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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: firstname.lastname@example.org
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, 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
characteristics of nursing homes and quality).
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