Transcript Part 4: Identifying Meaningful Improvement Approaches

The Basis For Improving and
Reforming Long-Term Care
Part 4: Identifying Meaningful
Improvement Approaches
Steven A. Levenson MD, CMD
1
Objectives of This Segment

Previous segments have identified key
conceptual foundations

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For providing high-quality care
For overseeing and trying to improve care
quality
This final segment

Applies earlier discussions to assess current
and prospective efforts to improve and
reform nursing home care
2
Recommended Approaches
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A number of specific approaches herein
Based on the foregoing discussions

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Correctly define the problems
Identify their diverse causes
Present a cohesive strategy
Many of them differ from the
conventional wisdom
Should be taken seriously
3
Ongoing Criticism of Nursing
Home Performance

Continuing allegations
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Significant improvement still needed
Many important issues and conditions
remain inadequately recognized and
managed or, conversely, overtreated
Nursing home industry response
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In past decade, significant improvement
Competent care despite challenges
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More sophisticated postacute care more than in
4
other settings
What is the Truth?
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Is care as good as some claim?
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If so, why so many more reform efforts?
If not, why would more of the same be any
more beneficial?
Which approaches are likely to produce
dramatic improvements?
Just how good are the current
improvement and reform efforts?
5
Important Historical Context

Important to understand history of
attempts to reform nursing homes
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Just as patient history helps us understand
his or her current condition
Attempts to reform long-term care have
succeeded to some extent
6
Important Historical Context

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Previously, much of criticism of nursing
homes and their care has been
warranted
Challenge for nursing home staff,
practitioners, and management to
identify which of the numerous alleged
solutions are viable and worth pursuing
7
Important Historical Context

Some good intentions have gone astray
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Inconsistent and incomplete
implementation of pertinent ideas
Inaccurate and inappropriate advice
Questionable agendas of various interest
groups
Considerable resistance or sabotage
Abundant and problematic political
opportunism
8
Foundation For Subsequent
Reforms

Further tinkering is inadequate because
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Resources are limited
Waste is problematic
Results count more than ever
Important to consider reasons for
success or failure of previous efforts
9
Recommendations to Improve &
Reform Long-Term: Summary
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Reconsider current improvement and
reform efforts
Challenge the conventional wisdom
Vigorously subdue “political
correctness”
Rethink the research agenda
Focus attention on basic care principles
and processes
10
Recommendations to Improve &
Reform Long-Term: Summary

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Suppress reductionism and jurisdiction
over care
Reconsider notions of competency and
expertise
Change approaches to assessing and
trying to improve quality
Develop biologically sound
reimbursement
11
Reconsider Current
Improvement and Reform
Efforts
12
Sources of Efforts to Improve
and Reform Long-Term Care
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Governmental
Industry groups, associations, and
coalitions
Public and consumer initiatives
Physician initiatives
Insurance initiatives
Non-industry organizations and
associations
13
Types of Efforts Targeting
Reform
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Laws and regulations
Assessment tools
Workforce initiatives
Quality-improvement strategies
Work groups
Campaigns
Consumer initiatives (e.g., “culture
change”)
14
Categories of Approaches
Targeting Reform: Examples

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Improve information systems for quality
monitoring
Strengthen the regulatory process
Strengthen the care giving workforce
Provide consumers with more
information
15
Categories of Approaches
Targeting Reform
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Strengthen consumer advocacy
Increase Medicare and Medicaid
reimbursement
Develop and implement practice
guidelines
Change the culture of nursing facilities
16
Problems and Solutions
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Current reform initiatives
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A potpourri of approaches
Still lacks a comprehensive problem
statement and cohesive strategies
Inadequate to just aggregate multiple
“solutions” and reform agendas, e.g.

[Agenda A] + [Idea B] + [Campaign C] +
[Proposal D] + [Notion E]
17
Reform Misconceptions
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Easy to identify that something is amiss
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May not = having appropriate solutions
Analogous to care planning for a
complex patient
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Consequences may have multiple causes
Various causes may have multiple
consequences
18
Reform Misconceptions
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Before trying to “fix” the problems
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Define issues and identify root causes
More interventions are not necessarily
better
Some proposed approaches are
pertinent and meaningful

