“In God we trust. All others, bring data.”
—W. Edwards Deming,
American statistician and professor

Across the country, the years of budget crunches have taken their toll on many state-funded programs, not least of which is states’ investment in ensuring assisted living facilities (ALFs) are living up to quality standards.
While nursing facility inspections are subsidized by the federal government through the Centers for Medicare & Medicaid Services, surveys of ALFs are entirely the state’s responsibility.
Wisconsin, for example, found itself presented last year with an ever-growing number of ALFs to inspect but without enough funding to hire the people to inspect them.
New Jersey’s funding of health department inspections had decreased to a point where ALFs were going almost three years between surveys.
The associations representing ALFs in those states were also concerned about the issue.
“Our fear,” says Paul Langevin Jr., president of the Health Care Association of New Jersey (HCANJ), New Jersey’s association for ALFs as well as nursing facilities, “is that like all other human beings, some people who operate assisted living facilities might lose their focus” on quality without someone outside the facility coming in regularly to inspect it and ensure its compliance with state regulations.
Without regular inspection, the quality of care that residents receive could slip. That’s unacceptable in and of itself. Such a situation could also result in complaints that generate public outrage and cause legislators to decide they must address the issue, resulting in the kinds of onerous regulations nursing facilities contend with, Langevin says.

New Connections

In Wisconsin and New Jersey, these concerns brought state ALF associations and health departments together to forge a new path to ensuring quality.

And not quality just good enough to pass the standard health department inspection, but good enough to meet higher benchmarks and inspire ALFs to reach for ever-improving quality.
These programs also are not satisfied with a nebulous idea of quality. They are designed to collect hard data to demonstrate an ALF’s quality.
“What we were looking for in New Jersey is a reliable indicator of services being delivered that consumers could look at that was based on empirical data collected routinely,” says Langevin.
With an eye on those trends and an awareness of the increasing involvement of managed care in assisted living, the National Center for Assisted Living (NCAL) will be collaborating with the New Jersey Hospital Association Institute for Quality and Patient Safety to collect data so that providers and policymakers will have national benchmarks for important clinical quality measures.
“Quality should be driven within the profession,” says Langevin, “so rather than follow the road nursing homes have followed, we’ve taken the bull by the horns and set higher standards for ourselves.” And soon they’ll have the concrete evidence to prove it.

New Jersey’s Advanced Standing Program

In February of last year, HCANJ collaborated with New Jersey’s Department of Health and Senior Services to create Advanced Standing, the first such program of its kind in the nation. Advanced Standing encourages participating ALFs (and comprehensive personal care homes) to make a commitment to strive for an ever-higher quality of care and to demonstrate it by submitting quality data. Those ALFs able to prove that their quality outstrips state requirements won’t have a state surveyor showing up at their doors, barring a complaint or other such issue.
But there’s a hitch: While any ALF in the state—it doesn’t have to be a member of HCANJ—may apply to join the program, it must first demonstrate that it’s already providing care that is among the highest quality available in the state.
That’s accomplished through an application process that includes submitting quality indicator data to a peer review panel (made up of HCANJ and state health department representatives as well as an ombudsman). An ALF’s data will have to demonstrate that the facility is meeting quality benchmarks that go well beyond government health and safety licensing regulations.

Starting With A Clean Slate

Before any of that even begins, the facility must be in compliance with all applicable local, state, and federal regulations and be willing to submit an affidavit to that effect. It will also need to sign a contract with HCANJ that details the Advanced Standing criteria, and all fees (which vary depending on the size of the ALF) must be paid up front during the time period indicated in the application. The application fees pay for a consultant to perform an initial inspection and monitor the facility from there on.
Once approved by both the Advanced Standing program and the state health department, the Advanced Standing consultants will continue to conduct annual surveys at the ALF and assist the ALF in resolving any quality concerns that arise. The ALF will provide quality data at regular intervals—as yet to be determined by a peer group.
Those facilities awarded Advanced Standing status will no longer have annual health department inspections, and each participant will have the right to market itself as an elite Advanced Standing facility.
“The good news as a consumer is that you can be assured the building is surveyed at least annually by a competent individual,” says Langevin. In fact, the program, in which about 75 ALFs are currently taking part, has engaged the master trainer of all assisted living surveyors in the state to perform this function.
“The key element for me, anyway, is this is the profession seizing its own future and being responsible for the quality of care, rather than relying on an outside agency to tell it what to do,” says Langevin.

Wisconsin kicks Off Excellence Program

The agency within Wisconsin responsible for oversight of the assisted living sector, the Bureau of Assisted Living (BAL) in the Wisconsin Department of Health Services, found itself with a growing problem several years ago.
The number of assisted living beds (including those in community-based residential facilities, residential care apartment complexes, and adult family homes) had been growing steadily since 1979. In fact, the phenomenal growth caused the number of assisted living beds to outpace those of nursing facilities in 2008, and every year saw the lead widen significantly.
But the bureau was being required to operate on a static budget—money to pay for keeping tabs on all of these new ALFs was not being added to the budget.
In 2009, as it became increasingly clear that soon it would be impossible for BAL to fund the provision of even adequate oversight for the burgeoning sector, concerned leaders began to search for a budget-neutral solution.
BAL could find only one real option: to somehow find a way to safely relinquish most of the work of monitoring ALFs that were consistently high performers so that it could concentrate on those that weren’t performing up to snuff.

