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Purpose: In this commentary, we examine nursing
home quality and indicators that have been used
to measure nursing home quality. Design and
Methods: A brief review of the history of nursing
home quality is presented that provides some context
and insight into currently used quality indicators.
Donabedian’s structure, process, and outcome (SPO)
model is used to frame the discussion. Current quality
indicators and quality initiatives are discussed, includ-
ing those included in the Facility Quality Indicator
Profile Report, Nursing Home Compare, deficiency
citations included as part of Medicare/Medicaid
certification, and the Advancing Excellence Cam-
paign. Results: Current quality indicators are
presented as a mix of structural, process, and out-
come measures, each of which has noted advan-
tages and disadvantages. We speculate on steps
that need to be taken in the future to address and
potentially improve the quality of care provided
by nursing homes, including report cards, pay for
performance, market-based incentives, and policy
developments in the certification process. Areas
for future research are identified throughout the
review. Implications: We conclude that improve-
ments in nursing home quality have likely occurred,
but improvements are still needed.
Key Words: Quality of care, Nursing homes, Long-
In the past, nursing home care and long-term
care were synonymous. If elders needed long-term
care, it would invariably be provided in a nursing
home. In recent years, the long-term care sector
has changed considerably and is arguably evolving
into a “system” in which care can be provided in
settings that are more appropriate for consumers’
needs. This includes care by home health provid-
ers, adult day care, residential care, and assisted
living (to name just four). However, nursing homes
are still an essential component of the current long-
term care system. In the United States, approxi-
mately 1.6 million elderly and disabled persons
receive care in 1 of the 17,000 nursing homes
(National Nursing Home Survey, 2004). Enduring
issues surrounding nursing homes have been quality
related. The often-poor quality of nursing homes
has been a consistent issue of concern for consum-
ers, government, and researchers.
In this commentary, we first provide a brief
review of the history of nursing home quality. This
centers on how nursing home quality has been
What Is Nursing Home Quality and How Is It
Nicholas G. Castle, PhD, MHA, AGSF*,1, and Jamie C. Ferguson, MHA1
1Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pennsylvania.
*Address correspondence to Nicholas G. Castle, PhD, MHA, AGSF, Professor, Graduate School of Public Health, University of Pittsburgh,
A610 Crabtree Hall, 130 DeSoto Street, Pittsburgh, PA 15261. E-mail: email@example.com
Received March 18, 2010; Accepted June 7, 2010
Decision Editor: William J. McAuley, PhD
Vol. 50, No. 4, 2010
measured and provides some context and insight
into currently used quality indicators in the nurs-
ing home industry. In doing so, we note that the
concepts of what is measured, who does the mea-
suring, and why measures are used are intertwined.
We secondly provide our opinion on the relative
merits of indicators of quality. Notable current
quality indicators are presented. We then speculate
on steps that need to be taken in the future to
address and potentially improve the quality of care
provided by nursing homes. These steps include
policy changes and future research that is needed.
Numerous definitions of quality exist. A current
well-cited example comes from the Institute of
Medicine (IOM) (1996): “The degree to which
health services for individuals and populations
increase the likelihood of desired health outcomes
and are consistent with current professional knowl-
edge” (p. 5). Operationalizing “quality” from defi-
nitions such as these proffered by the IOM can be
problematic as the definitions are extremely gen-
eral and subjective and as such resulting measures
tend to be unable to fully realize the quality con-
cept (Castle, Zinn, Brannon, & Mor, 1996).
Because of this inability to adequately realize
“quality” in nursing homes, quality indicators are
prevalent rather than quality measures. This helps
denote a less precise association between the “indi-
cator” and actual quality (i.e., they are surrogate
measures). This has also fostered the creation of
many quality indicators. For example, in choosing
the quality indicators to be reported in Nursing
Home Compare (www.medicare.gov/NHCompare;
discussed subsequently), 181 indicators were con-
sidered. With many quality indicators available,
some organization is useful. In this regard, in con-
ceptualizing and organizing quality indicators, the
approach of Donabedian (1985) is valuable.
Donabedian proposed that quality could be mea-
sured in terms of structures (S), processes (P), and
outcomes (O). Structural measures are the organi-
zational characteristics associated with the provi-
sion of care. Process measures are characteristics of
things done to and for the resident. Outcome mea-
sures are the desired states one would (or would
not) like to achieve for the resident. Donabedian’s
SPO approach is somewhat pervasive in the quality
literature. For example, in MEDLINE (2005–
2010), 57% (N = 3,950) of nursing home studies
either directly or indirectly applied this approach of
conceptualizing quality indicators. This approach
of conceptualizing quality indicators as SPO mea-
sures is also used in this commentary.
The SPO approach also has theoretical under-
pinnings in that good structure should facilitate
good process and good process should facilitate
good outcomes. However, we note that the theo-
retical SPO underpinnings were not developed
specifically for nursing homes and some have ques-
tioned its suitability for this setting (Glass, 1991).
Moreover, SPO linkages are not always validated
in the nursing home literature (Gustafson, Sainfort,
Van Konigsveld, & Zimmerman, 1990). Some
scholars have also further substantially developed
components of this approach by including factors
such as culture (S) and work groups (P) (Scott
Poole & Van De Ven, 2004), whereas others in
long-term care have modified the SPO theory, for
example by combining it with contingency theory
(Zinn & Mor, 1998).
A Brief History of Nursing Home Quality
A significant influence on nursing home quality
has come from federal and state oversight bodies.
This is the result of nursing home facility licensure
and certification requirements and payments nurs-
ing homes receive from federal and state programs.
Thus, a history of nursing home quality is inter-
twined with developments in these federal and
state entities. We highlight key federal and state
activities that have influenced quality indicators.
State health departments use a licensure process
to establish standards for nursing home care. In
1961, the Public Health Service (as part of the U.S.
Department of Health, Education, and Welfare)
began studying nursing home state licensures after
problems were being reported by the Commission
on Chronic Illness and by a number of states
(IOM, 1986). The Public Health Service issued
the Nursing Home Standards Guide that expressed
the need for standardized definitions of nursing
homes and other critical terminology (i.e., admin-
istrator, advisory council, and resident). This guide
also recommended “basic minimum standards
applicable to all nursing homes” (Department
of Health, Education, and Welfare, 1961, p. 5).