Others may exacerbate situation or just
circumvent underlying causes
19
Reform Efforts: Desirable and
Problematic
Desirable Efforts
Problematic Efforts
- Cohesive and compatible
- Fragmented, piecemeal,
uncoordinated, inconsistent,
incompatible
- Arise from thoughtful
discourse
- Based on inadequate
understanding of problems
and underlying causes
- Respect precedent
- Tend to reinvent the wheel
- Biologically sound
- Biologically unsound
- Promote all essential
elements
- Overly complicated; missing
key elements
20
Reform Efforts: Desirable and
Problematic
Desirable Efforts
- Promote full care delivery
process
Problematic Efforts
- Do not emphasize all care
delivery process components
- Emphasize empirical methods - Underemphasize rational
for clinical problem solving
clinical problem solving
- Emphasize good outcomes
- Emphasize good intentions
- Assess both results and
related processes
- Unbalanced emphases
- Valid approaches to
identifying care quality
- Inadequate approaches to
identify care quality
21
Reform Efforts: Desirable and
Problematic
Desirable Efforts
Problematic Efforts
- Focus on underlying care as
well as treating specific
conditions
- Overemphasize treatment of
specific conditions at expense
of underlying concepts
- Promote balanced care and
treatment in “context”
- Promote unbalanced or
superficial care
- Avoid false “medical / social”
model dichotomies
- Unbalanced emphasis on
“medical” or “social” models
- Balanced approaches to
regulatory compliance
- Excessive preoccupation with
regulatory compliance
- Promote vital management
role in effective care
- Downplay or overlook key
management role
22
Strategies: Reconsider Current
Improvement & Reform Efforts

Evaluate compatibility of various reform
efforts with key philosophical and
scientific principles
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Including evidence-based care and full care
delivery process
Focus more on defining issues correctly
and identifying root causes
23
Challenge the Conventional
Wisdom
24
Challenge the Conventional
Wisdom

“Conventional wisdom”
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“A belief or set of beliefs that is widely
accepted, especially one which may be
questionable on close examination”
Susceptibility of reform to the
conventional wisdom
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Only some of it is accurate and pertinent
25
Challenge the Conventional
Wisdom
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CW can impede genuine improvement
and reform if it
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Fails to identify issues correctly
Diverts attention and resources
Leads to inadequate or inappropriate
interventions
Both political and clinical CW
Diverse sources of CW
26
Political CW
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Political CW
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Refers to platitudes about nursing homes, their
staff, and quality of care, as well as to alleged
solutions
Clinical CW
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Refers to habitual and widespread approaches to
aspects of care
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Often inconsistent with evidence or fail closer scrutiny
May be so widespread that it becomes a false
“standard of care”
27
Political CW Example: RAI and
High-Quality Care
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Resident Assessment Instrument (RAI)
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Including Minimum Data Set (MDS)
Meant to improve on previously haphazard
and inadequate assessment
Can be helpful if used as originally
intended

