Quality of Care in Nursing Homes

The Online Journal of Clinical Innovations 2005 December 1;8(4)1-61

Quality of Care in Nursing Homes Mary Sue Gorski ARNP, PhD Diana Hackbarth RN, PhD, FAAN SIGNIFICANCE The number of persons 65 years of age and older increased from 25.7 million in 1980 to 34.7 million in the year 2000. This age group is projected to reach 69.4 million persons by 2030, at which time the elderly will represent an unprecedented 20% of the population. The most rapidly growing subpopulation of elderly is those over 85 years of age.(1) Individuals older than 85 are more likely than their younger counterparts to experience chronic illness and need the level of nursing care provided in nursing homes, either for short-term rehabilitation or extended periods of time. Because of this, the Congressional Budget Office (CBO) has predicted that national spending on long-term care, including nursing homes and home health, will more than double to $295 billion by 2030 and nearly triple to $346 billion by 2040. Ensuring the quality of care for the elderly in nursing homes is important today and will be increasingly important over the next 30 years as the population ages and the demand for this type of care increases.(2) This manuscript synthesizes the literature about quality of care in nursing homes and discusses implications for nursing practice. Nursing homes, for the purpose of this manuscript, are defined as facilities offering residents a variety of supportive health services including skilled nursing care for short-term and long-term care needs. The importance of specific guidelines for nursing home practice cannot be overstated. The

anticipated increase in need, coupled with the projected nursing shortage, demands that the nursing profession develop a plan to address the important issue of quality of care for vulnerable elderly in nursing homes. This comprehensive review explores this concept using an open systems framework. Open system components that address quality issues are outlined and related to practice. Implications for improving quality of care in nursing homes are outlined for nurse researchers, clinicians, administrators, and policy makers. SOURCES AND PROCEDURES TO ESTABLISH THE KNOWLEDGE BASE To accomplish the goal of a comprehensive review, an initial search of both the CINAHL® and MEDLINE® databases was conducted using the terms “quality of health care,” “nursing homes,” and “long term care” through the year 2004. Additionally, Psych Info, Philosophers Index, Sociology Abstracts, and the Health Care Financing Administration (HCFA; renamed The Centers for Medicare and Medicaid Services [CMS] in 2000) website were accessed initially for this review. The keywords that were productive in refining the search were quality indicators, policy, Minimum Data Set (MDS), Resident Assessment Instrument (RAI) and quality of life. The literature sources were further delimited by choosing only those from refereed journals. Each article identified in the search was reviewed for relevance individually using both the abstract and full text. Investigators with recurrent citations in the literature and bibliographies on quality of care in nursing homes include Kane, Harrington, and Rantz. The research group directed by Hawes and including Phillips, Mor, Fries, Hughes, Schnelle, Morris, and Zimmerman has also published a number of

Quality of Care in Nursing Homes. Copyright©2005, Cinahl Information Systems

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individual and group projects. The key references cited in the authors' publications were searched separately for additional titles pertinent to the topic. Kane offers a broad clinical view of quality in nursing homes from a medical perspective. This view is derived from 30 years of practice and research in the area of geriatrics and long-term care. Harrington has completed extensive work in health care policy, especially related to professional nurse staffing in nursing homes. Rantz, a very influential author, has been involved in determining quality indicators in nursing homes using existing data sets. The research and work groups composed of Fries, Hawes, Mor, Morris, Schnelle, Phillips, and Zimmerman have published individually and in groups on measures of quality. Although the entire list of authors is extensive, these ten researchers have made significant specific contributions in the area of interest.

Websites for health care organizations, government, medicine, nursing, aging, and long-term care were searched and key organizations were identified. Each of these organizations’ websites were searched for titles and projects; this yielded 55 titles. Table 1 identifies the names of the organizational websites divided into five categories of organizations. The initial literature set was further refined by a periodic systematic scan of titles for new research. Since the literature review continued through a three year period, searches were performed, using the outlined key words. The final October 2004 extensive search using key words (nursing home, long term care, and quality care) in CINAHL and Medline resulted in 5 additional relevant titles using the same techniques for screening previously employed.

Table 1. Key Organizations Organizational Category

Website

Health Care Organization

Academy for Health Services Research (AHSR), Joint Commission on Accreditation of Health Care Organizations (JCAHO), American Health Care Association (AHCA)

Government

Agency for Health Care Research and Quality (AHRQ), Centers for Medicare & Medicaid Services (CMS previously HCFA), Department of Health and Human Services (DHHS)

Medicine

Institute of Medicine (IOM)

Nursing

American Nurses Association (ANA), National Gerontological Nurses Association (NGNA), National League of Nursing (NLN)

Aging and Long-term Care

Administration on Aging (AOA), American Association of Retired Persons (AARP), Gerontological Society of America (GSA), National Citizen's Coalition for Nursing Home Reform (NCCNHR), The Commonwealth Fund (CWF)


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KEY TERMS, CONCEPTS, AND THEORETICAL PERSPECTIVES Historical Perspective The size and scope of nursing home care has increased dramatically over the last 40 years.(3) The number of individuals living in nursing homes in the United States increased fivefold from 300,000 in 1950 to 15,000,000 in 1990, and was estimated to be 1.6 million in 2003.(4) Further, 20% of heath care costs for those over 65 years of age are spent on nursing home care; half of the funding in 1997 came from government sources, primarily Medicaid.(2) By 1997, 68% of nursing home residents depended on Medicaid to cover at least part of their expenses. The growth in nursing home care has been affected by increased longevity of the disabled elderly, changes in family demographics and ability to care for elderly, and, finally, incentives for facilities to qualify for government reimbursement for care in nursing homes.(5, 6) The services provided by nursing homes have evolved over the last 60 years. Dieckmann(7) studied the history of one nursing home during the years 1945 through 1965. Her case study illustrates the transition of nursing homes from poorlyfunded almshouses to publicly-funded facilities that offer full rehabilitation services. The only appropriate options for care of the elderly prior to this time were care in the home by family or private duty nurses. Those who were unable to afford care at home or did not have family were automatically relegated to the almshouses. These houses received little public support; in fact, they were 30% less expensive than prisons to maintain at the time.(7) Nursing homes advanced from ignored and poorly-funded almshouses prior to 1940 to

ignored government-funded facilities in 1965. The years between 1965 and 1985 represented a time of structural changes in nursing home facilities that were designed to meet standards for government reimbursement. The changes were modeled after those in acute care institutions but did not result in consistent delivery of quality care in nursing homes. Since the mid-1980s, new regulatory standards stimulated interest in the concept of quality of care in nursing homes. Figure 1 illustrates a timeline that represents nursing home quality and traces events at the state, federal, and societal levels that had an impact on nursing homes. In 1985, the National Coalition for Nursing Home Reform(8) conducted a study in which more than 450 residents from 105 nursing homes throughout the US volunteered to participate in open-ended discussions surrounding the question, "What is quality nursing home care?" Specific quality indicators were identified and ranked according to the number of times they were discussed. Priority indicators were staff, environmental factors, food, activities, medical care, cleanliness, administration, religion, resident council/resident rights, and transportation. Most of these indicators relate to the structural components of care, with medical care and staff being the only process measures. It is interesting to note that residents did not specifically identify any outcome measures. The components represent residents’ perspectives and have been used in subsequent studies on quality of care in nursing homes. The implicit goal of the regulatory system is to ensure that a person requiring nursing home care is able to enter any certified nursing home and receive appropriate care, be treated with courtesy, and enjoy continued civil and legal rights. In May 1982, HCFA announced a proposal to ease the regulatory requirements for certification


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of nursing homes in response to providers' complaints of “unreasonable rigidity.” The proposal by HCFA was strongly opposed by consumer groups. The controversy resulted in a contractual agreement between the Institute of Medicine (IOM) and HCFA for the IOM to conduct a study.(9) In addition, the inability of the regulatory system to force substandard facilities to improve their performance was a major factor underlying the 1986 study. The IOM report, Improving the Quality of Care in Nursing Homes, directed by Sydney Katz, marked a change

in emphasis for quality of care in nursing homes. The purpose of the study was to recommend changes in regulatory policies and procedures to enhance the ability of the regulatory system to assure that nursing home residents receive satisfactory care. The IOM report considered that quality is meeting the individually determined functional, medical, social, and psychological needs of residents through careful assessment and care planning -- steps that require professional skill and judgment.


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Figure 1. Nursing Home Quality Timeline

1972 State

Federal

1985

1987

IOM OBRA Report

Reagan General Health Care Nursing Home

1988 1990 1991 1992 Decentralization of Health Care to States Staffing Surveys NA certification Nursing Assess MD Reimburse

RAI

Fully implemented

Bush

Clinton

RUGS

Bush

Acuity of NH Patients

Varieties of care options

Legend RUG – Resource Utilization Group NH – Nursing Home OBRA – Omnibus Budget Reconciliation Act RAI – Resident Assessment Instrument IOM – Institute of Medicine DRG – Diagnostic Related Group NA – Nurses’ Aide


On-line

2000

Acuity care hospitals

DRGs, Cost Containment, Managed Care

Custodial Care

1998

5

2001

New reports continue to document poor care in Nursing Homes


The conclusions of the 1986 IOM report were: 1. Quality of care and quality of life in many nursing homes are not satisfactory 2. More effective government regulations can substantially improve quality in nursing homes 3. Specific improvements are needed in the regulatory system 4. There are opportunities to improve quality of care in nursing homes that are independent of changes in the Medicaid payment policies or bed supply 5. Regulation is necessary but not sufficient for high quality care 6. A system to obtain standardized data on residents is essential 7. The regulatory system should be dynamic and evolutionary in outlook The report suggests regulation as a partial answer to improved quality of care. Based on these findings, the Omnibus Budget Reconciliation Act of 1987 (OBRA) included extensive nursing home regulatory language. Although Katz(9) also suggested that quality in nursing homes was related to characteristics of residents and their care needs, implementation of the IOM report’s conclusions translated into regulatory oversight based upon the medical model. The 1987 OBRA regulations were fully implemented by 1991, with subsequent heightened interest in quality of care in nursing homes and actual improvements in quality. Several important themes emerged during this time, including consumers’ preference for long-term care in the community rather than in

nursing homes. Other important concepts which first appeared in the literature at this time were proposed by Kane(10) and Rantz.(11, 12) Kane described expected decline, quality of life, and residence aspects of care. Rantz reinforced the multidimensional nature of quality and the importance of a resident and family focus. Another IOM report on Quality of Care in Nursing Homes was published in 2001.(13) This report indicated continued poor quality, despite OBRA implementation. The historical perspective provides a foundation for contemporary examination of quality of care in nursing homes. Review of the literature continues with an overview of broad general concepts related to nursing home quality. Theoretical Frameworks Two frameworks have been used to guide this literature review. The first is Donabedian's(14-16) quality of care framework and the second is Dr. Imogene King’s(17) open systems framework. Donabedian’s structure, process, and outcomes framework is frequently used in the literature to describe quality. However, Donabedian’s model has limitations for the purposes of this review. The addition of King’s nursing theory adds clarity and applicability to nursing practice. King(1719) includes the social system, interpersonal system, and personal system in her nursing conceptual framework. These three interrelated systems provide an additional mechanism to organize the literature. Donabedian’s structural components are analogous to King’s social system; process components fit into King’s


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interpersonal system, and finally patient outcomes may be considered in King’s personal system. As the components outlined by Donabedian are reviewed in the appropriate system of King’s framework, the complex interrelated nature of quality of care, as viewed by a nurse, can be more clearly understood. Several general concepts have emerged related to quality of care in nursing homes. First, evolution of community based care as an alternative to nursing homes resulted in the concept of longterm care; there are many types of longterm care available for elders. Second, focus on the resident perspective has resulted in an increased emphasis on quality of life as a component of quality of care. Third and finally, two experts, Kane and Rantz, have outlined key concepts related to quality of care in nursing homes and each bear reviewing here. Each of these three areas will be discussed below. Long-Term Care Although nursing home care is the focus of this work, institutional care is only one type of care available for the elderly. “Long-term care” is a term that encompasses a broad range of services and includes all aspects of care for an individual who requires support to accomplish activities of daily living (ADLs) for an extended period of time. The majority of long-term care in this country is provided by family members in the resident's home. Home health care provides services in an individual’s home for both skilled and nonskilled support. Residential facilities provide supportive environments for those who require some assistance with housekeeping, meals, and transportation (nonskilled services). Licensed nursing

facilities or nursing homes provide 24hour skilled nursing care to individuals for both short term (less than one month) and extended periods of time. Medicaid expenditures for the various levels of long-term care were examined in 13 states. Wiener and Stevenson(20) in their paper Long-term Care for the Elderly, summarized efforts in thirteen states to control the rate of increase in Medicaid long-term care expenditures for the elderly. Three mechanisms of care delivery were evaluated in Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin. The long-term care delivery mechanisms examined were licensed nursing facilities (nursing homes), licensed residential facilities, and licensed home care. The study revealed that approximately 44% of those over 65 years of age needed long-term care and 84% of the total Medicaid and Medicare funds allocated for long-term care was being spent to reimburse nursing facilities. Licensed nursing facilities accounted for the largest expenditure of the three types of care delivery in all states, but there was significant variation in the availability of types of care to those over 75 years of age. Variation in spending in selected states, as it relates to the availability of specific services, was also studied. The variability between states in the availability of service suggests inconsistent definitions of the three mechanisms for delivery in long-term care between the states. Despite these limitations, results indicated that the majority of Medicaid reimbursement for long-term care is spent in nursing homes in the states studied.


