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OCR for page 45
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Concepts of Quality, Quality
Assessment, and Quality
Assurance
This chapter discusses three basic concepts: (1) what
is meant by quality of care and quality of life in nursing
homes; (2) what is known about the techniques available
for quality assessment--that is, for determining how good
the quality of care and quality of life are in a nursing
home; and (3) how these concepts should affect the design
of a regulatory system that would effectively ensure that
nursing homes provide care of acceptable quality.
The discussions in the chapters that follow presume
understanding of these concepts.
QUALITY OF CARE IN NURSING HOMES
The attributes of quality In nursing homes are very
different from those in acute medical care settings such
as hospitals. The differences stem from the ~character-
istics of the residents of nursing homes, their care
needs, the circumstances and settings in which the care is
provided, the expected outcomes, and the fact that for
many residents the nursing home is their home, not
merely a temporary abode in which they are being treated
for a medical problem. Thus, quality of life is very
45
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46 / NURSING HOME CARE
important for its own sake (that is, as an outcome goal)
and because it is intimately related to quality of care in
nursing homes.
Characteristics of the Residents
According to the 1977 National Nursing Home
Survey, 70 percent of nursing home residents were
75 years of age or older, about 70 percent were women,
only 12 percent had a living spouse, and they had a wide
range of physical, emotional, and cognitive disabilities.
Nursing home residents differ in their social circum-
stances compared with noninstitutionalized persons of the
same age group. Thirteen percent of residents had no
visitors in the course of a year, but about 62 percent had
visits from family or others on a daily or weekly basis.
Nursing home residents are disproportionately single,
widowed, and childless, and they are poorer than the
elderly population in general.2 These data are
important because of the links that have been shown to
exist between social support and health service needs and
outcomes.3~7
Residents fall into two broad categories classified by
length of stay. The largest group, the "long stayers,"
consists of those who are no longer able to live outside
of institutions and who generally reside in the nursing
home for many months or years, often until they die. The
second group, the "short stayers," generally comes from
hospitals and will be discharged home or will die in a
fairly short period of time.8
Care Needs
Nursing home residents vary in the amount and types of
care they require as well as in their lengths of stay.
Many of the "short stayers" require intensive nursing and
rehabilitative services. For these, the goal of nursing
home care is rehabilitation and discharge home. Some are
rehabilitated and discharged; some die either in the
nursing home or shortly after discharge. The "long
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CONCEPTS OF QUALITY / 47
stayers" present a spectrum of care requirements, ranging
from those who are relatively independent and require only
modest amounts of care to those who are physically very
disablers mentally impaired and incontinent and who
~ ., , ;,
require assistance in all activities or daily 1lvlng
(ADL). In a special study commissioned by the committee,
longitudinal data derived from monthly assessments of all
residents in 107 nursing homes in 11 states and the
District of Columbia were analyzed.9 In these
nursing homes, about 63 percent of new residents either
died or were discharged within 3 months of admission.
That is, a substantial proportion of persons admitted to
the nursing homes stayed for a relatively short period of
time. But those who remain in the homes for long stays
account for most of the resident bed-days. About 70
percent of all residents in bed on a particular day in all
of these nursing homes were still alive and in the same
nursing home 18 months later. On the basis of standard
assessments of all residents and a standard way of
estimating nursing time required per day, the residents on
any day in this set of nursing homes fell into three broad
categories: 10.8 percent required little care (40 to 60
minutes per day); 48.9 percent required "medium" care (61
to 134 minutes per day) and 40.3 percent required "heavy"
care (135 to 268 minutes per day).
The Care Setting
Nursing home care is both a treatment and a living
situation. It encompasses both the health care and social
support services provided to individuals with chronic
conditions or disabilities and the environment in which
they live.9 Nursing homes are "total institutions"
in which care-givers, particularly nurse's aides, repre-
sent a large part of the social world of nursing home
residents and control their daily schedules and
activities.~° This is the total environment for
many nursing home residents for the duration of their
stay, which may be several years. As a result, defi-
ciencies in medical or nursing care or in housekeeping
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48 / NURSING HOME CARE
or dietary services, which could perhaps be tolerated
during a brief hospital stay, become intolerable and
harmful to well-being when they are part of an indi-
vidual's day-to-day life over a longer period.
