Years ago, as a licensed nursing home administrator, I was 100% responsible under regulation for everything my staff did in my facility 24/7. I accepted this responsibility. I took it seriously, making certain that background checks and extensive pre-hire screenings were carried out on all applicants. These days, facilities with Corporate Integrity Agreements are required to screen all new hires and all employees annually against Federal Exclusion lists. And many long-term care companies are now going above and beyond: screening all employees annually as part of their routine compliance activities, even though they are not required to do so.
Despite the best of intentions, even annual screenings of employees can be woefully inadequate when it comes to protecting vulnerable populations against dangerous caregivers.
Sadly McKnights Long-Term Care News reports that the long-awaited national database of caregivers to be unveiled March 1 is incomplete .
According to the Los Angeles Times, 22 years have elapsed since Congress ordered the national database deployed and next week's release date debuts a deficient database. Their investigations showed that many states submitted reports only occasionally, and some states submitted incomplete information on registered nurses. States were especially deficient in reporting more recent disciplinary actions taken against problem workers. Apparently some of the missing cases were people who had done harm to residents, “a nurse, for instance, whose license was pulled after she injected a patient with painkillers in a drugstore parking lot and improperly prescribed methadone to an addict who later died of an overdose.”
With the burden of responsibility resting squarely on the shoulders of individual long-term care leaders, what does it take to get complete and accurate information from those who hold us accountable for resident safety?
The industry as a whole has never been more serious about preventing resident abuse and carefully screening job applicants in the interest of protecting residents. To wait 22 years and then have the database be incomplete and inaccurate is an insult to the tremendous efforts being made by long-term care leaders. Certainly it is in the public interest to get this right.
Tuesday, February 23, 2010
Wednesday, February 17, 2010
Good Company Policies: the road to good healthcare practices or to a 3-ring circus?
Companies that take the time to conceive good policies set the stage for good practices in healthcare. I say conceive because all too often, there’s a long road between the idea of the policy, and even the preparation of the policy, and its translation into practice on the floor. And the closer you get to the bedside, the longer that road becomes.
Michael Rasmussen, president of Corporate Integrity LLC, outlines a very clear process for making sure that policies stay relevant and current. He proposes a “lifecycle” approach to policy management that includes four elements, creation, communication, management and maintenance. Creation is an iterative process of ownership, authorship and approval. Communication involves publication, training, and attestation. Management includes enforcement and exception management. Finally, management includes review and archival.
I find this scheme very useful for its simplicity and easy application. The process itself is challenging, but this framework is a user-friendly road map.
Rasmussen also makes a compelling argument for the importance of well-managed policies in compliance and risk management. Since organizational psychology defines culture as the way work gets done, it’s easy to see the essential role that policies and procedures play by defining the way work gets done and establishing clear expectations for compliance.
The Proverbial 3-Ring Circus....
Why is it then, as vital as good policies are, that so many long-term care companies focus on policy binders rather than on content?
So why is it, as important as they are, that so many long-term care companies focus on their binders rather than their content, burying themselves under so many policies that it becomes virtually impossible to manage the binders much less the policies effectively?
Too often, I find that when a monitor or surveyor reviews a policy, they find it outdated or not being followed. In my own work over 30 years, I have universally found policies to be little known and little used tools. Thus, the very policies that should articulate our culture of service, care, and compliance actually work against us. Or maybe we work against them.
I think it is time to rethink the way we create, communicate, manage, and maintain organizational policies and procedures so that they serve the needs of the organization and its customers in real time. I’d like to see policies that make the organization think and learn and grow so that policies grease the wheel of performance improvement, continuously moving the company toward greater and greater achievements. Working with clients to develop tools and policies in tandem so that the principles of performance improvement are built into every practice is a major focus of our work for this very reason.
Michael Rasmussen, president of Corporate Integrity LLC, outlines a very clear process for making sure that policies stay relevant and current. He proposes a “lifecycle” approach to policy management that includes four elements, creation, communication, management and maintenance. Creation is an iterative process of ownership, authorship and approval. Communication involves publication, training, and attestation. Management includes enforcement and exception management. Finally, management includes review and archival.
I find this scheme very useful for its simplicity and easy application. The process itself is challenging, but this framework is a user-friendly road map.
Rasmussen also makes a compelling argument for the importance of well-managed policies in compliance and risk management. Since organizational psychology defines culture as the way work gets done, it’s easy to see the essential role that policies and procedures play by defining the way work gets done and establishing clear expectations for compliance.
The Proverbial 3-Ring Circus....
