From Funding to Fines, Why ‘More of Everything’ Won’t Solve Endemic Nursing Home Problems Alone

To improve the quality issues in nursing homes — many of which pre-dated COVID-19 but were brought into a harsh spotlight because of the pandemic — the entire system of skilled nursing care needs to be completely overhauled, according to one physician in the space.

“I believe that our consistent failures in nursing home quality stem not from the negligence of a few, but the lack of rational thinking and evidence-based [thinking] in our overall system design,” Dr. Arif Nazir, chief medical officer at the Louisville, Ky.-based Signature HealthCARE said at a public webinar held by the National Academies of Sciences, Engineering and Medicine on Tuesday.

The presentation was part of an ongoing project by the National Academies of Science, Engineering and Medicine on improving quality in nursing homes, sponsored primarily by the The John A. Hartford Foundation.


He noted that his remarks represented his own views “as a clinician and advocate in this setting,” rather than a representation of the operator.

During his presentation, Nazir argued that several “well-funded and well-thought-out trials” aimed at improving quality on a range of fronts have produced disappointing results, despite the extra attention paid to the nursing home setting.

“Their results highlighted that even with additional funding and expertise, current nursing home environments make it impossible to implement and improve quality,” he said. “Simply more of everything — for example, funding, regulations, citations, and staffing — is not going to suffice as a solution.”


Nazir made four arguments aimed at persuading the committee serving on the Quality of Care in Nursing Homes study that “improving quality of our nursing homes requires a complete, evidence-based redesign of every aspect of the system, including care delivery systems, teamwork, leadership, physical upgrades, etc.”

The first argument he made is that regulatory checklists have “hijacked” the agenda for nursing home quality, citing the example of a nurse who moved to a training position so she could continue to provide makeup and hairstyling to residents, who particularly wanted those skills of hers. She specifically switched to a non-clinical position because of being reprimanded for doing these “unessential tasks” for residents, Nazir said.

“Please don’t get me wrong: We do need regulatory structures for assuring standardization and accountability in many areas — for example, environmental standards, campus safety, temperature limits on food, professional conduct, etc.,” he told the committee. “But when these frameworks impinge on the clinician-patient connection, they become problematic.”

His second argument was for an overhaul of the accountability system for nursing homes. He argued that state surveyor checklists do not capture staff providing conversation or human connection, but focus instead on “a gotcha approach” for any omission on complex care protocols.

“Our nursing homes don’t have a carrot-and-stick accountability system, but rather a sticks-and-then-more-sticks accountability system,” Nazir said. “When we rely on a system that directly employs regulatory citations and the financial penalties — and indirectly employs reputational threats and humiliation through overused litigatory process to make health care teams do the right thing — we propagate the notion that the majority of team members are knaves rather than well-deserving knights.”

Nazir also pointed to a “broken quality measurement system,” pointing out the failures of the Centers for Medicare & Medicaid Services (CMS) five-star system and alternative payment models as examples of what can go wrong when trying to make complex care easily legible on a dashboard: “inaccurate and irrelevant metrics that are conducive to gaming, particularly for those with resources.”

The solution for this is to create meaningful quality measures by looking to other industries, such as restaurants, for what they measure, he argued.

Lastly, he argued that while advocacy is critical, it cannot improve quality on its own — citing as an example his grandmother in Pakistan asking him not to take the vaccine for COVID-19 because she had heard immigrants were being used to study vaccine safety. In fact, he argued that a lack of consensus among stakeholders who care about nursing home residents contributed to the various struggles to improve nursing home quality, even before the pandemic.

“Sometimes people who are advocating for our best interests may not have all the right answers,” Nazir said. “For the best solutions every single time, we need to rely on available evidence. Can you imagine the outcome if a cardiologist instead of using best available evidence waited to hear from all family members and waited for their agreement before treating unstable angina? How about if the Centers for Disease Control and Prevention had waited for consensus among well-intended stakeholders before implementing a ban on nursing home visitation earlier in the pandemic?”

Nazir highlighted five key areas foundational to improving quality in nursing homes, while noting that he supports solutions from other experts and those outlined in the Care for Our Seniors Act proposals from lobbying and trade groups the American Health Care Association and LeadingAge.

Those areas are:

  • Upgrades in survey and accountability systems and moving quality improvement organizations that use a supportive and coaching approach
  • Using behavioral economics and related strategies for quality improvement and change
  • Creating relevant quality measures with timely, meaningful incentives
  • Discarding burdensome documentation systems and using technology to automate documentation and provide real-time data analytics and outcomes
  • Focusing on wellness and purpose in nursing homes

“Nursing homes can be perceived as places where people come to die,” Nazir said bluntly. “There’s emerging evidence on wellness strategies such as creative engagement, music, volunteerism, spirituality. We need to design reimbursement mechanisms to implement such programs properly, and then invest in high-quality and inclusive research to study the impact. Investment in wellness and purpose-driven care is long overdue.”

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