The physical, psychosocial, and environmental
circumstances and outcome expectations of nursing home
residents distinguish the goals of nursing home care from
those of acute medical care. In acute care, treatment
goals are based on medical diagnosis. In nursing homes,
the care goals are based on physical and psychosocial
assessment. They focus on restoration, maintenance or
slowing of the loss of function, and on alleviation of
discomfort and pain.
Requirements for High-Quality Care
The characteristics of nursing home residents, their
care needs, and the care setting underlie the three
central requirements for providing high-quality nursing
home care: (1) a competently conducted, comprehensive
assessment of each resident; (2) development of a
treatment plan that integrates the contributions of all
the relevant nursing home staff, based on the assessment
findings; and (3) properly coordinated, competent, and
conscientious execution of all aspects of the treatment
plan. The assessments should be repeated periodically and
the treatment plan adjusted accordingly.
Most nursing home residents suffer from various medical
problems, and accurate, careful medical diagnosis and
problem identification are very important. But a major
determinant of care goals in nursing homes is functional
status, that is, the ability of the individual to perform
the activities of daily living (bathing, dressing,
toileting, transfer, feeding, and continence.
Functional status is a sociobiologic construct that can
be used to indicate the existence of chronic conditions
and to objectively measure their severity. It also can be
used to determine service needs and outcomes resulting
from service use among homogenous groups of patients. For
example, the Index of Activities of Daily Living, or its
variants, has been used to study chronically ill
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CONCEPTS OF QUALITY / 49
people, including those with hip fracture, cerebral
infarction, multiple sclerosis, paraplegia, quadriplegic,
rheumatoid arthritis, and other chronic conditions among
institutionalized and noninstitutionalized people.~3~~9
The importance of functional status in predicting
outcomes is also suggested by studies that were designed
to measure the relationship between process and outcome
measures of quality care. Those studies found residents'
initial functional status to be the best predictor of
health care outcomes.20~22
Mental status also predicts disability levels and
service needs among nursing home residents.23~25 An
estimated 50 to 66 percent of nursing home residents have
some type of mental or behavioral problem. A
substantial amount is attributable to senile dementia of
various types, but depression and psychosis also are
prevalent. In part, this is attributable to the massive
discharges of patients from state mental hospitals during
the 1970s. During that period, the number of elderly
persons in mental hospitals decreased by about 40 percent,
while the mentally ill in nursing homes increased by over
100 percent.27
Although the elderly suffer from disorders that affect
younger persons (for example, neuroses, alcoholism,
schizophrenia), the two most frequent diagnoses among
those in nursing homes are depression and intellectual
impairment (organic brain syndrome, confusional states,
dementia, and so on).28 Contrary to the beliefs of
many health professionals, age per se is no bar to
effective psychiatric treatment. This is particularly
true for depression.29
Planning and Providing Care
The initial comprehensive assessment of a resident
should include the resident's functional status, medical
and dental conditions and needs, mental and emotional
status, social interactions and support, personal activity
preferences, and financial circumstances. This entails a
team effort involving, at a minimum, a nurse, a physician,
a social worker, and a physical therapist. The knowledge
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and specialized skills of other profess
,ionals, such as
dentists, psychologists, audiologists, speech therapists,
occupational therapists, and podiatrists, should be drawn
on as needed. Assessments must be recorded in such a way
in the resident's medical records that they can be
understood and used by all staff responsible for providing
care--including nurse's aides.
The plan of care developed to meet the resident's needs
requires participation by all professional staff in the
nursing home because there is almost no aspect of care
that is the exclusive domain of one professional group or
another. Physicians need to know from nursing staff the
effectiveness of efforts to deal with depressed patients
and whether drugs should be adjusted in dosage or the
regimen altered; nurse's aides need to be instructed on
specific rehabilitation efforts--such as range-of-motion
exercises--that should be incorporated as part of the ADL
support provided to residents; staff in the recreation
department need to know that a close watch is being kept
on certain residents for the side effects of drugs.
