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APPENDIX E
Key Indicators of
Quality of Care
Key indicators are resident outcomes that suggest the
presence of either good or bad care. They should be
chosen because they indicate the extent of a facility's
compliance with regulatory criteria, that is, the
elements, standards, and conditions of participation. Key
indicators of inadequate care are prima facie evidence
of a problem, but further investigation is required to
determine whether the problem stems from bad care or from
factors that are not within the facility's control. Key
indicators can be used to distinguish between adequate and
poor-quality care and between adequate and good or
excellent care.
The following illustrative list contains key indicators
that have been tested and used by various states or
facilities. Some apply to all residents, others only to
residents in one or two of the four case-mix groupings
proposed in Chapter 4.
EXAMPLES OF KEY INDICATORS OF CARE
QUALITY TO BE USED BY SURVEYORS
Meclications. Excessive use of tranquilizers and
antipsychotic drugs, medication errors, and adverse drug
378
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APPENDIX E / 379
interactions are evidence of poor quality in nursing
homes.~~7 Thus, one means of measuring the quality
of a nursing home's performance would be to examine the
use of chemical restraints and medication errors.
Survey procedures and protocols for determining proper
medication administration for nursing home residents have
been developed and are being used.~~r2 Elements
from these protocols for proper drug administration could
be used in examining facility records, observing
medication passes for a sample of residents in the
facilities, and observing residents. Using the "case-mix
referencing" system for selecting samples of residents,
the survey could focus its observation on those
particularly at risk for overmedication (for example,
residents with depression or anxiety).
Decubitus Ulcers. Another potential indicator of
poor quality of care is the development of bed
sores.~3~4 Protocols have been developed for
identifying and measuring the severity of such skin
breakdowns and pressure sores.~0~3~~5 The survey
would particularly concentrate on a sample of very
physically dependent residents (those who are bed- and
chair-fast) anti measure the incidence and severity of
decubiti.
Urinary Tract Infections. The development of
infections among nursing home residents with indwelling
urinary catheters may also be a sign of poor
care.~6~20 One measure of quality, for purposes of
comparing facility performance, would be the incidence of
urinary tract infections among the residents in the
facility who are catheterized.
Management of Urinary Incontinence. Another
indicator of quality might be the use of indwelling
catheters as opposed to bladder training programs and
prompt staff attention to individuals when they need to
urinate. Many view the excessive use of indwelling
catheters as a sign of poor care, and protocols have been
developed for their proper use i0'i4~6~7~2~22 Thus
another measure of quality would be the number of
indwelling catheters among incontinent residents in
nursing homes. The survey should take into account
whether the facility has attempted a bladder training
program for catheterized residents.
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380 / APPENDIX E
Dehydration. Dehydration among nursing home
residents is frequently cited by physicians in admitting
hospitals as a major problem.23~24 It is also a
predictor of poor care and has been proposed as one of the
sentinel health events that should be preventable, given
adequate care. As Himmelstein and colleagues
note,24 in the absence of documentation in the
resident's record of rapid free water loss, dehydration
usually indicates inadequate attention to fluid intake.
The survey would focus in particular on every physically
dependent and severely mentally impaired resident in
surveying for dehydration.
Other Examples of Medical, Nursing, and Rehabilitative
Care Inclicators. Other key indicators of medical and
rehabilitative care include the blood pressure of
hypertensive residents (because elevated diastolic
pressure has been shown to correlate directly with events
such as heart attack and stroke), changes in weight,
contractures, existence of physical restraints, decline in
functional status, and the ability to perform the
activities of daily living (ADL).
Nursing and Personal Care. Issues relating to
nursing and personal care are very relevant to both
quality of care and quality of life experienced by nursing
home residents and to their sense of well-being,
satisfaction, and mental and social functioning.26
In their outcome-oriented licensure survey, the Iowa
Department of Health utilizes an index of service delivery
on 17 nursing and personal care items, involving
observation and resident interviews.~39 When the
observations and interviews are completed on all 17 items,
a score is constructed to indicate the level and quality
for this service. A similar set of items and scoring
procedures could be developed for the federal survey.
Examples of items include whether residents' hair and
nails are clean and neat, whether they are dressed in
their own clothing, whether the clothing is clean, and
whether residents receive daily oral hygiene. In
addition, the surveyors might observe whether call lights
and other resident requests for assistance are promptly
acknowledged, whether indwelling catheter tubes are clean,
and whether catheter tubes and bags touch the floor.
