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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.

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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. 1981. Infections in Nursing Homes: Policies, Prevalence, and Problems. New England Journal of Medicine 305(September):731-735.

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APPENDIX E / 3 8 7 18. Ouslander, J. G., and R. L. Kane. 1984. The Costs of Urinary Incontinence in Nursing Homes. Medical Care 22(January):69-79. 19. Ouslander, J. G., R. L. Kane, and I. B. Abrass. 1982. Urinary Incontinence in Elderly Nursing Home Patients. Journal of the American Medical Association 248:1194. 20. Irvine, P. W., N. Van Buren, and K. Crossley. 1984. Causes for Hospitalization of Nursing Home Residents: The Role of Infection. Journal of the American Geriatrics Society 32(February): 103- 107. 21. Platt, R., B. F. Polk, B. Murdock, and B. Rosner. 1980. Mortality Associated with Nosocomial Urinary-Tract Infection. New England Journal of Medicine 307:637. 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 Systems Corporation. November 1976. Regulatory Use of a Quality Evaluation System for Long-Term Care. Final report to U.S. Department of Health, Education, and Welfare, Contract No. HSM 110-73-499. 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 Elderly. In L. Breslau and M. Haug (eds.), Depression in tile Elderly: Causes, Care, and Consequences. New York: Springer Publications. 27. Brody, E. M., M. P. Lawton, and B. Liebowitz. 1984. Senile Dementia: Public Policy and Adequate Institutional Care. American Journal of Public Health 74(December): 1381 - 1383. 28. Zimmer, J. G., N. Watson, and A. Treat. 1984. Behavioral Problems among Patients in Skilled Nursing Facilities. American Journal of Public Health 74:1118-1121.

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388 / APPENDIX E 29. Cohen, G. D. 1977. Approach to the Geriatric Patient. Mectical Clinics of North America 61 (4~:855-866. 30. Anderson, N., and L. Stone. 1969. Nursing Homes Research and Public Policy. The Gerontologist 9:214-218. 31. Greenfield, S., N. Solomon, R. Brook, and A. Davies-Avery. 1978. Development of Outcome Criteria and Standards to Assess the Quality of Care for Patients with Osteoarthritis. Journal of Chronic Diseases 31:375-388. 32. Keeler, E., R. Kane, and D. Solomon. 1981. Short- and Long-Term Residents of Nursing Homes. Medical Care 19(March):363-370. Larson, R. 1978. Thirty Years of Research on the Subjective Well-Being of Older Americans. Journal of Gerontology 33:109- 125. 34. Lawton, M. 1980. Residential Quality and Residential Satisfaction Among the Elderly. Research on Aging 2:309-328. 35. Lawton, M. 1982. Competence, Environmental Pressure, and the Adaptation of Older People. In M. Lawton, P. Windley, and T. Byerts (eds.), Aging and the Environment: Theoretical Approaches. New York: Springer. Kahana, E., J. Liang, and B. J. Felton. 1980. Alternative Models of Person-Environment Fit: Prediction of Morale in Three Homes for the Aged. Journal of Gerontology 35(July):584-595. 37. Noelker, L., and Z. Harel. 1978. Predictors of Well-Being and Survival among Institutionalized Aged. The Gerontologist 19:562-567. 38. National Citizens' Coalition for Nursing Home Reform. 1985. A Consumer Perspective on Quality Care: The Residents' Point of View. Washington, D.C. 39. DiBernardis, J., and D. Gitlin. November 1979. Identifying and Assessing Quality Care in Long-Term Care Facilities in Montana. Report to the Department of Social Rehabilitation Services, State of Montana, under contract no. 80-070-0016. Center of Gerontology, Montana State University. Bozeman. 40. Kane, R. 1981. Assuring Quality of Care and Quality of Life in Long-Term Care. Quality Review Bulletin 7~0ctober):3- 10.