A minimum data set with basic functional,
behavioral, and psychosocial information
28
Conventional Wisdom: The
Other Side
Conventional Wisdom
Unconventional Viewpoint
- Reformers are above
reproach
- Reformers deserve scrutiny
- Reformers may be blocking
legitimate solutions
- More laws and regulations
are needed
- Laws and regulations need a
biologically sound basis
- Nursing homes need to
measure performance
- Measurement has limits in
improving performance
- Nursing homes need
minimum staffing levels
- Numbers are just one part of
a much bigger picture
- Stronger enforcement is
needed
- Accountability needs to be
consistent and evidence-based
29
Conventional Wisdom: The
Other Side
Conventional Wisdom
Unconventional Viewpoint
- More research is needed to
solve these big issues
- Implementation of existing
knowledge is vital
- Interdisciplinary teams are
essential
- IDTs must function properly
and know their limits
- The more care that is given,
the better the quality
- More care may simply be
irrelevant or hazardous
- There are only a few poor
performing facilities
- Performance varies widely in
and among facilities
- Quality measurement
measures care quality
- Relevance of some current
quality measurement is unclear
30
CW Example: RAI
Misinterpretation and Misuse
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Regrettably, RAI has a life of its own
Often serves as primary or sole
informational basis for care
MDS has spawned new job description
(MDS coordinator) and many
consultants
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Many efforts to validate assessments and
conclusions that are based on it
31
RAI Use and Misuse
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RAI serves a purpose
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However, a limited guide to effective
clinical decision making
MDS does not consider detailed,
chronological patient history
RAI provides only a limited basis for
more complex care planning
32
RAI CW: Basis for Meaningful
Reform
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More realistic and balanced view needed of
the RAI and MDS
Intended for specific purposes
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Excessive reliance on assessment instruments has
become problematic
Limits to how much it can improve care or
give basis for sound reimbursement
Responses to concerns have not necessarily
been substantive
33
Political CW: The Virtues of
Interdisciplinary Teams
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Interdisciplinary team
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Use individuals of multiple disciplines to
provide care
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Key tenet of geriatrics and long-term care
Also referred to as interdisciplinary care,
interdisciplinary care teams, and
interdisciplinary collaboration
Approach has proven beneficial
34
Interdisciplinary Team:
Implications and Limitations
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Teams are a means to an end
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Not an end in themselves
Benefit of teams depends heavily on
training, knowledge, qualifications, and
performance of team members
Improper realization of IDT team
approach may
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Distort purpose
Impede care quality improvement
35
Team Approach:
Misconceptions
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Team approach can be redundant,
inefficient, or hazardous
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If team members exceed scope of
knowledge and skills
Having more participants does not
necessarily improve the care
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For example, separate “teams” for issues such
as weight loss, skin care, falling, and pain
A single comprehensive collaborative
review may be more biologically sound
36
Amount of Care as a
Reflection of Quality
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More interventions do not necessarily
produce better results
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A single intervention targeted at a root
cause may be preferable
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For example, hypothyroidism or medicationrelated adverse consequences
Evidence: more care may result in more
unnecessary treatment or complications
Amount of care not a reliable measure
of quality
37
Team Approach: Basis For
Meaningful Reform
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Need to reexamine how nursing homes
actually implement true IDT approach
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Such scrutiny is likely to show significant
variability and deficits
Ineffective or inappropriate team
approach can contribute to redundant,
irrelevant, or problematic care
38
Clinical CW: Alleged Virtues of
Antibiotics
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Many long-term care residents/patients
have infections
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Colonization is also very common
Antibiotics are commonly prescribed for
diverse symptoms and test results
For several decades, concerns about
use of antibiotics in various situations
39
Clinical CW: Alleged Virtues of
Antibiotics
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Specific criteria for antibiotics use exist
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Generally inadvisable to treat colonization
Misdiagnosis and inappropriate
antibiotic treatment are common
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Routine use of antibiotics for behavior
symptoms is largely unwarranted
40
Clinical CW: Alleged Evils of
Antipsychotic Medications
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Concerns about antipsychotic
medications a major driving force
behind nursing home reform efforts
Concern about inappropriate use of all
medications is warranted
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However, issues are far broader than any
one category of medications
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Including correct assessment and management
of behavioral and psychiatric issues
41
Clinical CW: The Alleged Evils
of Antipsychotic Medications
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Nursing home staff and practitioners often
bypass the care process
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Including meaningful details about behavior
Frequent push for psychiatric consultations
for changed or problematic behavior
Inadequate search for underlying causes may
lead to
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Poor outcomes
Unnecessary or problematic treatment
42
Clinical CW: The Alleged Evils
of Antipsychotic Medications
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Drug treatment of behavior and mood
disturbances often based on guesswork
New generation of medication-related
issues compared with traditional ones
Genuine reform requires attention to
issues underlying medication use
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Including related clinical problem-solving
and decision-making activities
43
Clinical CW: Pressure Ulcer
Prevention and Treatment
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Pressure ulcers arouse strong emotions
and fervent efforts at reform
Prevention and management of
pressure-related wounds has improved
overall in nursing homes
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It remains problematic in other settings,
and still in some nursing homes
Topic still influenced by mythology and
misinformation
44
Clinical CW: Pressure Ulcer
Prevention and Treatment
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CW heavily promotes nutrition to
prevent and heal pressure ulcers
CW promotes the idea that pressure
ulcers cause increased energy
expenditure
However, evidence often does not
support the CW

Despite evidence, pressure ulcer care still
haunted by myths and dogma
45
Clinical CW: Pressure Ulcer
Prevention and Treatment
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Poor personal, medical, and skin care still
common in diverse settings, including
hospitals
Continuing need for initiatives says much
about widespread and longstanding
inconsistent care
Genuine reform requires addressing basic
care failures in all settings