Clear, easily understood records are essential to carry
out such coordinated care because there is seldom time for
meetings to share all of the necessary information.
Moreover, staff on duty evenings and weekends have to rely
on records to make critical decisions.
In sum, long-term care is directed primarily at
relieving conditions that result from chronic physical or
mental disorders or the chronic after-effects of acute
disorders. Equally important is relief of pain and
discomfort. Assessing functional competence or impairment
gives direct information about these conditions, which is
needed for care planning.
Chronic conditions generally require restorative or
maintenance services with an emphasis on attaining small
improvements or preventing undue decline, rather than the
intensive efforts of acute medicine that usually aim for
cures, remissions, or other substantial improvements.
Many residents in nursing homes will remain there for
long periods, often until death. Their well-being is
affected by the environment, by the quality of the
medical/nursing and social support services they receive,
and by the nature of their health problems.
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CONCEPTS OF QUALIFY / 51
QUALITY OF LIFE
The quality of life experienced by anyone is related to
that person's sense of well-being, level of satisfaction
with life, and feeling of self-worth and self-
esteem.30~3t For nursing home residents this in-
cludes a basic sense of satisfaction with oneself, the
environment, the care received, the accomplishment of
desired goals, and control over one's life.3 For
instance, a resident's quality of life is enhanced by
close relationships and meaningful interchange with
others, an environment supporting independence and
incorporating personal belongings, and the opportunity to
exercise reasonable control over life decisions.
Opportunities for choice are necessarily somewhat limited
in a nursing home, but they need not be as limited as they
are in some nursing homes.33 Participation in care
planning is one important aspect of personal autonomy.
But even such seemingly small choices as mealtimes,
activities, clothing, or times to rise and retire greatly
enhance the sense of personal control that leads to a
sense of well-being. Lack of privacy for visits with
family and friends, for medical treatment, and for
personal solitude contributes to lack of self-esteem.
Opportunities to engage in religious, political, civic,
v ~
recreational, or other social activities foster a sense of
worth. The quality and variety of food are often cited as
some of the most important attributes of quality from the
resident's perspective.3~34 Quality of life also
includes such life circumstances as personal assets,
financial security, physical and mental health, personal
safety, and security of one's possessions.35~37
Many aspects of nursing home life that affect a
resident's perceptions of quality of life--and therefore'
sense of well-being--are intimately intertwined with
quality of care.
This is evident in the findings of a
study conducted during 1984-1985 by the National Citizens'
Coalition for Nursing Home Reform.34 The study was
designed to obtain nursing home residents' views on
quality of care. Its findings are based on a series of
discussions held in 15 cities involving 455 residents from
more than a hundred nursing homes. The sample of
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residents was drawn from a group who volunteered to be in
the study, who were able to attend three meetings outside
of their own facility, and who were able to participate
actively in group discussions.
The highest importance was attached by residents to the
qualifications, competence, attitudes, and feelings of
staff, and the quality of the interactions among staff and
residents. This follows from the circumstance that 80 to
90 percent of the care is provided by nurse's aides and
the quality of their interactions with the residents--how
helpful, how friendly, how competent, how cheerful they
are and how much they treat each resident as a person
worthy of dignity and respect--makes a big difference in
the quality of a resident's life.
Success in improving function and greater independence
are associated with enhanced sense of well-being.~38
A number of writers have stated that, because the major
concern of quality of care is with improving or
maintaining function, care should routinely incorporate
rehabilitation exercises. This means reliance on nurse's
aides to see that these exercises are done as prescribed.
There are indications that some functional impairments in
the elderly may be the result of inactivity and disuse and
that even very elderly residents respond to rehabilitation
exercises.
Conflicts of values and ethics are inherent in nursing
home care--for example, conflicts between care
requirements, as judged by professionals, and the rights
and preferences of the resident. Should a very old,
perhaps mildly demented resident, who is not legally
incompetent and who declines to eat, be fed by naso-
gastric tube even if he strongly objects to it? What
about residents who decline to take medication or other
treatments prescribed to manage their chronic disease?
Should dietary preferences of a resident override
adherence to a medically prescribed dietary regimen?
