Vol. XXV. No. 11
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Copyright © 1977 by the American Geriatrics Society
Printed in U.S.A.
Evaluating the Quality of Nursing Home Care JOHN B. HOWARD, MD* and KENNETH E. STRONG, FACNHAt
Roland Thatcher Nursing Home, Wareham, Massachusetts ABSTRACT: Evaluation of the quality of care that a nursing home patient receives is difficult and requires physician participation as well as the participation of specially trained nursing ·personnel. A form of limited medical audit is suggested to aid in such evaluation. In the proprietary nursing home studied by the authors, the quality of care was not being effectively assessed by the survey process then employed. In addition to other factors, emphasis is now placed on the avoidance of additional costs or extra paper work in the process of determining the quality of care. The quality of care that the nursing home patient receives is also of serious concern to the survey team. At the nursing home that the authors have studied, the evaluation of the quality of care is directed mainly at the nursing level with very little directed at the physician level. Items of interest seem to be the adequacy of nursing notes, the cleanliness of the patients and their bedside areas and the presence or absence of decubitus ulcerations. Over the past five years the authors, as medical director and as administrator of a 100-bed, level III, proprietary nursing home, have noted several ways in which a survey process might be modified to monitor more sensitively the quality of care. This paper is a report of that five-year study.
Periodic surveys of nursing homes are required by State and Federal regulatory agencies. These surveys are conducted at varying intervals and are often associated with licensure procedures. The main focus of anyone survey may vary considerably. The reviewers may be particularly concerned, for example, with whether or not the nursing home is in compliance with life safety codes. They may stress compliance with regulations on. medication procedures. This type of review or survey focuses on compliance as it is documented in the nursing home records. In effect, this is mainly a matter of "paper work." In addition to compliance documentation, the survey process may also concern itself with the area of cost containment. A large percentage of the health care budget is related to nursing home care. Intensive efforts are being made to contain or limit these costs. With this in mind, the reviewers may evaluate all patients to determine iftheir assigned level of care is appropriate. If the patient is found not to need as much care as he is receiving, assignment to a lower level of care at less cost may be required. The ratios of patients to various levels of nursing personnel (RN's, LPN's and aides) may be calculated to see that there is neither excessive nor inadequate nursing service.
STUDY FINDINGS In order to evaluate that part of the review process that we have called the documentation of compliance, we studied the medication order sheets of the 100 patients at this facility, and reported the findings in detail (1). We found that excessive numbers of drugs were being prescribed and that the use of "as needed" or PRN drugs was excessive. Moreover, many drug incompatibilities were noted and the overall quality of the prescribing practices was not of high quality. Yet, as far as the survey teams were concerned, the medication sheets were in compliance. That is, the orders had been rewritten every sixty days as required and had been signed by a
* Clinical Instructor in Medicine, Boston University School of Medicine, Boston; Medical Director, Roland Thatcher Nursing Home, Wareham, MA. Correspondence to be addressed to: John B. Howard, MD. 106 Main Street, Wareham, MA 02571. t Administrator, Roland Thatcher Nursing Home, Wareham, MA.
