A significant influence on nursing home quality has come from federal and state oversight bodies. This is the result of nursing home facility licensure and certification requirements and payments nursing homes receive from federal and state programs. Thus, a history of nursing home quality is intertwined with developments in these federal and state entities. We highlight key federal and state activities that have influenced quality indicators.
State health departments use a licensure process to establish standards for nursing home care. In 1961, the Public Health Service (as part of the U.S. Department of Health, Education, and Welfare) began studying nursing home state licensures after problems were being reported by the Commission on Chronic Illness and by a number of states (IOM, 1986
). The Public Health Service issued the Nursing Home Standards Guide that expressed the need for standardized definitions of nursing homes and other critical terminology (i.e., administrator, advisory council, and resident). This guide also recommended “basic minimum standards applicable to all nursing homes” (Department of Health, Education, and Welfare, 1961
, p. 5). The recommendations consisted of 77 health and safety standards—55 of these were structural quality indicators.
The nursing home industry continued to develop. By the late 1960s, by today's standards, what we would call the modern nursing home industry existed. This industry development and growth were primarily in response to the newly created Medicare and Medicaid programs. Certification was a requirement for nursing homes to receive reimbursement for Medicare and/or Medicaid residents. This certification process occurs approximately yearly and consists of an on-site inspection by a team of surveyors. These surveyors monitor quality of care and assess whether the facility meets standards for certification (see review by Castle, Men, and Engberg, 2007
, of the current certification process).
Despite the entry into the nursing home market of many new facilities, demand outstripped supply. Many nursing homes operated at 100% occupancy, and nursing homes generally did not incur much in the way of competitive pressure from each other. Quality issues remained, and health and safety standards continued to be developed and implemented. By 1974, 90 health and safety standards existed (for what were termed Skilled Nursing Facilities), with 59 of these as structural quality indicators.
In 1977, a new federal organization, the Health Care Financing Administration (HCFA) was created specifically for the coordination of Medicare and Medicaid. As part of this coordination, HCFA assumed jurisdiction over the nursing home certification process and development of standards for certification. HCFA continued to amend the standards and the certification process during the 1980s. One major change included using deficiency citations (Spector & Drugovich, 1989
). That is, a deficiency citation represents an area in which a facility does not meet a Nursing Home Standard for certification.
As part of the improvements to the standards for certification, process quality indicators were introduced. For example, process quality indicators included the prevalence of daily physical restraints, occasional bladder/bowel incontinence without a toileting plan, and indwelling catheters. By 1987, certification consisted of 136 health and safety standards, with 98 of these structural quality indicators and 38 as process quality indicators (IOM, 1986
Despite the amendments to the standards and the certification process that occurred during the 1980s, these generally did not keep pace with the increasingly complicated medical needs of residents. The nursing home industry's solution was to lobby to weaken the certification process. This move by the nursing home industry was contrary to media reports that had identified fraud, abuse, neglect, and poor care in nursing homes. Thus, HCFA commissioned the IOM to examine and report on nursing home regulations (IOM, 1986
). The expert committee assembled by the IOM to examine nursing home regulations concluded that care was “shockingly deficient” (IOM, 1986
, p. 2). This was further verified by a General Accounting Office report (GAO, 1987
). Both the IOM and the GAO reports advocated for stronger government oversight to protect nursing home residents.
The IOM and GAO recommendations were incorporated into Subtitle C of the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). The specific nursing home reform provisions are sometimes referred to as the Nursing Home Reform Act (Emerzian & Stampp, 1993
). The changes were regarded as significant and wide ranging. Forty-seven recommendations were included. A timetable was established for implementation, and not all the changes to standards and enforcement were in effect until 1995. OBRA-87 was largely responsible for the quality environment in which nursing homes operate today. This includes a more stringent survey process, revised care standards, sanctions and remedies, training of nurse aides, and use of the Resident Assessment Instrument (of which the Minimum Data Set (MDS) is a major component).
The IOM report recommended that nursing home regulations should be refocused and to move from assessment of structure and process to an assessment of outcomes. This was facilitated by the MDS. The MDS is a summary assessment of each resident. The original MDS developed in 1990 and implemented in 1991 was redesigned as the MDS 2.0 in 1995 (Rahman & Applebaum, 2009
). This includes measures of residents’ functional status and health conditions. With this information from the MDS, outcome indicators were developed (e.g., falls, behavioral symptoms affecting others, symptoms of depression, bladder/bowel incontinence, and urinary tract infections). In 1999, the Nursing Home Standards for health and safety used during the certification process consisted of 153 standards; 81 of these were structural quality indicators, 48 of these were process quality indicators, and 24 of these were outcome quality indicators.
The progression over time in use of quality indicators as part of the Nursing Home Standards is shown in . For parsimony, this time line is simplified as information from only 5 years are presented. The use of these various SPO quality indicators has evolved gradually, and few watershed events have prompted substantial change (with the exception of OBRA-87).
Progression Over Time in Nursing Home Standards and Deficiency Citations
The drivers of use of these SPO quality indicators are also simplified. The drivers not only include federal/state oversight as described (i.e., as part of the certification process) but also include advances in measurement science and data availability (e.g., the MDS). They also include prompts from external bodies, such as the Joint Commission. The Joint Commission accredits relatively few nursing homes but as part of the Oryx system in the late 1990s emphasized outcomes of providers (Morrissey, 1997
). This invariably had a spillover influence on nursing homes.