Frequently Asked Questions
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Nursing home providers speak of assessing both quality of care and quality of life. What’s the difference?
In nursing homes, "quality of care" generally refers to the adequacy of medical and other health-related services, including assessment and treatment of such common problems as depression, dehydration, weight loss, incontinence, pain, bedsores, and the like. "Quality of life (QOL)" is a multidimensional construct that encompasses emotional, health, and functional domains but reaches beyond these to embrace additional dimensions of life. In a recent study, Kane, who has written extensively on the topic, identifies 11 QOL domains pertinent to nursing home life: comfort, functional competence, autonomy, dignity, privacy, individuality, meaningful activity, relationships, enjoyment, security, and spiritual well-being (1).
There is a tendency among many—nursing home staff, policy makers, researchers, even family members—to view nursing homes as places that take care of often very sick people and ignore the fact that they are also places where people live out their lives. As a result, improvement efforts often suffer the same bias, focusing almost exclusively on quality of care, not other aspects of daily life in the nursing home.
You can use our Interview Protocol to develop questions that specifically assess QOL domains other than those related to health care. Our ready-to-use assessment instruments primarily address quality of care, but include questions that probe such QOL dimensions as daily care preferences, availability of choices, dignity, and enjoyment. Be sure to include some open-ended questions that invite residents to comment on what is most important to them.
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Is our facility obligated in any way to share results of a quality improvement assessment with outside surveyors?
No. Federal regulations require nursing homes to establish internal quality assessment and assurance (QA) committees that meet at least quarterly to identify and respond to quality deficiencies within the facility. But according to the U.S. Office of the Inspector General (2), “surveyors do not have access to QA committee minutes due to the confidentiality of these documents mandated (by law).” Surveyors assess compliance with the regulations by interviewing a facility’s administrative staff “to determine that it has a QA committee and that its required membership and frequency of meetings comply with (regulations)” as well as to identify the process the facility uses to respond to quality deficiencies (2).
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Besides interviews with residents, are there other ways to assess quality of care and quality of life?
While resident self-reports are considered the gold standard for assessing quality of life, preferences for care and satisfaction with care, nursing home care quality also can be evaluated using other methods, including proxy reports by family members and staff members who presumably know the resident well, direct observations of residents and staff, and review of medical charts and Minimum Data Set (MDS) assessments. Before adopting any of these methodologies, you should understand the strengths and limitations of each approach.
Proxies: In light of research that shows discordant viewpoints between nursing home residents and their proxies, it seems “unjustified to use proxies as the sole source of data when residents themselves can self-report (3).” Proxies are best consulted for a second, separate opinion or when the resident is unable to communicate at all.
Direct Observations: Structured observations of residents and the care they receive provide an objective measure of care quality, which is useful for determining whether residents are receiving the type and amount of care recommended in clinical practice guidelines and that they themselves prefer. Are residents, in fact, helped in and out of bed at the times they prefer? Are they engaged in social activities that they reportedly like most? Are they actually offered a choice of foods at mealtimes? Though the vast majority of residents, including those with cognitive impairment, can reliably answer these and similar questions (4, 5), we nevertheless recommend a periodic double-check based on direct, independent observations. These, our research has found, provide a stable measure of the status quo and unlike resident reports, are not subject to an acquiescent response bias. Direct observations of care delivery also yield information that is significantly more accurate than medical record documentation of daily care delivery.
Direct observations, however, can be time consuming and difficult to conduct. We don’t recommend observations when the care routines in question occur sporadically throughout the day, such as incontinence care and walking assistance. Observations are most feasible when the targeted care routines or staff behaviors are expected to occur within a specific time period in a known place such as mealtimes, bedtimes, or during morning and afternoon social activities. On these occasions, a supervisory-level staff person can stand ready, checklist in hand, to witness and record elements of usual care. For an example of a standardized observational protocol, see our Mealtime Observational Protocol or our Quality Improvement Observation Form: Meals.
MDS and Medical Chart Data: Evidence of often blatant inaccuracies recorded in medical charts and MDS assessments dictate against using these as the sole data sources for quality improvement efforts. Through a combination of care requirements that exceed industry resources and a survey process dependent on chart reviews, we have created a culture of inaccurate documentation in nursing homes. Under the current system, nursing homes risk penalties if their staff fails to record that such tasks as feeding assistance and repositioning are occurring regularly. So staff members make sure to chart the care as provided consistent with federal regulations, but too often do not actually deliver it. Surveyors, however, cannot easily detect this ultimate failure.