The recommendations consisted of 77 health and
safety standards—55 of these were structural quality
The nursing home industry continued to develop.
By the late 1960s, by today’s standards, what we
would call the modern nursing home industry existed.
This industry development and growth were primar-
ily in response to the newly created Medicare and
Medicaid programs. Certification was a requirement
for nursing homes to receive reimbursement for
Medicare and/or Medicaid residents. This certifi-
cation process occurs approximately yearly and con-
sists of an on-site inspection by a team of surveyors.
These surveyors monitor quality of care and assess
whether the facility meets standards for certification
(see review by Castle, Men, and Engberg, 2007, of
the current certification process).
Despite the entry into the nursing home market
of many new facilities, demand outstripped sup-
ply. Many nursing homes operated at 100% occu-
pancy, and nursing homes generally did not incur
much in the way of competitive pressure from each
other. Quality issues remained, and health and
safety standards continued to be developed and
implemented. By 1974, 90 health and safety stan-
dards existed (for what were termed Skilled Nurs-
ing Facilities), with 59 of these as structural quality
In 1977, a new federal organization, the Health
Care Financing Administration (HCFA) was cre-
ated specifically for the coordination of Medicare
and Medicaid. As part of this coordination, HCFA
assumed jurisdiction over the nursing home certi-
fication process and development of standards
for certification. HCFA continued to amend the
standards and the certification process during the
1980s. One major change included using deficiency
citations (Spector & Drugovich, 1989). That is, a
deficiency citation represents an area in which a
facility does not meet a Nursing Home Standard
As part of the improvements to the standards
for certification, process quality indicators were
introduced. For example, process quality indicators
included the prevalence of daily physical restraints,
occasional bladder/bowel incontinence without a
toileting plan, and indwelling catheters. By 1987,
certification consisted of 136 health and safety stan-
dards, with 98 of these structural quality indicators
and 38 as process quality indicators (IOM, 1986).
Despite the amendments to the standards and
the certification process that occurred during the
1980s, these generally did not keep pace with the
increasingly complicated medical needs of resi-
dents. The nursing home industry’s solution was
to lobby to weaken the certification process. This
move by the nursing home industry was contrary
to media reports that had identified fraud, abuse,
neglect, and poor care in nursing homes. Thus,
HCFA commissioned the IOM to examine and
report on nursing home regulations (IOM, 1986).
The expert committee assembled by the IOM to
examine nursing home regulations concluded that
care was “shockingly deficient” (IOM, 1986, p. 2).
This was further verified by a General Accounting
Office report (GAO, 1987). Both the IOM and the
GAO reports advocated for stronger government
oversight to protect nursing home residents.
The IOM and GAO recommendations were
incorporated into Subtitle C of the Omnibus Bud-
get Reconciliation Act of 1987 (OBRA-87). The
specific nursing home reform provisions are some-
times referred to as the Nursing Home Reform Act
(Emerzian & Stampp, 1993). The changes were
regarded as significant and wide ranging. Forty-
seven recommendations were included. A timetable
was established for implementation, and not all
the changes to standards and enforcement were in
effect until 1995. OBRA-87 was largely responsible
for the quality environment in which nursing homes
operate today. This includes a more stringent survey
process, revised care standards, sanctions and
remedies, training of nurse aides, and use of the
Resident Assessment Instrument (of which the
Minimum Data Set (MDS) is a major component).
The IOM report recommended that nursing
home regulations should be refocused and to move
from assessment of structure and process to an
assessment of outcomes. This was facilitated by
the MDS. The MDS is a summary assessment of
each resident. The original MDS developed in 1990
and implemented in 1991 was redesigned as the
MDS 2.0 in 1995 (Rahman & Applebaum, 2009).
This includes measures of residents’ functional sta-
tus and health conditions. With this information
from the MDS, outcome indicators were developed
(e.g., falls, behavioral symptoms affecting others,
symptoms of depression, bladder/bowel inconti-
nence, and urinary tract infections). In 1999, the
Nursing Home Standards for health and safety used
during the certification process consisted of 153
standards; 81 of these were structural quality indi-
cators, 48 of these were process quality indicators,
and 24 of these were outcome quality indicators.
The progression over time in use of quality indi-
cators as part of the Nursing Home Standards is
shown in Table 1. For parsimony, this time line is
simplified as information from only 5 years are
presented. The use of these various SPO quality
indicators has evolved gradually, and few water-
shed events have prompted substantial change
(with the exception of OBRA-87).
The drivers of use of these SPO quality indica-
tors are also simplified. The drivers not only include
federal/state oversight as described (i.e., as part of
Vol. 50, No. 4, 2010429
Table 1. Progression Over Time in Nursing Home Standards and Deficiency Citations
5 of 555 of 595 of 98 5 of 81 5 of 104
Patient Care Advisory
The resident has the right
to receive information
in a language he/she can
The resident has the right to
manage his/her finances
and are not required to
deposit their personal
funds with the facility.
The resident has the right
to choose a personal
Patient Care Attending
Charge Nurse on staffPatient rights Use of charge
services 24 hr
a day (F389)
nurse or licensed
practical nurse on staff
and on duty at all times
Sufficient number nursing
personnel on duty at
all times (only
on what current state
The activities program
must be directed by a
The facility must help
residents who have
difficulties with vision and
hear make appointments
5 of 225 of 31 5 of 385 of 48 5 of 62
upon admission and
once every 2 months
The facility must conduct
initial and periodic
of each resident’s
Each resident must be
examined at minimum
every 3 months by the
facility and revise the
based on the findings.
A comprehensive care plan
must be developed within
7 days after completion
of the comprehensive
A physician may delegate
tasks to a physician
practitioner, or clinical
nurse specialist who is
acting within the scope
of practice as defined by
Only use physical
Written nursing care
Serious illness, accident,
or death reporting
(Table continues on next page)
The Gerontologist 430
5 of 22 5 of 315 of 385 of 48 5 of 62
In accordance with State
and Federal laws, the
facility must store all
drugs and biologicals in
under proper temperature
controls, and permit only
authorized personnel to
have access to the keys.
Outcome3 of 3
5 of 24 5 of 24
A resident who is
incontinent of bladder
treatment and services
to prevent urinary tract
infections and to restore
as much normal bladder
function as possible.