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The Commonwealth Fund study(5) also suggested cost savings may not always be realized by changing the setting of service provision. However, quality of life may be significantly improved through promotion of maximum autonomy. Some types of care for the elderly may be more effectively and efficiently delivered in community settings, but the expensive nature of nursing home care may still require the majority of long-term care funding be directed to nursing homes. Quality of Life Quality of care and quality of life in nursing homes are inextricably linked. The study of quality of care cannot be complete without consideration of the quality of life of the residents of nursing homes. Acceptance of the importance of quality of life in nursing homes as an indicator of quality of care necessitates identifying appropriate measures of quality of life in nursing homes to support the quest toward improved care. Bowers(21) and Kane(22) developed models of quality from a resident perspective that illustrate the importance of quality of life in nursing home care. Schnelle(23) strongly supports a renewed emphasis on quality of life as an outcome. Elsner(24) completed a narrative analysis of centenarians in Georgia to illustrate the incongruence of fiscal and policy constraints on quality care for the oldestold. He found that less than optimal care was provided for these elders. Six policy reforms were suggested for meeting the needs of the oldest-old before and after institutionalization: 1) integration of resident involvement in care decisions, 2) development of alternate models of care, 3) greater input from nurses concerning nursing care of special

populations, 4) more effective family and community involvement in the caring of elderly populations, 5) increased research to promote function and independence, and 6) increased education of personnel and nursing students to allow for more accurate assessment of cognitive and physical status. Although recurrent themes of functional status and staffing are present, quality of life issues such as family involvement also were found. Throughout discussions in the literature of quality of care in nursing homes, themes consistent with quality of life recurred. Quality in health care is defined as a subjective multidimensional concept that encompasses excellence and has unique aspects related to permanency of the resident's situation.(23, 25-27) The subjective nature of quality and the residential aspect of the nursing home links, quality of life to quality of care. Grant(28) examined indicators of quality in long-term care facilities in Calgary, Canada by utilizing the critical incident technique to determine the perception of 52 residents, 58 significant others, and 37 nursing staff in five longterm care facilities. Fourteen major indicators were identified: 1. Nature of facility 2. Nature of relationships 3. Acknowledgment of the personhood of the resident 4. Nature of communication with residents 5. Disposition of decision making 6. Judgment about assistance required 7. Degree and nature of surveillance 8. Presence of planning and judgment about care 9. Nature of communication with the health care team


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10. Performance of assistance with activities of daily living (ADLs) which residents cannot do for themselves 11. Performance of assistance with other activities which residents cannot do for themselves 12. Manner in which ADLs and therapeutic activities are carried out 13. Nature of interaction with significant others 14. Provision use and attributes of resources The findings from Grant's qualitative study are consistent with the authors’ perception that previous quality studies have tended to examine the health care provider's view of quality of life, rather than the actual perceptions of residents who are most affected by care. Questionnaires in quantitative studies are often limited to questions about the technical quality of care and those aspects of quality most interesting to the providers of care. The quality indicators in Grant's study revealed perceptions of residents and their families, such as nature of relationships with staff and acknowledgment of personhood of the resident by staff. Two of the fourteen indicators identified family relationships as important to quality. This observation reinforces concepts of quality of life and the role of the family in quality care of the resident. Other quality of life indicators that emerged are the nature of interactions with significant others and the manner in which ADLs are carried out. These attributes of quality are related to the process of how tasks are carried out and showing respect for the resident, rather than the result of the action. Grant acknowledged limitations in her study because of differing perspectives of the three populations questioned: nurses, residents, and

families. She also acknowledged that residents and families may not be aware of the measures of quality (such as management style) that support positive interactions and respect for the individual while offering assistance with ADLs. However, documentation that families may perceive quality differently than health care professionals is an important concept. The indicators of quality of life measured in the RAI were discussed in a panel sponsored by HCFA and reported by Hawes.(29) The key presenter was Catherine Hawes, with responses by Kathleen Cantaben, Charlene Harrington, and Mary Ousley. Hawes discussed a conceptualization developed by Zimmerman(30) of the University of Wisconsin in recommending a three-tiered approach to using the quality of life indicators from the RAI.The first tier of the indicators represents a "high probability" of a link with quality of life and includes either individual or combined RAI items. For example, social engagement has been shown to capture aspects of quality of life and may be reflected in some of the following MDS measures: 1) participation in assessment and decisions about care planning, 2) prevalence of physical restraints, 3) behavior management, 4) distressed mood, 5) activities, and 6) maximizing functional independence and minimizing effects of impairment. Tier two indicators include those that "may indicate" a link with quality of life, such as respect for resident's privacy and dignity, autonomy, and residents’ feelings about their life in the facility. These indicators are not directly measured by the MDS, but some related items that may be indicative of them


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are: 1) unsettled relationships, 2) autonomy and end of life decisions (e.g., advanced directives), and 3) distressed mood and behaviors. The final tier suggested by Zimmerman includes indicators for residents with special risks for quality of life problems. The MDS items that may indicate these problems are: 1) potential social isolation, 2) little social engagement, 3) severe communication deficit, 4) severe pain, and 5) potential for treatment that violates privacy and dignity. Hawes recommended further research to determine the validity of the three-tiered measures of quality of life available in the MDS data. The panel members responded with a combination of enthusiasm and caution. Harrington cited studies that support increased levels of staffing promoting quality of care and suggested that even if quality of life is measured by these factors, there may not be sufficient numbers and preparation of staff available to support quality of life. Ousley and Cantaben(31) cautioned that before the MDS items are assumed to measure quality of life, there must be additional studies to determine the value of the items in measuring this concept. The attributes of quality of care in nursing homes stem from the characteristics of the residents, their care needs, the circumstances and settings in which the care is provided, and expected outcomes. The fact that - for many residents - the nursing home is their permanent home and not merely a temporary abode in which they are being treated for a medical problem incorporates quality of life into quality of care.(32) Quality of life, thus, is very important for its own sake (that is, as an outcome goal) and because it is

intimately related to the quality of care in nursing homes. Expert Perspective The third and final general concept to be discussed is the perspective of expert’s on quality of care in nursing homes. Two expert opinions were chosen for the depth and breadth of the information presented. Each of the authors made significant contributions in the area of research and publications in the area of quality of care in nursing homes. Kane is a physician researcher who offers a broad based perspective built on a foundation of extensive research and practice experience in the areas of geriatrics and long-term care. He(10) suggested three priority areas for improving long-term care for the elderly: (1) care must be offered in the correct setting, (2) regulations should be outcome-based, and (3) there should be a separation of housing and health care needs of residents. Disincentives in our present system serve as roadblocks to providing care in the most appropriate setting. The fixed reimbursement associated with diagnosis-related groups (DRGs) is frequently cited as an incentive for premature discharge from hospitals to nursing homes and home health services. Kane suggested that extending the fiscal responsibility of the hospital beyond discharge would minimize the incentive for inappropriate early discharges. Hospitals would then realize the system burden created when residents are transferred to nursing homes or their own home before they are stable. Conversely, some residents transferred from the nursing home to the hospital could be better managed in the nursing home. Inappropriate transfers to the hospital incur unnecessary costs and


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risks to the resident. Kane(10, 33) recommended geriatric nurse practitioner (GNP) services in nursing homes to assist in care planning and clinical decisions, and closer affiliation of nursing homes with hospitals as two mechanisms to support care in the appropriate setting. Outcome-based regulation is a second priority for change in long-term care that was outlined by Kane. He stated, "For long-term care, the emphasis on outcomes is best expressed in a ratio of achieved/expected (i.e., what proportion of the results reasonably expected on the basis of statistical predictions that take into account client characteristics was actually received)."(10, p. 708) Most residents in longterm care experience deterioration in function due to age and chronic disease. Simply rewarding “good outcomes” essentially rewards the selection of healthy clients by facilities. The programmatic goal is exactly the reverse: there should be incentives to reward the quality of care for those in most need, which also may include those with the most rapidly deteriorating conditions. Measures for quality should be expressed as a ratio and include physiological function, cognition, social function, and satisfaction with the environment.(10) King's framework accounts for these attributes as a part of the personal system; whereas, Donabedian's category of outcomes is less likely to incorporate resident perceptions. Finally, Kane suggested a separation of the housing aspect of resident needs from health care needs. Nursing homes provide the dual function of health care services and a place to live for disabled and the elderly by bringing the resident to the provider of care. However, the structure of the care environment is often organized around the health care needs

of the residents and less on their housing needs. Kane suggested an expansion of the concept of long-term care to include providing health care for residents in congregate care settings, with the emphasis on meeting the needs of the individual in his/her own environment. Additional challenges in defining and measuring quality emerge from Kane’s work. The first is incorporating expected deterioration and individual risk in measurement. In most criteria for quality, the desired outcome is good health, return to function, or discharge home. In nursing homes, people can be expected to deteriorate as a natural phenomenon of their age and condition. Thus, quality may better be conceptualized as the ‘best possible decline in health.’ The second challenge relates to the definition of quality. Since the nursing home may be the individual’s last place of residence, there are aspects of quality that encompass more than just the health care needs of the individual. These other aspects must be included in the quality equation. Marilyn Rantz is a nurse researcher who has been instrumental in the initial testing and application of the geriatric minimum data set (MDS) which was developed and implemented in 1991 as a response to federal regulations mandating comprehensive assessment to improve quality. Rantz and colleagues(34) developed a multidimensional theoretical model of quality of care in nursing homes using data gathered from three focus groups. Participants with a wide variety of experiences providing care in nursing homes participated in the focus groups. The sample included nursing home administrators, directors of nursing, social workers, activity directors, activity personnel, physicians,


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nurses, state regulators, long-term care consultants, and staff from professional home care, hospice, and mental health services. Participants were asked to describe the attributes of a nursing facility that exemplified good quality of care and poor quality of care. The two core variables identified in the survey were interaction and odor. Related concepts were environment, individualized care, treatment, safety, staff, and quality measures. Participants did not primarily identify clinical outcomes as measures of quality of care; rather, process and structural components emerged as important. From these observations, Rantz et. al.(34) concluded the central focus of quality nursing home care is the needs of the residents and their families. Supportive concepts to the central focus are interaction, milieu, environment, individualized care, staff, and safety. Her multidimensional theoretical model provides a framework from which to continue the discussion of quality of care in nursing homes. "While the model primarily focused on care processes, it is complementary to outcome measures developed for nursing home care."(34, p. 38) Rantz undertook a second study(35) to discover the defining dimensions of nursing home care quality from the viewpoint of consumers of nursing home care. Eleven focus groups were conducted in five Missouri communities. The views of consumers and families are compared with the results of the previous study of providers of nursing home services. The seven dimensions of the consumer multidimensional model of nursing home care quality that emerged are staff, care, family involvement, communication, environment, home, and cost. Family involvement in nursing

homes was consistently identified as a measure of quality. The resultant multidimensional theoretical model was developed from both providers’ and residents’ perspectives.(34) Rantz(11) used her model to design a brief quality assessment tool. The tool successfully identified quality when tested in Iceland and Missouri. Although Rantz's work provides insight into the issue of quality of care in nursing homes, the components of quality that are supportive to the central focus are primarily observable phenomena in the nursing home environment. A resident may be dressed appropriately and look clean, but they have been in the same wheelchair for six hours. The facility may smell clean and look bright, but the electrical system is dangerous. The aspects of milieu, environment, and safety are structural components of care; whereas, staff interaction and individualized care are related to processes of care. The central resident focus (personal system) is supported by the nursing care (interpersonal system) and the environment (social system). Rantz's work offers insight into measurable aspects of quality. Summary Nursing homes evolved from ignored almshouses in the 1940s to government regulated and funded institutions in the 1980s. Reports of poor quality of care(9) stimulated regulatory legislation (OBRA, 1987) and renewed interest in improving the quality of care in nursing homes. Over the next several decades, two general concepts emerged illustrating the changing nature of nursing homes. Long-term care evolved with an increased emphasis on community base care delivery offering a


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wide variety of care choices in addition to nursing homes. An increased emphasis on quality of life as a component of quality of care reveals an increasing interest in the resident perspective. The multidimensional nature of quality has been illustrated in the works of Kane(10) and Rantz.(11, 34) The complexity of quality of care in nursing homes as illustrated by these two authors is reinforced by the breadth and scope of the literature. King's social, interpersonal, and personal framework provides further direction for the continued examination of the literature, as does the structure, process, and outcome framework explicated by Donabedian. Each of King’s systems social, interpersonal, and personal - will be used to group related concepts and themes identified. Federal, state, and facility policy affects quality of care and can be classified as belonging to King’s social system or Donabedian’s structural components of quality. OVERVIEW OF RELEVANT RESEARCH LITERATURE Structural Components of the Social System Policy is a dominant theme in the structural components of the social system as it relates to quality of care in nursing homes. Lowi(36) proposed three major types of policies: distributive, regulatory and redistributive. Distributive policies refer to allocation of limited resources to a few recipients. These policies serve the needs of smaller interest groups. Regulatory policies involve many groups, and a choice as to who will be indulged or denied. There are obligations of individuals and punishment for noncompliance. Redistributive policies reallocate

resources or rights among groups or social classes; thus these policies affect society on a larger scale.(37) Medicare and Medicaid are examples of redistributive policies that extract resources from one group (i.e., working people) and give them to another, such as persons unable to pay for their own nursing home care. Nursing home quality is affected by aspects of the social system in the form of federal, state, and facility policies. At the federal and state level, policies are primarily redistributive and regulatory (e.g., licensure, Medicaid reimbursement, certification, and professional regulation). Facility policies affect only those in the facility so they are primarily distributive. The Office of Inspector General (OIG) in the Department of Health and Human Services (DHHS) completed a report entitled Quality of Care in Nursing Homes: An Overview.(38) The report described general conditions in nursing homes and recommended strategies for improvement. Multiple methods were used to compile the report, including nursing home survey results, a literature review, and structured telephone interviews. The report concluded that serious quality of care problems persist in nursing homes and suggested inadequate nursing staff, weakness in the survey system, and lack of evaluation of present legislation as contributing factors to poor quality. Recommendations for improvement included changes in the structural aspect of quality related to survey and certification, development of staffing standards, and other enforcement strategies. Establishing care guidelines by standardizing interventions based on available data was one recommendation. Resident satisfaction


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and family involvement were also seen as important to quality improvement. The OIG recommended systematic assessment of the effectiveness of the legislation, with the following priorities: appropriate medication use, resident assessment, resident rights, quality of life, resident well-being, and maintenance of safe environment. Another recommendation was to utilize existing databases to accomplish ongoing assessment of these factors.