Although medical chart and especially MDS data are widely used to evaluate quality of care in nursing homes—the quality measures publicly reported by the Centers for Medicare and Medicaid Services are derived from MDS data, for example—we have repeatedly found some of this information to be inaccurate (4-6) and so recommend its use only in conjunction with data gleaned from other assessment strategies, such as resident reports or direct observations. In fact, we strongly encourage you to use our resident interview protocols to more accurately assess residents’ care preferences, for the purpose of both MDS assessment and care planning.
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What is the Nursing Home Quality Initiative?
The initiative’s government sponsor, the Centers for Medicare and Medicaid Services explains:
“In November 2002, the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, began a national Nursing Home Quality Initiative (NHQI). The goals of the initiative are essentially twofold:
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What are Quality Improvement Organizations?
Quality Improvement Organizations (QIOs) are government-sponsored organizations that work to improve the quality of health care provided by physicians, hospitals, home health agencies, and nursing homes. QIOs—one in each state—have new responsibilities under the Nursing Home Quality Initiative to help nursing homes improve care quality.
The website of the Centers for Medicare and Medicaid Services (CMS) describes the role of QIOs: “For purposes of the Nursing Home Quality Initiative, QIOs have been given the responsibility to promote awareness and use of publicly reported nursing home quality measures, and to provide assistance to nursing homes in their State which seek to improve performance. QIOs will seek to accomplish this by conveying the message that some nursing homes do better than others in regard to quality measures important to beneficiaries and caregivers, and by making available information and assistance to facilities about how they can achieve better performance.”
You can find your state’s QIO by using the QIO Locater on the website of the American Health Quality Association. You may also want to visit the websites of other state QIOs to see what materials and information they offer nursing homes.
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The Centers for Medicare and Medicaid Services(CMS) Reports Quality Measures for the Nation’s Nursing Homes. Are These Accurate Indicators of Care Quality?
The CMS quality measures—there are 11 of them pertaining to chronic care—report the prevalence of such common conditions in nursing homes as weight loss, incontinence, and the use of physical restraints. The underlying assumption is that differences in the quality of care provided by facilities explain differences in their prevalence quality measures. Thus, for example, if the percentage of residents who experienced a weight loss episode is 10% in Nursing Home A and 35% in Nursing Home B, then Nursing Home A presumably is doing a better job of assessing risk and preventing weight loss than Nursing Home B.
Such assumptions can be fallacious, however. In a series of studies, we found that some quality measures did indeed reflect differences in care quality between facilities (4), while others did not (5-7). In one case, we found that, contrary to popular assumption, nursing homes reporting a higher prevalence of chronic pain among residents did a better job of assessing and treating pain than homes reporting a lower prevalence (4). Overall, we found that very few nursing homes were adequately addressing any of the common problems reflected in the quality measures.
CMS notes that its quality measures are “dynamic” and continue to be refined based on recommendations from a National Quality Forum comprised of nursing home providers, consumers and researchers. It cautions consumers that the “quality measures are only one thing to consider when deciding about nursing home care” and recommends that they visit nursing homes to evaluate care and review other facility information from additional sources—recommendations that we wholeheartedly endorse.
For nursing homes, particularly those with poor scores on their report cards, the quality measures are a concern, as they are meant to be. As such, they have successfully sparked new improvement efforts in nursing homes nationwide. From a quality improvement standpoint, the measures, essentially prevalence rates, provide meager information to guide improvement programs. Though some signal a serious problem within a facility, none show how to correct it. For that kind of guidance, this website can help (see our Training Modules as can the state Quality Improvement Organizations and other organizations found on our Links page).
More FAQs
Our Interview Protocol includes answers to these FAQs:
- Nursing home providers speak of assessing both quality of care and quality of life. What’s the difference?
- Is our facility obligated in any way to share results of a quality improvement assessment with outside surveyors?
- Besides interviews with residents, are there other ways to assess quality of care and quality of life?
- What is the Nursing Home Quality Initiative?
- What are Quality Improvement Organizations?
- The Centers for Medicare and Medicaid Services reports quality measures for the nation’s nursing homes. Are these accurate indicators of care quality?
- More FAQs
Nursing home providers speak of assessing both quality of care and quality of life. What’s the difference?
