What Is Nursing Home Quality and How Is It Measured?

Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA.
The Gerontologist (Impact Factor: 3.21). 08/2010; 50(4):426-42. DOI: 10.1093/geront/gnq052
Source: PubMed


In this commentary, we examine nursing home quality and indicators that have been used to measure nursing home quality.
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, including 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 Campaign.
Current quality indicators are presented as a mix of structural, process, and outcome measures, each of which has noted advantages 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.
We conclude that improvements in nursing home quality have likely occurred, but improvements are still needed.

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    • "It is generally assumed, in rational–functional models of systems theory, that organizations rationally process the problems, requirements and resources of their social environment by differentiating goals, programs, tasks, structures and processes and linking an " input " of money, personnel and material to an " output " of services, which then leads to the desired " outcome " quality of social services (Donabedian 1966; Roth 2007). In long-term care of the elderly, the main goals are a relatively low mortality and as high a quality of life as possible for the patients, especially the maintenance or improvement of functional and cognitive faculties and the avoidance of admissions to hospitals or nursing homes – for similar problems and risk groups (Castle and Ferguson 2010; Hutchinson et al. 2010). For this reason, risk adjustments and controlling for age and cognitive and functional limitations are indispensable in comparative quality assessments. "
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    ABSTRACT: Objective: Although the quality of long-term care has improved, many problems still remain, and better processes seem to be necessary. Hence, outcome-oriented management is of particular importance. The Resident Assessment Instrument (RAI) is a tool that has been used successfully in many countries to improve quality of care. However, there are problems of implementation and it lacks information on the conditions of successful or failing information of the RAI. The aim of this article is to find out to what extent technical/qualification requirements help to introduce or lead to failure of the implementation of an assessment instrument like RAI. Methods: Therefore, a cluster randomized controlled trial showed services using RAI intensively tend to have better outcomes after 12 months. But the effects depend on the success of the implementation. Using a factor analysis, an index was built to divide the care providers into "optimal" and "suboptimal" RAI users. Results: Some factors that seem to lead to a rather successful implementation could be detected: A higher proportion of qualified staff, a lower perceived quantitative workload, a small size of care providers, the type of ownership (for-profit) and a late entry in study [Correction made here after initial online publication.]. Conclusion: The success or failure of the implementation of an outcome-oriented control instrument is determined by professional, organizational restrictions. The results show that a better implementation leads to better outcomes for clients.
    Full-text · Article · Jul 2014 · International Journal of Health Planning and Management
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    • "In line with previous studies [37], for our participants interpersonal and technical quality criteria of the process of care prevailed over both structural aspects -facilities, cleanliness, independence- and outcome-related aspects -survival, falls, etc.- [1,10]. "
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    ABSTRACT: The quality of care in nursing homes is weakly defined, and has traditionally focused on quantify nursing homes outputs and on comparison of nursing homes' resources. Rarely the point of view of clients has been taken into account. The aim of this study was to ascertain what means "quality of care" for residents of nursing homes. Grounded theory was used to design and analyze a qualitative study based on in-depth interviews with a theoretical sampling including 20 persons aged over 65 years with no cognitive impairment and eight proxy informants of residents with cognitive impairment, institutionalized at a public nursing home in Spain. Our analysis revealed that participants perceived the quality of care in two ways, as aspects related to the persons providing care and as institutional aspects of the care's process. All the participants agreed that aspects related to the persons providing care was a pillar of quality, something that, in turn, embodied a series of emotional and technical professional competences. Regarding the institutional aspects of the care's process, participants laid emphasis on round-the-clock access to health care services and on professional's job stability. This paper includes perspectives of the nursing homes residents, which are largely absent. Incorporating residents' standpoints as a complement to traditional institutional criteria would furnish health providers and funding agencies with key information when it came to designing action plans and interventions aimed at achieving excellence in health care.
    Full-text · Article · Jun 2013 · BMC Geriatrics
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    • "Also, we include contract staff, as some work has shown the use of these staff may influence quality of care (Bourbonniere et al., 2007; Castle, 2008). Similarly, physician extenders (e.g., nurse practitioners and physician assistants) and staffing levels of medical directors and top management are included as potentially influential staffing characteristics when examining nursing home quality (Castle & Ferguson, 2010). Smaller nursing homes tend to be of better quality as these facilities often place a greater emphasis on quality of communication and specific expectations of staff members (Lucas et al., 2007). "
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    ABSTRACT:  This study examines the association between nursing home accreditation and deficiency citations.   Data originated from a web-based search of The Joint Commission (TJC) accreditation and On-line Survey Certification of Automated Records from 2002 to 2010. Deficiency citations were divided into 4 categories: resident behavior and facility practices, quality of life, quality of care, and the most severe citations. Data were analyzed through negative binomial regression, where the number of residents at risk for each measure was the exposure level for that measure.   TJC-accredited nursing homes had fewer deficiency citations in all 4 deficiency categories examined. Comparing citations in the year of accreditation with the first year after accreditation, 3 of the 4 deficiency categories were significant. In comparing deficiency citations after 8 years of accreditation, all 4 categories of deficiencies were significant. In all cases, accreditation was associated with fewer deficiency citations.   Our results indicate that TJC-accredited nursing homes improve their quality immediately after accreditation and continue to maintain these improvements over the long-term. These findings support the need for further discussion and facilitation of voluntary accreditation in nursing homes.
    Full-text · Article · Mar 2012 · The Gerontologist
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