Residents who have not
used antipsychotic drugs
are not given these drugs
unless antipsychotic drug
therapy is necessary to
treat a specific condition
as diagnosed and
documented in the
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
that this is not possible.
No development of
in range of
Activities of daily
living do not
and vision (F313)
rates of 5% or
Note: Some quality indicators can be categorized either as process or outcome quality indicators (Zimmerman, 2003).
aThese standards were recommendations that predate federal nursing home standards. States were responsible for implementing
and enforcing all nursing home standards at this time.
bStandards are presented.
cDeficiency citations are presented (deficiency citations are notice given to a nursing home to identify an area that is not meet-
ing the minimum requirements [standards] set forth by law). The notation following the deficiency citation (i.e., F number)
represents the coding on the survey form.
Table 1. (continued)
Vol. 50, No. 4, 2010 431
the certification process) but also include advances
in measurement science and data availability (e.g.,
the MDS). They also include prompts from external
bodies, such as the Joint Commission. The Joint
Commission accredits relatively few nursing homes
but as part of the Oryx system in the late 1990s
emphasized outcomes of providers (Morrissey,
1997). This invariably had a spillover influence on
Advantages and Disadvantages of SPO Indicators
The use of varying SPO quality indicators over
time connotes improvement. This may not be the
case; we have little evidence that quality indicators
have improved in their association with actual
quality. Moreover, some research has determined
that current quality indicators do not meet accepted
standards for measures (Nakrem, Vinsnes, Harkless,
& Paulsen, 2009). It is also tempting to state that
an improved association with quality may be espe-
cially true for outcome indicators. A prevailing
view is that we should use more outcome indica-
tors to improve quality (Spector & Mukamel,
1998). This is an issue we now discuss as SPO indi-
cators have both advantages and disadvantages.
Structural Quality Indicators
Structural quality indicators are advantageous in
several respects. Most significantly, structural quality
indicators are easy to measure. Data used are often
routinely available and relatively inexpensive.
Structural quality indicators also have disadvan-
tages. Nursing homes can meet structural quality
measure standards but not necessarily provide qual-
ity care. Echoing this, Donabedian (1988) noted that
structural quality indicators can be blunt instru-
ments. Although structural quality indicators are
considered important for assuring quality, they are
best viewed as “necessary but not sufficient.” This is
typified by the nursing home staffing level literature.
Staffing levels are included in many current qual-
ity initiatives. It would seem almost intuitive that
providing higher levels of caregivers would improve
quality of care. However, the literature in this area
is somewhat ambiguous—with many empirical
studies finding no such relationship (Castle, 2008).
As a way of explaining this apparent anomaly, staff-
ing levels are viewed as likely extremely important,
but how staff are used (i.e., processes) may be just
as inherently linked to quality (Castle).
Process Quality Indicators
Process quality indicators have advantages.
They are often easy to interpret. For example,
either a resident received a pneumonia vaccination
or they did not. Many are also easy to enumerate
and do not require adjustment (described subse-
quently). Process quality indicators may also help
pinpoint how to improve quality of care. The
Nursing Home Compare measure—prevalence of
occasional bladder/bowel incontinence without a
toileting plan—would indicate that a toileting plan
should be used for residents with bladder/bowel
incontinence. For consumers, this asset may be less
important as a quality indicator, but for providers,
this is of use.
Process indicators may also have inefficiencies as
quality indicators. In many cases, process indica-
tors assess what is being done and not necessarily
the appropriateness of what is being done. Medica-
tions (a process indicator) can be given to the wrong
resident (Handler et al., 2008). Other medication
errors include incorrect dose, incorrect time, incor-
rect prescription, or even given when not needed
(to name just four; Handler et al., 2008).
Process measures are often criticized as repre-
senting measures of documentation rather than
actual care. Such criticisms of paper compliance
are often a drawback levied on physical restraint
use care, for example. To prevent the damaging
side effects of immobility due to restraint, federal
regulations mandate that restrained residents
should be released, exercised, and repositioned
every 2 hrs. However, Schnelle, Simmons, and Ory
(1992) determined that actual care and the docu-
mentation of this mandate were often inaccurate.
As measures assessing what is being done, pro-
cess quality indicators are limited in that some com-
ponents of care are difficult to measure. Technical
expertise is important in many components of care.
For example, use of physical restraints does not
include a dimension for how well this procedure
was implemented. A nursing home resident can be
placed in physical restraints in such a way that
bruising or restricted circulation can occur.
Outcome Quality Indicators
Outcome indicators are considered more strin-
gent quality indicators than structural or process
indicators because deviations from appropriate
care should influence residents’ health outcome
(Donabedian, 1988). Moreover, outcome indicators
in many cases are important to know—they have
intrinsic interest. Mortality rates, for example.
Nevertheless, outcomes can be problematic
measures. To be a valid indicator, the change in
residents’ health status (i.e., outcome) must be
attributable to prior care (i.e., under the control of
the provider). Spector and Mukamel (1998)
describe this attribution difficulty as the difficulty
in isolating the facility effect. This attribution is in
many cases unclear. In addition, many outcomes
are influenced by genetic, environmental, or other
factors unrelated to care. That is, care is only one
of several determinants of health status (Mant,
To help mitigate these confounding issues
(genetic, environmental, or factors unrelated to the
care process), outcome measures are often statisti-
cally manipulated to account for differences in risk
for adverse outcome among residents (and/or facil-
ities). The process and science of “risk adjustment”
has many issues, most of which were previously
discussed by Spector and Mukamel (1998). One
important issue is a real risk of either over or under
adjustment of the value of the outcome indicator—
which will bias the reported outcome rate.
One particularly challenging issue for risk
adjustment is the often interrelated nature of the
constructs used. For example, a factor associated
with the development of pressure ulcers is malnu-
trition. So if facilities receive a high number of
residents with malnutrition, some adjustment
would seem necessary. However, if the nursing
home influenced the malnutrition in the first place,
then as a characteristic used for risk adjustment,
this is clearly inappropriate.