Why is it then, as vital as good policies are, that so many long-term care companies focus on policy binders rather than on content?
So why is it, as important as they are, that so many long-term care companies focus on their binders rather than their content, burying themselves under so many policies that it becomes virtually impossible to manage the binders much less the policies effectively?
Too often, I find that when a monitor or surveyor reviews a policy, they find it outdated or not being followed. In my own work over 30 years, I have universally found policies to be little known and little used tools. Thus, the very policies that should articulate our culture of service, care, and compliance actually work against us. Or maybe we work against them.
I think it is time to rethink the way we create, communicate, manage, and maintain organizational policies and procedures so that they serve the needs of the organization and its customers in real time. I’d like to see policies that make the organization think and learn and grow so that policies grease the wheel of performance improvement, continuously moving the company toward greater and greater achievements. Working with clients to develop tools and policies in tandem so that the principles of performance improvement are built into every practice is a major focus of our work for this very reason.
Monday, February 8, 2010
The result of regulation? It’s all in how you look at it…
Brian Garavalia, Ph.D. makes a compelling case about the relationship between regulation and environmental improvements in long-term care facilities. Hinting that regulation has led the industry to improve the appearance of physical plants, he observes that the resulting improvements don’t necessarily make facility surroundings more homelike for residents. I agree. You don’t judge books by their covers or choose post-acute facilities by theirs.
In an industry dedicated to protecting vulnerable populations, regulation has been a catalyst for improvement. It is also true, however, that highly regulated organizations naturally tend to pull control upwards—to the top—and then maintain compliance through the application of heavy monitoring mechanisms throughout the organization. Hence, we have audits of the audits; and monitors who monitor other monitors. This is true at the facility level and at the State and Federal regulatory level. Any facility that has had a look-back survey understands this dynamic.
So the downside of regulation occurs when a company focuses so hard on basic compliance—measuring quantity, not quality—that decision-making moves away from the bedside and then rests with the monitor.
A quantity-focused company will scrutinize whether this or that form is in the chart, or whether the note is written to reduce risk; and then check to see whether this or that audit was completed before the survey begins.
Instead, a quality-focused company asks whether the whole story of the person is in the record; if a given incident is fully and critically analyzed for root causes by the interdisciplinary team; and whether a personalized care plan is visible. Moreover, its true litmus test might be, “Do we have data to validate that we are doing for residents what we say we will do and what they need most?”
Complex and sometimes conflicting regulations can work against a person-centered approach to compliance.
In such a regulated environment, it’s easy to see how a company might pay more attention to meeting the floor of compliance to please its regulators, and less time on achieving the highest possible quality of care and life that is attainable for its residents. Telling the story can inadvertently reveal information that makes facilities vulnerable to regulatory backlash. Facilities and companies are reluctant to say too much that could potentially make them open to more difficulty.
While it takes a real commitment from their management and staff, the best long-term care companies focus on attaining the best possible quality of care and life for their residents and, within that framework, meets and then exceeds the regulatory requirements.
In an industry dedicated to protecting vulnerable populations, regulation has been a catalyst for improvement. It is also true, however, that highly regulated organizations naturally tend to pull control upwards—to the top—and then maintain compliance through the application of heavy monitoring mechanisms throughout the organization. Hence, we have audits of the audits; and monitors who monitor other monitors. This is true at the facility level and at the State and Federal regulatory level. Any facility that has had a look-back survey understands this dynamic.
So the downside of regulation occurs when a company focuses so hard on basic compliance—measuring quantity, not quality—that decision-making moves away from the bedside and then rests with the monitor.
A quantity-focused company will scrutinize whether this or that form is in the chart, or whether the note is written to reduce risk; and then check to see whether this or that audit was completed before the survey begins.
Instead, a quality-focused company asks whether the whole story of the person is in the record; if a given incident is fully and critically analyzed for root causes by the interdisciplinary team; and whether a personalized care plan is visible. Moreover, its true litmus test might be, “Do we have data to validate that we are doing for residents what we say we will do and what they need most?”
Complex and sometimes conflicting regulations can work against a person-centered approach to compliance.
In such a regulated environment, it’s easy to see how a company might pay more attention to meeting the floor of compliance to please its regulators, and less time on achieving the highest possible quality of care and life that is attainable for its residents. Telling the story can inadvertently reveal information that makes facilities vulnerable to regulatory backlash. Facilities and companies are reluctant to say too much that could potentially make them open to more difficulty.
While it takes a real commitment from their management and staff, the best long-term care companies focus on attaining the best possible quality of care and life for their residents and, within that framework, meets and then exceeds the regulatory requirements.
