Quality of care in nursing homes is a complex concept, confounded by regulations, debates about what should be measured to assess quality, case-mix, facility characteristics, and methods of measurement (Mezey, 1989; Mezey and Lynaugh, 1989). ''Quality of nursing home care has proven to be one of the most politically volatile—yet societally critical—issues confronting the American public. The issue strikes at the core of individual concern about possible functional impairment and potential loss of impairment and potential loss of independence [, c]omplicated by the likelihood of personal impoverishment …" (Wilging, 1992b, p. 13). In short, it is the focus of providers, consumers, regulators, and public policymakers.
Defining quality in nursing facilities has been a difficult process. Quality of care in nursing homes has been defined both as an input measure and as an outcome (Kruzich et al., 1992). The Institute of Medicine (IOM) definition is cited in Chapter 5. As elaborated there, quality can be approached in terms of three concepts: structure, process, and outcome. Table 6.1 presents an illustrative list of the measures of quality of care in nursing homes. These include human, organizational, and material resources.
Traditionally, nursing home quality has been measured by structural variables. Important among these are (1) inputs, such as the level and mix of staffing; (2) characteristics of facilities, such as ownership, size, accreditation, and teaching status; and (3) characteristics of the facility's residents, such as demographics and payer mix. Staffing is a structural measure that affects the processes and outcomes of care in nursing facilities, but it is considered in part to be determined by facility ownership and payment sources. Case-mix relates to quality in that demands on staff (both numbers and quality) are highly related to the needs of patients. Studies indicate that a low percentage of private-pay patients in a facility is a negative indicator of quality of care (using deficiencies as indicators). It is argued that because private-pay residents pay a higher per diem rate than do Medicaid residents, nursing homes generally compete for private-pay residents on aspects of structure and process associated with quality. This competition may be desirable because it also creates an incentive to provide quality care even in a bed-shortage environment. (Nyman, 1988b; Spector and Takada, 1991).
Although structural measures assess the availability of resources as a necessary precondition for their use, process measures examine actual services or activities provided to or on behalf of residents. In the context of nursing homes, the process of care focuses on providing special care and treatment to prevent problems with outcomes such as cognition, hearing and vision, physical functioning, continence, psychosocial functioning, mood and behavior, nutritional and