How to win friends and influence people

I’m sure readers of a certain vintage will quickly recognize the name Dale Carnegie and probably remember the title of his early 20th century best-seller (I’ve stolen it above). This was one of the first business self-help books of the modern era and spawned a set of Dale Carnegie courses that, for all I know, are still offered throughout the United States. I sure hope so because I have a wonderful “student” in mind: the federal Centers for Medicare & Medicaid Services (CMS).

I think—in fact, I know—that CMS would dearly love to influence nursing homes to improve their quality. And the agency has gone about this in a couple of ways—one bad and one good, to put it in simplest terms.

Regular readers of this column will know that I’m not a big fan of the Minimum Data Set (MDS). I realize its good intentions and recognize that there are nursing homes that will swear by its effectiveness in guiding them toward better quality performance. And those who have mastered its intricacies command not only my respect but my awe. But I’ve always thought that its by-the-numbers, heavily coded and subcoded micromanagement of resident care was asking too much of institutions as staffing-challenged as nursing homes tend to be. In many situations, it’s an invitation to the cynicism of “paper compliance.”

I also realize that as inextricably bound up as it is in facility survey compliance, quality monitoring, and reimbursement, the MDS will never go away. It’s just that I don’t see it making a lot of friends for quality improvement.

Now for CMS’s “good way.” As everyone knows by now, the CMS Nursing Home Quality Initiative has taken a quite different tack toward achieving improved performance. Via its quality improvement organizations (QIOs) in every state, which actually show facilities best practices and how to implement them, along with Quality Measures giving facilities quick and easily understandable feedback on how well they’re doing, this is the most classic of training approaches. Tell, show, monitor, respond—gee, it seems to work!

Recently, the Journal of the American Geriatrics Society published a report on a collaborative pain management program for nursing homes run by Quality Partners of Rhode Island (the nation’s lead QIO) and Brown University. After showing selected facilities some of the latest concepts in pain management, the partners found these nursing homes increasing use of pain assessments from 4 to 44%; increasing use of pain intensity scales from 16 to 74%; increasing use of nondrug pain treatments from 41 to 82%; and achieving a 41% reduction overall in residents’ pain. Other QIO reports have described similarly mind-boggling improvements by nursing homes in managing pressure ulcers.

This indicates the presence of a vast reservoir of desire among nursing homes to do better— that, far from the popular image of a bunch of shoddy, run-down operations that couldn’t care less (although there are more of these still with us than there should be), many nursing homes really want to perform well, if they could only be shown how and given a chance to succeed.

Come to think of it, CMS doesn’t need Dale Carnegie to tell them that, MDS or no MDS.


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