The WCCEAL Initiative

After much networking and discussion, a group of representatives of several organizations met in November of 2009 and agreed to collaborate on an initiative they called the Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL). The group was composed of representatives of the Wisconsin Department of Health Services, the state’s ombudsman program, the four assisted living associations working in the state, and the Center for Health Systems Research and Analysis (CHSRA). CHSRA is a collaboration between the Preventative Medicine and Industrial Engineering Departments at the University of Wisconsin-Madison. The organization’s researchers create performance measures and decision support systems and supply other information to improve long term care.
Together they developed a program that would reduce BAL’s workload by removing the need for it to provide inspections to facilities whose quality was so good that the inspectors routinely turned up nothing of note.
But that wasn’t all the program did. It also ensured participating ALFs would have both the incentives (reduced regulatory oversight) and the resources that would spur them to set that bar ever higher.
The WCCEAL initiative was officially launched in November 2012. Currently, 218 ALFs (community-based residential facilities, adult family homes, and residential care apartment complexes) participate, according to Alfred Johnson, director of BAL, which licenses and certifies 3,384 ALFs in the state.
ALFs eligible to participate in the WCCEAL program must be licensed by the state and belong to one of the four associations and enroll in its quality improvement/quality assurance program, for which the association charges a fee to cover expenses.
The associations provide member facilities with quality improvement tools, networking opportunities, educational programs, leadership development, mentoring, consultation, and other resources.
“After an assisted living community has enrolled into the WCCEAL program,” says Johnson, “the Bureau of Assisted Living will continue to conduct complaint and self-report investigations. For communities that qualify for our abbreviated survey, we will conduct less frequent abbreviated surveys.”
In fact, adds Brian Purtell, executive director of the Wisconsin Center for Assisted Living (WiCAL), participating ALFs could “go as far as five years, possibly, without being surveyed.” Although avoiding inspections isn’t the reason why Purtell or his members are doing this, he says.
To receive the abbreviated survey, the ALF must have been licensed for three years and within the last three years have had no substantiated complaints filed against it and no state enforcement brought to bear.

Quality Programs Weighed

But BAL wanted demonstrable proof of the participating facilities’ quality efforts. After talks with CHSRA, they agreed that the best measurement of the ALFs’ quality of care would be to gather data on a wide range of quality improvement variables that would measure a facility’s performance, customer satisfaction, and regulatory compliance.
They also agreed that these variables should look at a facility’s structures, processes, and outcomes—the three components identified by Avedis Donabedian, a physician and health services researcher at the University of Michigan, as those that would most accurately evaluate a health care facility’s actual quality.
So, every quarter the ALFs would submit to CHSRA, using a secure website, data on the facility itself and its residents, as well as on clinical processes, outcomes, and satisfaction levels. CHSRA collects and, along with the facility’s association, analyzes the data. Purtell points out that a firewall has been built into the system to ensure the health department doesn’t see data from individual facilities.
“The provider associations work along with the community to address negative trends or issues that arise out of the regulatory surveys/investigations,” says Johnson. “There is accountability built into the quality improvement/quality assurance programs to ensure communities are addressing issues.”
The facilities would be able to compare their efforts to peers, identify trends, and pinpoint areas needing improvement so that leadership can allocate resources appropriately and provide positive feedback to relevant staff.
But the facilities wouldn’t be on their own as they worked to remedy a quality problem. CHSRA, in addition to identifying any problems in their individualized reports, would be able to help the facility come up with a strategy for improving the situation.
In addition, the facility’s association would be there to offer assistance and advice. In fact, the associations were tasked with holding their participating members responsible for implementing the quality improvement/quality assurance program.

Collecting The Right Data

Among the data Wisconsin ALFs would submit are demographics and quality improvement structure, process, and outcome indicators, conforming to what is considered the most effective way to measure a health care facility’s quality—a model of evaluation developed decades ago by Donabedian.
BAL wanted to make sure ALFs were working to align their quality of care with recognized, evidence-based standards of practice. These standards are updated as appropriate, says Johnson. “As the internal group becomes aware of standards of practice, we post the information on a secure website for WCCEAL assisted living communities,” says Johnson. “The provider association’s quality improvement/quality assurance programs also incorporate the standards of practice.”
WCCEAL, working collaboratively with CHSRA, created standards of practice and performance measures, along with related decision support systems.
The standards of practice surround the following topics:
■ Activities of daily living
■ Diabetes
■ Dementia
■ Pain
■ Pressure ulcers
■ Person-centered care
■ Abuse and neglect
■ Falls
■ Mental health
■ Infection control
■ Emergency management
■ Medication
■ Food safety
While WiCAL’s ALFs aren’t yet submitting a lot of clinical quality data, the satisfaction data are very useful to them, says Purtell.
“They can access it and slice and dice it, see how they stack up against other members and how they perform against the rest of the WCCEAL population,” he says. In addition, ALFs are able to access the comments section of the surveys almost immediately, Purtell says, so that they can address any issues early.
“I was very strong about the first measurement having a standardized satisfaction tool,” says Purtell. It’s important to place “a big emphasis on resident and family satisfaction issues rather than just compliance issues.”

