Best practices guide statewide QI project

Benchmarking achieves significant improvement

In what its sponsors say is a first-of-its-kind program in the United States, the Pennsylvania Department of Health has shown that quality of care can be improved significantly for nursing home residents through a systematic and consistent implementation of best practices protocols.

The Pennsylvania Nursing Care Facilities Best Practices Project employed methods based on quality indicators to benchmark and measure the success of certain best practices in nursing facilities’ treatment plans.

The project, which began implementation in March 2002, has achieved these results:

1. 30% to 40% improvement in residents’ capabilities in activities of daily living (eating and dressing);
20% to 40% improvement in the behavior of residents indicating pain;
22% improvement in depression management, compared to a 15% decline experienced by control facilities.

"We here in Pennsylvania and in many other states have a lot of data reflecting what happens to patients at nursing homes in terms of minimum data sets, so we can look at outcomes," explains Richard Lee, MPA, Pennsylvania’s deputy secretary for quality assurance, based in Harrisburg.

"However, while we in QI often get involved in measuring inputs, we don’t get involved as often on the outcome side," he adds.

As part of his department’s role in improving quality, Lee contends it was important to help providers. "We were in a position to know much more about the system than they did, so it made sense for us to take a lead role in quantifying what works and what doesn’t."

Determining best practices

The state went through a complicated process in identifying the best practices, Lee says. "Our main contractor was Morrison Informatics Inc. [in Mechanicsburg PA], an information management company, but there were a number of subcontractors." These included the Hebrew Rehabilitation Institute in Boston, which, Lee says, is known as an international expert on nursing homes, and Clifton Gunderson, a CPA firm that does a lot of management consulting in nursing homes and long-term care. "In the operations area, we used Kendall Crosslands, a nursing home provider in Pennsylvania that has done a lot of creative long-term care work," he adds.

What resulted was a multidisciplined team that was experienced in statistical quantitative evaluation, as well as the clinical side, Lee explains.

"We also had advisory committees, the most important of which was made up of actual nursing home residents, people representing nursing facility associations, and state government people from the departments of aging and public welfare, as well as advocates for the elderly." They came up with a list of 15 to 20 best practices they felt could influence care in nursing homes in the state, he points out.

"We [then] mined the minimum data set data [MDS]," Lee continues.

MDS is a comprehensive, standardized database the federal government requires state agencies to collect on every resident. It includes evaluation of a resident’s needs, strengths, and preferences upon admission, quarterly, annually, and upon significant change in status.

"We use it as part of our reimbursement tools," he explains. "The data are collected by nurses at the facilities."

The benefit of having this information, he notes, is that "people didn’t have to go to a new source; they mined a very rich data source no one else was mining."

It was the MDS-adjusted mega quality indicators that were used to evaluate the effectiveness of the best practices protocols on the quality of care.

Lee then went back to the consultants at Hebrew Rehabilitation to determine which areas of patient care they thought the project actually could influence, revisited with the surveyors and the working group, and ultimately chose pain, depression, and activities of daily living as the three areas for which protocols initially would be provided.

Getting under way

For the first phase of the project, 10 test and 10 control facilities were chosen. "We identified a number of good, solid performing nursing homes, of which 70 to 100 volunteered," Lee recalls. "We did not want to pick those with serious histories or problems, or a history of survey or satisfaction problems. Nor did we want those that always seemed exemplary."

Other selection criteria included size and geographic location, to get a variety of both, as well as for-profit and not-for-profit facilities. "We wanted to demonstrate you did not have to be a certain type of facility to have positive outcomes," says Lee, noting that the companion facilities were chosen for the purpose of having a control and for generating additional data.

In March 2002, the department began giving the selected nursing homes their protocols as well as assistance in the form of a nurse educator.

Why was the project so successful? "We think it’s because we found out what had helped the residents in the past, provided lots of technical assistance to the nursing homes, and the fact that the staffs all responded positively," he says.

The team, Lee explains, picked very sophisticated protocols, explained them to the staffs, and helped them implement them.

"When Mrs. Smith has pain, the staff know right up front what to do," he observes. "The staffs try to have pain medication available in advance; everyone in the facilities is sensitive to the idea of pain, and they have learned how to notice when there’s pain even if it is not verbalized by the residents — i.e., a grimace, lack mobility, a lack of interest." Thus sensitized, he notes, the staff member can initiate questions about whether the patient is in pain.

The project now is in its second phase, which will include protocols for urinary incontinence reduction and the reduction of decubitus ulcers (bed sores). "We expect to measure our results at the end of May 2005," Lee says.

Need More Information?

For more information, contact:

• Pennsylvania Department of Health, P.O. Box 90, Health and Welfare Building, Harrisburg, PA 17108. Phone: (877) PA-HEALTH. Web: