LTC Quality: The Sound and the Fury



Far from “signifying nothing,” as per Shakespeare, today’s quality initiatives seem to be signaling big change


With the word “quality” sounding as a steady drumbeat throughout, the past two years have seen a flurry of announcements, pronouncements, programs, projects, and publications trumpeting a movement toward improved long-term care. Skeptics have had to yield to emerging evidence showing that long-term care facilities have indeed grasped the opportunity to learn new best practices and put them into effect. Solid proof of an industry-wide upgrade is a long way off, to be sure. But there is no shortage of initiatives on several fronts.

The forerunner in all this has been the federal Centers for Medicare and Medicaid Services (CMS), which has moved beyond its state survey-oriented Quality Indicators to develop Quality Measures (QMs), in concert with a consultative organization called the National Quality Forum (NQF), and assigned its quality improvement organizations (QIOs) to collaborate hand-in-hand with individual nursing homes throughout the United States on specific care improvement projects. NQF is overseeing the brand-new National Commission on Quality Long-Term Care, which has been charged with monitoring, reporting on, and proposing policy recommendations for improving care. Taken altogether, this is, in essence, a quality-oriented network that didn’t even exist four years ago.

LTC provider organizations have responded in kind with programs under the common title “Quality First”; the American Health Care Association (AHCA), the Alliance for Quality Nursing Home Care (a coalition of 14 major national chains), and the American Association of Homes and Services for the Aging (AAHSA) have each come up with their own interpretation of quality improvement through development of extensive guidelines and helpful “tool kits” for their members, whose commitment is sealed by their signing of “covenants” to that end.

How has the quality movement fared thus far? Let’s take the initiatives-and the players-one-by-one.

The CMS/NQF/QIO Network
In 2002, CMS launched its Nursing Home Quality Initiative as an adjunct to the established state survey process. It was, in effect, a response to LTC provider organizations’ longtime call for a collaborative relationship with government on quality improvement, rather than exclusive reliance on a state-enforced policing system. CMS joined forces with NQF, a broad-based organization founded in 2000 and consisting of representatives of healthcare system stakeholders (including providers, consumers, purchasers, and researchers), to develop 10, and eventually 14, long-term care QMs. These were intended to help nursing homes identify operational problems and gauge their progress in solving them. (For all levels of the healthcare system, NQF invites stakeholders to propose standards, which NQF then reviews, develops, publishes for comment, and revises, in a process modeled on the federal government’s rule-making approach. Government agencies are, in turn, legally required to adopt NQF’s voluntarily developed standards [unless they can come up with a solid reason not to].) The 14 QMs are the culmination of the process for long-term care; today, NQF is moving onto other areas, such as home healthcare.

CMS has used the QMs as a blueprint for guiding specific quality-improvement projects developed by its 50-plus QIOs in conjunction with selected nursing homes in their areas. QIOs were founded originally to monitor and work with physicians and hospitals billing Medicare on fixing their quality problems. Today, each QIO works directly with approximately 10 to 15% of the LTC facilities in their respective areas but strives to dispense information to all facilities. So far, it is the QIOs that have produced the most specific data on nursing homes’ quality-improvement progress.

According to a January report by CMS based on QIO data, for example, the percentage of residents with chronic pain has dropped by one-third since 2002, and the percentage of residents who were physically restrained declined 15%. Although pressure ulcer incidence actually increased somewhat (for reasons that are unclear but could reflect better diagnosis, more problematic hospital discharges or, simply, poorer performing nursing homes), individual facilities did have success stories. The American Health Quality Association (the QIOs’ professional organization) published these dramatic results on its Web site this spring: a 66% reduction of pressure ulcers in 90 days at Westwood Hills Nursing Home (Poplar Bluff, Missouri); a 69% reduction in facility-acquired pressure sores at St. Mary’s Nursing Center (Leonardtown, Maryland); and an almost 50% reduction of pressure ulcers at Chestnut Hill Convalescent Center (Passaic, New Jersey)-all as a result of the intensely focused programs by the facilities involved.

Approximately 20 QIOs are initiating a project this year with state survey agencies to identify nursing homes that have had repeated problems with higher-than-average deficiencies in their surveys and to work directly with them. Other new projects include train-the-trainer sessions for coaching nursing homes on resident-centered care and continuing education teleconferencing. “QIOs are loving working with nursing homes,” says Gail Patry, project manager for Rhode Island Quality Partners, the lead QIO overseeing the CMS Quality Initiative. “This has become a great interest for them, and they’ve warmed very much to this environment.”

Finally, in another recent government-related development, CMS has activated its Sharing Innovations in Quality (SIQ) Web site ( for long-term care-a repository of clinical standards and guidelines promulgated by various professional groups for managing specific medical conditions in nursing homes.

Figure. American Health Care Association/National Center for Assisted Living’s Foundations for Quality pyramid. Reproduced with the permission of the American Health Care Association/National Center for Assisted Living. (Click on image to enlarge)
Quality First: The Providers’ Response
Shortly after CMS announced its Quality Initiative, three major LTC organizations responded with Quality First. Although using the same program title and the same covenant-signing approach for their members, each organization has developed its own particular take on implementing Quality First.

