Understanding How Nursing Home Quality is Measured

Public Health experts from the University of Pittsburgh published an article outlining the history of nursing home quality measurement. The article was the feature article of the 50th anniversary edition of The Gerontologist. The purpose of the article was to examine the meaning of the phrase nursing home quality and outline the indicators that have been used to measure it.

Long gone are the days when nursing homes were synonymous with long-term care.

Historically, nursing homes have had a reputation for poor quality care and a low quality of life for their residents. Today they have to compete with a growing pool of long term care options that range from home health care to continuing care retirement communities (CCRC). Care quality has become more important than ever for nursing home providers who are trying to compete in an increasingly complex long term care industry.

The drive for nursing home quality has primarily been lead by state and federal oversight bodies in response to widespread concerns about care quality. In 1961 the Public Health Service published the first Nursing Home Standards guide after reviewing state licensure procedures because of consistency problems found during a review process conducted by the Commission on Chronic Illness. These standards have undergone ongoing revision and refinements ever since in attempts to further improve care provision.

The focus of care quality measurement throughout the years has been on structural, process, and outcome quality. Currently structural quality indicators focus on deficiency citations regarding policies related to abuse and patient preferences, employing individuals convicted of abuse, and director certification. Process quality indicators ensure that proper treatments are being conducted, such as: treatment of pressure sores and incontinence, proper catheter implementation, pain management, reduced use of restraints, proper medication treatments, etc. Outcome quality measures range from successful ADL functioning and reduced pressure ulcers to falls prevalence and symptoms of depression.

The article points out that various ambiguities exist with current quality indicators and a large number of quality indicators exist. All of this creates confusion. To make matters worse, today’s nursing home resident population is more complex than before.  The downsizing of the state hospital systems have lead to a growing number of severely mentally ill adults moving into nursing homes. Some of this complexity may hide some positive changes that have been taking place as a result of the nursing home report cards and culture change movement.

The author concludes that despite the breadth and depth of the nursing home quality measurement system it is still very hard to determine what the state of the industry is today.


Source: Castle, N., Fergeson, J. 2010. What is nursing home quality and how is it measured? The Gerontologist 50(4): 426-442.

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