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Quality of Care Most Important Nursing Home Measure

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Press Release Date: June 7, 1999

In spite of their different and sometimes adversarial roles, nursing home advocates, administrators, regulators, ombudsmen and nursing service directors agree on the three most important yardsticks for measuring how good a job the nation's nursing homes are doing, according to a new study sponsored by the Agency for Health Care Policy and Research (AHCPR)—the Department of Health and Human Services (HHS) agency responsible for research aimed at improving the quality, effectiveness and accessibility of health care.

The five nursing home "stakeholder" groups said that the quality of the care they provide is the most important yardstick, followed closely by the quality of life of their residents, and then by their residents' rights. The three areas are among 17 "categories of quality" that HHS's Health Care Financing Administration (HCFA) regulations require state governments to evaluate to determine if nursing homes should be certified for participation in Medicare and Medicaid. State agencies survey the nearly 17,000 nursing homes every 12 to 15 months on behalf of HCFA.

In 1995, the Clinton Administration issued the nation's toughest-ever nursing home enforcement rules, which led to measurable improvements in quality of care. Building on those reforms, HCFA last year started a series of further steps to promote higher-quality care, strengthen enforcement, and provide easy access to valuable information to help nursing home residents and their families.

"Knowing how these different groups view quality could prove important for the eventual development of nursing home 'report cards.' Today's findings add to the science base necessary for structuring quality improvement efforts that work," said AHCPR's administrator, John M. Eisenberg, M.D.

HCFA Administrator Nancy-Ann DeParle said, "This survey shows that we are on the right track in asking state inspectors to focus on quality of care and quality of life when they visit nursing homes. All Americans deserve to know that they and their loved ones will receive quality, compassionate care in a nursing home."

The study, which was led by Charlene Harrington, Ph.D., R.N., a professor of social and behavioral sciences at the University of California, San Francisco's School of Nursing, found that 89 percent of the stakeholders ranked quality of care among the three top categories, nearly 88 percent placed quality of life there, and about 75 percent put residents' rights among the top three.

Although the stakeholders agreed on the three most important categories for measuring quality, they differed in how they thought each should be ranked. Nursing home advocates and nursing directors tended to give quality of care the highest ranking, whereas administrators and state licensing and certification survey agency training coordinators were more likely to pick quality of life as the most important category. State nursing home ombudsmen generally chose residents' rights as the most important.

The stakeholders saw the remaining 14 categories as being much less important. These categories—and the percentage of respondents who thought them important enough to be among the top three—are:

  • Resident behavior: 38.4 percent.
  • Nursing services: 36.5 percent.
  • Admission/Transfer: 31.9 percent.
  • Resident Assessment: 30.7 percent.
  • Dietary Services: 17.7 percent.
  • Physical Environment: 17.2 percent.
  • Physician Service: 16.6 percent.
  • Rehabilitation Services: 14.3 percent.
  • Infection Control: 12.9 percent.
  • Administration: 10.1 percent.
  • Pharmacy Services: 8.8 percent.
  • Dental Services: 7.5 percent.
  • Other Activities: 6.3 percent.
  • Laboratory Services: 5.8 percent.

Overall quality of care provided to residents, followed by their ability to carry out usual everyday activities, such as bathing, dressing and eating (Activities of Daily Living), and care specifically aimed at helping residents maintain their ability to conduct these activities, were selected as the three most important subcategories of quality of care.

The three most important subcategories of quality of life were dignity, self-determination and participation, along with the accommodation of residents' needs, while exercise of rights, informing residents of their condition, and freedom from reprisal ranked first, second and third in the residents' rights category.

The survey, which was conducted in 1996, involved administrators and nursing directors drawn from a random sample of nursing homes, ombudsmen and survey training and certification coordinators from 50 States and the District of Columbia, and nursing home advocates from 34 States.

Details are in "Stakeholders Opinions Regarding Important Measures of Nursing Home Quality for Consumers," which was published in the May-June 1999 issue of the American Journal of Medical Quality.

Note to Editors: For interviews of Dr. Harrington, contact Rebecca Sladek-Nowlis at (415) 476-1045. For information about HCFA's nursing home regulations, call Craig Palosky at (202) 690-6145.

For additional information, contact the AHCPR Press Office (301) 427-1364: Karen Migdail (301) 427-1855 (

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