5. Measures of quality should incorporate its many dimensions, especially quality of life 6. Providers are to be held accountable by standards set, evaluatory tools developed, and information shared with those accountable 7. Capable adequate staff are necessary 8. Government commitment must support quality 9. Ongoing objective evaluation and changes are needed(13, p. 31)

The OIG(38) report indicated that improved quality is dependent on continuous assessment of existing structural components, as well as effective processes of care with an emphasis on resident-focused quality measures. Recommendations also emphasize continuous assessment of current regulations, not necessarily new regulations.

Federal Policies to Improve Quality

The Institute of Medicine completed a second report on nursing home quality of care in 2001.(13) Recommendations included directives for change to improve quality in five areas: “access to appropriate services, quality assurance through external oversight, strengthening the work force, building organizational capacity, and reimbursement issues.”(13, p. 17) The nine general principles underlying the recommended changes are: 1. Consumer is the center of care 2. The needs of diverse resident populations must be met 3. Easily accessible information allows residents and family to make informed choices 4. Access is necessary for quality of care and quality of life

Redistributive policies such as Medicare and Medicaid are those that receive the most attention in discussions about quality of care in nursing homes. In 1989, Medicare paid $2.8 billion to nursing homes; this was almost 5% of the total Medicare budget. In 1996, this amount increased to $10.6 billion, representing 9 % of Medicare expenditures. Medicaid expenditures for 1996 totaled $24.3 billion.(38) Medicaid expenditures for nursing homes were projected to be over $41 billion in 2002.(39) Federal Medicaid funds are allocated to the states with a matching fund formula that varies from state to state. Richer states must pay a 50% match for Medicaid funds; poorer states contribute less (a redistributive policy). Societal influences are important in allocation of these funds within the states and are dependent on the political climate. The OBRA of 1987 was the beginning of the current movement to improve the quality of care in nursing homes. The 1986 IOM report served to refocus standards on actual delivery of care and the results of the care. OBRA revised facility care requirements, modified the survey process, and introduced


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additional sanctions for homes that failed to meet standards. Prior to this time, standards for participation in Medicare and Medicaid focused on a nursing home’s ability to provide care, rather than on the quality of the care delivered. Marek and colleagues(40) interviewed 132 professional and nonprofessional staff members and 56 residents in six states to determine the affects of the OBRA legislation. Issues concerning nursing home staffing and quality of care were explored. From the perspective of administrators, licensed nurses, and nurses’ aides, the quality of care had improved since the initiation of the OBRA guidelines. However, nursing home advocates, regulators, and professional association staff found no change in quality of care. "While some intentions of the OBRA '87 may have been accomplished, the question remains, have we achieved a level of care, quality, and services which approaches an acceptable level or merely reached the floor?"(40, p. 38) Marek et al. suggested that there had been improvements to this point, but only to the level of minimal standards and encouraged continued efforts to improve quality.

The 1987 OBRA legislation has continued to frame the current federal regulatory process. The federal responsibility for overseeing nursing facilities belongs to CMS an agency of the DHHS. CMS contracts with state agencies to conduct surveys and DHHS provides oversight of the survey process through certification of facilities, and complaint investigation. A team of state surveyors spend several days on site conducting a broad review of care services.(41) The standard survey is conducted every 9-15 months in each nursing home to certify that the facility meets requirements to participate in the federal Medicare and state Medicaid programs. A focused review may also be conducted on the basis of a complaint about a facility’s quality of care. The states have the responsibility to determine the level of compliance with federal guidelines. When a survey is conducted, any deficiencies identified are classified using a standard federal format. CMS classifies nursing homes deficiencies using the criteria detailed in Table 2 below. However, there is considerable variation between states in interpretation of federal guidelines, leading to inconsistencies between states.

Table 2. CMS Nursing Home Deficiency Classifications CMS Category Immediate jeopardy to resident Actual harm, but no immediate jeopardy No actual harm, potential more than minimal No actual harm, potential of minimal harm

Level Most serious Serious Less serious Minimal


Compliance Noncompliant Noncompliant Noncompliant Substantially Compliant

15


CMS also classifies deficiencies by their scope or extent as follows: 1. Isolated, defined as affecting limited numbers of residents 2. Pattern, affecting more than limited number of residents 3. Wide spread affecting all or almost all(41)

When a facility receives a survey with ‘minimal isolated deficiencies’ or ‘no deficiencies,’ as defined by the standards, it is certified as a participant in the Medicare and Medicaid programs and is eligible for reimbursement for care provided to recipients of these government programs. If more serious patterns of deficiencies are identified, sanctions are imposed. These sanctions differ from state to state. The sanctions usually include a grace period of 30-45 days to address the care problems, plus a scheduled resurvey to assess if problems have been corrected. If care problems persist after resurvey, facilities can be prohibited from accepting Medicare and Medicaid residents as new admissions until improvements are made; current residents can continue to receive Medicare and Medicaid funding. If patterns of serious problems that represent immediate jeopardy to the health of the residents continue, a facility may be closed to state and federal funding. All residents then are transferred to a certified facility within a prescribed time frame. In response to allegations of avoidable deaths in California nursing homes, the US General Accounting Office (GAO) prepared a report directed by W. Scanlon to the U.S. Senate Special Committee on Aging in 1993. The report was entitled, California Nursing Homes: Care Problems Persist despite Federal and

State Oversight.(42) The GAO used data generated by the Online Survey Certification and Reporting System (OSCAR) from 1,445 California nursing homes. Facilities were visited and selected chart review used to establish the reliability of the survey data. HCFA, DHHS, and other pertinent agency officials were interviewed personally for input into the study results. Although results of the study did not conclusively establish the wrongful death claims that were made, they did indicate that serious quality problems existed. Nearly one in three, or 407 of 1,370 California nursing homes, was cited by state surveyors for having serious or potentially lifethreatening care problems. Further, they observed that HCFA enforcement policies had not been effective. Furthermore, a substantial number of homes that had been terminated and reinstated had soon thereafter been cited again for serious deficiencies. The GAO report concluded that these weaknesses are indicative of system-wide problems and not unique to California.(42) In response to the GAO report on quality of care in California, an additional report, Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards, was compiled in March 1999. This report concluded that HCFA had taken steps to improve oversight of nursing homes, but had not achieved the goal of compliance with federal standards. These nationwide data supported the California findings and indicated 25% of homes had deficiencies. Although most homes corrected their deficiencies, the problems often recurred. Forty percent of homes with problems in the first year of the study had similar problems again the second year. Threat of sanctions


16


seemed to have little effect. Rather than impose more regulation or change the existing ones, the GAO recommended improving enforcement of the present standards. Sanctions available to enforce compliance include civil monetary penalties, temporary imposition of outside management, denial of payments, directed inservice training, directed plan of correction, state monitoring, and termination of certificate.(41) Both of the GAO reports(41, 42) recommended improved enforcement of federal regulatory standards with sanctions imposed for noncompliance as a means to improve quality of care in nursing homes. Enforcement of standards through surveys and sanctions represents one type of federal regulation designed to improve quality. The results of the report supported Marek's findings(40) which indicated a continued need for quality improvement, despite gains realized since OBRA. Gold(43) summarized the key legislative events surrounding nursing home regulation that arose from the 1998 GAO report and resulted in the subsequent focus on increased enforcement using quality indicators. The Action Plan for Further Improvement of Nursing Home Quality by CMS(44) outlines 18 initiatives in 2005 to improve the effectiveness of the annual nursing home surveys. Current regulatory policies have proven inadequate to assure quality, partially due to the framework of enforcement which focuses on finding the "bad” facilities.(45) A focus on regulations and sanctions concentrates on structure and process to meet regulatory requirements, rather than actions to meet identified resident needs.

Redistributive programs such as Medicare and Medicaid provide reimbursement for some nursing home residents after it has been determined that the nursing home adheres to minimal standards of care. Federal Medicaid funds are allocated to the states with a matching fund formula that varies from state to state and increased Medicaid funding has been shown to improve quality of care when it was used to increase staffing.(46) Medicaid expenditures for nursing homes are projected to be over $41 billion in 2002.(39) Chen(47) proposed a three-tiered system using both public and private sector funds for nursing home care. Private and social insurance would be added to personal funds, with Medicaid as the safety net for those who were unable to cover costs using the three tiered system. The three-tiered system may eventually decrease the burden on the federal system but long-term care insurance and personal funds currently account for the minority of nursing home costs. Further investigation of the most appropriate payment formulas to promote quality is important.(48) Mitty(49) and Rosko(50) outlined the value of a prospective reimbursement system based on resident care needs. Structural differences between nursing homes and hospitals suggest that reimbursement in nursing homes should be based on functional health of the resident rather than diagnoses as in hospitals. To this end, a system was developed in 1985 using information on services provided to 3,400 residents in 52 nursing-home facilities in New York. A two-stage process was used to form the Resource Utilization Groups (RUG), which are based on functional status of the


17


resident, not medical diagnosis. In the first stage, professional clinical judgment related to resident need was used to form five groups reflecting different levels of care. Then, the five clinical groups were divided into 16 resident categories that were distinguished by the level of physical functioning as defined by the activities of daily living (ADL) index. The resultant classification scheme explained 52% of the variation in resource consumption. Classification of residents into groups dependent on care needs results in a more equitable reimbursement system and appropriate allocation of resources. There is, however, a potential risk that facilities will accept high need residents and maintain them (on the records) at a high level of care in order to receive higher reimbursement.(51) In the RUG system, reimbursement is based on a formula that combines the direct care components of care with ancillary costs per resident. The RUG system relies on nursing documentation of resident care delivered; that is, resources used. Implemented at the same time as DRGs, the RUG system is not based on length of stay, diagnosis, or age; rather, ADLs drive the system. There are 16 RUGs (that is, 16 case-mix indexes and 16 reimbursement levels), ranging from skilled rehabilitation and intensive skilled nursing care to light custodial care. Medicare reimbursement for nursing homes has been based on the RUG categories since 1999. Many states have also adopted RUGs as a guide to state-level Medicaid reimbursement for nursing homes. RUGs are expected to become the standard for Medicare and Medicaid reimbursement in the U.S.(52-

54)

Grabowski(55) found that the use of case mix reimbursement (e.g., RUGs) improved access for more dependent residents and decreased overall staff costs while maintaining quality care. Federal policy for the purpose of improved quality of care can be conceptualized as an open system that encompasses reimbursement of care based on resident needs and enforcement of regulatory standard. The following themes related to federal policies to promote quality recur in the literature: 1) allocation of resources through various payment systems, which are then underfunded; 2) variation in implementation of federal standards; and 3) state-monitored compliance with sanctions for violations. State Policies to Improve Quality State level policies interact with federal policies at the level of the social system. Redistributive and regulatory policies constitute the most influential state policies to promote quality. These policies focus on implementation of federal guidelines within the framework and priorities set by each state.(42) Nursing home policies are generally delegated to the state by the federal government. The state policy process is influenced by reports of nursing home neglect, facility profit priorities, residents, families, and legislators. The major political actors are the for-profit nursing homes, with a strong agenda building force aimed at maintenance of the current high profit margins realized in nursing home care.(56-58) A second major influence continues to be regulatory legislation in the form of OBRA, which has been in place since


18


1987. The key question is how this legislation is implemented and evaluated. Gertson(59) defines implementation as, "…the conscious conversion of policy plans to reality."(59, p. 95) Some issues that promote implementation of public policy are adequate funding, simplicity (limited number of agencies involved), and accurate interpretation of policy intent. In contrast, implementation can be obstructed by lack of funds, changes in priorities, and poor oversight.(59) Nursing home care is administered and regulated by multiple agencies between and within each state. The interpretation of the policy intent occurs in each state with differing priorities and politics. Federal oversight of regulations is minimal and funding is inadequate. Given these challenges, it is important to determine how public policy is implemented in nursing homes. Arling(60, 61) discussed utilization of casemix (based on resident characteristics) reimbursement strategies for Medicaid recipients in Mississippi and South Dakota. Resident assessment data and Medicaid cost reports were used from 154 facilities in Mississippi and 107 in South Dakota in 1992 and 1993. The RUG classification system was used to determine case mix. This led to improved access for heavier care residents and increased direct care expenditure in facilities with higher acuity residents, indicating a more equitable distribution of resources. However, Davis(62) performed a similar study in Kentucky to examine the effect of case mix reimbursement and market factors on nursing home performance. He found that "those facilities that increased their use of poor nursing practices often associated with heavy

care residents contained increases in expenditures while boosting gains in margins.”(62, p. 820) There was a tendency to accept needier residents who could bring in higher reimbursement, and then, to decrease care-related costs. The result was a decrease in quality of care and an increase in organizational profits. Kane(63) further documented state differences, illustrating wide variations in funding allocation for long-term care. Average annual long-term care Medicaid expenditures per person over 65 years of age were found to vary from $2,720 in New York to $380 in Arizona. Arizona low spending level may be partially explained from cost savings realized from managed care involvement. In most states, Medicaid expenditures for nursing homes represented the majority of expenditures (average 79%). There was, however, wide variation - 96% in Mississippi to 50% in Oregon. Kane concluded that state-to-state variations are significant and, if further responsibility for long-term care quality is placed on the states, the variation will likely increase. Reimbursement based on case mix shows promise in promoting quality care, but more study is necessary to determine if funds allocated for resident care are actually used to meet the higher needs of residents. Although federal policy related to OBRA guidelines is consistent across states, enforcement and monitoring are delegated to the states. This results in “let the states handle it.” The variability in adherence to standards and quality at the state level reflect the federal policy of delegating implementation. Many studies related to quality of care in nursing homes have focused on federal