This malnutrition example also raises the issue
that the baseline distribution of many outcomes
(or resident characteristics) is also not random
among nursing homes. For example, some nursing
homes specialize in treating some outcomes (e.g.,
pressure ulcers) or gain a reputation for providing
high quality care in a specific area, thereby receiv-
ing more residents with that condition. For these
nursing homes, unadjusted outcome scores will
not accurately reflect the quality of care.
The period of observation for some outcome indi-
cators may also be untenable (Brook, McGlynn, &
Shekelle, 2000). For the resolution of clinical con-
ditions, such as depression, knowing that there
was no clinical reoccurrence may be a more appro-
priate quality indicator than a simple prevalence
rate. However, the period of follow-up observation
needed is unclear, the data collection needed
becomes more complex, and the resident may not
reside in the facility long enough for the indicator
to be of use.
Current Quality Indicators
The “quality” of nursing homes is generally
assessed using several quality indicators, usually
including a mixture of several SPO indicators.
Current important sets of quality indicators are
the deficiency citations used as part of Medicare/
Medicaid certification, the Facility Quality Indica-
tor Profile Report, those used by Nursing Home
Compare, and the Advancing Excellence Cam-
paign. These current sets of quality indicators are
important because they are national in scale and
include a comprehensive scope of quality indica-
tors. They influence which quality indicators: pro-
viders address, consumers pay most attention to,
and regulators examine. The quality indicators
used in these initiatives are shown in Table 2 and
are categorized into SPO indicators.
Deficiency citations are influential quality indi-
cators because they represent an assessment of
quality coming from the main nursing home over-
sight body. They are presented in many report
cards (including Nursing Home Compare) in gov-
ernment reports (such as those from the GAO) and
in the lay press.
Facility Quality Indicator Profiles
The Center for Health Systems Research and
Analysis developed indicators that could be
used to evaluate nursing home care (Zimmerman,
2003)—these are often called the Nursing Home
Quality Indicators (or QIs). These were developed
from the clinical research literature and care plan-
ning guidelines. There were a total of 24 indicators
that covered 12 areas of care that were found to be
the most relevant through information from the
MDS (Meiller, 2001). These Quality Indicators
are influential because through the National Auto-
mated Quality Indicator System, regulators can
gauge quality issues as a preliminary step to the
certification process (Zimmerman). Specifically,
the Facility Quality Indicator Profile Report identi-
fies areas for further emphasis during the survey
process. These reports are not available to the pub-
lic but are available to each provider.
Vol. 50, No. 4, 2010433
Table 2. Quality Indicators Used in Prominent Quality Initiatives
initiative StructureProcess Outcome
Residents who were physically restrained Residents who have increased
depression or anxiety
Residents with a urinary tract
Residents who have an increased
Residents who have a decreased
ability to move about in and
around their room
Residents who have increased their
need for help with daily activities
Residents who spend most of their
time in bed or in a chair
Low-risk residents who lose control
of their bowels and/or bladder
Residents who spend most of their
time in bed or in a chair
Residents who have moderate to
High-risk residents who have
Low-risk residents who have
Short-stay residents with delirium
Short-stay residents who had
moderate to severe pain
Short-stay residents with pressure
Long-stay residents given the influenza
Long-stay residents who were assessed
and given the pneumococcal vaccine
Short-stay residents who were assessed
and given the pneumococcal vaccine
Short-stay residents given the influenza
Prevalence of occasional or frequent
bladder or bowel incontinence
without a toileting plan
Prevalence of indwelling catheters
Prevalence of tube feeding
Incidence of new fractures
Prevalence of falls
Prevalence of behavioral symptoms
Prevalence of symptoms of
Prevalence of antipsychotic use in the
absence of psychotic and related
Prevalence of antianxiety/hypnotic
Prevalence of hypnotic use more than
two times in the last week
Prevalence of daily physical restraints
Prevalence of little or no activity
Prevalence of depression without
Use of nine or more different
Incidence of cognitive impairment
Prevalence of bladder or bowel
Prevalence of fecal impaction
Prevalence of urinary tract infections
Prevalence of weight loss
Prevalence of dehydration
Prevalence of bedfast residents
Incidence of decline in late loss ADLs
Incidence of decline in ROM
Prevalence of little or no activity
Prevalence of Stage 1–4 pressure
(Table continues on next page)
The Gerontologist 434
Nursing Home Compare
Nursing Home Compare was developed by the
Centers for Medicare and Medicaid Services (CMS;
in 2001, HCFA changed its name to CMS). Via the
Internet, Nursing Home Compare provides infor-
mation on all Medicare/Medicaid-certified nursing
homes in the United States. This information
includes what are called Quality Measures (GAO,
2002), which are intended to represent indicators
of quality of care. The number of Quality Mea-
sures has varied over time and currently consists
of 19. The Quality Measures were the result of
extensive testing that included both provider and
consumer concerns of what indicators were
most useful (Abt Associates, 2004). Nursing Home
Compare is influential because it presents publicly
available standardized quality information on
most nursing homes in the Unites States.
Advancing Excellence Campaign
The Advancing Excellence Campaign was insti-
tuted in 2006. It is a voluntary coalition of providers
(such as the American Health Care Association
[AHCA]) with the goal of promoting excellence in
nursing home care (Advancing Excellence in Americas
Nursing Homes, 2009). This includes measuring
quality indicators (see Table 2). Nursing homes
voluntarily work on improving three of the eight
quality goals. The Advancing Excellence Campaign
5 of 104 5 of 625 of 24
Facility must develop and
implement written policies
and procedures that
neglect, and abuse of
resident property (F226)
Facility may not employ
persons who have been
found guilty of abuse
Facility must have written
policies and procedures
that prohibit abuse and
Facility should have policies
residents’ needs and
Facilities director must be
fully qualified (F249)
Proper treatment to prevent or treat
pressure sores (F314)
ADLs do not decline unless
Resident is not catheterized, unless
No reduction of ROM, unless
Appropriate treatment for incontinent
Residents are free of any significant
medication errors (F333)
Proper care and services for resident
with nasogastric tube (F322)
Each resident’s drug regimen must be
free from unnecessary drugs (F329)
Facility must provide sufficient fluid
intake to maintain proper hydration
and health (F327)
Reduce the use of physical restraints
Improve treatment of pressure ulcers
Residents who use antipsychotic
drugs receive gradual dose
Reduce pressure ulcers
Incorporate resident and family care
experiences into improvement plans
Measure staff turnover and
Improve pain management for
Improve pain management for
Set clinical quality targets yearly
Assigning the same nurse aides to the
Note: The notation following the deficiency citation (i.e., F number) represents the coding on the survey form.
