Long-Term Care Survey Alert

How to save time, money and head off F tags.

You know the sayings "Don't fix what isn't broken" and "Don't throw the baby out with the bath water." Yet with all the emphasis on survey deficiencies and the need for quality improvement, nursing facilities often end up doing exactly that -- and forego some needed horn tooting, to boot.

Key examples: Facilities will have a fall program in place but surveyors will say, "You still have people falling," although, of course, you can't prevent all falls, observes nurse attorney Barbara Miltenberger. In such situations, the facility managers should sit down with surveyors and explain the facility's fall program, how staff have implemented it and addressed specific residents' fall-risk factors, she says. But "you don't see that kind of dialogue occurring that often," adds Miltenberger, partner, Husch Blackwell Sanders LLP, in Jefferson City, MO. Miltenberger has also seen facilities that are working with their state Quality Improvement Organization to improve an area of care that surveyors subsequently find deficient. An option in that case would be for the facility staff to talk to the survey agency and take credit for the improvements with the QIO staff there to support them. But instead the facility will try to implement a new program to address surveyors' concerns, she notes.

The problem: It is very hard to train staff how to use an all-new system and get them into a routine in implementing it.

Not only that: If you look at Joint Commission findings for sentinel events, bad outcomes are consistently related to a communication problem, says nurse attorney Edie Brous, in private practice in New York City. "And a lot of communication has to take place when a facility implements new policies and procedures," she adds.

Miltenberger notes that surveyors often seem to want to see a change in a program to address a deficiency, and may not think it sufficient for the plan of correction to say the facility will reinforce its existing program. But if the facility has a good system in place, it should take credit for it and merely re-evaluate the program rather than starting over again, Miltenberger suggests.

These strategies can help you avoid change that undermines rather than improves your outcomes.

• Don't completely turn over the reins to consultants to make changes. Sometimes consultants "swoop down on a facility in trouble," introducing new policies and procedures without making sure staff understand what was wrong and ensuring that they replace old habits with new ones, observes attorney Joseph Bianculli in Arlington, VA. "If not done properly, the facility winds up with a mish-mash of old and new" and no one knows "who really is doing what," he says.

Instead: Create more of a partnership with a consultant and stay on top of the quality improvement process yourself.

• Make sure changes aren't out of date. The interventions should be based on the latest evidence and survey guidance, advises Holly Sox, RN, RAC-CT, an MDS nurse in Lexington, SC. If not, the facility is not only wasting its time, but also opening the facility up to more deficiencies, she cautions.

• Obtain a historical perspective. The first thing a new DON or administrator should do before making changes in response to a deficiency or for quality improvement is to talk to staff who know the survey history, what the facility has tried and the outcome, Sox counsels. For example, the facility may have been cited in the past for the very policy and procedure that a new manager wants to implement.

Also ask frontline staff what they think is working well to address a clinical issue, Brous advises.

• Avoid using a shotgun approach. Rather than totally changing an entire system, analyze the steps in a process to determine what is really broken and where the fix needs to occur, especially when in the throes of addressing a deficiency, advises Nancy Augustine, MSN, RN, a consultant with PointRight Inc. in Lexington, MA.

Example: TSW Management Group, which manages and owns nursing facilities in California, takes a systematic approach to quality improvement. Suppose a facility's falls went up for three months, says Kathy Hurst, JD, RN, director of healthcare operations for the Anaheim-based company. "We may find that staff weren't assessing the root cause of falls," she says. "So we give them a tool to do that more effectively."

But that doesn't do the trick in reducing fall rates. Next, the team provides more activities when falls are occurring, which lowers the falls rate, but not enough. Then the fall team "drills down" further and figures out the facility may need more assistive devices for residents. "So we order more equipment and find that falls drop dramatically," Hurst says.

• Analyze before you act in response to a rising or outlier QI/QM. "Frequently, a facility overreacts to QI/QM information and moves in a direction or focus that is not based on analytical data," says Augustine. For one, make sure MDS miscoding of the items that drive or risk adjust the QI/QM isn't the culprit. The facility may have had a temporary change in patient mix that explains a bump up in certain QIs/QMs.

• Tap the state QIO to help you tackle a problematic area. Involving the QIO helps facilities take credit for improvements and innovative systems, in Milten- berger's view. And it avoids "surveyor-imposed plan of correction," she adds.