The Quality Indicator Survey: Background, Implementation, and Widespread Change

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

Reducing Antipsychotic Medication Use in Nursing Homes: A Qualitative Study of Nursing Staff Perceptions

Background and Objectives

The purpose of this study was to use qualitative methods to explore nursing home staff perceptions of antipsychotic medication use and identify both benefits and barriers to reducing inappropriate use from their perspective.

Research Design and Methods

Focus groups were conducted with a total of 29 staff in three community nursing homes that served both short and long-stay resident populations.

Results

The majority (69%) of the staff participants were licensed nurses. Participants expressed many potential benefits of antipsychotic medication reduction with four primary themes: (a) Improvement in quality of life, (b) Improvement in family satisfaction, (c) Reduction in falls, and (d) Improvement in the facility Quality Indicator score (regulatory compliance). Participants also highlighted important barriers they face when attempting to reduce or withdraw antipsychotic medications including: (a) Family resistance, (b) Potential for worsening or return of symptoms or behaviors, (c) Lack of effectiveness and/or lack of staff resources to consistently implement nonpharmacological management strategies, and (d) Risk aversion of staff and environmental safety concerns.

Discussion and Implications

Nursing home staff recognize the value of reducing antipsychotic medications; however, they also experience multiple barriers to reduction in routine clinical practice. Achievement of further reductions in antipsychotic medication use will require significant additional efforts and adequate clinical personnel to address these barriers.

Quality indicator survey versus traditional survey in New York State: a comparison of results from annual nursing home surveys

Despite the passage of OBRA'87 for nursing home reform, concerns about care in facilities continue. The Centers for Medicare and Medicaid developed new regulations and the Traditional Survey (TS) process for annual nursing home survey. The survey is conducted by state regional offices to determine facility compliance with federal regulations. Despite the regulations and new survey process, the TS inconsistently identified problems. A computerized process called the Quality Indicator Survey (QIS) was subsequently developed. This study was designed to compare results from TS and QIS on overall deficiencies, select quality indicators, high-severity deficiencies, and severity differences of seven quality indicators in New York State over a 6-year period from 2010 through 2015. Results of t-tests determined a significant difference in the overall mean number of deficiencies (p < .001), and on four indicators: choices (p < .001), nursing staff (p < .001), dental (p < .001), and dignity (p < .05). Facilities using the TS showed a higher mean number of harm level or higher deficiencies (p < .001). Chi-square tests for severity levels showed significantly more higher severity deficiencies on two quality indicators: nutrition (p < 0.001) and hydration (p < 0.05). Thus, the QIS produced a greater mean number of deficiencies, while TS produced more higher severity deficiencies in New York State.

Improving antipsychotic prescribing practices in nursing facilities: The role of surveyor methods and surveying agencies in upholding the Nursing Home Reform Act

BACKGROUND

Inappropriate prescribing of antipsychotics is a longstanding challenge to providing high quality care in nursing facilities. The 1987 Nursing Home Reform Act (NHRA) had an initial impact in reducing inappropriate prescribing, but rates returned to pre-NHRA levels. While the recent Partnership to Improve Dementia Care in Nursing Homes (Partnership) initiative has been successful in reducing the prescribing of antipsychotics in skilled nursing facilities/nursing facilities (NF), it is not known how this guidance initiative impacted prescribing practices and other care processes concerning NF residents with dementia.

OBJECTIVES

The objectives of this study were to explore surveyor observations of NF care practices subsequent to participation the Partnership guidance program and to use a social ecological framework to estimate how these observations were influenced by individual, organizational, and contextual factors.

METHODS

A total of 320 NF surveyors responded to a 49-item questionnaire designed in collaboration with CMS officials and state surveying agency personnel, and distributed by state agency directors. Three outcome variables: measuring improvements in clinical care, deficiencies in clinical care, and falsification of records in response to the Partnership initiative, were created from survey responses. A four-level social ecological framework describing the NF surveyor's environment was used to identify potential influences on surveyors' care observations. Logistic regression was used to evaluate the relationship between environment and outcome variables.

RESULTS

Surveyors observed both improvements in clinical care, including 80.6% reporting nursing facility providers responding to consultant pharmacists' recommendations, and deficits in clinical care in response to the Partnership initiative. Furthermore, 39.7% of surveyors observed a new, but false, diagnosis of psychosis (as defined by the surveyor). Surveyor characteristics and methods and surveying agency and culture were found to substantially impact the success of the Partnership initiative. The most distal level of the framework evaluated in this study, state contextual effects, was found not to impact care observations.

CONCLUSIONS

There is substantial variation in surveyor observations of changes to clinical care in response to the Partnership guidance initiative. Further investigation is needed into the type and severity of falsification of records observed by nursing facility surveyors. When constructing interventions to care for residents in NFs, policymakers must consider the environment in which surveyors operate.

Policies to protect persons with dementia in assisted living: déjà vu all over again?

Continued growth in the number of individuals with dementia residing in assisted living (AL) raises concerns about their safety and protection. In this Forum, we review current AL practices relevant to residents with dementia and present a rationale for examining the government role in protecting these individuals within this context. Since public oversight of AL is currently a state prerogative, we assess states' regulatory activity across 3 domains closely related to safety and protection of persons with dementia: environmental features, staffing, and use of chemical restraints. We then step back to consider the state policymaking environment and assess the feasibility of developing a minimum standard of regulations from one state to the next. This Forum concludes with a historical comparison between the contemporary AL market and the nursing home care market prior to the Nursing Home Reform Act of 1987, and we discuss how an increased amount of federal interest could improve existing state efforts to protect persons with dementia residing in AL.

Use of Quality Indicators in Nursing Homes in Victoria, Australia

Objective: This study aimed to characterize the use of mandated quality indicators (QIs) in public sector nursing homes by describing their adherence to established principles of measurement and whether nursing homes respond to QI data to improve care. Method: Data were collected from a descriptive cross-sectional quantitative study using a confidential survey questionnaire distributed electronically to senior staff in all public sector nursing homes in Victoria, Australia. Results: Staff from 113 of 196 facilities completed the survey (58%). Adherence to principles of measurement was suboptimal, with variation in applying QI definitions and infrequent random audits of data ( n = 54, 48%). QI data triggered reviews of individual residents (62%-79%), staff practice (44%-65%), and systems of care (45%-55%). Most facilities (58%-75%) reported that beneficial changes in care occurred as a result of using QIs. Discussion: QI performance data are positively received and used to improve care. Standardization of data collection, analysis, and reporting should strengthen the program’s utility.