhD, of the University of Michigan Institute of Gerontology is assisting in these tasks.

Best-practices protocol implementation is being conducted under the direction of Beryl Goldman, RN, MS, NHA, of The Kendal Corporation, Kennett Square, Pa.; technical assistance is provided by Sally McCue, MBA, of Clifton Gunderson LLP, an accounting firm in Calverton, Md.; and public information services are being provided under the direction of Nancy Sacunas, APR, of Sacunas & Saline, a public relations firm in Harrisburg, Pa.

Advisory Groups. An Executive Advisory Group and Stakeholders Work Group were formed to provide input on project developments. The Executive Advisory Group includes executive leadership from the Pennsylvania Department of Health’s Executive Offices and the Bureau of Facility Licensure and Certification, along with the Pennsylvania Department of Aging’s Intra-Governmental Council on Long Term Care. The Stakeholders Work Group includes representatives from the Pennsylvania Department of Health; Pennsylvania Department of Public Welfare; Pennsylvania Medical Directors Association; Pennsylvania Health Care Association; Pennsylvania Health Law Project; Pennsylvania Catholic Health Association; Center for Advocacy for the Rights and Interests of the Elderly; Pennsylvania Association of Non-Profit Homes for the Aging; Pennsylvania County Affiliated Homes; Hospital and Healthcare Association of Pennsylvania; the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services; and residents and family members.

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