Should a frail, unsteady resident with osteoporosis, who
insists on walking by herself, be permitted to walk around
unescorted even though there is a substantial risk that
she will fall and suffer a hip fracture?
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CONCEPTS OF QUALITY / 53
The quality of medical and nursing care provided, the
way it is provided, the quality of the interaction between
staff and residents, the range of services and amenities
available to residents and their ability to make personal
choices and to influence the range of choices, and the
facility's ambiance--all affect residents' functional,
physical, and mental health status (objective well-being)
and subjective well-being. Subjective well-being includes
such factors as the extent of depression-demoralization,
satisfaction-dissatisfaction, absence of discomfort-pain.
For the very sick and disabled, the quality of the care
and the way it is provided are probably the most
significant contributors to well-being.
QUALITY ASSESSMENT CRITERIA
The widely accepted criteria used in assessing medical
care quality can be used for assessing quality of nursing
home care. They have structural, process, and outcome
components.43
Structure
Structure refers to the health care facility's or
provider's capacity to provide good-quality care.
Structural criteria include the training, experience, and
number of the care-givers; the organizational arrangements
within which they function; the safety and appropriateness
of the environment; and the adequacy and appropriateness
of the equipment and other available technology.
Structural factors are relatively easy to assess, although
determining what technology, equipment, staff qualifi-
cations and numbers, and organizational arrangements are
necessary to provide good medical care is a matter of pro-
fessional judgment and subject to change as new knowledge
is acquired and new technology developed. Moreover, struc-
tural factors have only a potential relationship to
quality: the availability of the capacity to provide good
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54 / NURSING lIOME CARE
care does not mean that good care is delivered.43
The use of structural criteria to assess quality of care
in nursing homes is based on the assumption that such
criteria represent necessary, although minimal, conditions
associated with acceptable levels of resident care
services and outcomes.44 The evidence to support
this assumption is mixed. Studies on the linkages between
structural measures and the process of care in nursing
homes have not found them to be strong.45~48 But there
is evidence that environmental circumstances influence
personal well-being.32~49~5i Environments that
foster autonomy, integration, and personalized care
promote better morale, life satisfaction, and
adjustment.52~55 They also have positive effects on
staff attitudes and behavior.
There also is evidence that, in some circumstances,
structural criteria directly affect the process of care.
One study that investigated the use of psychotropic drugs
in nursing homes found that staff-to-resident ratios are
associated with rates of use of such drugs. That is,
understaffed facilities may make excessive use of
antipsychotic drugs to substitute for inadequate numbers
of nursing staff.56 Moreover, in such areas as life
safety codes, structural measures of quality clearly
predict outcomes. In general, however, structural
capacity, the care actually provided, and the outcomes of
care are not always associated. Although the capacity to
provide care may exist, it may not be used appropriately,
or not be applied in sufficient quantity or with adequate
skill.
Process
Process criteria assume that quality is related to the
services provided, how they are provided, and the
resources used in doing so. Some studies conducted on
relationships between process measures and resident
outcomes in nursing homes have yielded mixed findings,20~22~57
but a few have shown positive relationships under certain
circumstances.46'58~60 (The studies vary in scientific
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CONCEPTS OF QUALITY/55
quality; many are descriptive rather than controlled.)
These recent studies, and professional experience, suggest
that process measures should not be ignored. If care
related to improving function is neglected (for example,
exercises to avoid contractures, bed positioning to avoid
bed sores), residents' quality of life is affected
adversely.6t
Outcomes
Outcomes are changes in a resident's functional or
psychosocial health that are associated with the care
provided. Outcome measures of care have received a great
deal of attention as the most direct way to approach the
assurance of quality in long-term care. Proponents argue
that a focus on outcomes avoids arguments about
effectiveness of structure and process factors by letting
the results, resident outcomes, speak for themselves. The
use of outcomes allows providers flexibility in deter-
mining the most cost-effective means of achieving specific
outcomes, an important consideration in "low-technology"
care where substitution of personnel and technique seems
Possible 3i,49,62
-
Two kinds of outcomes are measured: subjective and
objective. For nursing home residents, the subjective
components may include a basic sense of satisfaction with
oneself and one's environment and the level of
satisfaction with a range of aspects of nursing home
care. The objective components of outcome include such
things as changes in functional and mental status.