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APPENDIX E / 381
Mental Status. While the elderly in nursing homes
suffer from mental disorders that affect younger persons
(for example, schizophrenia, neuroses), the two most
frequent diagnoses among nursing home residents are
depression and intellectual impairment (organic brain
syndrome, confusional states, dementia).27 In the
case of depression, the elderly are just as responsive to
psychiatric treatment as younger people.28
Depression, demoralization, and social isolation have been
measured and associated with social functioning,26
physical health status, premature mortality,29~32 and
activity levels.33 Thus, greater attention should
be paid to mental health aspects of care, including
appropriate assessment and management techniques for
mental and behavioral problems, and specialized activities
programs.27
One possible indicator of quality in this domain is
appropriate use of medications for this population,
particularly for residents with depression. Some measures
of resident satisfaction (discussed below) may also
capture important elements of mental status, particularly
depression, demoralization, and social isolation.
There is substantial evidence that environmental
circumstances of older persons have an influence on
personal well-being.34~35 For example, environments
that foster autonomy, integration, and personalized care
promote higher morale, life satisfaction, and better
adjustment.36~37 Some of the measures of facility-level
capacity and performance, such as availability and
appropriateness of activities, and some of the residents'
satisfaction items, will be relevant to this domain of
quality.
Diet, Nutrition, and! Food Service. Diet, nutrition,
and food service are especially important to quality of
care and life for residents of a nursing home.
Therapeutic diets, for instance, are vital to the physical
health status of some residents (for example, those with
conditions such as hypertension and diabetes). Adequate
nutrition is essential to the physical health status of
all residents. Residents with functional impairments may
require assistance in eating or special utensils. Without
such needed assistance, the quality of the diet or
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382 / APPENDIX E
menu is meaningless, since such residents may not, in
effect, "receive" the food they require and the facility
provides. Finally, the quality of the food--whether it is
warm when served, well seasoned, and whether residents
have some choice in their menus--has been found to be a
major element of their rating of the "quality" of a
facility.38~39 As Rosalie Kane observes,40
"Most people sit down to meals rather than to diets; the
criteria for a satisfying meal may not be the same as
those for a satisfactory diet, yet both are relevant." A
key indicator of food quality, adequacy, and choice could
be the proportion of residents not eating their entire
meals or residents' personal observations about food
quality.
Activities and Social Participation. A variety of
activities and choices among activities have been shown to
be significant elements of residents' concepts of
quality.38 Environmental circumstances, the availability
of individualized activities, opportunities for social
interaction and participation in activities inside and
outside the nursing home that reduce social isolation are
associated with improved mental and physical
status 34-37.40
Quality of Life. The quality of the living environment,
particularly cleanliness and the ability of residents to
have personal possessions and furnishings in their rooms,
is one of the prime components of residents' concepts of
quality.40 The quality of the living environment is
related to the physical safety of residents (for example,
in bathrooms) and their health (cleanliness is related to
risk of infection). Staff attitudes and treatment of
residents also affect quality of life. The dignity with
which residents are treated and the friendliness and
caring of staff, especially aides, are critical
prerequisites to a quality life experience. Opportunities
for personal choice in the details of daily life--
mealtimes, time to rise and retire, activities, and
clothing--can allow residents a small but important
measure of control over their surroundings and personal
lives and significantly enhance the quality of life in a
nursing home.
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APPENDIX E / 383
OPERATIONAL USE OF KEY INDICATORS
The proposed standard survey relies on key indicators to
determine whether a facility is providing high quality,
moderate but acceptable quality, or potentially poor
quality of care and quality of life. Taken together, the
indicators must therefore discriminate among the degrees
of quality. And the "pass/fail" score for each must be
developed. For facilities failing the key indicators in
the standard survey, a full or partial extended survey
will be conducted, more fully to investigate whether there
are care or life deficiencies and the reasons for them.
Following is a brief illustrative list of possible key
indicators in various domains of quality of care and life
and the types of follow-up investigation that would be
required in the extended survey.