ADLs = activities of daily living; ROM = range of motion.
Table 2. (continued)
Vol. 50, No. 4, 2010435
is included as an influential quality initiative as it
includes several leaders in quality from govern-
ment agencies, foundations, and providers.
We do note that many other public and private
entities influence quality indicators used for nursing
homes. These include Quality Improvement Organi-
zations (QIOs; Kissam et al., 2003) and the Agency
for Healthcare Research and Quality. Many states
also have initiatives in place that address one or two
specific indicators (e.g., Indiana Pressure Ulcer
Quality Improvement Initiative; www.in.gov/isdh
/24611.htm). Other states are using pay for perfor-
mance (P4P), also known as Value-Based Purchas-
ing, initiatives as part of Medicaid reimbursement for
nursing homes. Given the link to reimbursement, the
quality indicators used are clearly important for nurs-
ing homes in these states (Briesacher, Field, Baril, &
Gurwitz, 2009) and are discussed subsequently.
Issues With Current Quality Indicators
The previous sections highlight ambiguities in
quality indictors used in nursing homes. SPO quality
indicators each have various advantages and disad-
vantages. No clear delineation or consensus on which
sets of SPO indicators should be used exists. A large
and confusing number of sets of quality indicators
are prevalent. Individual quality indicators and sets
of quality indicators, in general, are also encumbered
by several other issues. These are further discussed.
No single quality indicator represents the over-
all quality of a nursing home (i.e., a global mea-
sure). Possibly, the closest global measure is the
Five Star Quality Rating System recently intro-
duced by CMS as an addition to the Nursing Home
Compare Web site. The Five Star Quality Ratings
give consumers a “snapshot” or simplified look at
how a nursing home compares on quality. This
rating system provides a graphical representation
(i.e., stars) of overall high and low performance in
three areas: Health Inspections, Staffing, and Quality
Measures (CMS, 2010).
The availability and use of multiple quality indi-
cators have limitations. One disadvantage of using
multiple quality indicators is that findings can be
inconsistent. Empirically, quality indicators have
orthogonal relationships (Mor, 2005). That is,
multiple dimensions of quality are thought to exist.
This likely occurs because nursing homes provide
care across multiple dimensions (medical and
social, to name two); and they are not consistent in
the quality of care for each dimension.
Thus, the number of “needed” quality indica-
tors is a vexing issue. A narrow focus on a single
(or a few) quality indicator may be misleading
and may lead to erroneous, incomplete, or simply
incorrect conclusions. However, a focus on more
quality indicators introduces the risk of confusion
and may be no less misleading or incomplete.
For relatively rare outcomes, quality indicators
have limited ability (power) to detect real differences
in quality. The standard errors for rare events are
large, giving rise to several issues. First, the true qual-
ity level lies within the standard error so that reliabil-
ity of a single measure is questionable. Second, this is
compounded when comparing more than one facil-
ity. With large bands of standard errors, it can be
problematic to differentiate whether one facility has a
truly better/worse quality level than that of the other.
A further issue is the assumed linearity of qual-
ity indicators. That is, does a 10% rate represent
twice the quality problem of a 5% rate? Also, lin-
earity assumes full use of the scale such that 0%
and 100% are possibilities. This is improbable for
many quality indicators. For example, pressure ulcer
rates less than 2% are considered improbable (Lyder,
2003). So the implied scales are not necessarily
clinically achievable. Experience shows that the
functional form of quality indicators is often unex-
pected and nonlinear (Castle & Engberg, 2005).
As part of process and outcome quality indica-
tor assessment, ascertainment bias can occur
(a type of detection bias). Assessing the elements
included in a process or outcome quality indicator
may vary by provider. As Mor, Angelelli, Gifford,
Morris, & Moore (2003) have described, higher
quality nursing homes may be more able to make
these assessments than lower quality nursing
homes. Higher quality nursing homes may be
actively “looking” for problems. Alternatively,
lower quality nursing homes may have high staff
turnover or high agency staff use, for example, and
may inadequately complete documentation (Sangl
et al., 2005). As such, higher quality nursing homes
may have systematically higher quality indicator
rates, and lower quality nursing homes may have
systematically lower indicator rates.
The issue ascertainment bias (detection bias)
has been of particular concern with quality indica-
tors formulated from the MDS data (Sangl et al.,
2005). That is, the reliability and validity of the
data have been subject to some criticism (Rahman &
Applebaum, 2009). Issues such as interrater vari-
ability are often raised as problems influencing the
usefulness of these data.
Detection bias is a measurement issue inherent
to deficiency citations. Considerable variation in
the use of deficiency citations across different
locations exists. Many states do not emphasize the
same deficiency citations, and some are more or
less aggressive in the use of deficiency citations in
general. The high degree of variation can limit the
usefulness of deficiency citations not only for CMS
but also for consumers and providers.
Nursing Home Characteristics
U.S. nursing homes consist of a diverse group of
providers. Some of the diversity in structural char-
acteristics of nursing homes can work against the
use of many quality indicators. One obvious exam-
ple is that the small average number of beds limits
statistical power. Less frequently noted is the unit-
based nature of many nursing homes. This struc-
tural arrangement can lead to distinct practices and
outcomes in different units. Powell Lawton main-
tained that we could learn substantially more about
nursing home quality by using a unit-based perspec-
tive. Mor and colleagues (2003) also indicate that
intra-provider variation may be helpful. Simply put,
the averages reported on facility quality may hide
substantial and important variation in quality.
However, examining intra-provider variation limits
statistical power but can also add to the quality
indicator overload (by reporting quality indicators
on each unit). Nevertheless, a reasonable question
would seem to be should a facility with widely dis-
parate quality levels, yet somewhat reasonable aver-
age levels, be required to report this variation?
Nursing home residents are also quite varied.
Some residents spend very little time in the facility
(e.g., for rehabilitation), which limits their expo-
sure time to facility influences. Moreover, health
status can be transitional, and untangling these
transitional health changes from adverse changes
precipitated by facility care can be problematic.