Some outcomes have been defined and measured in
long-term care. For example, rehabilitation outcomes
have been studied, as have patient discharge rates.22~48~63
Studies also have associated particular attributes of
Social isolation and
intellectual decline have been linked with premature
death.64~65 Health status has been tied to morale
and to behavior.57~66~70 And expected intermediate
and final outcomes have been studied for a number of
specific conditions such as stroke and hip fracture.~7~-73
individuals to ranges of outcomes.
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state,8i categorizes residents into five clinically
distinct and statistically different groups on the basis
of the resources used to meet resident service needs.
Each clinical group is further divided by an ADL index
score into subgroups distinguished by level of physical
functioning.
Instruments also have been developed by nursing home
chains for purposes of rate setting and internal quality
assurance. For example, the Patient Care Profile System
assesses functional impairment in personal hygiene,
bathing, dressing, mobility, eating, and positioning, as
well as the presence of incontinence and decubitus ulcers,
and the need for skilled procedures and restorative
nursing. This system is being installed in over 300
Hillhaven Corporation nursing homes.82 The National
Health Corporation has developed the Patient Assessment
Computerized system83 to collect standardized
information on functional impairment in the areas of
walking, ADL, bladder and bowel continence, decubitus
ulcers, special senses, communication, orientation, and
behavior. Reliability is measured by quarterly audits of
a 10 percent sample of residents' forms by nurse
consultants. The state of Montana uses this instrument to
obtain case-mix information for use in its Medicaid
payment determinations.
These and other instruments (only a few have been
mentioned) are useful for quality assurance because they
make it possible to reliably identify residents who have
similar characteristics--that is, similar levels of
disability, need for personal assistance and nursing,
likelihood of discharge, chance of recovery, and risk of
mortality. By collecting the same assessment data on the
same residents at regular intervals, longitudinal data on
the distribution of outcomes for residents with similar
characteristics can be obtained.
Intellectual Impairment/Behavioral Problems
Among nursing home residents, this debility usually
occurs as dementia of the Alzheimer's or multi-infarct
type. It can be assessed with brief interview techniques
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CONCEPTS OF QUALITY / 59
that are reliable in the hands of both trained
professionals, such as nurses and social workers, and
trained nonprofessionals. For example,
1. The Mental Status Questionnaire has been used widely
in geriatric research and practice.84~85 It con-
sists of 10 short questions testing cognitive function
that have been correlated with clinical diagnosis of
organic brain syndrome. It has demonstrated high
reliability and can be administered without extensive
training. The Philadelphia Geriatric Center Mental Status
Questionnaire is an extension of the Mental Status
Questionnaire and includes items that are sensitive to the
specific situation of nursing home residents.86
2. The Mini-Mental State Examination measures cognitive
functioning using items similar to those of a clinical
mental-state examination.87 External validity has
been demonstrated on the basis of clinical assessments of
the presence/absence of cognitive disorder.
3. The Comprehensive Assessment and Referral Evaluation
Instrument (CARE), which includes the Geriatric Mental
Status Schedule, is designed to replicate clinical
judgments among community and institutional
populations. Instrument reliability and validity
have been tested in various ways.
The information obtained from these instruments and
others makes it possible to place residents into
comparable groups with defined characteristics such as
probability of being intellectually incapacitated
(demented), needing special investigations, having a
behavior problem (such as wandering), requiring
supervision, progressively deteriorating, and dying. The
measurements are repeatable. Additional information, such
as duration and course, increases the relevance to quality
assurance.
