What Is Nursing Home Quality and How Is It Measured

In the past, nursing home care and long-term care were synonymous. If elders needed long-term care, it would invariably be provided in a nursing home. In recent years, the long-term care sector has changed considerably and is arguably evolving into a “system” in which care can be provided in settings that are more appropriate for consumers’ needs. This includes care by home health providers, adult day care, residential care, and assisted living (to name just four). However, nursing homes are still an essential component of the current long-term care system. In the United States, approximately 1.6 million elderly and disabled persons receive care in 1 of the 17,000 nursing homes (National Nursing Home Survey, 2004). Enduring issues surrounding nursing homes have been quality related. The often-poor quality of nursing homes has been a consistent issue of concern for consumers, government, and researchers. In this commentary, we first provide a brief review of the history of nursing home quality. This centers on how nursing home quality has been measured and provides some context and insight into currently used quality indicators in the nursing home industry. In doing so, we note that the concepts of what is measured, who does the measuring, and why measures are used are intertwined. We secondly provide our opinion on the relative merits of indicators of quality. Notable current quality indicators are presented. We then speculate on steps that need to be taken in the future to address and potentially improve the quality of care provided by nursing homes. These steps include policy changes and future research that is needed. Numerous definitions of quality exist. A current well-cited example comes from the Institute of Medicine (IOM) (1996): “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (p. 5). Operationalizing “quality” from definitions such as these proffered by the IOM can be problematic as the definitions are extremely general and subjective and as such resulting measures tend to be unable to fully realize the quality concept (Castle, Zinn, Brannon, & Mor, 1996). Because of this inability to adequately realize “quality” in nursing homes, quality indicators are prevalent rather than quality measures. This helps denote a less precise association between the “indicator” and actual quality (i.e., they are surrogate measures). This has also fostered the creation of many quality indicators. For example, in choosing the quality indicators to be reported in Nursing Home Compare (www.medicare.gov/NHCompare; discussed subsequently), 181 indicators were considered. With many quality indicators available, some organization is useful. In this regard, in conceptualizing and organizing quality indicators, the approach of Donabedian (1985) is valuable. Donabedian proposed that quality could be measured in terms of structures (S), processes (P), and outcomes (O). Structural measures are the organizational characteristics associated with the provision of care. Process measures are characteristics of things done to and for the resident. Outcome measures are the desired states one would (or would not) like to achieve for the resident. Donabedian's SPO approach is somewhat pervasive in the quality literature. For example, in MEDLINE (2005–2010), 57% (N = 3,950) of nursing home studies either directly or indirectly applied this approach of conceptualizing quality indicators. This approach of conceptualizing quality indicators as SPO measures is also used in this commentary. The SPO approach also has theoretical underpinnings in that good structure should facilitate good process and good process should facilitate good outcomes. However, we note that the theoretical SPO underpinnings were not developed specifically for nursing homes and some have questioned its suitability for this setting (Glass, 1991). Moreover, SPO linkages are not always validated in the nursing home literature (Gustafson, Sainfort, Van Konigsveld, & Zimmerman, 1990). Some scholars have also further substantially developed components of this approach by including factors such as culture (S) and work groups (P) (Scott Poole & Van De Ven, 2004), whereas others in long-term care have modified the SPO theory, for example by combining it with contingency theory (Zinn & Mor, 1998).