These residents may also require care that is dis-
tinct from other residents. In such cases, specific
outcomes are sometimes used (e.g., in Nursing
Home Compare). This specificity restricts the gen-
eralizability of these quality indicators.
In addition to short-stay residents, many other
subpopulations of residents exist in nursing homes
with distinct needs and characteristics—many of
which can influence quality. This includes not only
resident needs based on demographics age, gender,
and race but also resident needs based on character-
istics, such as religion. Thus, in many respects, there
is no such thing as a “typical” nursing home or a
“typical” nursing home resident. As such, this chal-
lenges much of the quality rubric (including assess-
ment, reporting, and development of indicators).
Quality indicators are also often criticized as
having a medical focus, and as such, some dimen-
sions of quality that consumers’ value do not get
reflected. Use of resident and family satisfaction
scores represent one means of including a con-
sumer “voice” as quality indicators (Sangl et al.,
2007). States such as Ohio include satisfaction
indicators in their report cards (Ejaz, Straker, Fox, &
Swami, 2003). However, this approach is uncom-
mon primarily due to the expense involved in col-
lecting satisfaction information (Sangl et al., 2007).
Resident and family complaints are investigated,
first as part of the Long-Term Care Ombudsman
Program if the complaint was filled through the
Ombudsman (Allen, Klein, & Gruman, 2003) and
second as part of the state certification agency if
the complaint was filled to this agency (Stevenson,
2006a). As consumer-generated quality concerns,
complaints were shown by Stevenson (2006a) to
be more timely than other quality indicators,
and they had the potential to supplement quality
Consumers of nursing home services examine
nursing home quality information from report
cards. Many report cards (e.g., Angie’s List) are
not associated with government entities. Some of
these report cards use many of the same quality
indicators as government-sponsored sites, such as
deficiency citations (Castle & Lowe, 2005), whereas
others offer consumer opinions/reviews of nursing
homes. This shows that a market for consumer-
based information exists and that it may have some
value. Stevenson (2006b) presents a review of pub-
lic reporting of nursing home quality.
Policy Initiatives and Quality
OBRA-87 undoubtedly changed nursing home
care in many ways. Some empirical research has
attributed OBRA-87 as successfully influencing
quality (Shea, Russo, & Smyer, 2000), whereas
Vol. 50, No. 4, 2010437
some studies have identified a relatively small influ-
ence on quality (Kumar, Norton, & Encinosa,
2006). However, OBRA-87 was a watershed event
in ways other than its influence on quality.
OBRA-87 represented the use of quality as a “tool”
that policy makers could use to influence the nurs-
ing home market. Until OBRA-87, policies had
focused on quality assessment (e.g., through the
certification process). However, OBRA-87 pro-
moted a more proactive approach that stipulated
specific actions needed for quality improvement
(although certification still remains a process pri-
marily consisting of assessment).
As a follow-up to the 1986 IOM report that
helped stimulate OBRA-87, a further report con-
tinued to highlight poor quality nursing home
care (IOM, 2001). Policy interventions have contin-
ued to address the nursing home quality issue, and
many of these continue to use quality indicators as
proactive tools to affect the nursing home market.
The first two policy interventions we discuss are
report cards and P4P. These generally come under
the rubric of what are called market-based incen-
tives (Werner & Konetzka, 2010). These initiatives
use provider competition (i.e., the market) as an
aggregate mechanism to facilitate quality improve-
ment. The next policy intervention is patient safety,
which is a movement with its genesis in the acute
care sector. Policy developments in the certification
process are next discussed. Finally, the potential
implications of the recent 2010 health care reforms
as part of the Patient Protection and Affordable
Care Act (P.L. 111–148) are discussed.
Somewhat recently, a consumer empowerment
movement has developed in health care. This
movement has influenced health care policy, and
one linchpin to this was the development of report
cards. Report cards have the potential to influence
quality of care. The mechanism behind this change
rests on consumers’ examining report cards and
migrating toward higher quality facilities and nurs-
ing homes in turn competing to improve their quality
in order to attract potential residents.
The AARP has published a compendium that
lists report cards available in each state (Kelly &
Gearon, 2008). The most widely discussed nursing
home report card is Nursing Home Compare
(Mukamel, Weimer, Spector, Ladd, & Zinn, 2008).
Since 2002, when Nursing Home Compare was
first widely released, improvements in the Quality
Measures have occurred. For example, Mukamel
and colleagues (2008) found two Quality Mea-
sures (from five examined) to show significant
improvement over time. However, the MDS is used
to construct the Quality Measures. It may be that
nursing homes have become better at completing
the MDS documentation.
Pay for Performance
P4P initiatives are policy options that seem to
be gaining some traction for influencing the quality
of the nursing home industry. From 2002 to 2007,
six states (Iowa, Minnesota, and Kansas, Georgia,
Ohio, and Oklahoma) have used nursing home
P4P (Arling, Job, & Cooke, 2009). An additional
program has been initiated by CMS, the Nursing
Home Value-Based Purchasing Demonstration
Program (Levenson, 2006). Quality indicators are
key components of all P4P initiatives.
Some results indicate that P4P has improved
levels of some nursing home quality indicators
(Arling et al., 2009), although others have noted
that there are not enough data to show that P4P
incentives are enough to change providers’ behav-
iors and there is limited evidence that P4P improves
overall quality of care (Briesacher, Field, Baril, &
These P4P initiatives are shaping the emphasis
on quality indicators. For the most part, existing
quality indicators are used. For example, residents
with pressure ulcers, catheters, physically restrained,
and whose mobility decreased. Thus, new quality
indicators are not included in P4P, but because of
their use in P4P schemes, these quality indicators
have assumed greater importance. Still, these qual-
ity indicators are subject to many of the issues dis-
cussed earlier. They are especially problematic
with respect to the number of needed measures as
the risk of using too few quality indicators is that
they can unnecessarily narrow the view of whether
quality has truly improved.
The To Err is Human (Kohn, Corrigan, &
Donaldson, 1999) report galvanized the public
and legislators partly by suggesting that as many
as 98,000 deaths attributable to avoidable mis-
takes occurred in U.S. hospitals. As a result, patient
safety has become an important topic for many
health care providers. Moreover, prominent national
organizations have developed various initiatives to
assess and improve patient safety in the nursing home
setting (e.g., AHCA, 2009; www.ahcancal.org).