19


guidelines, with few studies exploring the effect of state level implementation of federal or individual state policies. Although variability in quality from state to state is appreciated, little information is available about what aspects of state policy account for differences. Phillips (1999) sought assessments by directors of nursing (DON) in two states concerning the value of state level surveys. Questionnaires were mailed to a random sample of 400 DONs of nursing homes in Illinois and Missouri. Each state sample included 200 facilities, 100 for-profit and 100 not-for-profit. DONs were asked whether the survey process was informative, beneficial, reasonable, antagonistic, or fair. There were no significant differences in the evaluations of directors of nursing in not-for-profit or for profit facilities. There were, however, significant differences between the two states, with Illinois reporting consistently lower ratings. This study suggests there is variability of state enforcement of standards and resultant variable quality. This represents an area in need of further study. Facility Policies and Characteristics to Improve Quality Facility-level policies are another aspect of the social system relating to nursing home quality of care. State policies interact with individual facility policies. At the facility level, policies may be regulatory, distributive, or redistributive but affect only staff and residents of a particular facility. Nursing homes can be operated by government, nonprofit (e.g., religious or fraternal organizations), or for-profit entities. The organizations that own and operate nursing homes also design policies unique to their organizations. Private religious nursing

homes may choose to have a spiritual base for their policy development. Nursing home organizations operated for-profit often belong to large chains. Those organizations tend to have policies that differ from smaller nonprofit or private organizations. Harrington(58) examined whether investor ownership versus nonprofit status affects quality. She analyzed 1998 data from state inspections of 13,693 nursing facilities using a multivariate model, controlling for case mix, facility characteristics, and location. Investorowned facilities averaged 5.89 deficiencies per home, 47% higher than nonprofit facilities and 43% higher than public facilities. In multivariate analysis, investor ownership predicted 0.679 additional deficiencies per home; chain ownership predicted an additional 0.633 deficiencies. Nurse staffing was lower at investor-owned nursing homes.(58) These results were subsequently confirmed in a similar study.(64) Davis(65) analyzed the effect of profit or not-for-profit status on the quality of care in nursing homes. When he controlled for acuity and case mix of residents, there was no difference in quality. Mukamel(66) also studied facility ownership, using a similar model, and concluded that private nonprofit facilities generally had higher quality of care. His measures and methods of analysis were similar to those of Davis. Harrington(58) found a positive correlation between quality of care and non-profit status of nursing homes, confirming Mukamel's findings. The association of for-profit facilities with lower quality measures has been documented in research and expert opinion.(57, 58, 64, 67, 68)


20


The size and location of a facility and cost of care can also have an effect on quality. Nyman(69) showed, through multiple regression analysis, that the optimum size of a facility for cost containment and ability to afford services is 170 residents. However, the majority of facilities in the U.S. have fewer beds and Rantz and colleagues(70) found facilities with less than 60 beds in Missouri had higher quality. There is a possibility that if each facility were closer to the optimum size of 170, there would be an increased economic efficiency and consequent improved ability to provide quality care. However, quality of life might be compromised in very large facilities so that grouping residents in smaller care groups may provide quality and efficiency. Geographic location may influence quality by affecting the availability of staff and services to the resident population. Hospital-based nursing homes tend to have higher quality of care due to the close proximity and availability of medical services. They also have a stronger financial base, due to improved reimbursement for hospital services.(69) Ullman(71) documented a cost threshold, indicating there is a minimum level of charges per resident necessary for quality beyond which increased charges do not improve, but actually may decrease quality. Rantz(70) compared 92 high and low quality facilities in Missouri and found costs were not statistically different between groups. In fact, there was a trend to higher total cost of $13.58 per resident per day in poor quality facilities. More study is needed to determine the structural characteristics of facilities associated with quality. Several innovative programs provide insight into the quality of care in nursing homes and are examples of

distributive polices. One is a foundation-supported demonstration project in which universities partnered with nursing homes. The facilities received free staff, the university benefited by access to clinical and research sites, and the residents received improved quality of care. The first program began in 1986 with six associate degree programs in nursing (ADN) and was funded by the W.K. Kellogg Foundation as the Community College-Nursing Home Partnership. The purpose was to develop nursing in longterm care settings through staff education, and to influence ADN students to seek employment in longterm care. Positive results were seen in professional and nonprofessional care giving, as well as direct resident care. Increased leadership, improved assessment, improved documentation, and improved attitudes were realized in professional staff. Nonprofessional staff showed improved self-esteem, increased psychological skills, and improved technical skills following the program. Direct resident care improved in the areas of comprehensive assessment, individualized resident care, and staffresident interactions.(72) The author recommended continued support of partnerships. However, costs to the facilities and community colleges were not discussed, nor was there an indication of continuation of the program after grant funding was exhausted. The Teaching Nursing Home (TNH) is an innovative program to improve the quality of long-term care services by including an interdisciplinary approach.(73) Increased resident acuity, relative absence of professional


21


providers, and isolation of nursing homes from the mainstream of health care led to this project. The Robert Wood Johnson Foundation (RWJF) provided funding for 11 schools of nursing to collaborate with 12 nursing homes for the purpose of upgrading clinical care, creating an environment supportive of education, and promoting clinical research.(74) Each partnership included five essential elements: 1) school of nursing involvement, 2) faculty appointment to facility, 3) opportunities for graduate education, 4) commitment to interdisciplinary care, and 5) fiscal acknowledgement of and support for affiliation. The project funded 1.5-2.0 full time equivalent positions in each of 12 nursing homes filled primarily by faculty/clinicians from the schools of nursing. Most funded nurses were GNPs. Program outcomes included a 7% decrease in hospitalization rate of TNH residents, compared to an increase of 5% in nonTNH residents. Resident status improved on several clinical measures: bowel continence, dressing, transfer stable, episodes incontinence avoided, no restraints used on confused residents, and restraints checked every 30 min.(75) The barriers to TNH(76) included lack of fiscal resources beyond the funded project, lack of nursing home and school of nursing commitment, poor nursing home readiness, time constraints on faculty and staff, and lack of RNs to mentor students. The cost neutral model showed that the system-wide cost savings covered the cost of the increased staff. Further, the effects on the universities were positive: improved attitudes of students, additional access to residents for research, increased awareness of graduate students, enriched curricula, and innovative practices. The

TNH project generated more support for increase in professional staff and an increase in the understanding of the importance of professional nursing in promoting interdisciplinary coordination in nursing homes. The RWJF and Kellogg Foundationsupported demonstration projects provide evidence for the commonsense notion that an increase in professional staff leads to an increase in the quality of care. However, the cost savings achieved with increased professional staff were systemwide, such as decreased discharge to the hospitals, and did not necessarily financially benefit a facility which might choose to hire more professional staff. Unfortunately, many nursing homes will not increase staff without monetary incentives.(36) The challenge remains to provide incentives for incorporating increased professional staff into nursing homes throughout the US. A third innovative program designed to achieve quality care in nursing homes is summarized in Promoting Quality of Nursing Homes: The Wellspring Model.(77, 78) Eleven nursing homes were involved in the project to implement a model incorporating six key elements: 1. alliance of nursing homes with management committed to quality 2. shared services of a GNP 3. care resource teams to provide training across nursing homes in specific care areas 4. networking among facilities 5. empowerment of all staff related to their specific position 6. continuous reviews on resident outcomes and environmental factors


22


This model posits the interrelated aspects of quality of care. Nursing home administration must place quality as a high priority and support the organizational changes that lead to improved quality. Staff accustomed to supervisory decision-making power can delegate and empower their staff to make decisions. The concept of open systems is evident in the interfacility communication and networking inherent to the model. Free flow of ideas and services between the nursing homes involved in the project is reflected in four of the six key elements. Reinhard(77) suggested that quality is dependent on an open system with components in dynamic interaction. Stone(78) evaluated the implementation of the Wellspring Project and found an overall decrease or stabilization of cost and an increase in quality of care. The way a facility is managed and organized has received increased attention in relation to quality of care. The recent CMS(52-54) initiative on quality of care currently being pilot tested in several states seeks to examine the impact of process-oriented facility initiatives on quality indicators. Researchers are also examining organizational components that promote quality.(11, 68, 70, 79-85) Noting that nursing homes account for 12% of all health care expenditures and that problems continue to exist with quality of care, Stevenson(85) developed a literature-based conceptual model for quality of care designed to help administrators implement quality improvement. Three interacting dimensions were identified: organizing arrangements, social factors, and physical setting. Castle(81) documented

administrator turnover as a factor in overall quality in nursing faculties. Rantz(11, 82, 83) designed and implemented an organizational strategy similar to the Wellspring project which has shown improved quality of care. Berlowitz(80) examined the affect of organization change on quality indicators at the facility level. Anderson(79) found that facility practices that increase communication and interaction are important in care quality. Preliminary research in the area of facility organization and management is promising and indicates a need for continued study in this area. It is apparent that the structural components of quality reflected in the federal, state, and facility policies interact in an open social system. Federal policies affect state policies because of delegation of regulatory responsibility of states to assess nursing home to see if they qualify for Medicaid and Medicare program funding. State policies in turn, affect facility policies by creating highly regulatory environments that force all facilities to meet the quality standards in place, regardless of facility characteristics. Facilities in states with fewer regulations may take advantage of the loose regulatory environment to increase profits at the expense of quality of care. According to systems theory, a system functions effectively when all parts of the system interact in balance with one another. Unfortunately, there is considerable variation in levels of quality of care both within and between states, owing in part to the delegation of enforcement of federal guidelines to states and presence of multiple agencies within states.


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Process Components of Quality in the Interpersonal System Themes that emerge from the literature in the area of interpersonal systems affecting quality of care continue to validate the importance of the nurseresident relationship. The regulatory aspect of nursing staffing as a component of quality is related to the social system. However, availability of professional nurses to provide leadership and direct nursing care can be assessed within the interpersonal system; this emphasizes the importance of the availability of qualified nurses to provide quality care. Comprehensive assessment, a second theme, has emerged as a result of the 1986 OBRA mandate. Assessment aims to identify atrisk residents and assist in formulation of plans to minimize risk and promote quality care. In addition, a third element in the interpersonal system is specific intervention strategies for common resident problems that are thought to be ‘best practices’ and promote quality. The resident problems/needs most studied in relation to interventional strategies are incontinence, psychotropic drug use, and restraint use. Each of these areas will be discussed further in the following sections. Availability of Qualified Nurses Adequate professional staffing is essential to promote quality of care in nursing homes.(86-89) Harrington(86) defined adequate staffing and suggested regulatory mechanisms to ensure minimum levels are met. Her study documented that an increased ratio of licensed nurses to residents improves quality of care and that the higher the educational level of these nurses, the

higher the quality of care. Nyman(69) and Porell(90) also found licensed nursing care improved quality, but failed to conclude that the subsequent increase in cost associated with increase in professional nurses was justified by the increase in quality measured. Harrington's 1990 work focused on identifying staffing problems in nursing homes across the US. She found that wages were 15-40% lower in nursing homes than for comparable hospital positions, with resultant inadequate staff availability, high turnover, and lower levels of education and training in nursing homes. She cited poor quality of care as the direct result of these staffing issues. In addition, inadequate nurse staffing patterns have been associated with Medicaid cost containment efforts at the state level. Since nurses represent the highest cost center in nursing homes, cost containment at the facility level often results in decreased staffing levels. Harrington(87) suggested changes in public policy that support parity of wages and benefits and public accountability for nursing home expenditures. Munroe(91) focused on the extent to which registered nurse staffing patterns influence nursing home quality. A model for evaluating nursing home quality was developed with the following components: health-related deficiencies on surveys, ratio of RN-to-LPN nursing hours, case mix, facility, payer mix, average daily cost, ownership, nursing personnel salary, and staff turnover. Data from 455 Medicare-certified nursing facilities in California were analyzed using ordinary least squares regression to identify factors affecting quality. A positive significant


24


relationship was found between nursing home quality and the ratio of RN-toLPN hours per resident day. A similar study by Johnson-Pawlson(92) tested the hypotheses that 1) the presence of RNs improves the quality of nursing care and 2) increased numbers of nursing staff improve the quality of nursing care. The RN and total nurse staffing full-time equivalent positions per resident were correlated with quality of care, as measured by input from nursing home ombudsmen and records of facility survey deficiencies. A controlled variable was case mix, because facilities with higher case mix (residents with more care needs) have been shown in other studies to have more deficiencies cited on survey. Facility ownership was also controlled, due to previous studies indicating that non-profit facilities staff at higher levels of RNs than do proprietary facilities. Finally, payer mix was controlled to account for potential differences in quality of care attributed to the effect of lower Medicaid reimbursement for services. The findings of this study (198 facilities in Maryland in 1991) indicated that the ratio of RNs to residents was directly related to residents’ rights deficiencies. In addition, the ratio of total nursing staff to residents was directly related to a lower overall deficiency index and a higher quality of care score. Subsequent studies and expert opinion confirmed the positive impact of increased RN staffing on quality of care.(48, 93-98)

Bleismer(99) examined the relationship between selected nursing home attributes such as size, ownership, noncompliance with state correction order, and licensed and nonlicensed nursing hours on outcomes. Outcomes studied were functional ability, discharge home, and death for residents aged 65 and older. Age and previous functional ability were controlled variables. She found that licensed (but not non-licensed) nursing hours were significantly related to improved functional ability, increased probability of discharge home, and decreased probability of death. These findings were consistent with previous studies which supported the use of licensed nurses in nursing homes to improve quality. Rohrer(100) completed an exploratory analysis of 290 residents in two Veteran's Administration Hospitals in Michigan. Functional ability of the residents was assessed at the onset of the study and seven days later using RUG criteria. Four levels of care were determined: basic, unskilled, skilled, and psychosocial. Nursing time was calculated for the seven-day study period, with the average nursing minutes per resident by level of care as shown in Table 3. Five variables revealed significant relationships with outcome RUG scores at seven days when other factors were controlled. Decline in RUG score (which indicates improved functional status) was associated with an increase in nonRN treatment.


