An empirical test of the structure, process, and outcome quality paradigm using resident-based, nursing facility assessment data

Identifying Consistent and Coherent Dimensions of Nursing Home Quality: Exploratory Factor Analysis of Quality Indicators

BACKGROUND

There is a general belief that the markers of nursing home quality do not aggregate easily. Identifying consistent and coherent dimensions of quality that usefully summarize the multiplicity of nursing home quality measures is an important goal. It would simplify interpretation and help consumers, their families and advocates to choose nursing facilities.

OBJECTIVES

This study uses quality indicators (QIs) from a state nursing home report card to explore the dimensionality of quality in nursing homes and to determine whether aggregation at the resident versus facility level yields the same underlying dimensions.

DESIGN

Cross-sectional study.

SETTING

382 Medicare- and/or Medicaid-certified nursing homes in Minnesota.

PARTICIPANTS

Residents admitted to the nursing homes during 2011-2012.

MEASUREMENTS

16 QIs obtained from the Minimum Data Set 3.0 assessment instrument between 2011 and 2012 were used in the exploratory factor analysis.

RESULTS

Factor analysis results suggest four main factors or dimensions to characterize facility performance: continence care (including 4 QIs), restraints and behavioral symptoms (including 3 QIs), care for specific conditions (including 6 QIs), and physical functioning (including 3 QIs). The resident-level and facility-level results generally agreed for 11 QIs.

CONCLUSION

Nursing home quality of care can be captured in summary measures, which can be used by consumers, providers and researchers. Reporting at the resident or facility level will depend on the purpose. These summary measures can be used by policy-makers to identify and reward high-performing facilities and by families to choose nursing facilities for care.

The Relationship Between Quality of Care and Costs in Nursing Homes

The purpose of this study was to evaluate the impact of quality of care on costs in nursing homes. The sample consisted of 749 nursing homes in 5 states in 1996. Nursing home cost functions were estimated using weighted 2-stage least-squares regression analysis. Costs are measured as the facility's total patient care costs. Two outcome measures are used as quality indicators: pressure ulcers worsening and mood decline. Nonmonotonic relationships are observed between quality and costs for nursing homes in the sample. However, the pattern of the relationship is different depending on the quality indicator. For pressure ulcers, the authors observe an inverted U-shaped curve with increasing costs at the lower range of quality but decreasing costs associated with higher quality after a threshold. The opposite pattern is observed for mood decline, with a relatively flat curve at the lower range of quality but increasing costs after a threshold.

Nursing Home Deficiencies in the United States

This is a confirmatory factor analysis (CFA) of deficiencies in nursing homes obtained from the On-line Survey Certification and Reporting system (OSCAR), a national database on nursing home quality maintained by the U.S. Health Care Financing Administration (HCFA). A major goal was to identify a core set of items that would reliably reflect a meaningful set of dimensions of problems in quality of care. The analysis suggests that it is reasonable to posit a model of eight underlying factors to which state surveyors are responding as they assign deficiencies to nursing homes. Forty items are robust indicators of the eight dimensions of problems in quality of care. The data contain considerable random and probably systematic error worth understanding. Establishing that the data contain systematic variability is crucial because OSCAR data are a potentially valuable source of quality of care information for researchers, policymakers, and consumers.

Can hospital cultural competency reduce disparities in patient experiences with care?

BACKGROUND

Cultural competency has been espoused as an organizational strategy to reduce health disparities in care.

OBJECTIVE

To examine the relationship between hospital cultural competency and inpatient experiences with care.

RESEARCH DESIGN

The first model predicted Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores from hospital random effects, plus fixed effects for hospital cultural competency, individual race/ethnicity/language, and case-mix variables. The second model tested if the association between a hospital's cultural competency and HCAHPS scores differed for minority and non-Hispanic white patients.

SUBJECTS

The National CAHPS Benchmarking Database's (NCBD) HCAHPS Surveys and the Cultural Competency Assessment Tool of Hospitals Surveys for California hospitals were merged, resulting in 66 hospitals and 19,583 HCAHPS respondents in 2006.

MEASURES

Dependent variables include 10 HCAHPS measures: 6 composites (communication with doctors, communication with nurses, staff responsiveness, pain control, communication about medications, and discharge information), 2 individual items (cleanliness and quietness of patient rooms), and 2 global items (overall hospital rating, and whether patient would recommend hospital).

RESULTS

Hospitals with greater cultural competency have better HCAHPS scores for doctor communication, hospital rating, and hospital recommendation. Furthermore, HCAHPS scores for minorities were higher at hospitals with greater cultural competency on 4 other dimensions: nurse communication, staff responsiveness, quiet room, and pain control.

CONCLUSIONS

Greater hospital cultural competency may improve overall patient experiences, but may particularly benefit minorities in their interactions with nurses and hospital staff. Such effort may not only serve longstanding goals of reducing racial/ethnic disparities in inpatient experience, but may also contribute to general quality improvement.