Nursing Care. Key Indicator: A given percentage of
residents with weight loss of 5 pounds within 30 days
(source of data: medical records and observations of
residents). In the extended survey, the procedures would
include examining records for acceptable reasons for
weight loss (diagnosis of cancer, obesity, recent physical
activity level changes), examining the current dietary
program (caloric intake), observing residents for
treatable conditions (poor or missing teeth, depression),
observing meal presentation (temperature and taste of
food), observing and interviewing residents regarding
eating habits, need for assistive devices or staff
assistance, food preferences, and investigating nursing
staff levels and policies regarding food supplementation
and nursing assistance in eating.
Key Indicator: A given proportion of residents with
urinary tract infections associated with indwelling
catheters (source of data: medical records). The extended
survey procedures would include interviewing nursing staff
and examining nursing procedures regarding fluid
administration; investigating nursing staff levels; and
investigating physician oversight of residents' care.
Key Indicator: A given percentage of residents
physically restrained (source of data: observation of
residents, medical records). In the extended survey,
surveyors would investigate reasons for restraints to
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384 / APPENDIX E
determine justification from medical records and staff
interviews; investigate quality of care for restrained
residents by observing positioning, release, and
exercising of residents (from medical record reviews and
staff interviews); and investigate nursing staff levels
and nursing procedures.
Mental Status. Key Indicator: A given percentage
of mentally unimpaired residents with depression (source
of data: resident mental status interviews and medical
records). The extended survey would encompass
investigating the causes (physical disability, drugs,
dissatisfaction with quality of care or life); and
determining whether depression has been diagnosed and
noted in the record and whether a plan of treatment has
been formulated and is being carried out.
Medical Care. Key Indicator: Number of medications
per resident exceeding a threshold level (source of data:
medical records, resident interviews, and observation of
medication administration). The extended survey would
entail review of medical records and care planning
procedures to determine whether medications are
reconsidered monthly; review of drug interactions;
investigation of the adequacy of pharmacy review:
investigation of the extent of Medical Director
involvement in the drug prescription process;
investigation of nursing procedures regarding physician
contacts; investigation of nursing oversight of medication
complications; and investigation of the adequacy of care
planning.
Dietary Service. Key Indicator: Are a given
percentage of residents eating most of the food served?
(Source of data: observation of meal service.) The
extended survey would investigate nursing staff levels;
investigate availability of assistive devices; investigate
whether residents not eating are missing teeth or have
other dental or medical problems impeding eating;
interview residents as to whether they are given an
opportunity to make choices and express preferences for
food; and investigate excessive and rigid use of
therapeutic diets.
Quality of Life. Key Indicator: Do a given
percentage of residents report having friends among the
staff? (Source of data: resident interviews.) The
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APPENDIX E / 385
extended survey would investigate whether resident
isolation has been identified and recorded in medical
record and review care plan to determine if it is being
addressed, and investigate staff training by interviewing
staff and examining training procedures.
Key Indicator: Do a given percentage of resident rooms
have personal memorabilia, rugs, curtains, pictures,
plants? (Source of data: observation.) The extended
survey would involve interviews with residents to
determine why rooms lack personalization, and interviews
with staff and the administrator. Facility policies
regarding personal possessions in rooms would also be
reviewed.
NOTES
1. Mathematica Policy Research. January 1985. Evaluation
of the State Demonstrations in Nursing Home Quality
Assurance Processes. Final Report to the Health Care
Financing Administration.
2. Ray, W. A., C. F. Federspiel, and W. Schaffner. 1980.
A Study of Anti-Psychotic Drug Use in Nursing Homes:
Epidemiological Evidence Suggesting Misuse.
American Journal of Public Health 70(May):485-491.
3. Virginia Joint Legislative Audit and Review
Commission. March 2S, 1978. Long-Term Care in
Virginia. The Virginia General Assembly. Richmond.
4. Howard, J. 1977. Medication Procedure in a Nursing
Home: Abuse of PRN Orders. Journal of the American
Geriatrics Society 25:83-84.
5. U.S. Department of Health, Education, and Welfare.
July 1975. Long-Term Care Facility Improvement Study:
Introductory Report. Office of Nursing Home Affairs.
Washington, D.C.
6. Kalchtaler, T., E. Caccaro, and S. Lichtiger. 1977.
Incidence of Poly-Pharmacy in a Long-Term Care
Facility. Journal of the Ar''erica,' Geriatrics
Society 25:308-313.
