Page 67 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
Advancing Resident Self-Determination
ADVANCING RESIDENT SELF-DETERMINATION
The establishment of resident-directed, individualized care that would lead to fulfillment of OBRA ’87 is challenged by contradictions in the document itself. The resident right to a dignified existence, autonomy (including independence and self control), self-determination, refusal of treatment, the dignity of risk and more are contested by statutory requirements that hold the facility ultimately responsible for the resident’s care and safety.
In Long Term Care and a Good Quality of Life – Bringing Them Closer Together, Kane addresses the competing priorities:
“One little-tested assumption is that safety – defined vaguely or not at all – is the be-all and end-all of long-term care. Embedded in most of our rules and regulations is the idea that long-term care should aspire to the best quality of life as is consistent with health and safety. But ordinary people may prefer the best health and safety outcomes possible that are consistent with a meaningful quality of life.” (Kane, 2001)
Grant summarizes the challenge:
“Still, it will be no simple task for policymakers to balance the competing needs for safety and choice in a way that best meets the current and future expectations of key stakeholders such as residents and their families, consumer advocates, providers, payer, and regulators. The goals of nursing home care pose complex ethical dilemmas that must ultimately be addressed through open public debate.” (Grant, 2008)
In Moving to a Higher Level: How Collaboration and Cooperation Can Improve Nursing Home Quality, Koren addresses the potential for the work of the nursing home component of the Quality Improvement Organization (QIO), the grass roots “culture change” movement, and the “Nursing Home Quality Campaign, Advancing Excellence,” to move nursing homes toward a higher level of performance. She cites the work of the Rhode Island Department of Health’s “Individualized Care Pilot,” which connects surveyor identification of problems with technical assistance from the QIO to help providers improve quality. (Koren, 2008)
In Supporting Culture Change: Working Toward Smarter Nursing Home Regulation, Stone et al. discuss the challenges of moving forward in a partnership model. They cite Kansas, where the regulatory and technical assistance functions are separate departments of a single agency, and Oregon, where surveyors team up with nursing home staff to address the challenges together.
Stone emphasizes the challenges of partnership in regulatory reform:
The success of the partnership approach will depend, in a large part, on the extent to which the stakeholders buy into the process and assume responsibility for successful implementation. The regulatory agency staff at all levels – particularly midlevel managers and front line surveyors – must be committed to this new paradigm and integrate their training in both culture change and new
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