Magazine article Aging Today

How to Improve Nursing Homes-One Expert's 30-Year View

Magazine article Aging Today

How to Improve Nursing Homes-One Expert's 30-Year View

Article excerpt

When this editor was starting to cover issues in healthcare and aging in 1982, one of the first lecturers I heard on long-term care policy was Charlene Harrington, who was as sharp-minded as the RN and PhD on her business card might suggest. Today, Harrington is a professor at the School of Nursing, University of California, San Francisco (UCSF), the associate director of UCSF's John A. Hartford Center of Geriatric Nursing Excellence, and the director of the university's Health Policy in Nursing Doctoral Nursing Program.

Sadly, Harrington continues to find no improvement in the quality of nursing home care more than three decades after she began to study long-term care, often for the federal government and state agencies. In the following article, based on her recent testimony before the U.S. Senate Special Committee on Aging, Harrington explains what's wrong with U.S. nursing homes and what can be done to improve them.

I first became aware of the serious quality problems in nursing homes in 1976, when I was director of the California Licensing and Certification program. At that time, about one-third of California nursing homes were providing substandard care. Today, more than 30 years later, the substandard care in many nursing homes results in harm, jeopardy and premature death for residents every year. Dozens of studies by researchers, the U.S. Government Accountability Office (GAO), the U.S. Department of Health and Human Services Office of Inspector General and others have documented the persistent quality problems in a sizable subset of the nation's nursing homes-20 years after the federal Nursing Home Reform Act was passed in 1987.

Three areas need to be improved to ensure high-quality nursing home care: the enforcement of existing laws, nurse staffing levels and financial accountability for government funding.


The GAO should be commended for its 2007 report, "Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes From Repeatedly Harming Residents" (GAO-07-241). The report found that the number of serious deficiencies and sanctions declined in four states between 2000 and 2005, and that this decline was related to weaknesses in the survey system and inadequate use of sanctions. Often, quality problems are not detected-and when they are, the scope and severity of problems have been underrated. According to the report, nursing homes with serious quality problems continued to cycle in and out of compliance, causing harm to residents.

The GAO report recommends that the federal Centers for Medicare and Medicaid Services (CMS) improve the policy for imposing immediate sanctions for violations, strengthen the deterrent effect of certain sanctions, enhance the enforcement of laws involving facilities with a history of noncompliance, and increase the effectiveness of the data reporting systems on enforcement.

At UCSF our studies of the wide variations in enforcement procedures have found that states with better enforcement are those that receive higher allocations from CMS for the state agency that surveys facilities for compliance. State enforcement practices could be improved, in part, by increased funding for state survey agency activities.


Nursing home quality rests entirely in the hands of nurses, nursing assistants and other providers who deliver formal care and aid. Nursing homes are labor intensive and require well-educated, experienced nursing staff, who demonstrate compassion. Numerous studies reported by the Institute of Medicine (IOM) have shown the positive relationship between nurse staffing and quality of care. Higher levels of staffing hours per resident, particularly hours by registered nurses, have been consistently and significantly associated with overall quality of care, with outcomes ranging from improved resident survival rates to lower hospitalization rates. In addition, better staffing is associated with lower worker injury rates and less litigation. …

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