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A better alternative is to recognize this calm before the storm as an ideal opportunity to re-evaluate existing quality improvement (QI) programs and make any adjustments necessary to ensure that ongoing QI initiatives are up to the challenges presented by these looming changes. Ultimately, a well run QI program will safeguard a facility from increased risk during tumultuous times.

The Status of Quality Improvement
For many long-term care facilities, QI consists of regularly scheduled meetings at which committee members are presented with an extensive array of manually collected data points and statistics accumulated over the preceding period. Upon review, the committee identifies any problems and addresses them with changes to existing policies and procedures in the hopes of avoiding future issues.

While this approach may appear to be working, it isn't. It leaves the long-term tangible benefits of quality improvement on the table while frustrating front-line caregivers and placing the facility at risk.

Real QI starts with leadership's vision, which needs to be clearly communicated to every staff member throughout the entire facility. The vision should include goals based on facility-specific quality measurement trends and comparisons to state and national benchmarks.

QI success depends upon the understanding and support of every front-line caregiver. Too often, management spots what they perceive as a potential problem and issues a policy change in the hope of improving the situation. However, hasty changes result in new policies and procedures that may be impractical or impossible to implement. As a result, these changes are not followed by the caregivers. Instead of just one problem, now there are two. First, the perceived problem still exists, and second, there is a new policy and procedure not being followed.

The Road from QA to QI
When facilities reduce QI to a short-term reactive measure rather than a long-term proactive program, they can veer off course. In fact, many nursing homes take a detour, or simply stall, somewhere along the quality assurance road. Unfortunately, they never make it all the way to QI. After all, the QA road seems fairly straightforward and easy to navigate when facility managers adhere to the literal standards mandated by CMS F520, such as:

• Nursing homes must have a QA committee comprised of the DON, a physician and three other facility staff people.

• The QA committee must meet quarterly to identify issues related to QA.

• The QA committee must develop and implement a plan of action to identify and correct deficiencies.

Meeting these minimum standards, however, can create a false sense of accomplishment. Real rewards, such as improved quality measures, increased resident satisfaction, lower staff turnover and increased census are found beyond QA on the QI highway. Taking this highway, however, requires a mindset shift, as well as the development of new skills.

Best Practices for QI
Start with laying the proper foundation by having an established system for event reporting. Only with this foundation in place can a facility identify true problem areas, establish measurable and attainable goals for the future, and navigate the path to accomplishing these goals. Event reporting can be done manually, or by using a software application to help you capture, track and trend data more reliably. In general, the five universal steps to any event reporting system must include:

• evaluation or clinical assessment of the incident

• notification of family, staff and regulatory agencies when applicable

• investigation to determine the underlying cause of the incident

• intervention or a plan of action to avoid a recurrence of the incident

• resolution or continual monitoring and analysis to make sure that the intervention is effective.

The most effective QI programs are driven by leaders with clearly communicated goals. Developing the most appropriate goals requires input from all stakeholders including administrators, residents, family members, staff and even vendors. Once goals are established, identify those issues with the greatest potential to move the facility towards achieving the established goals. In the prioritization process, it is important to consider which projects will generate the greatest benefits for residents, staff and the organization.

To help identify and prioritize projects, consider examining the following data sources:

• incident/event logs (event reporting system)

• survey reports

• family/resident council information

• internal grievance concern process

• QM/QI information and trends

• consultant reports from the pharmacy, clinical, reimbursement, etc.

• at-risk populations that are high volume or problem prone areas.

Once you select a project, develop a well-defined system structure by identifying those responsible for managing the process and creating a team. Together, the team will develop a quality improvement action plan. While every action plan will be unique depending on the nature of the issue and the culture of the organization, a sound approach includes the following steps:

• Examine relevant policies and procedures to make sure they are practical, reasonable and meet current industry standards.

• Use root-cause analysis to investigate all events and any deviations from policy.

• Identify relevant data needed for collection: data elements, frequency, reporting and accountability.

• Set goals that are both measurable and attainable.

• Develop a written action plan: goals, responsibility, accountability, implementation process and timeframe.

• Create a method to accurately track, trend and analyze data.

• Communicate progress towards the goals.

• Follow through and continually monitor goals.

A Journey Worth Taking
QI is not a quick-fix with sole responsibility relegated to the QA committee chair. Continuous QI requires a well-planned, carefully executed, long-term initiative that starts with leadership's mission and vision. Not surprisingly, facilities with good QI programs have higher occupancy rates, more satisfied residents and families, and lower staff turnover.

While it may take a substantial amount of effort and time to implement, rewards such as improved outcomes, increased compliance, improved reimbursement and lower risk promise to make the journey a worthwhile investment.

Nancy J. Augustine & Susan LaBelle are senior healthcare specialists at PointRight Inc., Lexington, MA. DISCLOSURE: PointRight offers consulting services to LTC organizations.