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hether you call it quality improvement (QI), continuous quality improvement (CQI), quality assurance (QA), quality assessment/assurance, or any other name, the bottom line is quality. Proactive facilities have an ongoing process that goes far beyond “paper compliance” of Federal Tag 520 (Tag F520), regarding quality assessment and assurance, which states: “(1) A facility must maintain a quality assessment and assurance committee consisting of (i) The director of nursing services; (ii) A physician designated by the facility; and (iii) At least 3 other members of the facility’s staff. Tag F521, also regarding quality assessment and assurance, states: “(2) The quality assessment and assurance committee (i) meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary and (ii) develops and implements appropriate plans of action to correct identified quality deficiencies.”
       With the implementation of quality indicators and quality measures, many facilities only focused on these areas and came up short at survey time. This is due in part because they did not have or were not following a system that assured their ongoing processes were continuing to be followed according to pre-determined standards and policies. As director of nursing (DON), think about all of the care areas/processes for which you are ultimately responsible. If you were asked how you do these processes, you would probably be able to explain a policy/procedure, display tools required (forms, etc.), and describe required documentation for that process. However, who is looking to ensure that a process continues to be done as originally designed, and who analyzes results of such processes, if needed? Also, are these processes only reviewed when there is an obvious problem?
       Often we write policies/procedures and everyone jumps on board, and in the first few months it seems like everyone understands and follows the process. However, too often, a year or 2 later, staff changes, industry focus changes, and people do not continue to follow the process. Thus, what you say you do and what is actually done is quite different. Too often, I have observed facilities adopting procedures to correct a cited deficiency and a year later ignore the very processes they implemented to correct the deficiency. Why is this? Could it be that we do not have a system to “inspect what we expect?”
       In addition to ongoing consulting, our company, New Day Professional Services, often works with facilities that are suffering the results of a negative outcome survey. I have often found that the facilities had the proper policies/procedures at 1 time but the staff was not following them. This is often pointed out during the survey. For example, if I asked you what you do to prevent fecal impactions occurring in your residents, what would you tell me? You probably have some method of documenting bowel movements daily, and if a resident has not had a normal bowel movement in 3 days, other protocols were followed.
       If you randomly checked your methods of documenting, would you find consistent and accurate documentation of bowel movements—and would you find the protocol being followed? If you would not find that, neither would a surveyor who may be looking for the same thing, especially if that is the way your procedure states it will be done.
       While this is a simple example, it applies to many different areas within the facility and expands across all departments. Quality assurance should be an ongoing process that examines all aspects of facility operations. It should be used as an opportunity to conduct peer reviews, which not only benefits the QA process but also makes staff responsible for reviewing their own actions.
       Quality assurance committees must decide which QA activities are necessary. Most teams have definite areas that are reviewed, such as number and reason for falls, infections, drug errors, psychotropic drug use, complaints, ulcers, weight losses, accidents, etc. These are normally ongoing and, if a problem is identified, the QA committee decides on a plan of action to correct it. However, there are so many other areas that the DON could assign as peer reviews that would not only point out any concerns needing attention but also provide opportunities for positive input at the QA committee.
       It is most important that all staff understand the purpose of the QA committee and how they may bring concerns to the committee for consideration or review. It may even be advantageous to have an anonymous suggestion box for QA reviews. Some employees may observe areas they feel are not being handled appropriately but may be hesitant to report, especially if it involved their supervisor; an example of this might be something like consumption of meals being documented by a person who had not observed the meal intake or was given a list of intakes. A good peer review would be to develop a tool whereby an employee was assigned to observe several different residents’ meal consumption and later to check the documented consumption to see if it agreed with his or her observation. Of course this would need to be a facility-wide observation and not limited to 1 unit. It needs to be emphasized that there will be no repercussion for bringing attention to the QA things staff feel need review, but failure to do so could harm the resident and/or facility.
       In almost every plan of correction for deficiencies, I see some QA activity incorporated into the plan to keep the deficiency corrected. To be proactive and to assure quality of life and quality of care for your residents, revisit your QA process and identify all areas that you feel need to be reviewed for ongoing compliance. While I have emphasized mostly nursing situations in this article, every department should have some area of review in their departments every quarter, in addition to the normal QA reviews. Also, keep in mind that identifying issues is only the beginning; the next step is to develop an action plan that will correct or improve the issues identified.