The OBRA Guidelines For Quality Improvement ((FULL))
In the years after the law was passed, some experts believe nursing home quality improved significantly. Inadequate care at nursing homes has often been attributed to understaffing. After the act passed, many nursing homes increased and improved their staff. Proper staffing is an important improvement.
When developing a QAPI plan that will merge the resident-centered focus and systematic approach to assessing quality of care and life in the QIS process, an essential beginning is to create a culture of responsibility and accountability that is fully vetted and supported by top management and includes input and support by team members, residents and family members at all levels of the organization. While the QAPI process is never ending and must be systemic, there must be a strategy in place to collect, use and post data, identify gaps and opportunities for improvement, plan and conduct projects and measure against targets. By using best practice tools and techniques, such as checklists, audits, structured observations and direct interviews, teams should monitor a number of clinical, financial and operational triggered care areas, always keeping a sharp focus on MDS and other publicly reported data. The importance of accuracy goes well beyond preparing for annual surveys, since it could also impact Medicare/Medicaid reimbursement, quality care and care planning, securing revenue for quality care provided, etc.
In December 2010, CMS convened a National EPSDT Improvement Workgroup that included state representatives, children's health providers, consumer representatives, and other experts in the areas of maternal and child health, Medicaid, and data analysis. The members of the group will help CMS identify the most critical areas for improvement of EPSDT. The group, which meets periodically throughout the year, will also discuss steps that the federal government might undertake in partnership with states and others to both increase the number of children accessing services, and improve the quality of the data reporting that enables a better understanding how effective HHS is putting EPSDT to work for children.
We systematically searched electronic databases (PubMed, CINAHL, PsycINFO, EMBASE, MEDLINE (OvidSP), CDSR, CENTRAL, ScienceDirect, SSCI, RSCI, SciELO, and KCI) and other sources using relevant subject headings. We included peer-reviewed quantitative studies published over the last two decades, irrespective of its design or language. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two reviewers independently screened initially identified articles, reviewed the full-text of potentially relevant studies, extracted necessary data, and assessed the methodological quality of the included studies using a validated tool. The accreditation effects were synthesized and categorized thematically into six impact themes.
Although the only included RCT reported no or low association between accreditation and quality indicators [48], the methodological quality of this study was fair but not good enough to generalize this finding. It is noteworthy that several quasi-experimental and prospective longitudinal studies reported significant positive effects of accreditation on various quality of service aspects [8, 60, 96,97,98,99]. Accumulated evidence showed that longitudinal participation in accreditation translated into higher standards compliance [60], adherence to recommended guidelines [97], enhancement in structural and process elements [19, 28], and sustained change [98]. For instance, in a stepped-wedge multi-level study, accreditation resulted in significant improvement of various processes that did not meet the target performance during the 6-month period prior to the accreditation survey [99]. Participation in accreditation has shown tangible benefits in performance measures linked to acute myocardial infarction [79, 100], heart failure, and pneumonia [100]. Nevertheless, some studies have found that accreditation is not associated with hand hygiene compliance [101], medication administration error rates [102], and other performance measures [87, 103, 104].
Apart from estimating the cost of accreditation, which varied dramatically between countries and programs, accreditation was shown to have a significantly favorable effect on cost reduction [90], increase in the share of outpatient revenue [83], higher productivity [112], and improved efficiency [113,114,115]. For example, a large retrospective longitudinal study, tracking 748 hospitals over 10 years, reported a significant positive net impact of hospital accreditation on improving the mean efficiency as estimated through bootstrapped data envelopment analysis (DEA) at accreditation year and the 2 years following [113]. Another observational study found that hospital accreditation, ceteris paribus, was associated with 119% improvement on a quality index relative to baseline data, which translated into a combined saving of US$ 593.000 in two hospitals over 3 years [90]. On the contrary, participating in accreditation programs was found to have an inverse effect on hospital efficiency secondary to higher staffing demand and investment in equipment [116]. Other studies did not detect a major impact of accreditation on operating room efficiency [117], cash-flow margin, and total cost per case [83].
As an extension of previous reviews [13, 31, 32, 34], our analysis did not find a correlation between accreditation and higher patient satisfaction or experience. The earlier presumption that patient satisfaction is a reverberation of hospital quality of service [120] was not confirmed in our review. While our findings support the view that accreditation is a tool that stimulates improving internal processes delivery [121], the appropriate improvement threshold for being tangible is equivocal. Likely, the answer depends on the design of the accreditation standards and processes [4, 122].
The Department of Human Services (DHS) Office of Long-Term Living (OLTL) has announced a funding opportunity under an approved Home and Community-Based Services (HCBS) spending plan that will provide American Rescue Plan Act (ARPA) funds to HCBS providers. The purpose of the funding is for the implementation of quality improvement (QI) projects to improve the services available to HCBS participants through the Community HealthChoices (CHC) and OBRA 1915(c) waivers. This opportunity focuses on supplementing activities in a manner that improves and strengthens the quality of HCBS services. The use of the ARPA funding, however, is limited to those activities that supplement rather than supplant the existing services.
Recognition of depression in LTC residents is a crucial aspect of quality [29], with assessment being the cornerstone of effective treatment [30]. Despite what is already known about the prevalence, recognition, and treatment of depression in LTC, implementing these best practices into regulation is challenging. In research exploring the alignment of quality improvement in care of depression in home care services, Bao et al. [30] found funding incentives for reimbursement were misaligned with best practices in the care of people with depression, specifically, a lack of explicit recognition of the amount of nursing time that is needed when supporting a person with depression. Nurses in this study were aware that they were unable to implement best practice but felt inhibited by policy that incentivized productivity. They also found the electronic health record system they were working with was a barrier to completing ongoing assessments, as the electronic system only allowed a brief window of time for uploading supplementary assessments. This resulted in nurses being unable to supplement any initial screening with a more detailed mental health assessment. Boyle et al. [31] concluded, that whilst it was used inconsistently in their study, participants using the Geriatric Depression Scale (GDS) [32] felt it would improve quality. Similarly, 90% of experts endorsed the use of the GDS when developing guidelines for treating depression in nursing homes [33].
Although a deterrence approach to regulation dominates the LTC sector [17], other studies have described alternative approaches to achieving quality. These are characterised by participation, flexibility and responsiveness, collaboration and partnerships, dynamic learning, and self-enforced regulation [18, 20]. A study which explored the integration of best practice guidelines into system based protocols for quality monitoring in LTC, found a collaborative approach between educators and licensing agencies was a way to improve quality, whilst at the same time continuing to utilize the Minimum Data Set (MDS) [26]. However, some experts have found the MDS to be limiting in the field of depression [35], in part because its implementation in relation to psycho-social care had several barriers, including variation across jurisdictions and lack of federal guidance for its use [36].
Most researchers argue that improved quality of care is linked to improvements in staffing levels [62], and the ratio of registered staff to residents [55, 60]. Recognition of depression has also been associated with having enough numbers of registered nurses in LTC homes that are able to identify the symptoms of depression in their residents. Lapane & Hughes [60] studied organizational characteristics of nursing homes and their influence on care of depression. They found that there was increased use of anti-depressants in facilities where there were more professional nurses. Trinkoff [63] studied data from over 15,000 nursing homes across 50 states, exploring the impact of Certified Nurse Aides (CNA) training on the quality of care provided, concluding that higher training hours were linked to better care outcomes; and that facilities offering CNA training above federally mandated hours resulted in fewer adverse events in the facility. 153554b96e
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