Including failure to care for all relevant concerns
and risks
46
Clinical CW: The Alleged Role
of Rehabilitation
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Rehabilitation is a central tenet of
geriatrics and long-term care
Medical stability and illness have a
major impact on function
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Patients allegedly sent “for rehabilitation”
commonly have multiple active medical
comorbidities and risk factors
Rehabilitation therapies mostly address
impairments, not underlying causes
47
Rehabilitation Concepts and
Misconceptions
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In long-term care, rehabilitation
commonly equated with provision of
therapy services
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Physical, occupational, and speech
Rehabilitation has become erroneously
equated with function and functional
improvement
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More discipline-centered than patientcentered
48
Rehabilitation Concepts and
Misconceptions
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Inappropriate labeling of being “sent for
rehab”
Excessive jurisdiction and domination of
utilization review
Diversion from seeking underlying
medical causes of impaired function
Knowledge about therapy modalities
not same as knowing how to identify
underlying causes of impaired function 49
Challenging the Conventional
Wisdom
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Genuine reform and improvement
requires rethinking and undoing much
of the conventional wisdom
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Many common practices in long-term care
are unfounded
Many beliefs about long-term care are
incorrect or misleading
Current CW often prevails because it
serves diverse agendas
50
Strategy: Challenge the
Conventional Wisdom
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Seek and use available evidence to
assess conventional wisdom
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Regardless of its source
Identify and contest common practices
that have questionable basis
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Including undesirable de facto “standards”
of care, despite incompatibility with
evidence
51
Vigorously Subdue Political
Correctness
52
Vigorously Subdue Political
Correctness
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Politics
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The means by which societies try to
accommodate and reconcile diverse needs,
desires, and perspectives.
Politics can be constructive or
problematic
Presently, some serious imbalances
53
Political Correctness
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“Political correctness” (PC)
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Operates at all levels
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Promote or expect certain beliefs, words,
attitudes, or actions
Avoid, sanction, or fail to even consider others
Within social institutions, facilities, organizations
Often merely a rationalization for

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Maintaining the status quo
Gaining personal advantage
54
Political Correctness
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Commonly used tactic to restrict open
discussion, inhibit accountability, or fail
to identify and resolve problems
In nursing homes
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Failure to allow open discussion about the
root causes of facility care problems
Failure to identify or restrict those
practicing beyond scope of their knowledge
and training
55
Political Correctness
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Critics and reformers may get
disproportionate attention and
credibility
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Includes scapegoating to divert attention
from others’ shortcomings
Political interventions, laws, and
regulations can be helpful, irrelevant, or
problematic
56
Genuine Reform: Subdue
Political Correctness
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Genuine improvement and reform
require more open and balanced public
dialogue about
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Long-term care's virtues and weaknesses
Appropriateness of proposed “solutions”
from diverse sources
Alleged “expertise”
Staff and practitioners who do
inappropriate and problematic things
57
Strategies: Subdue “Political
Correctness”
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Broaden dialogue about
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Strengths and weaknesses of long-term
care
Proposals to improve and reform it
Reinforce accountability at all levels
Contest incorrect and misleading advice
and instructions about care practices
and performance improvement

Regardless of the sources
58
Strategies: Subdue “Political
Correctness”
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Focus on identifying and incorporating
valid existing evidence into practices of
all disciplines
Contest efforts to rationalize
inappropriate practice and performance
Promote vital critical scrutiny of all
alleged reformers and their
recommendations
59
Rethink the Research Agenda
60
Knowledge and Its Effective
Implementation
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Many contributions from decades of
research
Huge gap between knowledge and its
effective application
Research is a means to an end
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Not an end in itself
An evidence basis for care does not
necessarily improve that care
61
Knowledge and Its Effective
Implementation
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Billions of dollars spent on medical
research
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Billions of dollars pay for care that fails to
apply relevant evidence
Newest or latest research is not
necessarily more valid
Current geriatric and gerontologic
research is often redundant and
esoteric
62
Knowledge and Its Effective
Implementation
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Many published studies comment on need for
more research
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May not consider how to improve application of
existing knowledge
Already known how to provide, oversee, and
maintain high quality care
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Some highly competent nursing homes, staff and
practitioners exist
It is possible to identify why some succeed while
others do not
63
Respecting Precedent
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Desirable improvement and reform
activities respect existing knowledge

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Consider effectiveness of applying existing
knowledge
Emphasize enduring and universal clinical
and management principles
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For example, problem solving and linking
causes and consequences
64
Example: Medications

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For example, issues related to
medications have been identified for
decades
Researchers keep studying the topic
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Conclusions not remarkably different from
the past
Problem of adverse medication
consequences remains widespread