In nursing homes, "quality of care" generally refers to the adequacy of medical and other health-related services, including assessment and treatment of such common problems as depression, dehydration, weight loss, incontinence, pain, bedsores, and the like. "Quality of life (QOL)" is a multidimensional construct that encompasses emotional, health, and functional domains but reaches beyond these to embrace additional dimensions of life. In a recent study, Kane, who has written extensively on the topic, identifies 11 QOL domains pertinent to nursing home life: comfort, functional competence, autonomy, dignity, privacy, individuality, meaningful activity, relationships, enjoyment, security, and spiritual well-being (1).
There is a tendency among many—nursing home staff, policy makers, researchers, even family members—to view nursing homes as places that take care of often very sick people and ignore the fact that they are also places where people live out their lives. As a result, improvement efforts often suffer the same bias, focusing almost exclusively on quality of care, not other aspects of daily life in the nursing home.
You can use our Interview Protocol to develop questions that specifically assess QOL domains other than those related to health care. Our ready-to-use assessment instruments primarily address quality of care, but include questions that probe such QOL dimensions as daily care preferences, availability of choices, dignity, and enjoyment. Be sure to include some open-ended questions that invite residents to comment on what is most important to them.
Back to Top
Is our facility obligated in any way to share results of a quality improvement assessment with outside surveyors?
No. Federal regulations require nursing homes to establish internal quality assessment and assurance (QA) committees that meet at least quarterly to identify and respond to quality deficiencies within the facility. But according to the U.S. Office of the Inspector General (2), “surveyors do not have access to QA committee minutes due to the confidentiality of these documents mandated (by law).” Surveyors assess compliance with the regulations by interviewing a facility’s administrative staff “to determine that it has a QA committee and that its required membership and frequency of meetings comply with (regulations)” as well as to identify the process the facility uses to respond to quality deficiencies (2).
Back to Top
Besides interviews with residents, are there other ways to assess quality of care and quality of life?
While resident self-reports are considered the gold standard for assessing quality of life, preferences for care and satisfaction with care, nursing home care quality also can be evaluated using other methods, including proxy reports by family members and staff members who presumably know the resident well, direct observations of residents and staff, and review of medical charts and Minimum Data Set (MDS) assessments. Before adopting any of these methodologies, you should understand the strengths and limitations of each approach.
Proxies: In light of research that shows discordant viewpoints between nursing home residents and their proxies, it seems “unjustified to use proxies as the sole source of data when residents themselves can self-report (3).” Proxies are best consulted for a second, separate opinion or when the resident is unable to communicate at all.
Direct Observations: Structured observations of residents and the care they receive provide an objective measure of care quality, which is useful for determining whether residents are receiving the type and amount of care recommended in clinical practice guidelines and that they themselves prefer. Are residents, in fact, helped in and out of bed at the times they prefer? Are they engaged in social activities that they reportedly like most? Are they actually offered a choice of foods at mealtimes? Though the vast majority of residents, including those with cognitive impairment, can reliably answer these and similar questions (4, 5), we nevertheless recommend a periodic double-check based on direct, independent observations. These, our research has found, provide a stable measure of the status quo and unlike resident reports, are not subject to an acquiescent response bias. Direct observations of care delivery also yield information that is significantly more accurate than medical record documentation of daily care delivery.
Direct observations, however, can be time consuming and difficult to conduct. We don’t recommend observations when the care routines in question occur sporadically throughout the day, such as incontinence care and walking assistance. Observations are most feasible when the targeted care routines or staff behaviors are expected to occur within a specific time period in a known place such as mealtimes, bedtimes, or during morning and afternoon social activities. On these occasions, a supervisory-level staff person can stand ready, checklist in hand, to witness and record elements of usual care. For an example of a standardized observational protocol, see our Mealtime Observational Protocol or our Quality Improvement Observation Form: Meals.
MDS and Medical Chart Data: Evidence of often blatant inaccuracies recorded in medical charts and MDS assessments dictate against using these as the sole data sources for quality improvement efforts. Through a combination of care requirements that exceed industry resources and a survey process dependent on chart reviews, we have created a culture of inaccurate documentation in nursing homes. Under the current system, nursing homes risk penalties if their staff fails to record that such tasks as feeding assistance and repositioning are occurring regularly. So staff members make sure to chart the care as provided consistent with federal regulations, but too often do not actually deliver it. Surveyors, however, cannot easily detect this ultimate failure.
