Conference Spotlight: NADONA in Session
The National Association Directors of Nursing Administration in Long-Term Care (NADONA) 2014 National Conference is underway at the Disneyland Hotel in Anaheim, California (1150 Magic Way; 714-778-6600; https://disneyland.disney.go.com/disneyland-hotel/). Annals of Long-Term Care is providing up-to-date coverage on the 2014 NADONA National Conference.
Challenges in End of Life Care
Anaheim-End of life care’s purpose is to provide a patient with the highest quality of care and highest quality of life possible. Attaining this standard of care can become challenging when each patient’s special needs are taken into account. During a session at the 2014 NADONA National Conference, William M. Vaughan, RN, BSN, vice president of education and clinical affairs, Remedi SeniorCare, discussed balancing optimal end of life care with the wishes of the resident and the obstacles face by end of life care providers when trying to achieve that balance.
Mr. Vaughan stressed that decline in a patient’s health does not correlate to a deficiency in the care being provided. According to F-tag 325, “…the facility must ensure that a resident maintains acceptable parameters of nutritional status such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible… .” A patient’s clinical status may make it impossible for end of life care givers to maintain certain health standards. If care is consistent with the resident’s goals, reasonable attempts at altering the rate of decline are expected. Final decisions regarding decline are always made by the resident; if the resident is incapacitated, the appointed decision making party needs to serve as the point person.
Although pain management should be top priority, a resident in pain does not equal a deficiency in care. Barriers exist when attempting to determine and relieve the pain a patient is experiencing. A patient may be unable to communicate that they are experiencing pain or the level of pain they are experiencing. Patients with dementia and those who are non-verbal have difficulty communicating pain. A patient’s current medications may cause an adverse drug-drug interaction, making it ill-advised for a physician to provide certain pain medications. Also, a patient may not want to be on pain medication. Treatment does not always mean medication. A patient may prefer alternative treatments such as therapies.
Not all interventions are required when it comes to end of life events. A resident may choose not to allow intervention. It is normal for end of life caregivers to feel obligated to prolong life, but this may not be consistent with the resident’s goals. Mr. Vaughan suggests either liberalizing the resident’s care or providing sound rationale for continuing aggressive interventions.
“Bad decisions” made by a resident who is the primary decision maker will not rest on the facility. It is key to note that if a resident makes a “bad decision,” eg, smoking, it is not the facilities wrongdoing. End of life care facilities are subject to a residents wants.
End of life care requires many difficult decisions to be made. Ultimately, the actions of end of life caregivers must align with the goals of the patient.-Melissa Cooper
Implementing a QAPI Program in Nursing Homes
Anaheim-The Patient Protection and Affordable Care Act of 2010 requires nursing homes to have an acceptable Quality Assurance and Performance Improvement (QAPI) plan within a year of a final QAPI regulation, meaning each facility will have 1 year from the date of regulation to be in compliance. The Centers for Medicare & Medicaid (CMS), which is responsible for the implementation of QAPI and ultimately responsible for drafting the QAPI regulations, has not announced a date for publication of the final rule.
During a session titled, “Linking Survey to Quality: Using the QIS Methodology in QAPI,” Cindy Mason, LCSW, NHA, LHRM, vice president of provider services at Providigm, LCC, discussed how to use Quality Indicator Survey (QIS) methodology to implement QAPI at the 2014 NADONA National Conference.
QAPI is a data-driven, proactive approach to improving quality of life, care, and services in nursing homes. Mason described QAPI as 2 functions that go hand in hand—quality assurance (QA) and performance improvement (PI). QA is the process of meeting quality standards and assuring that care reaches an acceptable level. Nursing homes typically set QA thresholds to comply with regulations. They may also create standards that go beyond regulations. QA involves measuring and tracking indicators to find out where the facility is performing well and where there are opportunities for improvement.
PI is a proactive and continuous study of processes with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems. PI in nursing homes aims to improve processes involved in healthcare delivery and resident quality of life. PI can make good quality even better. PI is the reaction and correction to an opportunity to improve, explains Mason.
“QIS provides the framework for a QAPI system,” says Mason. Continuous survey readiness, continuous QA, and PI can be done with QIS, which uses a 2-stage approach. Stage 1 is preliminary investigations and Stage 2 is in-depth investigations.
CMS developed a general framework for implementing a QAPI program in nursing homes based on 5 key elements of effective quality management. The QIS methodology can be applied to help nursing homes prove that they meet these elements, explains Mason, who will provide an overview of 5 elements and examples of how the methodology can be applied. The 5 elements include:
- Design and Scope—All staff must know they contribute as individuals to the big picture: the successful achievement of the resident’s goals for quality of life and quality of care
- Governance and Leadership—Residents should have control over their lives, influence decisions which affect them, and know that their opinions matter
- Feedback, Data Systems, and Monitoring—A strong approach to quality management, such as QAPI, uses performance indicators to monitor a range of care processes and outcomes. Then it reviews against benchmarks and targets the facility has established for performance
- Performance Improvement Projects (PIPS)—Conducting PIPS allows the nursing home to examine performance and make improvements in any area identified as needing attention, or that is found to be high priority or high risk based on the needs of residents
- Systematic Analysis and Systematic Attention—To be effective, interventions or corrective actions should target elimination of root causes, offer long-term solutions to the problem, and be achievable, objective, and measurable
Establishing this framework as a foundation along with the collaboration of staff members and continuing conversations with residents can result in improved care across the board.-Eileen Koutnik-Fotopoulos