Perhaps worse than ever
65
Studying the Right Things
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Instead of continuing to study what is
overtreated and undertreated
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Real issue: is there optimal medication
intervention based on effective clinical problem
solving and decision making?
Cannot overlook existing information that
already bridges research and clinical practice
It may be time to think differently about

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Utility of research
Effective translation of findings into practice
66
Studying the Right Things

Important issues concern ability to
identify and apply existing knowledge to
specific circumstances

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For example, applying topical knowledge to
patient care
More pragmatic approaches outside of
the research arena may be useful

Successful implementation of these
approaches has varied
67
Questions and Answers

In all aspects of life, answers we get
depend on the questions we ask

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In research, overlooking hypotheses likely
gives results reflecting limited alternatives
Could depression be overdiagnosed or
overtreated?
Could issues concerning end-of-life care
relate to failed processes and practices?
68
The Need for Context

Research-related interventions may be
developed and tested under optimal
conditions
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Often differ from real-world conditions
Often highly standardized, intensive,
implemented by trained research staff
Disease-specific guidelines must be
applied in the proper context
69
The Need for Context

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Too much information and advice can
be confusing
Need to rethink current research
approaches
Need to expand scope of issues for
funding

Reconsider funding endless reiteration of
the same topics and hypotheses
70
Refining Research Community
Rethinking

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Expand research hypotheses to include
meaningful but largely overlooked
issues
Focus on basic challenges of
implementation
Seek more basic real-world solutions
Reveal predispositions and conflicts of
that taint current dialogue and inquiry
71
Meaningful Research
Hypotheses: Examples

What is impact of proper and improper care
process and clinical problem solving and
decision making on outcomes?

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Proper care delivery process task performance
essential to high-quality care
Lapses in care delivery process-related task
performance underlie care / quality issues
Failures of cause identification are major source of
avoidable negative outcomes
72
Meaningful Research
Hypotheses: Examples

How well do nursing home staff and
practitioners apply the care delivery process?

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Only some of them understand and apply the full
care delivery process
How much can nursing homes compensate
for knowledge and skill deficits?

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There are significant limits
Need more individuals who already have certain
basic knowledge and skills
73
Meaningful Research
Hypotheses: Examples

Are certain vital issues being overlooked
or downplayed?


For example, medication-related issues
have major impact on function and quality
of life
Is reliable current knowledge about care
process being used?


Nursing homes often advised incorrectly
Current evidence often not applied
74
Meaningful Research
Questions: Examples

Do nursing homes hold staff and
licensed professionals accountable
for their performance and practice?

Accountability is inconsistent, leading
to problematic care and outcomes
75
Meaningful Research
Hypotheses: Examples

Do treatment and care decisions
have a valid clinical rationale?
Valid rationale often missing or
incompatible with patient-specific
evidence
 Too much care is based on guesswork
and rote interventions

76
Meaningful Research
Hypotheses: Examples

How do practices and care in other
settings affect outcomes of patients
who are sent to nursing homes?

Many patients come after inadequate or
inappropriate care prior to transfer

Inadequate or inappropriate previous care has
major impact on


Achieving specific results
Avoiding complications
77
Meaningful Research
Hypotheses: Examples

To what extent do organizational and
operational issues impact care quality
and outcomes?

Facility management and care systems
profoundly influence


Care delivery process
Provision of appropriate, safe, and effective
care
78
Strategies: Rethink the
Research Agenda

Shift balance towards implementing
existing knowledge




Analyze failures in implementation
Recognize precedents, including
existing knowledge
Consider more pragmatic approaches to
influencing and improving performance
Broaden scope of research hypotheses
79
and questions
Strategies: Rethink the
Research Agenda

Redirect funding more towards
rethinking traditional approaches



Reduce repetition of conventional wisdom
Reexamine conflicts of interest that
impede free inquiry and dialogue
Focus much more attention on basic
care principles and processes
80
Focus Attention on Basic Care
Principles and Processes
81
Focus Attention on Basic Care
Principles and Processes




Good care results from painstaking
detective work
Nursing homes need more individuals
with basic generic competencies
Need a return to the roots of primary
care medicine and nursing
Need faithful adherence to the care
delivery process
82
Strategies: Focus on Basic
Care Principles and Processes



Move away from prescriptions and
procedures as surrogates for real health
care and real dialogue
Diagnostic inadequacies are recognized
as a basic patient safety issue
Nursing homes may not need highly
complex diagnostic capabilities