American Health Care Association. AHCA has modeled its Quality First strategy on its eight-year-old Malcolm Baldridge Program for Performance Excellence competition, called “Foundations for Quality.” This educates facilities about specific criteria for leadership values and performance excellence and now encompasses Quality First principles (figure). AHCA’s state affiliates are given the lead role in assessing their memberships, determining specific needs and distributing tool kits of principles and guidelines to individual facilities. “We’re not prescriptive,” says Chris Condeelis, AHCA’s senior director of quality and professional development. “We’re not a licensing or enforcement agency. We provide a baseline of performance that everyone can accept and, we hope, aspire to achieve.”

As a result, individual state affiliates have each taken their own approaches to implementing quality improvement. For example, while Minnesota has adopted the AHCA approach across-the-board, Florida has developed a Quality First credentialing program requiring all members to sign on, and Georgia has adopted an ambitious Web-based benchmarking approach (with the Internet company MyInterview) that, according to Condeelis, “has generated more data on facility operations than anyone in the country.”

AHCA’s affiliates have ranged in sign-up rates from more than 60% (Colorado, District of Columbia, Georgia, Maryland, Pennsylvania, and South Dakota) to less than 15% (California, Iowa, Maine, New York, Oregon, and Tennessee). Condeelis says, though, that AHCA has as its goal an 80% sign-up across-the-board by the end of this year. AHCA is encouraging not only nursing homes, but also assisted living facilities and facilities serving the mentally retarded and developmentally disabled (MR/DD), to get involved with Quality First.

“The great thing about Quality First,” Condeelis concludes, “is that it aligns providers with their real primary customers-the residents and families-and makes facility operations completely transparent to them. It gets at the basics of the relationship of the provider to the resident.”

Alliance for Quality Nursing Home Care. The coalition of 14 national nursing home chains that developed as an industry advocacy group during long-term care’s post-Medicare PPS difficulties has opted for a corporate-based approach to Quality First. Beginning with the CEOs themselves signing the pledge, they promulgated its principles throughout their organizations as guidelines for action by their facilities. The Alliance then hired the Health Strategies Consultancy company to study the results of their companies’ efforts and come up with recommendations for the future. The study’s results and the Alliance’s initial plans were announced this summer. According to William Altman, senior vice-president of compliance, risk management, and government programs for Kindred Healthcare, and de facto chairman of the Alliance’s Quality First Pledge Steering Committee, the Alliance’s plan for the next year or so is threefold: to research and develop a standardized resident/family satisfaction survey leading to nonclinical quality measures to supplement CMS’s clinically oriented QMs; to inspire sharing of best practices among the companies, specifically with a conference inviting providers, researchers, policymakers, regulators, and consumers to recommend best practices and ways to share them; and to commit to continuing the Quality First process indefinitely and reporting to the public on a regular basis. Although the companies are, of course, competitors, Altman notes that “we have viewed Quality First as an opportunity to collaborate, not compete; this is reflected in all that we’ve done thus far. In fact, improving quality is viewed by everyone as an imperative, as a way of justifying the public dollars that are spent on long-term care.”

American Association of Homes and Services for the Aging. AAHSA has moved beyond having members sign covenants (at press time 1,875, or one-third of the membership, had signed up) to distributing a detailed Self-Study assessment allowing members to grade themselves, on a scale of one to four, on how well they are measuring up with ten components of quality (table). It has also received written feedback from many of the covenant signatories, although only a few published on AAHSA’s Web site thus far have pointed to specific operational upgrades. Like AHCA, AAHSA is running Quality First with a light touch. “We don’t want this to be Washington-driven,” says Bruce Rosenthal, director of AAHSA Quality First. “I’ve been invited to run local meetings for our members, but I’ve responded that they know best how to improve quality in their organizations, and that they should try to learn from one another in their localities.”

Rosenthal concedes that hard data from Quality First efforts by any of the associations are still hard to come by, but he adds that the facilities involved do have a story to tell about quality, and sometimes miss the opportunity to tell their residents, families, and local media about it: “Some of them haven’t thought of this yet.”

Also like the for-profit organizations, AAHSA is seeking to spread the word about Quality First from nursing homes to nonnursing home members, including in AAHSA’s case, operators of senior housing and home- and community-based services. “Continuous quality improvement, better human resources management, and other elements of Quality First apply across the board,” says Rosenthal.

After years in which long-term care quality was defined as a deficiency-free survey, the definition of quality and the drive to achieve it have assumed the proportions of a major movement. Government has broadened and deepened its role as a helpful collaborator, quasi-government agencies are developing their own projects and data banks, and the professional associations have responded with their own vigorous initiatives. Early evidence suggests that it’s working, but much more data on solid achievement are needed. A skeptical public and many of its elected representatives remain to be convinced. AAHSA’s Rosenthal notes, “The drive to quality must be continuous because needs and capabilities change over time.” Long-term care providers need to demonstrate their commitment to that view.

Table. AAHSA Quality First’s Ten Elements of Quality
Although these elements are taken from AAHSA’s Quality First materials, they are echoed in somewhat different styles and formats by AHCA and the Alliance:

  1. Commitment
  2. Governance Accountability
  3. Leading-Edge Care and Services
  4. Community Involvement
  5. Continuous Quality Improvement
  6. Human Resources Development
  7. Consumer-Friendly Information
  8. Consumer Participation
  9. Research Findings and Education
  10. Public Trust and Consumer Confidence

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