7. Requarth, C. H. 1979. Medication Usage and
Interaction in the Long-Term Care Elderly. Journal
of Gerontological Nursing 5(March-April):33-37.
OCR for page 386
386 / APPENDIX E
8. Lee, Y. S., and S. Braun. 1981. Health Care for the
Elderly: Designing a Data System for Quality
Assurance. Computers, Environment, and Urban
Systems 6(Spring):49-82.
9. Lee, Y. S. 1984. Performance of Intermediate Care
Facilities in Iowa: A Preliminary Analysis. Performed
for the Iowa Department of Health, Division of Health
Facilities [or Nursing Homes and Quality of Health
Care: The First Year of Results of an
Outcome-Oriented Survey. Journal of Health anc!
Human Resource Administration 7(Summer):32-603.
10. Bisenius, M. F. 1984. Quality of Health Care in Iowa
Nursing Homes: Results from the ICE Outcome-Oriented
Survey, December 1, 1982 - November 20, 1983. Iowa
State Department of Health, Division of Health
Services, Des Moines.
11. Zawadski, R. T., G. B. Glazer, and E. Lurie. 1978.
Psychotropic Drug Use Among Institutionalized and
Noninstitutionalized Medicaid Aged in California.
Journal of Gerontology 33(November):825-834.
Simpson, W. 1984. Medications and the Elderly: A
Guide for Promoting Proper Use. Rockville, Maryland:
Aspen Systems.
13. Michoki, R. J., and P. P. Lamy. 1976. The Care of
Decubitus Ulcers Pressure Sores. Journal of the
American Geriatrics Society 245(May):217-224.
14. Michoki, R. J., and P. P. Lamy. 1976. The Problem of
Pressure Sores in a Nursing Home Population:
Statistical Data. Journal of the American
Geriatrics Society 24(July):323-328.
15. Shanks, N., et. al. 1983. Evaluation of the
Reimbursement Provisions of Amended Substitute House
Bill 176. A Report to the Ohio Department of Public
Welfare. Center for Health Services Research,
University of Colorado Health Sciences Center.
17.
Denver.
16. Zimmer, J. G. 1979. Medical Care Evaluation Studies
in Long-Term Care Facilities. Journal of the
American Geriatrics Society 27:62-72.
Garibaldi, R. A., Brodine, S., and S. Matsumiya.
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OCR for page 387
APPENDIX E / 3 8 7
18. Ouslander, J. G., and R. L. Kane. 1984. The Costs of
Urinary Incontinence in Nursing Homes. Medical Care
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19. Ouslander, J. G., R. L. Kane, and I. B. Abrass. 1982.
Urinary Incontinence in Elderly Nursing Home
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20. Irvine, P. W., N. Van Buren, and K. Crossley. 1984.
Causes for Hospitalization of Nursing Home Residents:
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21. Platt, R., B. F. Polk, B. Murdock, and B. Rosner.
1980. Mortality Associated with Nosocomial
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22. Miller, M. B. 1975. I&trogenic and Nursigenic Effects
of Prolonged Immobilization of the Ill Aged.
Journal of the American Geriatrics Society
23(August):360-369.
Illinois Department of Public Health and Medicus
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report to U.S. Department of Health, Education, and
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24. Himmelstein, D. U., A. A. Jones, and S. Woolhandler.
1983. Hypernatremic Dehydration in Nursing Home
Patients: An Indicator of Neglect. Journal of the
American Geriatrics Society (August).
25. Helen Smits, personal communication, 1984.
26. Gurland, B., L. Dean, and P. Cross. 1983. The Effects
of Depression on Individual Social Functioning in the
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Depression in tile Elderly: Causes, Care, and
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27. Brody, E. M., M. P. Lawton, and B. Liebowitz. 1984.
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28. Zimmer, J. G., N. Watson, and A. Treat. 1984.
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74:1118-1121.
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29. Cohen, G. D. 1977. Approach to the Geriatric Patient.
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30. Anderson, N., and L. Stone. 1969. Nursing Homes
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31. Greenfield, S., N. Solomon, R. Brook, and A.
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32. Keeler, E., R. Kane, and D. Solomon. 1981. Short- and
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Larson, R. 1978. Thirty Years of Research on the
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34. Lawton, M. 1980. Residential Quality and Residential
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35. Lawton, M. 1982. Competence, Environmental Pressure,
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Representative terms from entire chapter:
key indicators