But, they must improve on basic cause
identification
83
Strategies: Focus on Basic
Care Principles and Processes

Focus on




Strengthening care delivery process
Minimizing diagnostic fallacies and avoid
treating the chief complaint
Addressing challenges to providing safe
and effective care
Strengthening clinical problem solving and
decision making to help compensate for
these challenges
84
Strategies: Focus on Basic
Care Principles and Processes

Scrutinize impact of reform and
improvement initiatives on care delivery
process


At least, these activities must not inhibit or
contradict key principles
More accountability and consequences
needed for those who give inadequate
and incorrect instruction and advice
85
Suppress Reductionism and
Jurisdiction
86
Suppress Reductionism and
Jurisdiction Over Care


Time to reverse the trend to excessive
reductionism and jurisdiction over
aspects of long-term care
Reductionism


Misconception that aggregating pieces of
care = managing the whole patient
Jurisdiction

Giving various disciplines or settings rights
of supremacy to diagnose and treat
87
Suppress Reductionism and
Jurisdiction Over Care


Every conclusion and patient
intervention needs a proper context
Excessive jurisdiction



Is biologically unsound
Undermines proper clinical problem solving
and decision making
Need proper interdisciplinary application
of care delivery process

Including appropriate individual roles
88
Suppress Reductionism and
Jurisdiction

Capable staff and practitioners




Willingly explain evidence basis for their
conclusions and decisions
Take responsibility for results
Can analyze and recover from unexpected
or avoidable complications
Less capable individuals do not


Offer a valid basis for conclusions
Accept appropriate responsibility
89
Suppress Reductionism and
Jurisdiction


Shortages of qualified staff and
practitioners do not justify inappropriate
practices with adverse consequences
“Political correctness” must not inhibit
accountability for performance and
practices

Including setting appropriate limits on
clinical decision making prerogatives
90
Strategies: Suppress
Reductionism and Jurisdiction




Apply evidence and manage issues in
the proper context (phronesis)
Ensure that care is consistent with basic
physiological principles
Inhibit claims of primary or exclusive
rights to diagnose and treat specific
problems and body parts
Faithfully implement correct
91
interdisciplinary team approach
Reconsider Notions of
Competency and Expertise
92
Reconsider Notions of
Competency and Expertise




Nursing homes need direct care staff and
practitioners who can do basic tasks well
Shortage of both direct care work force and
professionals and practitioners
Could take many years to educate and train
enough additional staff and practitioners
Meanwhile, much more could be done to
improve current capabilities and performance
93
Critical Generic Workforce
Competencies







Make, report, document observations
Collect and organize information
Examine evidence
Provide a chronological story of events
Reason inductively and deductively
Formulate hypotheses
Draw conclusions

Providing rationale for those conclusions
94
Critical Generic Workforce
Competencies






Solve problems
Seek and identify causation
Give detailed answers to questions
Deal with multiple simultaneous causes
and consequences
Follow instructions and procedures
Abide by limits of personal knowledge
and skills
95
Reasons For Variable
Performance

Diverse reasons for desirable and
inadequate performance; for example




Inadequate knowledge
Failure to apply knowledge
Deficient clinical problem solving and
decision making skills
Effective reform efforts must address
these diverse issues and root causes
96
Strategies: Workforce
Functions and Competencies

Rethink key strategies about what
constitutes competency and “expertise”



Topical knowledge is important
Each topic must be applied in the proper
context
Knowledge about a topic does not
guarantee expertise in clinical problem
solving and patient management
97
Workforce Functions and
Competencies


Limited impact of knowing regulations
and survey issues on teaching key carerelated competencies
Vital to


Clarify individual staff and practitioner
functions
Emphasize competent performance of
tasks related to the care delivery process
98
Workforce Functions and
Competencies

Example


Observers and information gatherers
should be able to do capable job regardless
of the issue
Higher skill levels involve more
extensive capabilities in performing
more complex tasks; for example


Perform a detailed physical exam
Identify multiple causes of symptoms
99
The Cascade of Competent
Performance and Practice

Collect and analyze information
in order to perform
- Accurate problem definition & cause identification
resulting in
- Effective clinical problem solving and decision
making
leading to
- Evidence-based, individualized care
100
Workforce Training and
Preparation