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Table 3. Average Nursing Minutes per Resident by Level of Care Basic Minutes (%)

Unskilled Minutes (%)

Skilled Minutes (%)

Psycho-social Minutes (%)

Total Minutes (%)

RN

52.3 (12.7)

0.0 (0.0)

19.6 (4.7)

20.1 (4.7)

92.0 (22.1)

LPN/CNA

219.6(53.4)

47.4(11.5)

0.0(0.0)

52.2(12.7)

319.2(77.6)

Total

271.9(66.1)

47.4(11.5)

19.6(4.7)

72.3(17.4)

411.3(100.0)

Conversely, basic care time, treatment by RNs, and initial RUG score, were associated with a decline in the resident's condition (rise in RUG score), indicating a higher level of care needs. Psychosocial care and physician notes in the medical record were also positively related to improved resident condition. Rohrer concluded that a resident's future functional status can be predicted on the basis of present functional status and staff time they are consuming. This study examined the relationship of nursing time with outcomes, and documented that increased RN time correlated with decrease in resident functional status, with no decrease in quality of care. Nurses spend more time with residents with higher care needs. This illustrates the importance of adequate RN staffing (based on case mix) to assure quality. (101)

Mueller cited numerous studies that document improvement of quality of care with appropriate staffing levels in nursing homes, but lamented the lack of impact these studies seem to have on federal and state policy. OBRA guidelines (Public Law No.100-203, Subtitle C) established a floor by requiring the following minimum professional staffing in nursing homes: "24 hour licensed nursing service sufficient to meet the nursing needs of

residents and use of a registered nurse for at least 8 consecutive hours a day seven days a week."(101, pp. 169-170) Mueller supports the continued use of RUG criteria to establish mandatory nursing time based on resident case mix. The average nursing time for each of the RUG groups is posted on HCFA's Medicare Web site at www.hcfa.gov/stats/stmds.htm. This information is available to support increased professional staff as a path to improved quality. These data have not, however, led to increased nurse staffing in facilities nationwide that could be related to the accuracy of data. Most nurse staffing data is reported by the facilities with minimal audit. In an effort to improve nurse staffing information, CMS (2004) will develop quality measures that report on staffing in 2005. Kovner(102) reported the results of a oneday invitational conference with 30 health care professionals and nursing home advocates. The goals of the conference were to examine what is known about staffing and quality in nursing homes and to develop a research agenda for policy makers to help direct future research. Twelve research priorities were established. Eight priorities were related to nurse staffing issues such as educational level, professional mix, wages, and staff


26


turnover. One priority related to the ability of staff to be culturally sensitive. The final two were ‘care practice exemplars of quality’ and established validity and reliability of current nursing home resident assessment data. Of these 12 priorities for research in nursing home care, 10 relate to the process of care provided by nursing staff. More recently, Harrington(89) reported the recommendations of an expert panel convened to address staffing and quality of care in nursing homes. The panel reviewed existing studies that show a consistent positive relationship between higher nurse staffing levels, especially RN staff, and the outcomes of nursing home care.(69, 86, 91, 99) The RUG classification system was used, in combination with time studies from the OSCAR data set and HCFA, to make recommendations for federal mandatory staffing levels in nursing homes. The federal minimum standards recommended by the expert panel include bachelor's degree preparation for all RNs in the director of nursing role, RN supervisor 24 hours a day, 7 days a week, and a part-time RN as nurse educator. An additional RN was recommended in an assistant director role for facilities with more than 100 beds. The panel recommended standards for every category of direct care providers including RNs, LPNs, and CNAs, as well as staffing ratios for mealtimes. Mandatory inservice education at all levels and part-time nurse practitioner services at all facilities were also seen as important to quality care.(89) The relationship of professional nurse staffing to quality of care was further validated in subsequent studies.(88, 103)

In a focus group study of CNAs over a period of several weeks in four central Texas nursing facilities, Burke(104) sought insight into the experience of quality through the perspective of the CNAs. Ten questions were asked addressing dimensions of quality such as reliability, responsiveness, courtesy, competence, confidence, individual treatment, and physical clues to quality through the five senses. CNAs were able to identify quality indicators in residents and cited barriers to quality such as punitive and unsupportive management and professional nursing staff. CNAs saw constructive support from professional staff and recognition of quality care given as key to the provision of quality of care. Davies(105) also studied the effect of nonlicensed personnel on quality of resident care in nursing homes. She specifically examined verbal interaction through tape-recorded nurse-resident interactions by qualified and unqualified personnel. Findings suggest that although trained and untrained staff members use the same range of verbal strategies, trained staff used proportionally more professional strategies such as promoting dignity, self-respect, choice, and independence. Davies(106) and Burke(104) suggested that CNAs would benefit from supportive environments, including educational strategies to provide them with the information and skills needed to provide quality of care to residents in nursing homes. The utilization of GNP services in nursing homes relates to the interpersonal nurse-resident relationship. Kane(107) compared quality of care measures in 30 nursing homes employing GNPs with 30 matched control homes. The measures of GNP


27


impact were based on comparison of pre-GNP to post-GNP periods. Favorable changes were seen in 2 of 8 ADL measures, 5 of 18 nursing therapies, and 2 of 6 drug therapies. There was a significant decrease in resident days in the hospital and an increased rate of discharge to home from those facilities employing a GNP. This study was dependent on the facility employing GNPs as a part of a W.K. Kellogg Foundation-supported project. Study findings suggest a useful role for GNPs in the nursing home, but barriers to their practice continue to exist. These include the following: • Direct payment for services under Medicare part B require that a physician complete the initial assessment • Reimbursement for GNP services are 85% of the physician rate for the same services rendered • Cost of GNP salary is not supported by a facility, since physician services are not in the facility budget. Thus, the system-wide cost savings seen in decreased hospital stays and earlier discharges to home are not realized at the nursing-facility level. For these reasons, despite the identified improvement of quality and system wide cost savings, GNPs have not been extensively used in nursing homes. Kane(33) later compared GNPs’ nursing home care to MD care and found GNPs provided more efficient care of comparable quality. His more recent work uses a managed care model with system wide cost responsibilities which could mean system wide cost savings while maintaining quality.

Despite the fact that numerous studies have indicated availability of qualified nurses improves quality of care, as Mueller(101) suggested in her study on staffing, research evidence does not necessarily instruct policy. Low reimbursement rates for Medicaid, and the profit motive in many nursing homes are barriers to employing more professional nurses in nursing homes. Comprehensive Assessment to Identify High Risk Residents The Resident Assessment Instrument (RAI) was developed in response to reforms enacted by the US Congress with OBRA.(108) RAI development began in 1988 with 18 clinical work groups working to create an instrument that: 1) focuses attention on the whole person, 2) facilitates problem solving and communication, 3) creates a common language and understanding of the resident, 4) is feasible for use in the average nursing home, and 5) is reliable across users.(109, 110) It addressed recommendations for a uniform comprehensive resident assessment as a means to improve quality of care. In it, comprehensive functional assessment is viewed as the cornerstone of individualized care planning that focused on helping residents attain and maintain maximum level of functioning and well being.(109) Further, development of outcome-oriented measures of quality and the implementation of residentfocused quality assurance systems are dependent on a comprehensive assessment database. The RAI was developed by a research consortium under contract with HCFA, implemented in 1991, and is currently used by more than 90% of US nursing homes.(111)


28


Achieving RAI development goals required reviewing existing instruments, determining domains to be included, establishing reliability and validity, and, finally, developing training materials for implementation.(35) The resultant RAI includes three components. One is a set of core elements called the MDS for assessment and care screening (see Table 4). The second component is resident assessment protocols (RAPs) in 18 areas that represent common

problems or risk factors for nursing home residents (see Table 5). The RAPs are intended to link the MDS information to care plan decisions. The third element is a user's manual with detailed specifications about how to complete the RAI and RAP assessment process. The content of the RAI, including components and major domains, is summarized in the table below:

Table 4. Major Domains of the Minimum Data Set (MDS) for Resident Assessment and Care Screening (112, 113) Major Domains of the MDS Background and customary routines

Cognitive patterns

Communication/hearing patterns

Vision patterns

Physical functioning and structural problems

Continence

Mood and behavior patterns

Activity pursuit patterns

Disease diagnosis

Health conditions

Oral/nutritional status

Oral/dental status

Skin condition

Medication use

Special treatments and procedures


29


Table 5. Components of the Resident Assessment Protocols (RAP)(112, 113) Components of the RAP Delirium

Cognitive loss/dementia

Visual function

Communication

ADL functional/rehabilitation potential

Urinary incontinence/indwelling catheter

Mood state

Psychosocial well being

Behavior problem

Activities

Falls

Nutritional status

Feeding tubes

Dehydration/fluid maintenance

Dental Care

Pressure ulcers

Psychotropic drug use

Physical restraints

Rantz,(34) Schnelle,(114) and Vladeck(115) have defined quality as a complex multidimensional concept. The OBRA guidelines were designed in 1987 to improve quality in nursing home care in 1987. The initiative led to the development of standards to meet criteria for excellence, including the RAI. Resident Assessment Protocols (RAPs) represent one or a combination of MDS assessment points that identify risk for developing specific functional problems that may require further evaluation. Assessment data points that indicate increased risk are called ‘triggers.’ The RAPs provide structured, problem-oriented frameworks for organizing MDS information to develop individualized plans of care. The overall resident assessment instrument (RAI) framework is as follows: MDS + Triggers + RAPS Comprehensive Assessment Each of the domains listed above is defined in the MDS manual(116) to ensure information about each resident is collected, recorded accurately, and assessed by the nurse following specific

guidelines. Assessment is completed within 14 days of admission or readmission to the facility, quarterly, and when there is a significant change in the residents’ condition. Every facility that receives Medicare or Medicaid funds is mandated to complete the MDS and, since 1998, data must be entered online. Specific resident assessment is completed in the areas of incontinence, decubitus ulcers, independence in ADLs, cognitive/behavior changes, restraint use, changes in weight, and medication use. The assessment information is used to evaluate and improve the quality of care. A completed MDS triggers assessment points that indicate increased risk and need for further attention. These triggers then indicate RAPS that will assist in planning the care of the resident who has been identified as at risk.(116) The overall process is a comprehensive assessment to identify problems or risks, as well as a specific format to meet resident needs related to assessment. Reliability was tested by Hawes(117) and found to be excellent, with 89% of the items exceeding an intraclass correlation of 0.4. Psychometric characteristics of


30


the MDS were evaluated by Casten(118) using confirmatory factor analysis. The MDS was found to be reliable as a measure with cognitively intact residents; however, the measures were less reliable for those impaired cognitively. Lawton(119) examined the validity of the MDS data for the purpose of research and found the majority of the areas had modest validity coefficients. Hartmaier(120) and Morris(121) found the MDS cognitive performance scale (CPS) to correlate with other measures of cognitive ability. However, Phillips(122) found the CPS less reliable for use with cognitively impaired residents, which is a significant limitation. Snowden(123) and Stineman(124) studied the overall validity of the MDS and determined that it continues to be valuable as a quality measure. Morris(125) established the commitment to keep the RAI reliable through a process of adjustments and changes as new information became available. The current MDS 2.0 reflects several revisions since the original. The MDS 3.0 is currently being developed to more accurately reflect current standards and simplify its use (CMS 2004). Rantz(126) indicated the MDS data may be helpful to policy makers to determine quality of care issues. "Policy makers need more than utilization and cost analysis reports to evaluate the impact of their decision. Clinical assessment information brings to light the human conditions of residents so that their plight cannot be hidden in impersonal utilization and cost statistics."(126, p. 20) Won(127) went on to state that the MDS is much more than an imposed regulatory device: it is a tool that can be used for better accountability and quality improvement. Assessment is the first step in the process and serves as

a foundation for interventions to improve resident status. The MDS was linked to improvement in quality of nursing care seen in the early 1990s in the areas of restraint use, psychotropic medication use, incontinence, and documentation.(125, 128, 129) Hawes(109) found the development of the RAI helped to focus on the whole person, facilitate problem solving and create a common language. She also found it to be feasible and reliable. Decreases in hospitalization of nursing home residents were an additional benefit associated with introducing the resident assessment instrument.(130) Although components of quality that focus on the interpersonal relationships of nursing staff and nursing intervention strategies have provided insight into the quality of nursing care, there are limitations to their utility. Quality of care is a complex concept and comprehensive assessment in the form of the RAI has begun to recognize this complexity with a process that begins to determine quality from the resident’s perspective. Resident Care Interventions A process component of quality care includes nursing interventions with the express purpose of improved resident outcomes. Since 1987, research in the area of resident interventions has focused on psychotropic medication use, physical restraints, and urinary incontinence, which were identified as problem areas in the 1986 IOM report. Schnelle(131) evaluated a management plan assisting personnel in nursing homes to utilize physical restraints appropriately. The management system