Wednesday, February 3, 2010
Shouldn't the Stars that Rate Facilities be the Residents?
Who decides whether a nursing home gives good care? And who has the measures to say definitively whether a facility provides an excellent quality of life for its residents?
USA Today seems invested in the Five-Star rating program. Predictably, they reported that for-profit long-term care facilities rate much lower than nonprofit homes, noting that 27% of the for-profit homes listed in their analysis rated only one star.
By contrast, industry experts like AHCA, the American Health Care Association, say that the Five-Star program is flawed because it rates on a curve, meaning that fully one-fifth of all facilities must fall in the one-star category, regardless of how they perform. Furthermore, fifty percent of what constitutes a star rating is state survey findings, which are notoriously unreliable and variable from state to state, within states, and among evaluators. There is a lot of room for individual interpretation and preference in evaluator ratings, so it is easy to see how a facility’s profit status might influence even evaluators’ ratings, leading to poorer ratings for for-profit facilities and thereby resulting directly in fewer stars.
My point, though, is not to comment on the Five-Star program, but instead to raise the issue that in all of this rating and evaluating, customer satisfaction, the customer experience is absent. In the Guest Blog, CMS Five-Star—Friend or Foe, long-term care commentator and blogger Anthony Cirillo cites the 2008 study by the research and consulting firm Holleran, “In an analysis of data from more than 12,000 nursing home residents and family members across 32 states, Holleran found little to no association between the one through five ratings given by CMS and actual satisfaction ratings. Holleran's research reflects satisfaction across skilled nursing facilities primarily in the nonprofit sector. Nursing homes rated as below average by CMS are garnering satisfaction ratings in the mid 80s, according to Holleran, which suggests these results show there are missing key elements in the Five-Star Rating system.”
I think this is unfortunate and really misses the point, since long-term care consists of human beings providing intimate services to other human beings. It seems logical that the views of the recipients of care quality of life would be directly influential in determining how a facility ranks in the Five-Star system.
Even though this is the case, and I agree that the Five-Star system is flawed, I do believe it is here to stay. I think the public demand for transparency is growing as the boomers enter the marketplace for long-term care services and I hope the industry will do what it has historically done—rise to the occasion and use the Five-Star rating system to raise the bar on compliance and performance. I look to long-term care to capitalize on this program as an opportunity for reflection, analysis, and continuous improvement.
USA Today seems invested in the Five-Star rating program. Predictably, they reported that for-profit long-term care facilities rate much lower than nonprofit homes, noting that 27% of the for-profit homes listed in their analysis rated only one star.
By contrast, industry experts like AHCA, the American Health Care Association, say that the Five-Star program is flawed because it rates on a curve, meaning that fully one-fifth of all facilities must fall in the one-star category, regardless of how they perform. Furthermore, fifty percent of what constitutes a star rating is state survey findings, which are notoriously unreliable and variable from state to state, within states, and among evaluators. There is a lot of room for individual interpretation and preference in evaluator ratings, so it is easy to see how a facility’s profit status might influence even evaluators’ ratings, leading to poorer ratings for for-profit facilities and thereby resulting directly in fewer stars.
My point, though, is not to comment on the Five-Star program, but instead to raise the issue that in all of this rating and evaluating, customer satisfaction, the customer experience is absent. In the Guest Blog, CMS Five-Star—Friend or Foe, long-term care commentator and blogger Anthony Cirillo cites the 2008 study by the research and consulting firm Holleran, “In an analysis of data from more than 12,000 nursing home residents and family members across 32 states, Holleran found little to no association between the one through five ratings given by CMS and actual satisfaction ratings. Holleran's research reflects satisfaction across skilled nursing facilities primarily in the nonprofit sector. Nursing homes rated as below average by CMS are garnering satisfaction ratings in the mid 80s, according to Holleran, which suggests these results show there are missing key elements in the Five-Star Rating system.”
I think this is unfortunate and really misses the point, since long-term care consists of human beings providing intimate services to other human beings. It seems logical that the views of the recipients of care quality of life would be directly influential in determining how a facility ranks in the Five-Star system.
Even though this is the case, and I agree that the Five-Star system is flawed, I do believe it is here to stay. I think the public demand for transparency is growing as the boomers enter the marketplace for long-term care services and I hope the industry will do what it has historically done—rise to the occasion and use the Five-Star rating system to raise the bar on compliance and performance. I look to long-term care to capitalize on this program as an opportunity for reflection, analysis, and continuous improvement.
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