Corresponding evidence exists for other key content
areas. Subjective well-being (demoralization-depression;
dissatisfaction-complaints) has been measured and
associated with social functioning, physical health
status, mental status, and activity levels.50~89~90
Standardized instruments have been used to assess
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residents' satisfaction with nursing home care and
relationships between satisfaction and nursing home
characteristics.63~9~92 Behavior problems have been
described, measured, and associated with specific service
interventions as a part of nursing home management systems
(for example, the National Health Corporation's Patient
Assessment Computerized system) and in research
studies.93~95
PERSPECTIVE ON QUALITY ASSURANCE
At the most general level, quality assurance is a
mechanism or process for promoting excellence in the
performance of services or the production of goods. It
entails
· specification of criteria and standards of
performance quality,
· collection of accurate information about the quality
of current performance,
· comparison with information on desired or acceptable
standards of performance,
· analysis of the reasons for the differences between
actual performance and desired standards of performance
and determination of what needs to be done to eliminate
these differences,
· adoption of the changes necessary to eliminate the
differences between current performance and desired
standards of performance,
· repeated collection of information to monitor the
extent to which resolution of differences is taking place,
and
· periodic iterations of these linked steps.
Quality assurance--or quality control--is generally
practiced with varying degrees of formality by providers
of services and producers of goods, by consumers and
clients, and by government regulatory authorities. In the
nursing home industry, the main reliance has been on
government regulation, but a significant responsibility
for quality assurance rests on the nursing homes
themselves. Other factors affecting quality in nursing
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CONCEPTS OF QUALITY / 61
homes are important. They include the role of consumer
advocacy groups (including ombudsmen), industry self-
regulatory efforts (including accreditation), and efforts
to increase the professional standards and training of
administrators and other staff. These factors are
discussed in Chapter 6.
INTERPRETING AND USING INFORMATION
FOR QUALITY ASSURANCE
Measurement of Care Quality
In long-term care, there are areas where the medical
needs of a subpopulation can be defined and the outcomes
of care measured. Many measures used in general medical
practice may be used in long-term-care settings:
reduction in the blood pressure of hypertensives;
reduction in pain and improvement in functional status of
patients with angina; visual improvement for patients with
cataracts; restoration of function and reduction of pain
in patients requiring hip replacement.
Measures of effectiveness of care quality more specific
to nursing homes include the level of restoration of
function following such events as hip fractures and new
strokes, infection rates in residents with indwelling
catheters, skin breakdown in at-risk bedridden residents
and improvements in mood in depressed residents.
The choice of measure for evaluating quality of care
depends not only on the innate value of that measure but
on the context of its use as well. A measurement device
that is satisfactory for a large-scale research project
may be too expensive, too lengthy, or require too much
training for regulatory purposes. Similarly, the nature
and size of the target population must be considered.
Restoration of function after hip replacement may be a
very effective measurement of care quality when applied to
an acute rehabilitation facility associated with an active
orthopedic referral center, but it would be completely
useless in measuring the effectiveness of rehabilitation
services in a small nursing home in which only one or two
hips are replaced per year. Many of the measuring
devices described here have limited applicability for
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regulatory purposes because the numbers of residents with
even a common condition will be small within a single
nursing home.
Measurement for regulatory purposes must be clear-cut
and reliable. Both the regulated and the regulators must
be able to understand easily what is being measured and
why it is being used for regulatory purposes.
Disagreements about a particular measurement must be
capable of arbitration. The application of regulatory
quality measures must be satisfactory as legal evidence in
court.
The kinds of outcomes that have been suggested for use
as a part of the regulatory process are mostly avoidable
events that can occur across a fairly large subset of the
population if care is insufficient: decubitus ulcers in
the bedridden and catheter-induced infections are two
examples. Others are discussed in Appendix F.
Standards
Interpreting information on the structure, process, or
outcome of care in order to evaluate quality of care and
well-being requires comparison with some standards of
reference. Relative quality is more readily assessed than
absolute quality. The standards of reference are specific
to a given condition or circumstance since the definition
of good care or a good outcome may vary with the
particular circumstance or condition. Thus, when
comparing an observed level of care with a given standard
(for example, from institutions performing at a level
above an agreed percentile of performance), the comparison
must be made between residents with comparable conditions,
or, when making group comparisons, between groups with
comparable conditions.
Standards may be constructed on the basis of
professional experience and judgment, as reflected in
professional practice norms or standards, or by comparison
with information that can be collected under defined
circumstances:
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CONCEPTS OF QUALITY / 63
· from institutions judged to be exemplary,
· from the same institution at an earlier point in
time, or
· from the same or other institutions under varying
conditions.
