Nursing Facilities Participating in Advancing Excellence Still Among Worst Performers
Many nursing facilities that are identified by the federal government as among the facilities providing the poorest quality of care to residents in the country – the Special Focus Facilities (SFFs) – participate in the nursing home industry's voluntary quality improvement campaign, Advancing Excellence in America's Nursing Homes. Forty-three percent of all facilities identified by the Centers for Medicare & Medicaid Services (CMS) on December 15, 2011 as either newly-identified SFFs or SFFs that had not shown improvement have participated in Advancing Excellence for more than two years. Most of them have participated in both phases of Advancing Excellence, which was originally launched in October 2006.
Participation in Advancing Excellence has neither prevented facilities from being identified as SFFs nor helped them improve the quality of care they provide to residents to warrant removal from the SFF program.
That nursing facilities participating in a quality improvement campaign are nevertheless identified by the federal government as among the most poorly performing facilities in the country demonstrates, once again, that voluntary quality improvement efforts by the nursing home industry do not guarantee high quality of care for residents and cannot replace a strong public regulatory system.
This Alert reports on the Center's analysis of Special Focus Facilities participating in the Advancing Excellence campaign.
The Special Focus Facility Program
Each month, CMS identifies nursing facilities that are providing the poorest care to their residents, as determined by federal deficiencies cited in the prior three years. There are 15,568 nursing facilities in the United States. Only 150 facilities (less than 1%) were identified by CMS as SFFs that were either newly added to the SFF list or had not shown improvement as of December 15, 2011.
CMS identifies five categories of SFFs: facilities newly added to the SFF program, facilities that have not improved, facilities that have shown improvement, facilities that have "graduated" from the SFF program, and facilities that no longer participate in the Medicare program.
Advancing Excellence in America's Nursing Homes
Advancing Excellence is a voluntary quality improvement initiative implemented by the nursing home industry and others in October 2006. Phase one lasted from September 26, 2006 through October 21, 2009. Phase two began October 22, 2009 and continues to the present.
When Advancing Excellence was implemented in 2006, facilities chose at least three goals from among eight available goals. Four goals were clinical goals – reducing high risk pressure ulcers, reducing the use of daily physical restraints, improving pain management in long-stay residents, and improving pain management in short-stay residents. Four goals were non-clinical – setting individualized quality improvement targets; assessing resident satisfaction, family satisfaction, or both; measuring and reducing staff turnover; and consistent assignment of staff to residents. The four clinical goals continued in phase two (with the two pain measures combined into a single measure), although the Campaign made some changes to the non-clinical goals.
The Campaign reports quality trends in the four clinical Campaign goals, using data publicly reported on Nursing Home Compare. These data come from the Minimum Data Set (MDS) Repository. MDS data are self-reported by facilities and, according to CMS, are "not formally checked to assure accuracy."
The Campaign reports results in clinical goals by state and nationwide. It does not publicly report any information about which goals a participating facility chose or how the facility's performance on the goals (or the Campaign's other goals) changed over time.
The only information publicly reported about individual facilities is whether they participate in the Campaign. The Campaign identifies participating facilities by state, in three categories: facilities that participated in phase one (September 29, 2006 – October 21, 2009), facilities that participate in phase two (beginning October 22, 2009 – present), and Charter Facilities (facilities that participated in phase one and then re-enrolled in phase two prior to January 31, 2010). Facilities that participated in phase one and then re-enrolled in phase two after January 31, 2010 are not identified as Charter Facilities. The Campaign website's list of participating facilities records one, two, or three checkmarks next to each participating facility's name, reflecting participation in phase one, participation in phase two, and status as a Charter Facility.
The Center's Analysis
On December 23, 2011, the Center reviewed two lists of SFFs published by CMS on December 15, 2011 – the 24 nursing facilities that were newly added to the SFF program (Table A) and the 60 nursing facilities that had not shown improvement (Table B).
Using the Advancing Excellence website, the Center identified facilities that participated in the past or currently participate in the Campaign, or both.
The Center compared the names of SFFs that were newly added to the SFF program and SFFs that had not shown improvement with the list of facilities participating in Advancing Excellence. The Center did not look at the 66 facilities on the December 15, 2011 list that had shown improvement (Table C), the 29 facilities that "graduated" (Table D), or the five facilities that no longer participate in the Medicare program (i.e., they voluntarily or were involuntarily terminated) (Table E).
The Center's comparison may understate the numbers of SFFs that participate in Advancing Excellence if the name used by the facility in the Campaign is not the same as the name by which the facility is known to CMS.