Nursing Home Caregiver Staffing Levels and Quality of Care

In this research, the author reviewed 70 studies that had examined the relationship between staffing levels and quality in nursing homes (covering the years 1991 to 2006). The results of the review including all of this literature show that approximately 40% of the quality indicators examined show an association with nursing home staffing levels. Nevertheless, this finding is further interpreted in the context of the limitations of many of these prior studies. The author discusses the limitations of poor quality staffing data, small sample size, quality indicators used, methodological concerns, and underspecified models inherent to many prior studies. The author finds no study representing a “gold standard” exists in this area. Still, the few studies that seem methodologically most robust would seem to indicate that an association between nursing home staffing levels and quality exists. However, the author concludes that studies in this area need to be further enhanced.

A Nurse-staffing Taxonomy for Decision Making in Long-term Care Nursing Facilities

A nurse-staffing taxonomy is proposed to facilitate informed staffing decisions in long-term care nursing facilities and to set forth construct components for empirically related research. Recommendations from an expert workgroup were synthesized with current staffing research to define a staffing taxonomy. Refinements were made, incorporating on-site nursing home quality assessments and concepts founded on psychometric theory and Donabedian's model. A quality monitoring protocol, based on the staffing taxonomy, was used to assess quality improvement systems. Results from 48 US nursing facilities indicate that most long-term care facilities struggle with staffing allocation and the integration of staffing into a quality monitoring process.

Future Development of Nursing Home Quality Indicators

Nursing home quality indicators have been developed over the past 10 years to quantify nursing home quality and to draw systematic comparisons between facilities. Although these indicators have been applied widely for nursing home regulation, quality improvement, and public reporting, researchers and stakeholders have raised concerns about their accuracy and usefulness. We critically evaluate nursing home quality indicators from the standpoint of theory, measurement, and application, and we recommend strategies to make the indicators more valuable as quality assessment tools. We recommend that (a) more comprehensive quality indicators should be developed in conjunction with the new Minimum Data Set 3.0; (b) the validity and reliability of the indicators should be evaluated thoroughly with respect to both measurement and application; (c) statistical criteria should be incorporated explicitly into quality indicator scoring and outlier targeting; (d) the dimensionality and theoretical structure of the quality indicators should be carefully examined; (e) risk adjustment methods should be refined and broadened; and (f) quality indicator reporting systems should be strengthened and tailored to stakeholders' needs.

Policy and Research Issues for Small Assisted Living Facilities

Dramatic growth in Assisted Living (AL) has resulted in increasing research and policy interest. This analysis compares smaller and larger AL facilities in four states to determine whether extant measures of four key concepts, used to distinguish the AL sector, give advantage to larger facilities. Quantitative comparisons predominantly show differences favorable to larger facilities; qualitative information raises the prospect that current measures overlook beneficial aspects of smaller facilities. If small facilities are included under the AL banner. both policy provisions and quality assessment must be carefully crafted to avoid placing small homes in funding and oversight jeopardy as AL develops.

A systems framework for evaluating nursing care quality in nursing homes

Given the ongoing concerns about the quality of care in nursing homes, a theoretical framework to guide a systems approach to quality is important. Existing frameworks either do not model causality, or do so in a linear fashion in which the actual linkages between components of quality may not be well specified. Through a review of frameworks for nursing home quality, and empirical studies on the subject, the authors construct a framework for nursing home quality that links contextual components of quality with structure, structure with process, and process with outcomes, focusing on nursing care quality. Intrastructural relationships and feedback mechanisms are also modeled. The framework is matched with a discussion of multilevel structural equation analysis for statistical application. Future research should expand the framework to include non-nursing components of quality.

Nurse staffing patterns and quality of care in nursing homes

Using the structure-process-outcome framework and the resource-based view of the firm, this study considers both direct and indirect effects of registered nurse staffing patterns on the quality of patient care outcomes. Consistent with theory, registered nurse staffing patterns were found to affect quality of patient care both directly and indirectly through their positive effect on the processes of delivering care.

The Minimum Data Set Bedfast Quality Indicator

BACKGROUND

Excessive time in bed has negative effects on both physical conditioning and functioning. There are no data or practice guidelines relevant to how nurses should manage the in-bed times of nursing home residents, although all nursing homes receive a bedfast prevalence quality indicator report generated from the Minimum Data Set.

OBJECTIVES

To compare nursing homes that score in the upper and lower quartiles on the Minimum Data Set bedfast prevalence quality indicator for proportion of bedfast residents, activity and mobility nursing care, and amount of time all residents spend in bed, and to evaluate whether residents who spend more time in bed are different from those who spend less time in bed according to functional measures.

METHODS

A cohort design used medical records, resident interviews, and direct observation data to compare 15 nursing homes (n = 451 residents) on the proportion of bedfast residents, the amount of time residents spent in bed, the frequency of activity, and the scores on six activity and mobility care process indicators.