These standards (professional judgment and systematic
comparisons) are not mutually exclusive. Professional
judgment is informed by more systematic comparisons. It
also may be necessary when systematic comparison data are
not available. But systematic comparisons have the major
advantage of objectivity and can be refined over time.
Valid comparisons require that the information be
collected uniformly and reliably and on a large scale.
Also, the standards must be reviewed periodically and
revised to keep them up to date.
Case Mix
Case-mix stratification entails grouping residents
according to a select number of their characteristics
(age, sex, functional status, mental status, and so on)
and needs for services. Measurements of functional
impairment, intellectual impairment, and subjective
well-being, all of which predict needs for care, can be
used to define case-mix reference groups. Thus the care
given, as well as the changes in resident well-being
associated with the care given, can be measured and
evaluated for groups of residents with similar care needs.
case mix Is essential for measuring outcomes. The
outcomes of care can be measured by changes in the health
and functional status of residents. A study conducted by
Jones and colleagues in Massachusetts in the early 1970s
first demonstrated the feasibility of this approach to
quality assessment in long-term care.96 Outcomes
also can be related to groups in which members have
similar expected outcomes. A series of studies of
residents of "high-quality" nursing homes has been
undertaken by Kane in an attempt to link nursing home
payment to resident outcomes and nursing home
costs.63 Data collected on residents included a
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broad set of functional aspects covering six domains:
physical, functional (ADL), cognitive, affective, social,
and satisfaction, with measurements made at 3-month
intervals. The study introduced the concept of
"prognostic adjustment factor" (PAF) as an outcome
measurement of quality of care. The PAP reflects the
extent to which the actual outcome of care exceeds or
falls short of an expected level. The system is based on
resident data that are used to generate a predicted course
for the resident based on the experience of similar
residents: the resident gets better, stays the same, or
gets worse. Comparing the actual status of the resident
with the predicted status after a suitable period of time
gives the PAF for that resident over that time interval.
Morris and colleagues did a longitudinal analysis of a
multi-year data set on the residents of 107 facilities
located in 11 states and the District of Columbia. The
data were obtained from the National Health Corporation
and the state of Montana.8 The authors developed a
resident classification scheme differentiating among major
categories of residents, classified by physical and mental
functioning domains and care requirements. These
characteristics were measured against a range of
indicators that have quality-of-life implications,
including ADL, communication, behavior, activities,
outside contacts, family contacts, and decubitis ulcers.
New admissions and current residents were studied over
1 year and the changes in these quality-of-life-related
indicators, controlling for case mix, were shown. The
study shows the powerful potential for monitoring outcomes
and establishing standards that this type of data--
collected regularly--can provide.
Standard Instruments
The use of standard instruments increases the power of
interpreting and using information for quality assurance
purposes. Standard information is necessary to make
comparisons across institutions, which can lead to
industrywide reference standards against which nursing
homes can be evaluated for quality assurance purposes.
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CONCEPTS OF QUALITY / 65
Such instruments are currently being used by some nursing
homes and nursing home chains, and by state regulatory
bodies.
Nursing homes and nursing home chains are increasingly
using standardized instruments to collect resident
information for the purpose of service determination,
internal quality assurance, and rate setting. As
mentioned earlier, the National Health Corporation has
used such an instrument in its Patient Assessment
Computerized (PAC) system for about a dozen years. The
PAC data include sociodemographic, medical, functional,
and social components as well as service needs in
determining case mix. The data are obtained from every
resident each month and entered into a computer file. The
instrument is used in conjunction with the Management
Minutes System, an algorithm that uses resident assessment
data to calculate daily nursing time requirements for each
resident.97 PAC data can be used to establish the
costs of care, resident charges, and to budget nursing
labor. The data also can be used for various longitudinal
analyses, including outcome-based quality-of-care
measures. The PAC system is being used by Montana for its
Medicaid case-mix reimbursement system.
A similar effort has been undertaken by the Hillhaven
Foundation in the development and implementation of the
Patient Care Profile (PCP) system.82 This instrument
includes 19 variables related to functional status and
service needs that form the lowest common denominator of
need for nursing care, regardless of the resident's
medical diagnosis. The PCP is used to help determine
initial placement in the nursing home and to set rates for
private-pay residents. On the basis of assessment
findings, residents are grouped according to service need
and mental status to promote resident satisfaction and
effective use of human and material resources. The PCP is
also used as an internal quality assurance tool to assess
the effects of care on residents' physical performance
over time.