First Data Report In

WCCEAL ALFs were required to submit their first batch of quality data by April 15, and CHSRA has issued reports on it.
“The first quarter of quality improvement variables report was available to the WCCEAL assisted living communities in May/June 2013,” says Johnson.
CHSRA is still “in the early stages” of conducting performance analyses that will tell the individual ALFs how their quality efforts are doing, says Johnson, but has developed several different reports for ALF and provider associations to use.
“Currently there are a number of reports available regarding the community and aggregate data that the community will be able to compare to,” says Johnson. “As we secure additional funding to continue the WCCEAL program, it is expected that the reports and analysis will increase.”
At a later date, CHSRA will study the effectiveness of WCCEAL, providing BAL with reports on satisfaction and quality indicators for WCCEAL overall and for each provider association overall, as well as reports on various facility groups, such as those with similar demographics.
“The part I’d like to get across,” says Purtell, is that the “unique and exciting part of this is the collaborative nature, with provider associations, academics, resident advocates, and regulators working as a team with the common goal of performance improvement.”

NCAL Goes National

The National Center for Assisted Living (NCAL) is finalizing the details on a collaboration with the New Jersey Hospital Association Institute for Quality and Patient Safety, a patient safety organization (PSO), to collect and analyze data from across the country on clinical performance measures in ALFs, says Lindsay Schwartz, PhD, NCAL’s director of workforce and quality improvement programs. The organization hopes to launch the program this fall. Schwartz is excited about the prospect.
 “This is an amazing opportunity for our profession. “It’s an innovative [program] and something that’s never been done before.” It will be the first time national data on such items as fall rates will be available for assisted living.
Most ALF operators would agree with her. NCAL conducted a survey of its board members to find out if such a program would be of interest to its members, and “they were unanimously excited to participate in this,” says Schwartz.
As with the New Jersey and Wisconsin programs, ALFs will pay a fee to participate in a quality improvement program. The cost is still being negotiated, but NCAL is determined to ensure it will be affordable for small operators. The association will foot the start-up costs.

Teaming With A Safety Group

Participating ALFs will submit quality data to be analyzed. In return, the ALF will receive reports on how it measures up to its peers regionally or across the country, along with educational information and training around an array of issues. For an extra fee, ALFs can even receive root cause analyses in which experts look at specific incidents, drilling down to the heart of the problem and finding solutions, says Schwartz.
NCAL developed the quality measures, which it calls the Tier II Clinical Performance Measures, making sure to include both process and outcome measure. Structural measures are not yet included in this list but may be in the future, although NCAL has been collecting structure measures through other surveys. It’s in the final stage of negotiating a contract with the New Jersey hospital safety group, which will collect and analyze data and help the facilities improve their quality.
“The reason we’re going with the PSO,” says Schwartz, “is to protect the data. Under the federal Patient Safety Act, quality data submitted to PSOs are protected” from being mined by lawyers looking for an ALF to sue.
In some states, assisted living facilities will not be protected under the Patient Safety Act of 2005 due to the definition of “health care provider” in the act and how a state has licensed assisted living. NCAL is working with outside legal counsel to develop a checklist for NCAL members to use to determine if their ALFs would be covered as a “provider” under the act. These members can still participate, even though they will not be covered under the protection of the Patient Safety Act.
The act provides protection from legal discovery for data about quality and safety reported and shared by a health care provider, and the rule issued to implement the act authorized the creation of PSOs as the organizations that would safely collect and analyze that data.
Purtell is also concerned about the possibility of WCCEAL data being used by lawyers in Wisconsin looking for a case. WiCAL is training members how to report data in such a way as to qualify for state statutory protections surrounding performance improvement efforts.
“It’s ridiculous we have to worry about someone using something we’re doing to improve our quality to sue us,” says Schwartz.

Data Collection Increasingly Vital

“The health care system is changing,” says Schwartz. Accountable Care Organizations are looking to partner with community providers, and they’re increasingly looking for these clinical measures” and data-based proof of quality to choose who they partner with.
New Jersey’s Langevin agrees. “We think [quality data collection] is going to facilitate purchasing not only by consumers, but by managed care organizations in the state,” he says.
As ALFs find themselves providing more medical services than in the past, collecting quality data is “changing the landscape of assisted living,” says Schwartz. And that ALFs are choosing to participate in these programs without regulation requiring it is to their credit, Schwartz says. “It’s amazing that an organization and its members have a vision of improving themselves,” she says. “It shows a commitment to excellence.”
Kathleen Lourde is a freelance writer based in Dacoma, Okla.