RESULTS

Significant differences were found between upper (i.e., higher prevalence of bedfast residents) and lower quartile nursing homes in the proportion of time residents were observed in bed (43% vs. 34%, respectively; p =.007), and in the proportion of residents who spent more than 22 hours in bed per day (18% vs. 8%, respectively; p =.002). All nursing homes underestimated the number of bedfast residents. The residents of upper quartile homes showed more activity episodes and reported receiving more walking assistance than the residents of lower quartile homes.

DISCUSSION

Minimum Data Set bedfast quality indicator identified nursing homes in which residents spent more time in bed, but did not reflect differences in activity and mobility care. In fact, upper quartile homes provided more activity and mobility care than lower quartile homes. Across all the nursing homes, most of the residents spent at least 17 hours a day in bed. Further study of activity and mobility care and bedfast outcomes in nursing homes is needed, and nurses need to note the amount of time nursing home residents spend in bed.

Medicaid case-mix nursing home reimbursement in three states

Case-mix nursing facility payment raises issues of access, quality, equity, and cost. Case-mix should better match payment to costs, improve access, and provide incentives to increased staffing and quality of care; but it may also increase costs. This paper reports analysis of Medicaid cost-report data from three case-mix states. Case-mix did not discourage capacity building and was more equitable for providers. Medicaid access declined in one state but increased in another. There were shifts toward greater skilled care in two states, with evidence of greater focus of resources on patient care. Case-mix showed no evidence of cost-constraint and some signs of increased costs. Whether such mixed outcomes are viable in the current era remains to be seen.

Does quality of care lead to better financial performance?: the case of the nursing home industry

The study describes the relationship between quality of care and financial performance (operating profit margin) as it pertains to the nursing home industry. We found that nursing homes that produce better outcomes and process of care were able to achieve lower patient care costs and report better financial performance.

Nursing care quality in nursing homes: cross-sectional versus longitudinal analysis

This empirical study of the relationship between nursing care adequacy and nursing care quality demonstrates that a positive relationship exists between the process and outcome dimensions of quality of nursing care. The results from the analysis of national data on nursing homes' deficiencies highlight the importance of conducting a longitudinal study of the effect of nurse staffing and nursing care adequacy on the quality of care.

The quality of quality measurement in U.S. nursing homes

PURPOSE

This article examines various technical challenges inherent in the design, implementation, and dissemination of health care quality performance measures.

DESIGN AND METHODS

Using national and state-specific Minimum Data Set data from 1999, we examined sample size, measure stability, creation of ordinal ranks, and risk adjustment as applied to aggregated facility quality indicators.

RESULTS

Nursing home Quality Indicators now in use are multidimensional and quarterly estimates of incidence-based measures can be relatively unstable, suggesting the need for some averaging of measures over time.

IMPLICATIONS

Current public reports benchmarking nursing homes' performances may require additional technical modifications to avoid compromising the fairness of comparisons.

Designing a report card for nursing facilities: what information is needed and why

PURPOSE

This article presents a rationale and conceptual framework for making comprehensive consumer information about nursing facilities available. Such information can meet the needs of various stakeholder groups, including consumers, family/friends, health professionals, providers, advocates, ombudsman, payers, and policy makers.

DESIGN AND METHODS

The rationale and framework are based on a research literature review of key quality indicators for nursing facilities.

RESULTS

The findings show six key areas for information: (a) facility characteristics and ownership; (b) resident characteristics; (c) staffing indicators; (d) clinical quality indicators; (e) deficiencies, complaints, and enforcement actions; and (f) financial indicators. This information can assist in selecting, monitoring, and contracting with nursing facilities.

IMPLICATIONS

Model information systems can be designed using existing public information, but the information needs to be enhanced with improved data.

Strengthening research to improve the practice and management of long-term care

Past investments in long-term care (LTC) research have improved the quality of care and the quality of life for LTC recipients by conceptualizing the goals and measuring the outcomes of care, designing practical assessment tools, testing clinical interventions, and evaluating new service delivery programs and models. To build a balanced portfolio of LTC research that will yield and sustain increased dividends in quality and outcomes will require (1) increasing investment in both basic and applied LTC research to ensure that critical service delivery issues are addressed in a rigorous and timely fashion, (2) fostering better communication between researchers and users to ensure research salience and credibility, and (3) dedicating more resources to identifying and implementing successful methods for translating LTC research into practice.

Nursing facility staffing in the states: the 1991 to 1995 period

Trends in the average nurse staffing levels are reported for certified nursing facilities in the United States from 1991 through 1995. Data from the federal On-Line Survey Certification and Reporting system show a small overall increase in the staffing levels for registered nurses (RNs), licensed vocational and licensed practical nurses (LVNs/LPNs), and nursing assistants over the 5 years, but there are substantial variations across states and regions. A two-stage least squares panel analysis examined predictors of nurse staff levels in states. States with higher resident case mix levels had higher RN and LVN/LPN hours. States with higher percentages of large facilities had lower RN and LVN/LPN levels and states with higher percentages of for-profit facilities had lower RN staff levels. States with a higher percentage of Medicaid residents had higher LVN/LPN staff levels. These findings indicate the need for more studies of staff variations and public policies that affect staffing.