The Center's Findings
CMS added 24 nursing facilities to the SFF list on December 15, 2011. Eight of these 24 facilities (33%) participated in Advancing Excellence. Of the eight facilities, one participated only in phase one; three participated only in phase two; and four were Charter Facilities.
CMS identified 60 nursing facilities that had not shown improvement. These facilities had been on CMS's SFF list for durations ranging from two to 47 months. (The facility on the SFF list for 47 months, as of December 15, 2011, is West Virginia's Eagle Pointe, a Charter Facility in Advancing Excellence.) Twenty-eight of these 60 facilities (47%) participated in Advancing Excellence. Of these 28 facilities, three participated only in phase one; seven participated only in phase two; 16 were Charter Facilities; and two participated in both phases but were not Charter Facilities.
Of the 84 SFFs evaluated (24 newly-added SFFs and 60 facilities that had not shown improvement), 36 SFFs (43%) were members of Advancing Excellence. This participation rate is close to the national participation rate of 7861 facilities (50.2%) reported by Advancing Excellence on December 28, 2011.
Moreover, 22 of 36 facilities (61%) participated in both phases one and two, including 20 of 36 facilities (56%) that were Charter Facilities (i.e., they joined the Campaign during phase one (between September 29, 2006 – October 21, 2009 and re-enrolled in phase two before January 3, 2010).
Ten SFFs (three newly-added SFFs and seven SFFs that had not shown improvement) participated only in phase two of the Campaign (i.e., they joined the Campaign sometime on or after October 22, 2009).
Only four of the SFFs (one newly-added SFF and three SFFs that had not shown improvement) (11%) participated only in phase one of the Campaign (i.e., their participation ended on or before October 21, 2009).
These findings suggest that at least 89% of the 36 SFFs (the 32 SFFs that are Charter Facilities, that participate only in phase two, or that participated in phases one and two but are not Charter Facilities) were likely to have been participants in Advancing Excellence at the time they became, or continued to be identified as, SFFs. Participation in Advancing Excellence has neither prevented nursing facilities from being identified as SFFs nor helped them improve the quality of care they provide to residents so that they are removed from the SFF list.
SFFs are defined as among the 1% of worst performing nursing facilities in the country, yet they participate in Advancing Excellence at high rates. Many facilities appear to have participated in Advancing Excellence when they were first identified as SFFs. Participation in the Campaign clearly has not improved their performance.
These findings give little reason to believe that Advancing Excellence is making a difference in improving quality of care and quality of life for residents. And they provide no reason to believe that voluntary quality improvement campaigns can be a substitute for an independent, objective, public regulatory system.
 Last month, the Center for Medicare Advocacy released a report showing that Special Focus Facilities report high staffing levels and high performance measures. CMA, Nursing Facilities' Self-Regulation Cannot Replace Independent Surveys: A Study of Special Focus Facilities, Their Health Surveys, and Their Self-Reported Staffing and Quality Measures (Dec. 2011), http://cma.benfredaconsulting.com/wp-content/uploads/2011/12/SFFs-12.2011.pdf
 Kaiser Family Foundation, "Total Number of Certified Nursing Facilities 2009," https://www.cms.gov/CertificationandComplianc/Downloads/SFFList.pdf (site accessed Dec. 28, 2011).
 Performance measurement systems accurately identify the lowest performing facilities. See Charles D. Phillips, Catherine Hawes, Trudy Lieberman, and Mary Jane Koren, "Where should Momma go? Current nursing home performance measurement strategies and a less ambitious approach," BMC Health Services Research 2007, 7:93 (2007), http://www.biomedcentral.com/content/pdf/1472-6963-7-93.pdf.
 Center for Medicare Advocacy, "The 'New' Nursing Home Quality Campaign: Déjà vu All Over Again," Weekly Alert (Sep. 21, 2006), http://cma.benfredaconsulting.com/InfoByTopic/SkilledNursingFacility/SNF_QualityCampaign.htm.
 http://www.nhqualitycampaign.org/star_index.aspx?controls=eightgoals (site accessed Dec. 29, 2011). The non-clinical goals in phase two are: staff turnover; consistent assignment; advance care planning; resident/family satisfaction; and staff satisfaction.
 http://www.nhqualitycampaign.org/star_index.aspx?controls=nh_list (site accessed Dec. 23, 2011).
 https://www.cms.gov/CertificationandComplianc/Downloads/SFFList.pdf (site accessed Dec. 23, 2011).
 http://www.nhqualitycampaign.org/star_index.aspx?controls=nh_list (site accessed Dec. 23, 2011).
 http://www.nhqualitycampaign.org/ (site accessed Dec. 28, 2011).