These initiatives are also shaping current qual-
ity indicators. In the 9th Scope of Work for QIOs,
Patient Safety Culture is to be assessed in nursing
homes. Certification has likewise recently started
to address patient safety issues. This includes
emphasis on deficiency citations for patient safety
issues (e.g., medication administration). CMS also
recently extensively updated the pharmacy- and
medication-deficiency citations addressing medica-
tion errors (Krechting, 2006).
CMS has continued to refine the nursing home
certification process. For example, the timing of
survey visits was criticized as being highly pre-
dictable. Thus, more variation in this timing
was introduced (GAO, 1999). Sanctions (e.g.,
fines) were criticized as ineffectual. The sanctions
were further developed for facilities that received
deficiency citations (penalties of up to $10,000 a
day, denial of payment for new admissions, state
monitoring, temporary management, and termi-
nation from the Medicare or Medicaid programs;
A recent change in certification is the Special
Focus Facility (SFF) initiative. Nursing homes that
are determined to have a greater number of quality
problems, more serious problems than average,
and a demonstrated pattern of quality problems
are included in this initiative (CMS, 2008). For
nursing homes, inclusion in the SFF program
entails having two survey inspections per year
(rather than the standard one survey) and the
potential to be terminated from the Medicare and/
or Medicaid programs.
Health Care Reform
As part of the Patient Protection and Affordable
Care Act, there are requirements that would neces-
sitate nursing homes to disclose information on
ownership, accountability requirements, finances
(i.e., expenditures) and place information on stan-
dardized quality indicators on a Web site (much
like Nursing Home Compare) (Kaiser, 2010;
http://healthreform.kff.org/). Depending on how
these requirements are implemented, further quality
indicators for nursing homes may become widely
available (e.g., benefits paid to staff, staff wages,
Provider Initiatives and Quality
With respect to the development and use of
quality indicators, policy interventions are signifi-
cant. However, clearly, it is provider initiatives
that ultimately influence nursing home quality.
These initiatives include the use of Quality Assess-
ment (QA), Total Quality Management (TQM),
Continuous Quality Improvement (CQI), and Per-
fecting Patient Care (PPC; Spear, 2004). It is worth
clarifying also that the development and measure-
ment of quality indicators are not necessarily
related to solutions to quality. It is effective use by
providers that is most related to quality solutions.
Nevertheless, with respect to quality indicators,
one provider development, culture change, has sig-
nificantly affected the development and measure-
ment of quality indicators.
Since the early 1990s, some nursing homes have
adopted resident-directed philosophies (or resident-
directed care; also known as culture change).
Organizations, such as Action Pact, Inc. and Eden
Alternative, have fostered the growth of resident-
directed care. This places the resident at the center
of the decision-making process. It allows the tradi-
tional top down model of decision making to
become inverted to allow staff (e.g., nurse aides) to
work with the residents to make decisions (i.e.,
when to eat). This recognizes the importance of
residents’ Quality of Life (QoL; Castle, Ferguson, &
Hughes, 2009). Quality indicators used thus are
QoL related, which include measures such as energy
levels, sleep, self-esteem, and sense of mastery.
Culture change is primarily a provider develop-
ment. However, characterizing the public–private
intertwining of nursing home quality, CMS is influ-
ential in this area also. CMS directed QIOs to
facilitate improvements in nursing home culture
(Werner & Konetzka, 2010). The implementation
of the new MDS 3.0 is expected for October 2010
(Rahman & Applebaum, 2009). With this refor-
mulation, the MDS 3.0 is reported to include items
assessing resident QoL (www.cms.hhs.gov), which
is a departure from the primarily clinical focus of
most of the quality indicators coming from these
data (Rahman & Applebaum).
The benefits of culture change have proven dif-
ficult to gauge. After a 1-year study comparing
the first year of implementation of the Eden Alter-
native and a control nursing home run by the same
organization, very few quantitative differences
existed (Coleman, Looney, O’Brien, Zeigler, &
Vol. 50, No. 4, 2010439
Furthering Advances in Quality
We have identified substantial progress in the
area of “quality” of nursing homes. Numerous
quality indicators have been developed. Numerous
policy initiatives have been implemented. Numer-
ous provider initiatives also exist. For this narra-
tive, the “elephant in the room” remains what can
be done to further improve quality? We propose
that further advances in quality may occur: first,
by some long-term care integration policies;
second, enhanced current initiatives; and, third,
enhanced certification activities. These are dis-
cussed, along with additional research that may be
needed to make these advances a reality.
First, one somewhat troubling fact appears to
be that many nursing homes still have poor quality
levels. Yet, many of the initiatives discussed earlier
indicate that improvements in quality have
occurred. In this regard, we cite Cherry (1991)
who identified improved quality and poor quality
as not necessarily contradictory. Cherry pointed
out that in the nursing home setting, we are often
describing less poor care versus poor care, not nec-
essarily good versus poor care.
Alternatively, the poor quality levels that seem
to exist in many nursing homes may be a function
of the quality process itself. As we identify earlier,
it may be that quality indicators are simply not
accurate metrics for measuring actual quality.
Given the number of quality indicators, this is
likely not the case for all indicators. It may be that
given the number of quality indicators available,
the worst receive attention, whereas the best do
not. For example, physical restraint use has
declined, but a more recent emphasis on pain man-
agement has developed. Parenthetically, we note
that this does seem to be an issue with quality mea-
surement in general. We seek and report the worst
and not necessarily the best (with some exceptions
such as deficiency free nursing home status).
In addition, to be fair to nursing homes, resi-
dent case mix has increased. Thus, nursing homes
are challenged to care for sicker residents with
substantially more health problems. So quality
may have indeed improved, but this may not have
kept pace with the challenges presented by the res-
Long-Term Care Integration
One non-nursing home policy would be to
address integration and continuity with other areas
of the long-term care system (Konetzka & Werner,
2010). That is, to step back from nursing homes to
address the “system” of long-term care providers.
Many residents come to nursing homes with unmet
needs (and frustrations) that could (or should)
have been addressed in other settings. As the often-
final stop in several transitions across various long-
term care settings, nursing home quality would
surely benefit if residents were cared for appropri-
ately in these prior settings.