31


included education, documentation, and policy implementation and resulted in significant improvement in the appropriate use of restraints. Three weeks after the study, however, restraints use levels were similar to those prior to the study. The restraint management system was then reintroduced and a maintenance component was added with subsequent sustained improvements. The study concluded management techniques are successful with ongoing maintenance by nursing home personnel. This study illustrates an open systems framework at the facility level. Phillips(122) initially determined that residents who were physically restrained actually required more care time than matched residents with similar care needs who were not restrained. A decrease in use of physical restraints, with the resultant increase in quality, would not incur further costs. Phillips(129) further described that facility and area characteristics have a significant impact on the use of restraints in the nursing home, which would support the anecdotal use of restraints rather than resident needs-based use. His work revealed no improvement in quality with use of restraints and a lack of evidence to validate their use. The study findings have supported the overall decline in restraint use in nursing homes. Hughes(132) evaluated the relationship between psychotropic drug use and falls in nursing homes in five US states and five countries during 1993-1995. She was interested in the effect of the OBRA legislation on psychotropic drug use in the US and whether there were fewer falls than in other countries since the

legislation. Incidence of falls was used as a measure of quality since falls are often associated with inappropriate use of psychotropic medications. Her findings suggest that the overall psychotropic medication use is significantly less in the US than in Sweden, Denmark, Iceland, Italy, and Japan. This finding is significant, but does not assure that the decrease in medication use reflects higher quality of care. Iceland, Italy, and Japan had a lower risk for falls when compared to the US, despite higher rates of psychotropic medication use. In contrast, the risk of falls was increased in Denmark and Sweden. These data suggest that overall rate of prescribing psychotropic medications has been affected by the OBRA legislation, but it is less clear that this translates to improved quality of care as evidenced by fewer falls. Phillips(133) studied this question further when he analyzed the use of physical restraints and psychotropic medications in Alzheimer's Special Care Units (SCU). These units are designed to afford cognitively-impaired individuals a safe environment and structured activities to meet their needs. SCUs are also designed to allow physical independence and focused activities that may substitute for medication use. Phillips examined 71,000 nursing home residents in four states, including 1100 residents in 48 SCUs, and found no change in use of physical restraints and an increase in psychotropic medication use in the special care units, when compared to similar residents in nursing home facilities. Although the care units may provide other measures of quality of life for the participants, these results suggest that the use of restraints and


32


medications may not be different in these units. Measuring restraints and falls as outcomes indicating quality may not be appropriate. Other possible quality measures are resident autonomy and maximum functional ability, both of which are more difficult to measure. Holtzman(134) examined the process component of care for three measures of resident symptoms. He used an expert panel to determine the critical elements of care for fever, shortness of breath, and chest pain in nursing home residents. A random sample of 1405 Medicaid nursing home residents in Minnesota from 1984 and 1988 was used to test the process measures. After determination of critical elements by the expert panel, a retrospective chart review was performed and clinical scenarios were developed using the data gathered from these reviews. The clinical scenarios were rated by the expert panel using previously identified critical elements. The study validated the use of the process measures developed for fever, shortness of breath, and chest pain as indicators of quality of care. Findings suggest that quality care can be reliably determined by retrospective chart review using expert panels to determine the measures of quality. Moseley(135) studied the impact of the OBRA legislation on urinary catheter use among 3,149 pre-OBRA and 5073 post-OBRA Virginia residents. The results indicated the significant impact of OBRA on catheter use, with a less than 1% rate of inappropriate use of catheters for nursing home residents post-OBRA. However, there was an increase in incontinence post-OBRA, which may be related to changes in case mix or the decrease in use of urinary

catheters. Moseley suggested use of a urinary catheter is no longer a quality indicator, since they are generally being used more appropriately since OBRA. Frequency of use may not indicate poor quality, rather it may indicate the characteristics of the resident or case mix. Schnelle(136) devised a system for monitoring resident incontinence in nursing homes for the purpose of documenting improved quality of care. He found that, even with hourly checks, residents were wet a majority of the time and, in one of the four studied nursing homes with every two hour checks, 42% of residents would be wet 90% of the time. He concluded that merely changing the resident is not adequate; there must be implementation of absorbent pads to protect the skin when incontinence is so frequent. The goal to keep residents dry is inappropriate unless the pads are used to protect the skin. Studies of nursing interventions have improved our understanding of the process components of quality and the efficacy of treatment strategies. Restraint use has declined due to the work of Phillips(112, 122) and interventional management systems are maintained, due in part to Schnelle's(136) work. The continued challenge of quality measurement is illustrated in Hughes'(132) work when a decrease in falls was used as an indication of a quality resident outcome. In reality, falls may actually increase with an increase in resident autonomy. Holtzman,(134) Moseley,(135) and Schnelle(136) studied process components of quality and revealed strategies to improve resident outcomes. Saliba(137) recently used a modified Delphi method to identify 19 quality measures using expert opinion of geriatricians. The resultant process


33


measures of quality are difficult to interpret and further illustrate the complexity of quality of care. It continues to be a challenge to determine processes of nursing intervention promoting quality in nursing homes. Although this is important nursesensitive research, the nursing care provided in nursing homes is affected by multiple factors. The optimum care identified may not be obtainable if the federal, state, and local policies reimbursement, staffing, and case mix do not support quality care. Outcome Components of Quality in the Personal System The personal system can be conceptualized as specific attributes or outcomes exhibited by the individual resident as a result of being a recipient of quality care. Quality indicators are resident outcomes that suggest the presence or absence of good or bad care.(138) The literature related to resident outcomes encompasses the dynamic interaction of chronic disease, aging, disability, and end-of-life issues. Quality care includes the health care needs and housing needs of the elderly individual with chronic disease.(10) Therefore, quality in nursing homes includes aspects of quality of life, expected decline, and quality of health care. Quality indicators set a standard, which, if not met, almost certainly identifies poor quality of care.(30, 139) Since the elderly with chronic diseases have an expectation of gradual decline in their health despite high quality of care, there must be an adjustment to any measure of quality to account for this. In this population resident outcomes must be

risk-adjusted due to expected decline in resident condition. Resident Outcomes The increased emphasis on the use of resident outcomes as quality indicators has heightened the importance of their accurate interpretation.(140) Resident outcomes such as mortality, hospital discharge, discharge home, and prevalence of pressure sores have been used to indicate quality in nursing home care because they are accessible and measurable.(141) Braun(142) used death, rehospitalization, and discharge as indicators of quality and encountered limitations with these measures in the nursing home population. Since resident characteristics such as severity and prognosis of disease process influence these outcomes, they are crude indicators of quality at best. Incidence of falls has been used as an outcome indicating quality, but an increase in falls is often the price of independence.(143) Another measure of quality in nursing homes is pressure sore prevalence, since decubiti are measurable by universal standards and the presence of a pressure sore is generally believed to indicate poor care provided. Berlowitz(144) used pressure sores as a quality indicator in his study examining the effects of organizational change on quality. Maklebust(145) outlined the standardized staging of pressure sores, which is generally accepted as a national guideline to describe and document pressure sores. Leshem’s study(146) provided findings that illustrate the limitations of using pressure sore prevalence to determine quality of care in nursing homes. She followed 334 long-term care residents from 1988


34


through 1992 and documented the prevalence of pressure sores. She found that 3.4% of pressure sores developed in the long-term care facility, whereas 20% developed in the acute care facility before transfer to the nursing home. The majority (60%) of the pressure sores that developed in the acute care facility were stage III or stage IV, which are the most severe. The majority (87%) of the pressure sores that developed in the nursing home were stage I and II, which are the least severe. Therefore, quality of care in nursing homes is not reflected merely in the presence of pressure sores. There must be consideration of the acuity of illness of the person, where the pressure sore originally developed, and how the healing process is progressing. Rudman(147) selected two nursing homes for investigation by first examining pressure sore prevalence in 30 Veteran's Administration (VA) nursing homes. Nursing home "A" had the lowest prevalence and nursing home "B" had the highest prevalence. He proceeded to analyze these two nursing homes for five study periods at six month intervals. Each home was rated on 11 outcome indicators, including prevalence and incidence of pressure sores, aggressive and disruptive behaviors, six-month decline in ADL, and prevalence of underweight. Populations "A" and "B" were similar in terms of age, sex, length of stay, degree of dependency, and level of nursing care. All indicators for the first study period were more favorable in "A" than in "B," and the differences persisted over five study periods from 1988 to 1991. The populations in the two VA nursing homes were similar. However, when facility characteristics were examined,

there were significant differences. The location of the good "A" home was rural; it had 60 beds, and no academic affiliation. The facility with poor outcomes "B", was in an urban community, had 280 beds, and had an academic affiliation. Facility location, size, or affiliation may account for the differences seen. Resident characteristics other than those controlled, or level of family involvement, may have accounted for all of the differences in quality observed in the facilities.(147) Bleismer(148) surveyed staff and residents at two private nursing homes in a Midwestern metropolitan community. Using interviews with 17 quality care indicators (derived from NCCNHR data), she aimed to determine the relationship between importance and frequency of quality indicators. Fifteen residents and 15 staff were randomly selected from two nursing homes. The study group included five registered nurses, five licensed practical nurses, and five nurses’ aides from each facility. Each was asked to estimate the frequency with which the quality indicators occurred in the facility of residence or employment. The study results indicated no relationship between perceived importance and frequency of the 17 indicators of quality. Staff and resident perceptions of quality did not differ in terms of priority of indicators, but they did differ in the observed measures of quality. It is interesting to note that staff and residents noted the importance of indicators similarly, but they differed in reported frequency. Residents in both facilities rated prompt response as a low frequency indicator, whereas staff rated the same indicator high. The indicators used by Bleismer were predetermined and this may have


35


affected the results by implying that measures selected were the most valid indicators of quality. However, both staff and resident perceptions provide insight into quality of care and further validate that quality of care is a multidimensional subjective concept defined by the recipient of care and the caregiver in the context of the care given. Risk Adjusted Quality Indicators The unique characteristics of the vulnerable elderly in nursing homes result in limitations in using resident outcomes as quality indicators. The expected decline in functional ability and overall health status, as well as the expected mortality, affect outcome measures.(140) To address this limitation of outcome measure assessment, quality indicators can be risk-adjusted. Mukamel(66, 149) outlined limitations in early studies of quality by enumerating the types of quality measures used and highlighting risk adjustment as an important factor in accuracy. Deficiency citations and quality measures determined by expert panels have proven incomplete as quality indicators, due to their relatively poor correlation with outcome data. Nursing hours per resident day have been associated with quality, but these are input measures and do not address the personal system of the resident directly. Finally, adverse outcomes have been measured to indicate quality but have proven inadequate due to variance in risk factors and the expected decline. Mukamel suggests a more accurate determination of quality can be using risk-adjusted resident outcomes: "These measures compare the observed outcome rate in a facility with its predicted rate,

controlling for the risk of its residents.”(66, p. 79) This method was used when 525 private and public facilities in New York were examined in 1991 for cost of care and nursing home characteristics. Quality measures were based on resident level data, including information about each resident's demographic and health status, RUG case mix index, medical condition, and treatments. Three risk-adjusted measures were used including decline in functional status, worsening pressure ulcers, and mortality. Mukamel found that higher quality was not necessarily related to higher cost. When examined, the risk-adjusted measures suggested a variance consistent with quality care that substantiated their use as measures of quality of care. Although this study was primarily designed to answer the question of the relationship between cost and quality, progress in establishing riskadjusted resident outcomes to determine quality was made.(149) Four properties important for quality measures were proposed by Mukamel:(66) 1) the measure should be either a desirable or undesirable outcome, 2) the outcome should be affected by health and nursing care, 3) the measure should be based on the outcomes of a sufficiently large population to substantially reduce the influence of factors on performance measurement, and 4) the measure should take into account resident risk factors affecting outcomes that are beyond the control of the providers. Risk-adjusted scores were developed for four health outcomes and five quality indicators from resident level longitudinal case mix reimbursement data for Medicaid residents of more than 500 nursing homes in Massachusetts.(90) Two


36


additional elements thought to be important were: 1) performance should be measured over discrete time periods short enough to be recognized by regulators, and 2) performance measurement should be based on outcomes for all residents of the facilities over the time period during which performance is measured. Despite the addition of these measures to indicate quality by the identified outcomes, there was little variability across the nursing homes studied in the measures chosen by Porell. The author indicated the highly regulatory environment of the state of Massachusetts as a possible cause for this. He also suggested that since the Medicaid population in nursing homes is homogenous in age and risk factors, variations in outcome may be too subtle in relationship to quality care. It is also possible that facility level risk adjustment is not adequate to determine quality indicators and further study is indicated. HCFA contracted with the Center for Health Systems Research and Analysis (CHSRA) to complete the Nursing Home Case Mix and Quality Demonstration Project (NHCMQ) using the Missouri nursing home MDS to identify and analyze quality indicators for 456 nursing homes representing 44,331 Medicaid/Medicare-certified beds in Missouri.(150) The study group began with 27 Quality Indicators and narrowed those to 14 with sufficient variability among facilities to discriminate a range of quality and potential amenability to staff interventions to improve resident status. The fourteen quality indicators analyzed were: injuries, falls, behavior problems, more than nine scheduled medications,

incontinence of bowel/bladder, incontinence of bowel/bladder without toileting plan, indwelling catheter, fecal impaction, weight loss, bedfast state, daily physical restraints, little or no activity, stage 1-4 pressure ulcers, and foot care for diabetic residents. Higher prevalence of a quality indicator indicates lower quality of care; therefore prevalence in the 10th percentile reflects high quality care and prevalence in the 90th percentile represents poorest quality of care. To account partially for the variability in resident populations in facilities, four quality indicators were stratified by risk factors: falls, behavior problems, incontinence, and pressure sores. The initial research indicated the potential value of utilizing state level MDS data to determine quality indicators in nursing homes and validated the variance of the MDSderived quality indicators that was consistent with the variance in quality. Porell's work, utilizing facility level data did not show a consistent variability in these indicators with quality. This may suggest that a large sample size is needed to discern small differences, or as Porell suggested, it may be reflective of the highly regulated environment. It also may suggest that the risk-adjusted quality indicators are valid at the resident-level rather than using aggregate facility-level data. The research group continued its work of validating quality indicators and setting thresholds for the indicators.(12, 151) Using MDS data from 1994 and 1995 in Missouri, nursing homes were identified that performed particularly well and particularly poorly on the 14 quality indicators from the original CHSRA study. A purposive sample of seven homes each from the "good" and the


37


"bad" homes was selected. Ten agreed to participate; five in each category. Three instruments were designed to collect data reflecting quality of care and were administered by trained researchers. Frequency and severity of survey citations were also considered. Descriptive analyses of the results revealed a strong association between the MDS quality indicator scores, the data gathered using the instruments

designed by the research group, and the mean number of survey citations for each group. Authors noted that these 14 quality indicators offer enough variation to discriminate good quality from poor quality homes (Table 6) and concluded that quality indicators derived from the MDS can serve as a reasonable first step in determining what level of quality exists in a facility.