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EVALUATING THE QUALITY OF NURSING HOME CARE
physician. None of these survey teams had included a physician. A pharmacist had participated in one of the recent surveys, but he had not made any recommendations. It would seem reasonable that an appropriately trained pharmacist or nurse should critically evaluate the types of orders that are written and discuss the findings with a physician reviewer. Patients with a large number of PRN orders should be reviewed especially carefully. In addition, the medical director of the nursing home should be invited to discuss the results of the review with the survey team. It is noteworthy that in five years, the medical director of this facility was never asked for contributions to the survey nor was he directly consulted by the survey team once the survey has been completed. Physician services. Evaluation of the quality of care is directed mainly at nursing activities. Very little attention is paid to the quality of care that the physician is providing. It has been our experience that the Federal or State survey team has been mainly interested in the writing of physician progress notes at the required intervals of every sixty to ninety days. The major criticism has been that in some instances the progress notes have been too short. Notes such as "stable" or "doing well" were not acceptable, whereas a lengthy note, regardless of its content or appropriateness, was acceptable. From the point of view of cost accounting it is not a critical matter to monitor physicians services carefully. At this facility, the Medicaid reimbursement rate is about twenty dollars per patient per day. Physicians are allowed to bill for one patient-visit per month. Assuming that the physician bills twelve dollars for each visit, the physician cost is only 2 percent ofthe nursing home bill. From the point of view of the quality of care that the patient receives, however, it is very important to monitor physician activities. The auditing of medical care is now required in facilities for the care of acute diseases. Those who are actively involved in medical auditing at the hospital level are beginning to raise questions about the type of audit that should be made. They are also questioning whether the data obtained are significant and useful. Medical audit. If medical auditing is to be applied at the nursing home level, two conditions
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Vol. XXV
should be met. First, there should be no additional cost, either on the part of the survey team or on the part of the nursing home. Second, no extra paper work should have to be generated by the nursing home. An effective random audit on the topic of body temperature elevation could be performed in nursing home surveys without increasing the cost of the survey and without causing more paper work. This could probably be described as a process audit and would be pertinent to both nurse and physician performances. Data that might be recorded include the following: The duration of fever (oral temperature of lOrF for more than 24 hours), with listing of the dates and times. If the physician was notified, the date and time of notification. Laboratory tests ordered, if any. If the patient was examined by the physician, the date and time of the examination. Drugs ordered, with dates of the orders. Follow-up calls by the nurse or physician, and follow-up visits by the physician. Changes in the treatment program. Dates of hospitalization, if required. Hospital discharge diagnoses, and the outcome of treatment. Although carried out randomly, such an audit can sensitively monitor the quality of care. To be done well, it requires physician participation at some point in the survey process. Doubtless there are many areas that, when carefully reviewed by a survey team, would reveal whether or not the quality of care is adequate. Incident reports might be randomly studied in some depth. These reports might lead the survey team to an area of deficiency in care of the patients, not otherwise detected. The principal modifications we recommend in the survey process are directed towards the determination of whether or not the care that the patient receives from the nurses and physicians is of high quality. We hope these modifications can be implemented without increased cost and without requiring more paper work. REFERENCE 1. Howard JB, Strong KE Sr and Strong KE Jr: Medication procedures in a nursing home: abuse of PRN orders, J Am Geriatrics Soc 25: 83, 1977.
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Copyright © 1977 by the American Geriatrics Society
Printed in U.S.A.
Evaluating the Quality of Nursing Home Care JOHN B. HOWARD, MD* and KENNETH E. STRONG, FACNHAt
Roland Thatcher Nursing Home, Wareham, Massachusetts ABSTRACT: Evaluation of the quality of care that a nursing home patient receives is difficult and requires physician participation as well as the participation of specially trained nursing ·personnel. A form of limited medical audit is suggested to aid in such evaluation. In the proprietary nursing home studied by the authors, the quality of care was not being effectively assessed by the survey process then employed. In addition to other factors, emphasis is now placed on the avoidance of additional costs or extra paper work in the process of determining the quality of care. The quality of care that the nursing home patient receives is also of serious concern to the survey team. At the nursing home that the authors have studied, the evaluation of the quality of care is directed mainly at the nursing level with very little directed at the physician level. Items of interest seem to be the adequacy of nursing notes, the cleanliness of the patients and their bedside areas and the presence or absence of decubitus ulcerations. Over the past five years the authors, as medical director and as administrator of a 100-bed, level III, proprietary nursing home, have noted several ways in which a survey process might be modified to monitor more sensitively the quality of care. This paper is a report of that five-year study.
Periodic surveys of nursing homes are required by State and Federal regulatory agencies. These surveys are conducted at varying intervals and are often associated with licensure procedures. The main focus of anyone survey may vary considerably. The reviewers may be particularly concerned, for example, with whether or not the nursing home is in compliance with life safety codes. They may stress compliance with regulations on. medication procedures. This type of review or survey focuses on compliance as it is documented in the nursing home records. In effect, this is mainly a matter of "paper work." In addition to compliance documentation, the survey process may also concern itself with the area of cost containment. A large percentage of the health care budget is related to nursing home care. Intensive efforts are being made to contain or limit these costs. With this in mind, the reviewers may evaluate all patients to determine iftheir assigned level of care is appropriate. If the patient is found not to need as much care as he is receiving, assignment to a lower level of care at less cost may be required. The ratios of patients to various levels of nursing personnel (RN's, LPN's and aides) may be calculated to see that there is neither excessive nor inadequate nursing service.