A further policy option does not focus directly
on nursing homes but has a spillover influence.
That is, the emphasis on Home and Community-
Based Services (HCBS) as an alternative to nursing
home care (Reinhard, 2010). Policy makers have
expanded the coverage of HCBS (primarily under
Medicaid waivers) to redirect potential nursing
home residents to community settings (Wiener,
Tilly, & Alecxih, 2002). In addition, in the recently
enacted health care reform legislation (i.e., Patient
Protection and Affordable Care Act), barriers to
providing HCBS would be eliminated (section
2402), including increased coverage of services,
removal of limits on the number of participating
individuals, and incentive payment programs for
states to develop HCBS (Richards, 2010). This
may force more market-based competition among
Enhanced Current Initiatives
One intervention would be for policy makers
and providers to continue along their current
paths—but doing what they know in an enhanced
fashion. That is, for providers, culture change, QA,
TQM, CQI, and PPC could all be continued. To
continue with these initiatives, a change in empha-
sis is needed. Policy often focuses on aligning the
needed incentives, whereas these provider initia-
tives need an alignment of favorable conditions.
An extreme example would be Medicaid payment
reform. An argument could be made that providers
already have the tools for providing quality care
(i.e., QA, TQM, CQI, and PPC) but that resources
are needed to stimulate improvement. Empirical
research has shown that levels of Medicaid pay-
ment rates (as an essential resource for nursing
homes) are consistently associated with nursing
home quality (Grabowski, 2004). However, this is
presented as an extreme example as such reform is
unlikely in the current fiscal environment.
More subtle changes in emphasis may be needed
and more feasible. An example would be better
top management capability. Policy could promote
these more favorable conditions (e.g., subsidies for
nursing home top management education). How-
ever, the role of CMEs, state licensing standards,
and the role of training all need to be investigated
more thoroughly. Improving staffing levels and
staffing competencies could also produce an align-
ment of favorable conditions, although policy to
date has tended to emphasize stipulating staffing
conditions (especially staffing levels). These often-
unfunded mandates have the incumbent risk of
providers’ skimping in other areas—thereby nulli-
fying any potential quality gains.
One area of research from a feasibility stand-
point would be the notion that providers are
indeed able to effectively use existing tools for
providing quality care (Wagner, van der Wal,
Groenewegen, & de Bakker, 2001). Many of these
are built off the notion of using systems level qual-
ity improvement (Werner & Konetzka, 2010).
This orientation may be difficult to implement in
an industry that is technology deficient and reliant
upon a paraprofessional workforce. However, the
QIOs appear to have had some success in doing so
(Kissam et al., 2003). One recent notable quality
indicator development initiative has included the
resources available in the average nursing home
in choosing candidate quality indicators (Saliba
et al., 2005).
For policy makers, report cards, patient safety
initiatives, P4P, and the certification process could
all be continued. Each has its benefits and limita-
tions. Subtle changes could also be made, such as
providing aggregate information on chains; this
could promote more corporate involvement in
quality. P4P could be integrated with specific qual-
ity improvement activities such that payments are
for specific measures (such as improved staffing).
However, from a quality perspective, this creates a
vast number of quality indicators that need to be
tracked by providers and creates tensions between
providers and regulators. It also creates the risk of
accentuating measurement and not improvement.
One recent suggestion to overcome this quality
indicator overload is to focus on quality improve-
ment and not necessarily specific indicators
(Werner & Konetzka, 2010). That is, nursing homes
could chose areas for improvement and be credited
for these initiatives. This has the advantage of
overcoming the retrospective nature of quality
monitoring (Scott, Vojir, Jones, & Moore, 2005).
However, a disadvantage would be that public
reporting initiatives would still likely drive the
areas chosen for improvement. This would make
these quality indicators more salient.
The use of deficiency citations is thought to foster
minimal compliance by providers. That is, these can
create thresholds such that deficiency citations fos-
ter a quality floor rather than quality improvement.
Still, the certification process (beyond deficiency
citations) represents a viable and ongoing infrastruc-
ture for further quality improvement and develop-
ment of quality indicators. It may be possible to
make further use of this process and further use of
deficiency citations. They are ultimately used as
quality indicators with specifications as benchmarks,
rankings, and specific targets. Further development
of metrics for deficiency citations would appear
integral to their effective use as quality indicators.
The certification process is generally regarded
as fostering a compliance culture. It may be possi-
ble for nursing homes to form relationships with
State Survey Agencies, who conduct survey and
certification activities. This may move the compli-
ance orientation to a more proactive orientation
(Kissam et al., 2003).
Deficiency citations could be used for further
quality indicator development. As described, pro-
ducing a global quality indicator comes with many
issues. However, using deficiency citations may be
amenable to producing an aggregate quality score.
For each deficiency citation, 1 of the 12 categories
is used to define scope and severity of the problem(s)
identified. Some research exists in this area wherein
a numeric system for collapsing the scope and
severity information and reducing measurement
noise in survey results was developed (Antonova,
2008). This could be expanded as an aid to parsi-
moniously reporting deficiency citations.
Quality concerns in nursing homes still exist.
Many of these concerns have received considerable
attention in the public press. For example, the Lexus-
Nexus (a database of press reports) lists more than
500 accounts of poor quality in nursing homes in
2009. Empirical research studies still identify poor
quality and government reports continue to find fault
with care in nursing homes. Nevertheless, these cur-
rent accounts should be tempered by current nuances
that have occurred in our understanding of quality of
care in nursing homes.
Vol. 50, No. 4, 2010441
The scope of nursing home quality indicators is
phenomenal. The scale of what is routinely mea-
sured is also extremely broad. But somewhat iron-
ically, 45 years after the passage of Medicare and
Medicaid and more than 20 years after the passage
of OBRA-87, it remains somewhat difficult to
answer the following question: what is the quality
of nursing homes in 2010? What we can say with
some certainty is that improvements have likely
occurred, and what we can say with even more
certainty is that improvements are still needed.
This research was funded in part by a grant from the Commonwealth
Fund (20070403: a web-based staffing and quality simulation tool to
improve quality of care for frail elders) and in part by a grant from The
Agency for Healthcare Research and Quality (R01 HS016808-01: staffing
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