JAMDA 14 (2013) 60e61
JAMDA journal homepage: www.jamda.com
Brief Report
Implementation of Quality Assurance and Performance Improvement Programs in Nursing Homes: A Brief Report Kelly M. Smith a, *, Nicholas G. Castle MHA, PhD b, Kathryn Hyer PhD, MPP a a b
School of Aging Studies/Florida Policy Center Exchange on Aging, University of South Florida, Tampa, FL Department of Health Policy & Management, University of Pittsburgh, Pittsburgh, PA
a b s t r a c t Keywords: Quality assurance performance improvement
The purpose of this article was to investigate nursing homes’ (NHs’) readiness to implement a quality assurance and performance improvement (QAPI) program as required by Section 6102 of the Affordable Care Act. Nursing home administrators (NHAs) in 3000 NHs (response rate, 67%) were surveyed using a 70-item questionnaire to assess: (1) current facility approaches to quality, (2) NHA’s self-assessed knowledge of QAPI techniques; and (3) the use of QAPI techniques. The Online Survey, System for Certification and Administrative Reporting data and the Area Resource File were also used to examine and compare facility and market characteristics. As rated on a scale of 1 to 10, NHs are more likely to use quality assurance (rating, 7.2) and least likely to use total quality management (rating, 4.1). Few NHAs use tools for QAPI such as flow charts (23%), Plan-Do-Check-Act cycles (13%), or run charts (9%). A gap in knowledge of quality improvement tools has been identified signifying that the new QAPI regulations may pose an issue for NHAs who possibly lack the knowledge and technical expertise to implement a comprehensive QAPI program. Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.
Recent legislation requires the Secretary of Health and Human Services to implement a quality assurance and performance improvement (QAPI) program within nursing homes (NHs). Research has demonstrated a breach amid the collection and utilization of resident assessment data to guide quality improvement.1 Thus, it is unclear whether NH providers will be able to meet these new standards. The purpose of our research study was to explore NHs’ readiness to implement QAPI programs by assessing: (1) current facility approaches to quality; (2) NH administrators’ (NHAs’) self-assessed competence with QAPI techniques; and (3) use of QAPI techniques. Legislation contained within Section 6102 of the Affordable Care Act requires: (1) the secretary of Health and Human Services to implement a QAPI program within NHs; and (2) NHs to submit a plan of action to meet QAPI standards. Currently, under 42 CFR, Part 483.75(o), NHs are only required to maintain a quality assurance committee that meets quarterly. Based on a demonstration being conducted by the Centers for Medicare and Medicaid Services (CMS), new standards are expected to be published and a full rollout of the program in 2013.2 Under CMS requirements, NHAs are appointed by a governing body and required to have appropriate licensure. Although licensure The authors have no conflicts of interest and no funding was received for their work. * Address correspondence to Kelly M. Smith, School of Aging Studies/Florida Policy Center Exchange on Aging, University of South Florida, MHC1300, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612. E-mail address:
[email protected] (K.M. Smith).
requirements may vary among individual states, state licensing examinations focus on facility-level management skills such as knowledge of applicable laws (federal, state, and local), resource planning, staffing, financial management, marketing, and quality. Beyond a basic understanding of quality assurance processes, quality indicators, and quality measures, NHA training lacks substantive instruction on skills required to identify, quantify, and rectify deficiencies. Thus, we propose that NHAs are not knowledgeable about QAPI techniques (hypothesis 1) and NHAs do not use QAPI techniques on a regular basis (hypothesis 2). Method To examine NHs’ readiness to implement QAPI programs, we developed a questionnaire to assess NHAs’ current use and understanding of QAPI methodologies in NHs. The University of Pittsburgh Institutional Review Board approved this research. Development and use of existing QAPI surveys with NHAs as respondents is limited, with the exception of the survey used by Lucas and colleagues.3 This survey was used; however, because of the wide-ranging scope of QAPI in NHs, a literature review and interviews with directors of nursing and NHAs were used to create additional items. Details regarding the survey development process are not included because of space constraints, but they, as well as copies of the instrument, are available on request. In this research, we focus on 3 content areas. First, the facility approach to quality was assessed by examining how often specific
1525-8610/$ - see front matter Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc. http://dx.doi.org/10.1016/j.jamda.2012.09.010
K.M. Smith et al. / JAMDA 14 (2013) 60e61 Table 1 Descriptive Statistics of NH Administrators and NH Sample Mean (or %) Demographic Characteristics Male Age Education Master’s or higher Bachelor’s degree Employment Characteristics Years of experience as a NHA Tenure (months) Turnover DONs (past 3 years) Turnover NHAs (past 3 years) Organizational Factors Medicaid resident occupancy Size (number of beds) For-profit ownership Chain member Occupancy rate External Factors Medicaid reimbursement rate ($)* Competition (Herfindahl Index)y Elderly in county (per 1000 population) Per capita income ($)
Standard Deviation
72% 53
(11)
42% 43%
-
15 23 3.5 3.1 62% 121 60% 52% 84% 133 2100 143 27188
(7) (15) (2.6) (2.5) 22 67 15
61
Table 3 Descriptive Statistics of the Quality Assurance and Performance Improvement Methods Examined Method
Facility Uses Frequently, %
NHA Rating of Ability to Understand Quality Methods (0e10)*
Scorecards Root cause analysis Run charts Benchmarks Dashboards Adverse events or never events Trending of quality indicators Improvement targets Identification of problem-prone areas Control charts Pareto charts Flow charts Cause-and-effect diagram PDCA cycle
5 6 9 42 3 24 58 37 52 8 4 23 6 13
6.7 5.4 8.5 9.1 7.3 7.9 8.4 8.4 9.1 6.9 4.2 8.0 5.3 4.2
NHA, nursing home administrator; PDCA, Plan-Do-Check-Act. *Scale used was 0 ¼ very poor through 10 ¼ excellent (N ¼ 2318 NHAs).