Emphasize training in approaches and
philosophies that geriatrics represents


For example, managing syndromes, not just
symptoms and diseases
Derive competencies from understanding
roles, functions, and tasks related to


Care delivery process
Clinical problem solving and decision making
101
Workforce Training and
Preparation



Only so much can be done to
compensate for workforce deficits
Genuine reform requires a combined
approach
Need to expand teaching generic
competencies in public and health
professional education; for example


Organize and present complex information
102
Make and document observations
Workforce


Changes approaches to on-the-job
education and training
Limited proven effectiveness of many
current education practices


For example, in-services
More case-based training and learning

Including direct oversight of actual
performance on the job
103
Strategies: Reconsider Notions
of Competency and Expertise



Reconsider notion of expertise and
criteria for determining who is an expert
Distinguish genuine clinical and
management expertise
Rethink strategies and core
competencies for training work force
104
Strategies: Reconsider Notions
of Competency and Expertise



Focus public education on improving
key generic competencies
Shift health care professional education
to include key concepts
Shift approaches to training and
educating nursing home staff
105
Change Approaches to Assessing
and Improving Quality
106
Change Approaches to Trying
to Improve Quality


Rethink current approaches to assessing
and improving quality
Some current approaches are pertinent
and meaningful

Others may actually impede definitive
improvement
107
High Quality Care

High quality care has certain attributes


Safe, effective, efficient, person-centered,
equitable, timely
Attained by consistently doing the right
things in the right way

This approach may be most likely to attain
desirable results
108
Path to Quality Care
How Done 
What Is Done
Right Thing
Wrong Thing
Right Way
Wrong Way
+/+
+/-
-/+
-/-
109
Quality Improvement


Quality improvement principles and
practices are universal and enduring
Quality improvement activities try to
influence human performance by



Identifying and measuring performance
Giving feedback over time
Nursing homes vary widely in adopting
basic quality improvement approaches
110
Trying to Improve Quality


All facilities receive at least some external
data
Some facilities also routinely collect and
analyze their own data


Others do little of either
Genuine improvement and reform require
facilities to have successful quality
improvement activities

With balance between internal and external
sources of data and feedback
111
Limits of Measurement




Numerous efforts to improve quality by
collecting and analyzing data
Not everything being measured is
meaningful
Only some meaningful things are being
measured
Quality measurement and quality
indicators are a means to an end
112
Potential Complications From
Measuring Quality



Harm related to diagnostic fallacies
Overlooking other important issues not
covered by quality measures
Overemphasis on interventions


In contrast to full care process
Goal attainment at expense of method

“What” is done becomes too important
relative to “why”
113
Balancing Outcome and
Process Emphasis


Nursing home reform efforts driven by
concern about “paper compliance”
Institute of Medicine 1986 report


Recommended quality indicators based on
resident-centered measures of process
AND outcome quality
Unfortunate misunderstandings about
“process”
114
Balancing Outcome and
Process Emphasis



Care process compliance is not “paper”
compliance
Effective clinical problem solving and
decision making are vital for outcomes
Genuine reform requires better balance
between outcomes and care processes
as basis for assessing care quality
115
Divide and Combine


OBRA regulations and surveyor
guidance divide care by topic
Currently quality measures aggregated
and reported by facility

Then compare each facility to composites
116
Divide and Combine

However, these approaches have limits



Limited value to outcomes data without
seeking



Human physiological processes are closely linked
Often, multiple simultaneous causes and
consequences
Common causes of diverse clinical and operational
outcomes
Diverse causes of individual outcomes
Context and links among various areas of
concern are all important
117
Divide and Combine



Facility outcomes cannot be judged just
by comparing to other facilities
Patient characteristics and other factors
often influence results
Unsound practices may sometimes
produce desirable results but cause
potentially avoidable complications

For example, address pain but cause
anorexia, depression, or delirium
118
Divide and Combine

Must aggregate diverse outcomes per
patient


Cannot just look at rates of unplanned
weight loss, depression, and pain as
separate entities
Better balance needed between


Identifying aggregate outcomes and
Evaluating underlying processes and
practices in individual cases
119
Taking the Measure of
Measures


Some pertinent care process-based quality
measures exist
Must identify limitations as well as attributes
of alleged quality measures


Including those based on MDS
For example, a facility's scores on diverse
measures


Do not necessarily correlate
May fluctuate significantly over time, despite
consistent processes and practices
120
Taking the Measure of
Measures