STUDY FINDINGS In order to evaluate that part of the review process that we have called the documentation of compliance, we studied the medication order sheets of the 100 patients at this facility, and reported the findings in detail (1). We found that excessive numbers of drugs were being prescribed and that the use of "as needed" or PRN drugs was excessive. Moreover, many drug incompatibilities were noted and the overall quality of the prescribing practices was not of high quality. Yet, as far as the survey teams were concerned, the medication sheets were in compliance. That is, the orders had been rewritten every sixty days as required and had been signed by a
* Clinical Instructor in Medicine, Boston University School of Medicine, Boston; Medical Director, Roland Thatcher Nursing Home, Wareham, MA. Correspondence to be addressed to: John B. Howard, MD. 106 Main Street, Wareham, MA 02571. t Administrator, Roland Thatcher Nursing Home, Wareham, MA.
525
EVALUATING THE QUALITY OF NURSING HOME CARE
physician. None of these survey teams had included a physician. A pharmacist had participated in one of the recent surveys, but he had not made any recommendations. It would seem reasonable that an appropriately trained pharmacist or nurse should critically evaluate the types of orders that are written and discuss the findings with a physician reviewer. Patients with a large number of PRN orders should be reviewed especially carefully. In addition, the medical director of the nursing home should be invited to discuss the results of the review with the survey team. It is noteworthy that in five years, the medical director of this facility was never asked for contributions to the survey nor was he directly consulted by the survey team once the survey has been completed. Physician services. Evaluation of the quality of care is directed mainly at nursing activities. Very little attention is paid to the quality of care that the physician is providing. It has been our experience that the Federal or State survey team has been mainly interested in the writing of physician progress notes at the required intervals of every sixty to ninety days. The major criticism has been that in some instances the progress notes have been too short. Notes such as "stable" or "doing well" were not acceptable, whereas a lengthy note, regardless of its content or appropriateness, was acceptable. From the point of view of cost accounting it is not a critical matter to monitor physicians services carefully. At this facility, the Medicaid reimbursement rate is about twenty dollars per patient per day. Physicians are allowed to bill for one patient-visit per month. Assuming that the physician bills twelve dollars for each visit, the physician cost is only 2 percent ofthe nursing home bill. From the point of view of the quality of care that the patient receives, however, it is very important to monitor physician activities. The auditing of medical care is now required in facilities for the care of acute diseases. Those who are actively involved in medical auditing at the hospital level are beginning to raise questions about the type of audit that should be made. They are also questioning whether the data obtained are significant and useful. Medical audit. If medical auditing is to be applied at the nursing home level, two conditions
526
Vol. XXV
should be met. First, there should be no additional cost, either on the part of the survey team or on the part of the nursing home. Second, no extra paper work should have to be generated by the nursing home. An effective random audit on the topic of body temperature elevation could be performed in nursing home surveys without increasing the cost of the survey and without causing more paper work. This could probably be described as a process audit and would be pertinent to both nurse and physician performances. Data that might be recorded include the following: The duration of fever (oral temperature of lOrF for more than 24 hours), with listing of the dates and times. If the physician was notified, the date and time of notification. Laboratory tests ordered, if any. If the patient was examined by the physician, the date and time of the examination. Drugs ordered, with dates of the orders. Follow-up calls by the nurse or physician, and follow-up visits by the physician. Changes in the treatment program. Dates of hospitalization, if required. Hospital discharge diagnoses, and the outcome of treatment. Although carried out randomly, such an audit can sensitively monitor the quality of care. To be done well, it requires physician participation at some point in the survey process. Doubtless there are many areas that, when carefully reviewed by a survey team, would reveal whether or not the quality of care is adequate. Incident reports might be randomly studied in some depth. These reports might lead the survey team to an area of deficiency in care of the patients, not otherwise detected. The principal modifications we recommend in the survey process are directed towards the determination of whether or not the care that the patient receives from the nurses and physicians is of high quality. We hope these modifications can be implemented without increased cost and without requiring more paper work. REFERENCE 1. Howard JB, Strong KE Sr and Strong KE Jr: Medication procedures in a nursing home: abuse of PRN orders, J Am Geriatrics Soc 25: 83, 1977.
