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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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50 / NURSING HOME CARE 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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52 / NURSING HOME CARE 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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58 / NURSING HOME CARE 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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60 / NURSING HOME CARE 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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62 / NURSING HOME CARE 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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64 / NURSING HOME CARE 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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66 / NURSING HOME CARE 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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68 / NURSING HOME CARE 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.