A range of research and demonstration projects has
standardized case-mix instruments to establish service
needs and costs of care. For example, in 1983 the New
York State Department of Health initiated a major study to
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develop a case-mix reimbursement system for long-term care
facilities. The major objective was to develop a
reimbursement methoclology that matches residents' needs to
services and resources. The system will also provide
incentives for rehabilitation, discharge, and better
outcomes for residents. The system is based on Resource
Utilization Groups (RUGS II).82 It uses a classification
instrument that categorizes residents into groups, each of
which is different in clinical terms and different in
resource use. The system will be implemented on a
statewide basis in 1986.
National, Regional, and Local Uses
Interpretation of information for quality assurance is
clearly critical to efficient regulation of nursing
homes. Information collected through federal
demonstration projects being conducted by state regulatory
agenCleS IS currently being used to categorize nursing
home residents on the basis of service needs and costs of
care.
Most state-level case-mix systems collect information
for purposes of reimbursement. The same or similar
information can be used for quality assurance by comparing
the services actually received and resident outcomes with
those expected for residents in comparable case-mix
groups. The "expected" outcomes are determined
empirically by collecting longitudinal assessment data on
large numbers of residents.
The interpretation of information along the lines
described here can also be of great value when practiced
by the administrators ant! staff of the nursing homes
themselves:
· to monitor the quality of their own performance in
· ~
provlc lng care
· to track gains in productivity
· to review unexpected outcomes
· for planning and monitoring resource use to meet
changing case-mix requirements.
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CONCEPTS OF QUALIFY / 67
As noted earlier, nursing homes and nursing home chains
have interpreted and used information about residents'
characteristics and service needs for one or more of these
purposes.
Such comparative statistical information about nursing
home performance, developed from local, regional, or
national sources, can also be useful to consumers by
helping them to become better informed and, therefore
able to play a more effective role in the process of
quality assurance.
QUALITY ASSURANCE AND THE
REGULATORY SYSTEM
The current goals of federal regulation of nursing homes
for quality assurance purposes are to ensure the safety of
residents and the adequacy of their care. In practice, as
used by most states and the federal government, the term
"adequate" has been interpreted to mean "minimum"
acceptable\standards. This grew out of the original
circumstances prevailing when the Medicare and Medicaid
programs began. At that time, strict application of
higher-quality standards would have made most existing
nursing homes ineligible for certification. So two things
were done: the proposed standards were lowered and the
concept of "substantial compliance" was introduced to
allow many homes to participate in the Medicare and
Medicaid programs while they undertook the necessary
actions to bring them into compliance with the minimum
standards. This established a tradition of allowing
inadequate facilities to continue operating while the
state regulatory agencies exerted varying amounts of
pressure to bring them into compliance. (See Appendix A.)
In the last 10-15 years, however, there has been
sufficient experience to enable the setting of more
ambitious regulatory goals. It is now feasible for
federal and state governments to strengthen their
regulatory criteria, inspection processes, and enforcement
procedures so that the regulatory system can be expected
to reliably detect and quickly eliminate nursing home care
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of unacceptably poor quality that occurs anywhere in the
country. It also is reasonable to expect that better
quality assurance capabilities should result in
improvement in the level of performance of facilities that
are providing only marginally adequate care. Many of
these facilities are continuously in and out of
compliance. The strengthened quality assurance criteria
and procedures also are likely to exert a positive effect
on all other facilities so that the level of performance
of "average" nursing homes can be expected to improve.
This would increase overall levels of quality of care and
quality of life provided to most residents in most nursing
homes throughout the country.
To achieve these goals, the current regulatory system
will have to make major changes in quality assessment
criteria, inspection techniques and procedures,
information systems, and enforcement policies and
procedures. Chapters 3, 4, and 5 examine the current
regulatory system and recommend changes that are designed
to provide it with the increased capabilities that are now
possible.
Representative terms from entire chapter:
nursing homes
