Improving the Quality of Care in Nursing Homes (1986) / Chapter Skim
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2. Concepts of Quality, Quality Assessment, and Quality Assurance
2. Concepts of Quality, Quality Assessment, and Quality Assurance
Pages 45-68
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From page 45... ...
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.
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From page 46... ...
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 circumstances compared with noninstitutionalized persons of the same age group.
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From page 47... ...
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, represent 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, deficiencies in medical or nursing care or in housekeeping
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From page 48... ...
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.
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From page 49... ...
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)
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From page 50... ...
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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From page 51... ...
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.
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From page 52... ...
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 nasogastric tube even if he strongly objects to it?
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From page 53... ...
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.
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From page 54... ...
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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From page 55... ...
The use of outcomes allows providers flexibility in determining 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.
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From page 56... ...
An important result of this effort was the "Patient Classification for Long-Term Care," a collaborative effort of four research groups published in 1973.74 In 1980 the Technical Consultant Panel on the Long-Term Health Care Data Set of the National Committee on Vital and Health Statistics recommended that all public and voluntary reporting systems for long-term health care clients and services collect a minimum set of information to establish standard measurements, definitions, and classifications for long-term care. The information needs of the patient classification system and the minimum data set are similar and include sociodemographic items, functional competency/impairment, intellectual impairment/behavioral problems, and medical status.
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From page 57... ...
West Virginia assesses residents for dependency in functional impairment on the basis of 15 categories of service need, and Ohio on the basis of 14 categories.79 The Resource Utilization Groups (RUGS) classification system,8° which will be used to establish Medicaid reimbursement rates in New York
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From page 58... ...
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.
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From page 59... ...
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.
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From page 60... ...
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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From page 61... ...
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.
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From page 62... ...
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.
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From page 63... ...
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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From page 64... ...
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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From page 65... ...
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.
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From page 66... ...
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.
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From page 67... ...
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.
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From page 68... ...
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.
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