Table 6. Quality Indicators Derived from the Minimum Data Set(151) QUALITY INDICATORS Prevalence of any injury Prevalence of problem behavior toward others Prevalence of bladder or bowel incontinence Prevalence of bowel or bladder incontinence without a toileting plan Prevalence weight loss Prevalence of bedfast residents Prevalence of daily physical restraints

Although specific assessment data are helpful in determining quality, it is not only the presence of particular phenomena that indicate quality, but context. Pressure sore prevalence is helpful information, but can be deceiving, especially when residents are admitted from the hospital with pressure sores. Pertinent information about pressure sores, related to quality concerns, is prevalence of those sores that develop in the nursing home in low risk residents. Measures of quality which focus on resident-centered quality indicators, such as the 14 in Table 6,(151, 152) are likely to be the most valid. The common language established by the MDS is a valuable mechanism from which to form quality indicators. Wunderlich and colleagues, in the IOM report on quality of care in nursing homes state,

Prevalence of falls Use of nine or more scheduled medications Prevalence of indwelling catheters Prevalence of fecal impaction Prevalence of little or no activity Prevalence of stage I-IV pressure ulcers Insulin dependent diabetic with no foot care

All (recommendations to improve quality) are designed to further HCFA's goal of using the MDS, in both aggregate and individual level format to bolster and systematize the quality monitoring process. HCFA's vision of this process is that the MDS data constitute the basis for directing survey and certification activities, setting payment levels, and developing information about the quality of long-term care providers to consumers and purchasers.(13, p. 120) The quality indicators identified by The Center for Health Systems Research and Analysis (CHRSA) as well as others were further tested in summer 2002 by a CMS study reported by Berg et al.(153) From 143 indicators, 22 were recommended for use in comparing performance across facilities. A pilot study including 45 facilities in one state


38


was conducted with subsequent validation of 12 indicators or measures. Five measures pertain to chronic care residents and seven are appropriate for residents with higher care needs (i.e., post-acute care). The focus of the CMS initiative is to identify quality measures (QMs) appropriate to compare facilities. Further, their goal is to publish these outcomes to assist consumers in making informed choices.(154, 155) The publication of the validated quality measures is available for every facility in the United States eligible for the Medicare and Medicaid programs on the Nursing Home Compare website at http://www.medicare.gov/NHCompare/h ome. Providing outcomes information to facilities can improve quality,(156) however, the effort to inform consumers about measures of nursing home quality is a relatively new phenomenon. Although there is little disagreement about the importance of affording consumers the information necessary for informed decisions, the accuracy and clarity of the information is important. A report by the U.S. General Accounting Office(103) suggested the publication of indicators was premature. Harrington(56) outlined six components necessary for accurate and usable consumer web sites: 1) facility characteristics; 2) resident characteristics and case mix; 3) staffing indicators; 4) QMs; 5) deficiencies , complaints, and enforcement actions; and 6) financial indicators (daily charge, bankruptcy, net operating income, expenditures). Five of the six components are partially available on line to consumers but accuracy is questionable, especially the QMs. Financial indicators, the sixth component are not currently available or accessible and would be helpful to

consumers in their decisions related to quality of care. CMS has begun a more extensive nationwide testing of the identified QMs in over 200 facilities.(154, 155) However, those published on the web may be causing confusion rather than informed decision making. Although facilitating consumers’ informed choice would positively impact quality of care, the current information available is not yet complete or accurate enough to inform this choice.

Summary Poor quality of care in nursing homes has been a recurring issue in the US since nursing homes were established. Substandard quality of care in nursing homes was brought to light by the 1986 IOM report.(9) The OBRA regulations established in 1987 provided specific guidelines that were designed to improve quality. Implementation of standards was delegated to states. Confirmation that Federal standards have been met is required for Medicare and/or Medicaid reimbursement in each state. Availability of qualified nursing staff is an identified component of quality yet has not been explicitly defined in the standards nor uniformly interpreted by states. The RAI and its use to predict resident outcomes is helpful in defining attributes of quality care. Quality of care in nursing homes is a multidimensional concept that is best defined in the context of individual residents and their needs. Quality includes aspects of quality of life, positive resident outcomes adjusted for risk, and health care policies that are designed to promote quality of care. The evidence reviewed has been organized for this final analysis and


39


synthesis utilizing both Donabedian’s and King’s frameworks and the recurrent themes which emerged from the literature review. Both frameworks emphasize the importance of the interaction within and between systems to promote quality. Therefore it is important to examine each system and its components. Each concept in tables 8,

9, and 10 representing the social, interpersonal, and personal systems is linked to practice implications. The literature supporting the concept is coded using the criteria in Table 7 for both the source and the strength of the knowledge base from which it is derived.


40


Table 7. Source and Strength of Knowledge Coding Matrix ________________________________________________________________________ Knowledge Source Coding Matrix R RU QI M SR RV PP G L PGR PFR X GI U

= = = = = = = = = = = = = =

CP

=

Published research Published research utilization report Published quality improvement report Published meta-analysis Published systematic or integrative review Published review of the literature Policies, procedures, protocols Published guidelines Legislation Published government report Published funded report Practice exemplars General or background information Unpublished research, reviews, poster presentations or other such materials Conference proceedings, abstracts, presentations

Strength of Knowledge Matrix A = Supported by one or more clinical trials B = Supported by 1 clinical trial or 2 or more methodologically sound studies C = Supported by 1 methodologically sound study D = Supported by rigorous quality improvement study E = Supported by research utilization or clinical adoptions report using structured evaluation F = Supported by expert opinion SC = Supported by strong consensus

Clinical Implications and Analysis: Structure/Social System The components of quality seen in the social systems are represented in federal, state, and facility policies designed to promote quality. Examples are certification and regulations. Innovative strategies such as the teaching nursing

homes, and community college partnerships also address structural components. Finally, size of facility, ownership (profit/not for profit), competition and cost can be conceptualized as structural components within the social system. The evidence to support the practice implications of the social system is outlined in Table 8.


41


Table 8. Key Implications for Nursing Practice/Structural Components/Social System IMPLICATIONS FOR PRACTICE

Knowledge Source

Strength of Knowledge

ISSUES OF CLINICAL SIGNIFICANCE

Federal Policy

QI(38) PGR(41, 103) R(40)

C, E, F C, E, F C

Standards adequate but inconsistently enforced

State Policy

R(63, 157) PGR(41, 103)

F, C C, E, F

The inconsistent implementation is at the state level

R(46, 47, 55, 60, 61) GI(49, 50)

B

Reimbursement strategies to promote quality may also be used to promote profit

R(47)

C

R(58, 64, 65, 67, 158)

B

Quality of care is lower in proprietary facilities

Facility Size

R(69)

C

Optimum size for economic efficiency is 170 beds

Cost of care

R(66, 70, 71)

B

Quality and cost do not have a direct linear relationship

Administrator turnover

R(81)

C

Rapid turnover of administrators in nursing homes are related to poor quality

Teaching Nursing homes

R,(72, 76) RU(75) GI(73, 74)

E, B, F

Professional nurse consultants

R,(82) GI(83, 84)

A, D, E

Collaborative interdisciplinary networks

R, (78) PFR(77, 78)

C, E

Funding: Case Mix

Insurance

Facility Ownership

Facility Organization:

Attempts to improve quality within the social system are often federal or state policies that guide payment for care or regulate care.

Improvements demonstrated by research related to organization using a variety of models generally not deemed cost effective

Medicare reimbursement and regulatory policies designed to assure standards are met are extensively studied at the federal level.


42


The variability of implementation and quality from state to state raises the question of how well states adhere to federal standards. The stringent standards are inconsistently enforced at the state level, even though nursing homes are assumed to be highly regulated organizations. Standards are often perceived by staff as requiring unreasonable amounts of time and effort to comply and enforce, yet have been shown to be inadequate to assure quality. There is evidence that for-profit facilities provide poorer quality care; yet, the majority of facilities in the US are proprietary.(20) Many believe that when profit is the overriding motivation, standards of quality become secondary.(57, 88) The incentive to meet standards may be to obtain Medicare or Medicaid reimbursement and subsequently profit the organization, rather than to ensure quality. When there are no monetary penalties given for deficiencies, there is no incentive to meet standards -- especially if a monetary component is involved in conformance to the standards. Currently, there is imperfect information available to the nursing home consumer related to proprietary or non-profit status of a nursing home and quality. The CMS initiative sponsoring Nursing Home Compare web site is designed to remedy this problem.(56) Mezey(76) reported that teaching nursing homes showed consistent improvement in quality measures, including cost savings at the system level (such as decreased hospital days). However, the increase in cost associated with hiring a GNP may not be deemed cost effective, since quality of care measures affected by a GNP include items that are not specific to the facility cost center. Nursing home administrators or owners may not see improved quality as a goal unless it also decreases cost. Ullman(71) documented a cost threshold, indicating there is a minimum level of cost necessary for quality beyond

which cost does not improve, but actually may decrease quality. Since 68% of US nursing homes are proprietary, an emphasis on the profitability of high quality care or a uniformly enforced monetary disincentive for low quality care may positively impact resident outcomes. The trade group representing proprietary nursing homes, the American Health Care Association (AHCA) has been an active lobbyist for increased Federal and state reimbursement for nursing home care. However, increased reimbursement has not always resulted in increased quality.(57, 58) Federal standards are set uniformly to qualify for Medicare or Medicaid reimbursement and are implemented and enforced at the state level, which begs the question: What aspects of state regulatory and redistributive policies promote quality? Variability of implementation and enforcement at the state level provides opportunity to determine which components of policy promote quality.(63) Navarro(159) described physician dominance of the health care system and the use of the medical model. Two IOM reports(9, 160) on nursing home quality illustrate the dominance of the medical model on quality measures in nursing homes. The definition of quality of care in the profession of nursing includes more individual and personal care; whereas, medicine is more likely to define quality in technical and biological terms. Conceptual and methodological definitions are best determined within the profession that is providing the service to the resident.(161) Nursing has achieved autonomous care standards and educational standards of quality. Nursing standards emphasize functional status of the resident and maintenance of health as central to nursing quality of care. Quality is also defined in terms of the individual resident's perception


43


of needs, as well as family and community identified needs. Although nursing has independent standards, it is also held to standards developed by other professions. The certification standards for Medicare and Medicaid reimbursement are influenced by the dominance of the profession of medicine in health care. This may affect the ability to improve quality due to incongruence of values and beliefs of one discipline (i.e., medicine) imposed on another (i.e., nursing). Since much of the care in nursing homes is provided by nurses or nurses aides under the director of nursing, it makes sense to consider a nursing framework when determining quality indicators.

However, there is inconsistency in adherence to standards at the state level. The organizational and environmental components found to positively impact quality in the research literature do not necessarily translate into policy at the Federal, state, or local level. For example, increased reimbursement does not necessarily lead to increased quality of care; it may increase profit instead.(57) Further, explorations of state-level policies that support quality are necessary to examine this inconsistency.

The final question concerning components of quality in the social system is related to the most appropriate reimbursement strategies based on resident needs. Case mix reimbursement using RUG criteria has become a policy designed to ensure that care is reimbursed according to the acuity of the residents who are receiving services. There are indications that some proprietary facilities may seek to admit higher need residents in order to increase their reimbursement and profits. Poor quality of care could result if increased reimbursement is used to reward shareholders rather than to better the needs of high need residents.

Nurse staffing patterns, interventions, and comprehensive assessment are key components of the interpersonal system in quality of care in nursing homes (Table 9). Rantz(162) and Won(127) suggested comprehensive assessment as a model to be used in the pursuit of excellence. The minimum levels of nursing staff to promote quality has been documented in at least ten studies.(69, 87, 90, 163) Two studies indicated that improvement realized in quality did not justify the cost of increase in staff.(69, 90) Moseley(163) found no relationship in Nevada between deficiencies and RN staffing in Nevada nursing homes. The remainder of the studies on nurse staffing supported increasing staffing levels, especially RNs, as well as higher educational levels for professional staff.(69, 79, 86, 88-93, 95, 98, 103, 148) There is only one study, however, on the wages and benefits of nursing home nurses. Less highly technical care and more interaction with residents coupled with expected decline of the residents, contribute to the current status of nursing home nurses.(87)

The social system includes an environmental and organizational structure that may or may not support quality of care and standards of excellence. Regulatory, distributive, and redistributive policies likely to support quality include 1) reimbursement focused on resident need and 2) penalties for deficiencies in meeting the standards. Some policy analysis suggests the current regulations are adequate yet quality of care problems persist.