Although medical chart and especially MDS data are widely used to evaluate quality of care in nursing homes—the quality measures publicly reported by the Centers for Medicare and Medicaid Services are derived from MDS data, for example—we have repeatedly found some of this information to be inaccurate (4-6) and so recommend its use only in conjunction with data gleaned from other assessment strategies, such as resident reports or direct observations. In fact, we strongly encourage you to use our resident interview protocols to more accurately assess residents’ care preferences, for the purpose of both MDS assessment and care planning.
Back to Top
What is the Nursing Home Quality Initiative?
The initiative’s government sponsor, the Centers for Medicare and Medicaid Services explains:
“In November 2002, the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, began a national Nursing Home Quality Initiative (NHQI). The goals of the initiative are essentially twofold:
- To provide consumers with an additional source of information about the quality of nursing home care by providing a set of MDS-based quality measures on Medicare’s Nursing Home Compare web site, and
- To help providers improve the quality of care for their residents by providing them with complementary clinical resources, quality improvement materials, and assistance from the Quality Improvement Organizations in every state. “Many nursing homes have already made significant improvements in the care being provided to residents by taking advantage of these materials and the support of Quality Improvement Organization staff.”
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What are Quality Improvement Organizations?
Quality Improvement Organizations (QIOs) are government-sponsored organizations that work to improve the quality of health care provided by physicians, hospitals, home health agencies, and nursing homes. QIOs—one in each state—have new responsibilities under the Nursing Home Quality Initiative to help nursing homes improve care quality.
The website of the Centers for Medicare and Medicaid Services (CMS) describes the role of QIOs: “For purposes of the Nursing Home Quality Initiative, QIOs have been given the responsibility to promote awareness and use of publicly reported nursing home quality measures, and to provide assistance to nursing homes in their State which seek to improve performance. QIOs will seek to accomplish this by conveying the message that some nursing homes do better than others in regard to quality measures important to beneficiaries and caregivers, and by making available information and assistance to facilities about how they can achieve better performance.”
You can find your state’s QIO by using the QIO Locater on the website of the American Health Quality Association. You may also want to visit the websites of other state QIOs to see what materials and information they offer nursing homes.
Back to Top
The Centers for Medicare and Medicaid Services(CMS) Reports Quality Measures for the Nation’s Nursing Homes. Are These Accurate Indicators of Care Quality?
The CMS quality measures—there are 11 of them pertaining to chronic care—report the prevalence of such common conditions in nursing homes as weight loss, incontinence, and the use of physical restraints. The underlying assumption is that differences in the quality of care provided by facilities explain differences in their prevalence quality measures. Thus, for example, if the percentage of residents who experienced a weight loss episode is 10% in Nursing Home A and 35% in Nursing Home B, then Nursing Home A presumably is doing a better job of assessing risk and preventing weight loss than Nursing Home B.
Such assumptions can be fallacious, however. In a series of studies, we found that some quality measures did indeed reflect differences in care quality between facilities (4), while others did not (5-7). In one case, we found that, contrary to popular assumption, nursing homes reporting a higher prevalence of chronic pain among residents did a better job of assessing and treating pain than homes reporting a lower prevalence (4). Overall, we found that very few nursing homes were adequately addressing any of the common problems reflected in the quality measures.
CMS notes that its quality measures are “dynamic” and continue to be refined based on recommendations from a National Quality Forum comprised of nursing home providers, consumers and researchers. It cautions consumers that the “quality measures are only one thing to consider when deciding about nursing home care” and recommends that they visit nursing homes to evaluate care and review other facility information from additional sources—recommendations that we wholeheartedly endorse.
For nursing homes, particularly those with poor scores on their report cards, the quality measures are a concern, as they are meant to be. As such, they have successfully sparked new improvement efforts in nursing homes nationwide. From a quality improvement standpoint, the measures, essentially prevalence rates, provide meager information to guide improvement programs. Though some signal a serious problem within a facility, none show how to correct it. For that kind of guidance, this website can help (see our Training Modules as can the state Quality Improvement Organizations and other organizations found on our Links page).
More FAQs
Our Interview Protocol includes answers to these FAQs:
- When should quality improvement interviews with residents be conducted?
- Who should be interviewed?
- Who should conduct the interviews?
- Where should interviews be conducted?
- Is there anything I need to do before conducting the interview?
- How should interviews be conducted?
- What types of questions are most useful for improvement purposes?
- What types of questions should be avoided?
- How do I analyze responses?
- How do we interpret our findings?