32 2367 372 7701
NHA, nursing home administrator. *Percentage of residents using Medicaid as primary form of payment. y Measure of local NH market competition; (N ¼ 2,426 NHAs).
approaches (eg, quality improvement, total quality management) are used. NHAs were asked to rate their use on a scale of 1 to 10 (10 ¼ always and 0 ¼ never). Second, competencies in using quality tools were examined, with NHAs asked to rate their understanding on a scale of 1 to 10 (10 being the highest). Third, the facility use of specific quality tools (eg, run charts, Pareto charts) was examined. NHAs were asked to reply “no,” “yes,” a little,” or “yes, frequently.” A simple random sample of 3000 NHs from contiguous states was created and derived from the Online Survey, System for Certification and Administrative Reporting (OSCAR) data (see Kim, Harrington, and Greene4 for a description of these data). The University of Pittsburgh Institutional Review Board approved this research. Descriptive statistics were used. A summary score for each questionnaire item was generated. First, for the items using the “no,” “yes, a little,” or “yes, frequently” scale, the summary score represents the percentage of yes, frequently responses. Second, for the items using the 1 to 10 scale, the summary score in this case represents the mean of the values reported. These summary scores help facilitate parsimonious reporting. Results Responses were received from 2318 NHAs (66% response rate). Descriptive statistics of NHA respondents and sample are reported in Table 1. No significant differences between our sample and national Table 2 Descriptive Statistics of Nursing Homes’ Approach to Quality
samples (ie, 2004 National NH Survey; analyses not shown) were observed relating to facility and market characteristics were discerned. Results indicated that facility approaches to quality were most likely to be use of Quality Assurance (ie, rating, 7.2) and least likely to be Total Quality Management (ie, rating, 4.1). These results are shown in Table 2. Table 3 displays the QAPI methods and techniques used by NHs. Discussion The proposed QAPI regulations present a new orientation for potential quality improvement. However, findings from our survey suggest that NHAs do not typically use performance improvement tools such as Plan-Do-Check-Act cycles, cause-and-effect diagrams, root cause analyses, and Pareto charts. Consistent with CMS Quality Improvement Organization’s quality focus, approximately half of the facilities frequently use quality improvement methods such as trending of quality indicators and identification of problem-prone areas, suggesting that NHAs may lack some QAPI capabilities necessary to conform to the new QAPI regulations. Accordingly, policymakers and stakeholders may need to address other rudimentary issues beginning with a basic knowledge of quality improvement tools before the rollout of the QAPI program. The efficacy of quality improvement initiatives has been demonstrated5; however, a gap in knowledge exists between NHA familiarity with QAPI tools and the skills required to implement QAPI programs in NHs. As demonstrated in this research, these requirements may pose a problem for NHAs who may lack the knowledge and technical expertise required by a comprehensive QAPI program. References
Facility Approach
NHA Rating (0e10)*
How often do you use Quality Assurance to examine/improve your quality? How often do you use Quality Improvement to examine/improve your quality? How often do you use Continuous Quality Improvement to examine/improve your quality? How often do you use Total Quality Management to examine/improve your quality?
7.2 6.4 4.3 4.1
NHA, nursing home administrator. *Scale used was 0 ¼ never through 10 ¼ always (N ¼ 2318 NHAs).
1. Rantz MJ, Zwygart-Stauffacher M, Flesner M, et al. Challenges of using quality improvement methods in nursing homes that “need improvement”. J Am Med Dir Assoc 2012;13:732e738. 2. Stratis Health. Stratis Health leads national demonstration project to improve care in nursing homes (Quality Update). 2011. Available at: http:// www.stratishealth.org/pubs/qualityupdate/f11/qapi.html. Accessed August 20, 2012. 3. Lucas JA, Avi-Itzhak T, Robinson JP, et al. Continuous quality improvement as an innovation: Which nursing facilities adopt it? Gerontologist 2005;45:68e77. 4. Kim H, Harrington C, Greene WH. Registered nurse staffing mix and quality of care in nursing homes: A longitudinal analysis. Gerontologist 2009;49:81e90. 5. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II Collaborative quality improvement project. J Am Geriatr Soc 2011;59:745e753.