Questionable clinical validity of some quality
measures
Results on specific measures may vary over
time
Improving on specific measure does not
necessarily improve care overall
Must acknowledged limits of information
derived from fixed data sets
Need broader, more balanced approach
121
Efforts to Improve
Performance: Examples

Diverse efforts to try to improve results by
influencing performance and practice


Modified OBRA survey process and related
surveyor guidance
National campaign has focused on improving
performance through



Quality measures
Quality Improvement Organizations (QIOs)
Local coalitions
122
Limits of Impact of Measuring
Quality

Ultimately, quality measurement can
only improve performance somewhat



For example, giving more statistics to an
athlete does not necessarily produce
additional improvement
Also need capacity to improve and
proper guidance
Addressing root causes may improve
multiple performance aspects
123
Root Causes Are Vital

Nursing home reform requires
recognizing and addressing root causes


Not just finding more things to measure
For example


Identifying deficits in clinical problem solving
and decision making
Identifying inadequate accountability for
ineffective performance and clinical decision
making
124
Strategies: Change Approaches to
Assessing & Improving Quality



Balance assessing outcomes and
underlying processes and practices
Emphasize internal systems for
identifying and addressing quality issues
Recognize limits of measurement in
improving performance
125
Strategies: Change Approaches to
Assessing & Improving Quality



Find a balance between measuring
things and improving processes and
practices
Recognize limits of using aggregate
outcomes to judge care quality for
individuals
Recognize limits of fixed data sets as
basis to evaluate quality
126
Develop Biologically Sound
Reimbursement
127
Develop Biologically Sound
Reimbursement

Incentives ultimately are a major
influence on human behavior



Money is a major incentive in many
societies
Reimbursement must be compatible
with—and not inhibit—desirable care
Physiology does not obey payment rules


Payment must be biologically sound
At present, it is only partially sound
128
Develop Biologically Sound
Reimbursement

Payment for care is often based on
providers and treatments


Instead of patient characteristics and
needs
Evidence that combinations of patient
characteristics influence multiple
outcomes

Both causes and consequences are
relevant
129
Develop Biologically Sound
Reimbursement


Care is often reimbursed despite
incompatibility with key concepts,
practices, and processes
Payment sources still unduly influenced
by less significant things



Primary diagnoses / DRGs
Facility licensure or category
Treatments and services rendered
130
Develop Biologically Sound
Reimbursement

Insurers may pay for treatment




Without adequate problem definition and cause
identification in one setting
Additionally required because of earlier process
failures
MDS-based Prospective Payment System
(PPS) as an example
Payment must consider impact of both causes
and consequences
131
Root Causes of Wasteful Care


Much concern expressed about waste
and inefficiency in health care
“Reform” must identify and tackle key
root causes


For example, failures of the care delivery
process in diverse settings
Reimbursement must not distort care
approaches; for example,

Labeling patients based on treatment
132
Strategies: Develop Biologically
Sound Reimbursement


Recognize how reimbursement
influences care practices and quality
Modify reimbursement to



Promote biologically sound clinical problem
solving and decision making
Inhibit biologically unsound approaches
Limit expectations for pay-forperformance to help correct quality,
performance, or cost issues
133
Summary



Enduring improvement and reform
require focus on things not commonly
considered
Essential biological, medical, and
philosophical principles
Consider whether reform efforts


Reflect and promote desirable approaches
Avoid and inhibit undesirable approaches
134
Summary: General
Responsibilities For Reform

Better understanding by overseers and
reformers of




What they are trying to oversee and
improve
Their appropriate roles
Impact of social institutions and culture
on identifying and solving problems
Need for improvement in every
component of health care system
135
Summary: Reforming the
Reform Efforts


History of efforts to improve long-term
care reflects American society and
culture in general
Respecting essential, enduring, and
universal concepts and approaches
typically brings desirable results

Defying them brings perilous consequences
for health and well-being
136
Summary: Reforming the
Reform Efforts

Need much more attention to the basics



Not inadequate workaround “solutions”
Need universal accountability
Need to stop scapegoating nursing
homes for more universal failures


Politics of scapegoating are never
constructive
For example, hospitals and their
practitioners
137
Summary: Applying the
Lessons


Lessons of efforts to reform long-term care
apply to all facets of the health care system
Reform and improvement are entirely possible


Only by respecting and applying key concepts and
approaches
Law of gravity is universal

Either respect it to our advantage or defy it at our
own risk
138