Clinical Implications and Analysis: Process/Interpersonal Systems


44


Table 9. Key Implications for Nursing Practice/Process/Interpersonal system IMPLICATIONS FOR PRACTICE

Source

Strength of Knowledge


Nurses as managers

R(79, 93)

C

CNAs

R(94, 104)

C

Educational level

R(106)

C

Improved quality with higher nurse interaction CNAs give most of care, and attitudes are important Higher educational level in England improved care

R,(33, 58, 86, 88, 91,

A, D, E, F

Positive relationship between RN staffing and quality using a variety of research techniques and quality measures

R,(69, 90, 98) PGR,(103) GI(97)

A, E, F, SC

Positive relationship between licensed staffing and quality

R,(111, 117, 118,

A, F, SC

Rationale for development of tool and extensive testing establishes reliability and validity except with cognitive deficits

R,(122, 128, 130) PGR(112)

E, F, A

Improved quality seen; decreased indwelling urinary catheters, decreased use of restraint, decreased use of psychotropic meds

Process measures (shortness of breath, fever, CP)

R(134)

C

Individual interventions improve quality especially when coupled with comprehensive assessment

Psychotropic medication, falls

R(132)

C

Foley use

R(135)

A

Restraint use

R(122, 129, 131, 133)

A, D

Incontinence

R(136)

D

Availability of Qualified Nurses

RN ratios

92, 95, 99, 107, 163)

GI(89, 102)

Licensed staff ratios

Comprehensive Assessment Development and testing of MDS/RAI

120, 121, 123, 125)

GI(109, 110, 116)

Improved quality with comprehensive assessment

Interventions


45


How can the value of the care nurses provide be established? In proprietary facilities, increased professional staff does not lead to higher profits even though increased nursing staff is likely to increase quality. Higher staffing levels have been linked to quality in relation to discharge, death, readmission to the hospital, and resident functional ability. However, each of these measures of quality does not necessarily lead to decreased cost to the facility. In fact, they may actually increase costs. For example, residents discharged home no longer pay for their nursing home bed, and residents who have improving functional levels generate less reimbursement using case mix (acuity) formulas for funding. Therefore, monetary incentives (in the form of profits) to improve professional staffing levels are not supportive of a change. Given the information from teaching nursing homes and Kane's work(107) related to the impact of GNP practice on quality in the nursing homes, there is evidence to support a standard of employment of one GNP full time per nursing home facility. However, the resultant cost required for a GNP full time in each facility in addition to the minimum standards as described by Harrington(89) is considered prohibitive by nursing home organizations. The Wellspring Project has implemented and evaluated a quality improvement project including both increased staffing and GNP care.(78) The evaluation of the project indicates no net increase in costs overall because of a decrease in hospital admissions and improved patient functional status. An increase in state-level Medicaid reimbursement for facilities employing a GNP may be in order, and probably would not be a significant increase in overall cost of care due to the system wide savings realized. Case mix reimbursement strategies

in many states has focused on assuring that funding supports the neediest residents, but regulations must be enforced to assure quality is improved rather than simply having profits increased. A key process component of the interpersonal system is comprehensive assessment. The comprehensive assessment was designed as a quality assurance mechanism incorporating individualized risk factor assessment and care planning. Strategies are in place to improve the process of providing care in nursing homes in the form of comprehensive assessment, the RAI. However, the assessment tool is also used as a measure to determine enforcement of standards and reimbursement of services. Implementation of the RAI has resulted in improved quality of care as measured by fewer pressure sores, a decrease in catheter use, and a decrease in use of psychotropic medications. The accurate documentation of assessment data in the form of the MDS may be seen by some proprietary facilities purely as a tool to ensure reimbursement, meet standards, and pass state surveys. The additional cost of implementing quality assurance strategies based on assessment of risk may not be seen as cost effective or beneficial. Although RAPs are required when triggered by the MDS data, the implementation of the RAPs is less clearly mandated. The transaction of nursing care would be more effective using the RAI if there were clear incentives to ensure implementation of the entire process. These incentives would require the presence of qualified nursing staff. However, readily available qualified nurses could mean a potential increase in cost to the facility. To ensure conformance to the standards, monetary penalties or incentives affecting profitability of the facility could be uniformly applied.


46


The interpersonal system aspect of quality care in nursing homes incorporates excellence in the model of comprehensive assessment used for continuous quality improvement. The indicators incorporate technical as well as interactive measures of nursing. Although Donabedian provides a framework for considering the technical aspects of nursing care, interactive measures are incorporated into his model of process measures to a lesser extent. The effective system requires an organization to support nurse-resident interactions and transactions. Nurses improve quality of care not only through technical interventions but through ongoing assessment of patient care needs. The nurse improves interactions as an individual, through nurse leadership, and interaction with nonprofessional staff and families. Without availability of qualified nursing staff the processes of nursing interventions and comprehensive assessment are less likely to support quality. Clinical Implications and Analysis: Outcomes/Personal Systems The resident and their family are the focus of the personal system in this literature review. Rantz(34) described the family as central to quality. Family involvement

recurs as central to the personal system of the resident.(24, 28, 38) Since quality is contextual and subjective, it depends not only on the individual, but when and where the individual is, and how he or she is feeling. All of these outcome components of quality in the personal system relate to residents and their families. Excellence is a concept shared in all systems and is represented by models of excellence described by Rantz(150) and Bleismer(148) who added an additional dimension to excellence by introducing the residentcentral focus. Quality indicators were discussed as extensions of the comprehensive assessment. The personal system quality indicators are residentdefined and reflect resident-centered needs. The evidence to support clinical implications in the personal system are outlined in Table 10. Quality indicators that are process-oriented, such as bowel and bladder programs, are also components of the interpersonal system. Personal system quality indicators are resident-centered criteria such as the risk-adjusted incidence of skin problems. Resident-oriented aspects of quality indicators have been helpful in assuring that quality is not defined by the provider for the resident, but is actually focused on resident care needs.


47


Table 10. Key Implications for Nursing practice/Outcomes/Personal System IMPLICATIONS FOR PRACTICE

Knowledge Source

Strength of Knowledge Base


Resident Outcomes Functional ability, discharge to home, death

R(148)

A

Mortality, discharge, death

R(142)

A

Functional status, discharge, death, pressure sores, rehospitalization are common outcome measures used to define quality of care

Outcomes to facilities to promote quality

R,(156) GI,(140)

E, F

Pressure sores

R,(146, 147) PP(145)

A, F

Measures of quality

R,(35, 90, 138, 151155) GI,(12) PGR,(13) PFR(30)

A, E, F, SC

Quality indicators have been developed from MDS data points through extensive study

R(66, 149)

C

Quality indicators need to be risk adjusted

GI(139)

F

Quality of life may be partially measured by MDS data points

R,(88) GI(164)

F

Although the research data is very strong validating the quality measures, many experts question the validity of these measures

Bias in reporting is a problem in any documentation system. The calculation of acuity scores from the same data set used for quality measures introduces the risk of professionals’ documentation reflecting higher acuity than the resident warrants in order to increase reimbursement. The use of quality indicators for public reporting and regulatory compliance also may trigger less documentation. A facility could receive a positive score on pressure sores and pain management simply by purposely not asking about pain or looking for pressure sores. The incentive of current documentation systems may be to look good on paper for reimbursement and regulatory purposes,

rather than to reflect true patient care needs and outcomes. Reliable measures of quality of life have received recent focus, which assures their place in quality of care. A promising measure for quality of life in the nursing home environment is the potential utilization of clusters of MDS data points. Factors such as decline in activities or distressed mood, when examined together, may give indication of residents’ quality of life. The measures and conceptual definitions of resident outcomes that indicate quality are variable. Mortality and morbidity are not


48


valid measures of quality in nursing homes. Functional ability as reflected in ADLs is more accurate, but must incorporate the concept of expected decline and risk adjustment. The language of medicine, such as medical diagnoses, is not adequate to link nursing measures to outcomes. The language in the MDS is used universally in the nursing home to describe resident assessment and links nursing measures to outcomes. The RAI was designed to link assessment with care planning and risk. Assessment points in the MDS are potentially useful for research. Research is less adequate in the personal system, despite recurrent themes indicating the importance of resident-focused care. The question remains, what aspects of the personal system are most supportive to quality and how are they measured? The MDS data provide a mechanism to measure quality that may begin to answer this question IN CONCLUSION This synthesis of evidence about quality of care in nursing homes found support for using multicomponent measures of quality of care. Much progress has been made in actual use of reliable and valid comprehensive assessments in nursing homes (e.g., RAI) to evaluate presence of quality measures. However, evidence shows that assessments are often made to meet external standards and regulations, and thus, do not always drive care delivery. Nurses working in nursing homes need to work to further the clinical use of comprehensive assessments to enhance care and thus, improve quality for residents. Evidence shows that the highest level of professional staff possible in a nursing home will enhance care quality. Donabedian's model of structure, process, and outcome is widely understood and was

beneficial for organizing the medical literature, but less helpful with nursing care discussions. King’s open systems framework was used to more appropriately represent the nursing aspects of care in the interpersonal and personal systems. Quality is a judgment of value or goodness, which is achieved by exceeding indicators that are based on national standards. Quality is dependent on dynamic interaction of the following components of an open system: 1) structure that promotes quality in the social system; funding level, adherence to state and federal standards, physical environment and administrative organization of the nursing home; 2) process that promotes quality in the interpersonal system; numbers of professional nursing staff, and process of care delivery and; 3) outcomes that indicate quality in the personal system; quality of life, family involvement, and quality measures. The interrelationship of concepts was validated with an open system perspective, as each concept was shown to be related to quality in the literature review and analysis. The validity of literature was assured through a comprehensive review of the articles and critical analysis of the research. An open systems perspective of quality offers structured implications for nurse researchers, clinicians, administrators, and policy makers to improve quality of care in nursing homes. The identified components in the open system also offer rich opportunities for research. State policy, facility culture, implementation of the resident assessment instrument, and quality measures are examples of areas that need further research in order to improve the understanding of the impact of these components on quality of care. Federal regulations are delegated to the states and there is significant variation between states in Medicaid spending, resident outcome


49


measures of quality, and state survey results. Therefore, it is important to improve our understanding of state policies most supportive of quality. Facility culture is a second area that needs research. Some aspects of facility culture reviewed in this paper were; nursing and administrative staff mix and availability, family involvement, and optimum size of facility. More research is needed to improve our understanding of the facility culture that is most supportive of providing quality care. Nursing research is needed to understand how the Resident Assessment Instrument (RAI) can be used to improve quality, as it was intended. The Geriatric Minimum Data Set (MDS), as a part of the RAI, was designed for quality assurance and is now used for reimbursement and regulatory compliance. Finally, nurse researchers should participate in the CMS initiative to determine appropriate quality measures used in the Nursing Home Compare website. The quest for quality using resident outcomes must be based on a foundation of the most appropriate outcomes. Mortality has never been an appropriate outcome measure for nursing home care. State survey deficiencies also have not proven appropriate as outcomes due to the regulatory compliance variability across states. Guidelines for nurse clinicians and administrators can also be derived from the review and analysis of the literature surrounding quality of care in nursing homes. There continues to be controversy concerning the implications of research findings about the impact of professional nurse staffing on quality of care. However, there is little disagreement that RN staffing is an area to consider when organizing nursing home care. Professional nurses seem to have the most impact when assessing

residents, supervising care, or managing care. Further implications of the open system to nurse clinicians are related to policy. Despite the regulatory environment created by federal and state policy and reimbursement, the nurse clinician and administrator should focus purposely on resident and family centered outcomes to assure resident needs are met. Because of the current imbalance of the open system, there is a tendency to focus on facility profit goals or government regulations rather than resident care quality. Although nursing home nurses must be politically active, there are specific implications for nurse policy makers. The current policy of CMS to inform consumers has merit, but will need nurses advocating for policy to ensure that quality measures are appropriately interpreted and provide accurate information to the consumers and providers of care. Nurse policy makers should extend their advocacy role to explore the aspect of decreased quality of care in for-profit facilities. There currently is an incentive to increase reimbursement to increase profit, rather than improve quality. Nurse policy makers must continue to ask why some nursing homes continue to make profits, yet provide substandard care. Finally, this review indicates that nurse policy makers should advocate for a mandatory increase in professional nurse staffing. Further exploration of minimum standards is needed due to variability across facilities in acuity, size, and geographic location. The goal of this manuscript was to synthesize the literature about quality of care in nursing homes and to highlight and discuss implications for nursing practice. Specific guidelines for nursing home


50


practice are outlined. The projected increase in need for care of the vulnerable elderly in nursing homes demands the nursing profession develop a plan to assure quality of care. This literature analysis provides structured implications for nurse

researchers, clinicians, administrators, and policy makers for improving quality of care in nursing homes, and suggests a plan for the nursing profession to proceed toward this end.

With appreciation to the following subject matter expert peer reviewer for her significant substantive contributions to this manuscript: Maryalice Jordan-Marsh, R.N, Ph.D., FAAN Associate Professor Chair, Health Concentration Nurse Social Work Practitioner Option School of Social Work University of Southern California Los Angeles, California

Marilyn J. Rantz, RN, PhD, FAAN Professor School of Nursing University of Missouri – Columbia Columbia, Missouri


51


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