The public policies that pertain to quality of care in nursing homes were last stated in the 1986 Institute of Medicine (IOM) Report (Hawes, 1991) and the subsequent Nursing Home Reform Act, which is part of the 1987 Omnibus Budget Reconciliation Act (OBRA) (P.L. 100-203) legislation. These documents remain the basis for regulating the nursing home industry. State and federal regulations drive the evaluation standards for nursing homes, and annual inspections help determine certification for both Medicare and Medicaid reimbursement. Despite considerable efforts, however, regulations cannot guarantee the quality of care received by nursing home residents.
One hurdle is the lack of a universally accepted definition of quality. Donabedian (1988) conceived of quality of care in three categories: structure, process, and outcome. Structure refers to attributes of the physical setting (that is, facility, equipment, money), human resources (that is, number and qualifications of personnel), organizational structure, and methods of reimbursement. Process refers to hands-on patient care. Outcome refers to the effects of care on the patient and patient satisfaction with that care. The three categories are interconnected--good structure increases the likelihood of good process, which increases the likelihood of good outcomes--and together constitute quality of care.
Regulations concentrate on the process and structural aspects of quality of care because they are easy to measure and document. Nursing homes routinely collect and report information about their performance. Our case study site measures quality of clinical care with 24 clinical quality indicators including fractures, weight loss, prevalence of pressure ulcers, use of antipsychotic medications, and so forth. These indicators are monitored on a monthly basis. Structural characteristics such as staff-to-patient ratios, and process assessment (the provision of actual health care) are used as proxy measures to demonstrate quality, but compliance with the regulations on those measures will still not ensure that the resident receives quality care (Davis, 1991).
Outcome assessment is the most consumer-oriented portion of Donabedian's framework; it alone addresses the actual impact of care on the resident's physical and emotional well-being (Davis, 1991). The IOM committee, in 1986, and Congress, in the 1987 OBRA regulations, agreed that it was important to focus on "the quality of life experienced by residents, as well as making the regulations more resident-centered and outcome-oriented" [emphasis added] (Hawes, 1991, p. 158). Resident-centered care emphasizes quality of care as defined by the resident. Although the views of all stakeholders are important, it is vital to focus on the residents' views because they may not agree with the views of others about the importance of many items (Young, Minnick, & Marcantonio, 1996), and they are difficult to assess accurately. Many believe there has been too little emphasis on the quality aspects most meaningful to residents (Davis, Sebastian, & Tschetter, 1997).
A customer satisfaction survey can monitor concerns about nursing home quality. In fact, a survey can empower residents, because its primary purpose is to communicate "the point of view of the people for whom long-term care services are created in the first place" (CohenMansfield, 2000, p. 1). Despite well-known limitations to surveys of nursing home residents (such as fear of reprisals, difficulty in interviewing residents with dementia, disagreement about what to measure), satisfaction surveys may be the best way to comprehend and address resident-identified problems. It is interesting that quality assurance mechanisms that have looked at other areas are now beginning to focus on resident rights and on techniques to assess resident satisfaction with care (Applebaum, Straker, & Geron, 2000).
Social workers are essential to this type of assessment given their communication and interpersonal skills and training. …