The quality evolution in long term care has paralleled the transformation of the profession itself. Over time, shifting regulatory, marketplace, and consumer expectations, as well as a growing understanding of best practices and the application of continuous quality improvement to long term care settings, has altered the very concept of quality.

For 40 years, the quality journey has been at the core of Provider’s editorial content. As the flagship magazine of the American Health Care Association (AHCA) and the long term and post-acute care industry, Provider has delivered articles on quality trends, initiatives, and clinical best practices, chronicling the emergence of a culture of quality. 

That journey continues, and as Provider enters its fifth decade of publishing, the magazine celebrates with a look at quality through the ages.

In The Beginning…

The definition, measurement, and reporting of long term care quality was forged in the regulatory fires of the Omnibus Budget Reconciliation Act (OBRA).

“That’s when there was not just an expectation for change, but a mandate for change,” says Mary Ousley, a registered nurse and president of Ousley and Associates. That’s when nursing centers were required to provide the “highest practicable level” of physical, mental, and psycho-social well-being, she adds.

By establishing a threshold of “optimal” care, standards became “patient-centered, resident-centered, person-centered,” says Ousley, a past chairman of AHCA whose leadership in long term care quality is so extensive that AHCA renamed an award in her honor: The Mary K. Ousley Champion of Quality Award.

Enacted in 1987, OBRA regulations weren’t published in final form until 1990, with controversial enforcement rules released much later, in 1995. While battles over the substance and implementation of OBRA raged, the reforms ushered in an era that would reshape nursing centers and the long term care marketplace.

“Clearly, OBRA 87 was a huge transition point,” says David Gifford, MD, senior vice president of AHCA quality and regulatory affairs. “A lot has flowed from that.”

Key Turning Points

Several quality milestones cascaded directly from OBRA, while others were set in motion as regulatory and marketplace forces converged, introducing new models and measurement for systemic quality. Gifford points to several key turning points and influences, including:

■ The Medicare Minimum Data Set (MDS), which Ousley describes as “the largest database that exists anywhere in health care.” The MDS, a component of the OBRA Resident Assessment Instrument, was automated in 1998.

“Once we had standardized digitized information, collected in a standardized way with standardized frequency, it quickly became evident that we could use it to assess quality” and establish payment levels, Gifford says.

■ Medicare prospective payment system for skilled nursing facilities, which led to the advancement of rehabilitation and post-acute care and gave rise to a significant and growing population of short-stay nursing facility residents who are discharged from the hospital for these services, then return home or to a community-based setting;

■ Publicly reported quality data through Nursing Home Compare, the Centers for Medicare & Medicaid Services (CMS) website established in 2002, and later the Five-Star Rating System for quality;

■ The culture change movement, which spurred new person-centered models and philosophies of care; and

■ The national campaign to reduce the use of physical restraints, which emanated from OBRA’s right for individuals to be free from physical or chemical restraints that were “not required to treat the resident’s medical symptoms,” Gifford says.

The multifaceted effort, which CMS attributed to the work of “thousands of individuals in both nursing homes and in government,” has led to the steady reduction in the percent of residents who are physically restrained, from 21.1 percent in 1991 to 1.5 percent currently, according to CMS.

The success of the initiative set the stage for subsequent targeted quality improvement campaigns.

Seeds Of Market-Based Quality Reform

For several years in the post-OBRA marketplace, “quality was couched in a regulatory environment,” says Lane Bowen, executive vice president of Kindred Healthcare and president of its nursing division. “A good survey meant a quality operation,” says Bowen, who also serves as AHCA’s vice chair.

But in the 1990s, while OBRA dictated nursing facilities’ regulatory obligations, private-sector approaches to quality, such as total quality management and continuous quality improvement, which had been used for decades in manufacturing and other industries, began migrating to long term care.

This early movement was bolstered by the emergence of health information technology, which facilitated outcomes and performance measurement. A booming assisted living sector, built on the concepts of hospitality and customer satisfaction, also had an effect on providers’ acceptance of new ideas about quality.

“The influence that seniors housing and hospitality had on us through their involvement [in AHCA] is a notable feature of the quality journey for nursing homes,” says Dale Thompson, the recently retired president/chief executive officer of Benedictine Health Systems who served as president of AHCA in 1996 and 1997.

Under Thompson’s leadership, AHCA created the National Quality Award, a cutting edge program modeled after the rigorous Baldrige Award, which requires applicants to demonstrate systemic quality improvement.

The AHCA award program was created as a three-step process, allowing providers to grow their quality improvement efforts over time.

In 1996, 15 facilities received “Step 1” awards. Last year, there were 361 awards at that level, now designated as the Bronze, with 60 facilities taking home a Silver award, and five receiving the Gold. Over the lifetime of the program, there have been 3,215 Bronze, 317 Silver, and 18 Gold award recipients.

Leading Effort

AHCA’s long-standing leadership in quality improvement includes the 1994 formation of the Quality Assessment Task Force, chaired by Thompson, which developed guiding principles for change.

Significant quality programs sponsored by AHCA have included Facilitator, a 1997 quality management software system and precursor to today’s LTC Trend Tracker, which enabled AHCA members to track and compare their performance on key quality indicators.

In February 2012, the organization launched the Quality Initiative, which took leadership a step further by establishing voluntary but defined quality targets for members to work toward and achieve by March 2015.
Specifically, the initiative called for a 15 percent reduction in preventable hospital readmissions that occur within 30 days of admission to a nursing center; an increase in the portion of customers who would recommend the facility to others to 90 percent; and a reduction in nursing staff turnover by 15 percent. The initiative also called for a 15 percent reduction in the off-label use of antipsychotic medications by December 2013.

In its first 18 months, the Quality Initiative had a significant impact, says Gifford, with 6,206 skilled nursing centers having achieved one or more of the four goals, and 68 facilities having accomplished all of them.

Market-Driven Quality

Today, nursing centers operate in a marketplace where the expectation of regulatory compliance and good results on state surveys is compounded by the expectations of private-sector partners and payers, Bowen says.

Accountable care organizations (ACOs) and managed care organizations (MCOs) “are becoming more of a driver than government,” he says. MCOs and ACOs “manage lives,” and as a result they may dictate staffing levels, length of stay, even clinical pathways when a complication or change in a resident’s condition occurs, Bowen says.

To operate in this environment, Kindred has created “integrated markets,” consolidating all lines of business in a particular category and geographic area under a single manager to ensure consistency and efficiency.

“We can’t have clinical protocols change from one setting to another,” Bowen says.

“Today we have new expectations for financial performance and quality performance,” says Ousley. “Every financing model is now predicated on quality outcomes and metrics that determine the value of what you’re providing on a daily basis.”

While providers should always be striving to achieve excellence and compliance in the survey process, Ousley says, efforts cannot stop there “when you are looking to be part of an ACO or network of care” that expects quality performance on a daily basis.

“Only through robust quality improvement processes can you achieve that,” she says. ■

Lynn Wagner is a freelance writer based in Shepherstown, W.Va.