October 17, 2011

Improving care is rarely easy. Systems, even malfunctioning

ones, exist for reasons. They have a history and momentum, an

internal logic.

Dear Dr. Jeff:

I was recently hired as the medical director at a facility where I had previously followed several patients. I was aware of several problems at the facility and eager to improve the quality of care, as I had already helped to do at another nursing home where I am still medical director.

But neither the administrator nor the director of nursing seems to be eager to work on these problems, or even to meet with me to discuss them. As long as some basic paperwork is completed, they seem perfectly happy. My monthly paycheck always arrives on time, but I don’t feel that I am doing my job. What do you suggest?

 

Dr. Jeff responds: Although federal law requires that every nursing home have a medical director and assigns him or her certain specific responsibilities, the job descriptions and unwritten expectations for the position vary tremendously from facility to facility.

Some nursing homes regard the medical director as a valuable member of the leadership team. Others are unaware of what a qualified medical director might have to contribute. A few might have had unfortunate experiences with physician arrogance and insensitivity to the culture of the facility.

Some bullet points may be universal, but others may very well not work at all facilities. Obviously, the administrator knew you before you were hired, and most prudent administrators would not hire a medical director over the objections of the director of nursing, so the problem isn’t you as a person or as a medical professional.

All nursing homes want to give good care. Indeed, I am continuously amazed at the dedication of so many professionals and nonprofessionals to the needs of frail and vulnerable residents. There is little status or glamour in the work we do, while the reimbursement usually compares unfavorably to other parts of health care.

Regulations control nearly everything we do and are frequently unreasonable, constantly changing, and rigidly enforced. There is little appreciation from legislators, regulators, the media, families and friends of those we care for, or our fellow professionals. In this environment, many facilities that would like to improve care are overwhelmed by the demands of simple survival.

Those nursing facilities that haven’t had to respond to hurricanes, floods, earthquakes, or forest fires are endangered by the winds of change. Your director of nursing, having survived the recent transformation of Minimum Data Set (MDS) 2.0 to 3.0 and the changes in the Quality Indicator Survey, is now struggling to adjust to revisions in the MDS manual released Aug. 31 and going into effect this month.

Meanwhile, your administrator is struggling through the new Resource Utilization Groups (RUGS-IV) reimbursement methodology from Medicare, which has just begun cutting rates. In many states, there have been Medicaid reimbursement cuts and other changes as well. My state, New York, has also mandated new forms and practices for advance directives. All this has been superimposed on a major national drive to start keeping medical records electronically.

Reality Check

Although many of these changes (except the reimbursement cuts) may ultimately improve care, they probably trump your perfectly reasonable proposals to improve care. The survey process itself sets the priorities for change within facilities.

When the annual state or occasional federal surveyors identify the six deficiencies that are the national average, the facility is required to provide a plan of correction. Besides addressing immediate concerns, the facility is usually required to review all its residents to ensure that no similar problem has occurred, improve its policies and procedures, retrain its staff to prevent future occurrences, and conduct a periodic quality-assurance survey to confirm that the problem has been corrected.

The presumption is that the prevention of deficiencies requires optimal care systems, not simply discarding the occasional rotten apple. Although, in the narrow sense, all this is entirely reasonable, a single mistake or omission identified at survey may trigger a year of corrective actions. Priorities regarding which aspects of the care process will be addressed, revised, and monitored are set by the survey.

Again, the facility might be enthusiastic about your proposed improvements but simply unable to address them until other problems have been resolved. (Otherwise, a "repeat deficiency" on a survey could endanger the administrator’s or even the facility’s license.) If you haven’t already done so, you should review the details of the last survey to understand these concerns.

Financial concerns also create facility priorities. Regardless of one’s for-profit or not-for-profit status, the facility owner, board, or chain CEO is likely to evaluate the administrator on the basis of the bottom line, as well as survey results.

Changes in care that also produce a financial benefit to the nursing home – for-profit or not-for-profit – and decrease the work load on an overburdened nursing staff naturally seem more attractive than changes requiring financial investments.

For example, a proposal to eliminate the "baseline" chest x-ray at each resident’s admission – even for the vast majority of residents who have come directly from hospitals where such screening and more tests have already been done – might be well received because it will spare the residents unnecessary radiation exposure and the facility some expense.

As the new addition to the interdisciplinary team, you probably should listen first before making the suggestions you have in mind. In this case, it might be wise to ask the administrator and director of nursing what you might be able to do to help them achieve their goals. I wouldn’t be surprised if the very approaches you want to introduce are consistent with their aims.

For example, the administrator may be concerned that the resident census has been declining, which means less income for the facility. Your steps to improve care might decrease transfers of your residents to hospitals. At the same time, fewer hospital transfers might improve the nursing home’s local reputation, leading to more referrals. Finally, remember that hospitals are evaluated and sometimes financially penalized, in part, on the number of patients they discharge and then readmit within 30 days. Thus, one of your ideas that will prevent unnecessary hospitalizations of residents will benefit them, the facility, and the local hospital.

Getting Good Reception

The director of nursing at every facility where I have worked has been worried about maintaining adequate staffing in the face of rising nursing demands. Many innovations to improve care also decrease the nursing workload.

One example might be the elimination of inappropriate finger sticks of elderly diabetics. These tests require significant nursing time to perform and document, yet many physicians continue to order them way beyond current guidelines, particularly for patients who are not dependent on insulin or experiencing medical instability.

Reducing polypharmacy and simplifying drug regimens is another example of an intervention that is good for residents while decreasing required nursing time.

Another example might be the recruitment of a wound-care specialist as a consultant to the facility. Weekly wound care rounds should markedly improve documentation and allow changes in wound care regimens without forcing the nursing staff to track down physicians in their offices to persuade them to give verbal orders for the treatment of a pressure ulcer which they haven’t actually seen.

Again, this is good for patient care and good for the staff.

Of course, there are a few facilities that truly do not wish to change. I once interviewed for the position of medical director at a facility where I had a panel of patients. It provided excellent nursing care in a beautiful building, but many other aspects of resident care were outdated or frankly mediocre. I told the administrator in the interview that if the facility wanted everything to stay exactly the same, she shouldn’t hire me. She took my advice and hired a local internist with no experience in either geriatrics or nursing home care. And nothing has changed.

Improving care is rarely easy. Systems, even malfunctioning ones, exist for reasons. They have a history and momentum, an internal logic. It is not enough to simply be a "change agent," a champion for quality. Pointing in the right direction won’t necessarily make the whole team follow you. If you learn the dynamics of the team and work for change, much can be accomplished. After all, they chose you for a reason.CfA