Long-Term Care Survey Alert

Take advantage of this winning survey management and QA strategy.

Facilities that don't give their medical directors a key role in managing outcomes won't have a full interdisciplinary team on deck - and will likely hoist some high QIs and F tags.

Some nursing facilities think the medical director's role should be consultative where they call the person in when a problem occurs. But that means the facilities aren't being proactive in preventing survey problems, according to Jacqueline Vance, RN, director of clinical affairs for the American Medical Directors Association. Vance and AMDA executive director Lorraine Tarnove spoke on the medical director's role in the survey process and in promoting optimal quality of care at the most recent annual American Association of Homes & Services for the Aging convention in Nashville, TN.

"In some facilities, the survey comes and goes, and no one even calls the medical director," Vance observed. And that's a big mistake: "The medical director offers a key source of guidance and information for the survey agencies," she stressed. "The medical director should be present at least one day  to talk to surveyors and ask if   they have any concerns or medico-legal issues."

Example: "The medical director can explain to surveyors why a particular patient needs three anti-hypertensive medications," said co-presenter Tarnove. "The medical director can prove the resident's need for the medication with blood pressure readings, if she needs to," she told AAHSA convention attendees.

Survey tip: Medical directors can also explain advance directives to surveyors who may question why a resident is DNR and why CPR would be "medically inefficient" in a particular case, according to the AAHSA presentation.

The medical director should also attend the exit conference to counter surveyors' concerns before they end up on the statement of deficiencies (CMS 2567). Include the medical director in developing the plan of correction, as well.

If a facility ends up in informal dispute resolution, "the medical director can bring in AMDA practice guidelines" to show how the facility followed the standard of practice to prevent what was an unavoidable outcome, Tarnove added.

Improve Physician Care, OBRA Compliance

Medical directors can also get involved in privileging and contracting with attending physicians. That's increasingly important to do given that surveyors penalize facilities - not physicians - for noncompliance with OBRA. "Medical directors need not only the responsibility but also the authority to hold others accountable," such as attending physicians, said Vance.

Some facilities give medical directors the authority to step in when the attending physician isn't there to address a resident's emergent condition - or when the attending isn't making necessary visits or providing appropriate care, noted Vance and Tarnove.

A medical director's involvement can make a huge difference in a facility's quality of care - and in the attitude of staff because they have someone to go to address concerns about an attending physician's care, notes Nancy Augustine, MSN, RN, a consultant with LTCQ Inc. in Lexington, MA.

Staff can follow a protocol for notifying the medical director about a non-healing wound or when an attending physician isn't prescribing appropriate wound-care treatments. That's the procedure followed by TSW Management Group,  reports Kathy Hurst, JD, RN, director of human services and health care operations for the Anaheim, CA-based organization that manages several nursing facilities in the state.

Don't mix role responsibilities: Considering that 44 percent of medical directors do some attending physician work, facilities should be clear about their expectations for those separate job responsibilities, Tarnove cautioned.

Develop Critical Policies and Procedures

Enlist medical directors to help develop policies and procedures to address key medical, regulatory and payment issues. Examples include: