Modules - Quality-of-life Assessment
Selecting Residents to Interview:
Designing and Analyzing Interview Questions:
Nursing Home Report Cards:
Other Quality-of-Life Studies:
SELECTING RESIDENTS TO INTERVIEW
Selecting Nursing Home Residents for Satisfaction Surveys
Sandra F. Simmons, John F. Schnelle, Gwen C. Uman, A.D. Kulvicki, K.O. Lee, and Joseph G. Ouslander, 1997, in The Gerontologist, 37(4):543-550.
Many cognitively impaired nursing home (NH) residents are excluded from interviews measuring quality of life or care based on the belief that these residents cannot accurately answer questions. These exclusions are based on subjective criteria and ignore individual differences among cognitively impaired NH residents. This study describes a screening rule based on Minimum Data Set (MDS) data that provides an objective method for identifying residents capable of accurate report. Sixty percent of a sample of 83 NH residents who could answer yes or no questions about their care could do so accurately. Eighty-one percent of the sample was correctly classified by the MDS Cognitive Performance Scale (CPS). The MDS-derived CPS score ranges from 0 (cognitively intact) to 6 (severely impaired); and, residents with CPS scores of 2 or less were capable of accurately describing the daily care that they received from staff. The disadvantage of using MDS-derived CPS to select residents for interview is that it is cumbersome to calculate. (Back to top)
The Identification of Residents Capable of Accurately Describing Daily Care: Implications for Evaluating Nursing Home Care Quality
Sandra Simmons, John F. Schnelle, 2001, in The Gerontologist, 41(5):605-611.
This study confirmed findings from the study cited above but also simplified the resident selection criteria for ease of use in practice by both nursing home and survey staff. Specifically, this study showed that the Minimum Data Set (MDS) derived Recall Subscale, which is part of the Cognitive Performance Scale (CPS), can be used to identify residents who can provide accurate self-reports of their care. Based on interview responses from 186 incontinent residents, the study showed that selecting residents who scored two or more on the four orientation items that comprise the recall subscale correctly identified accurate self-reporters 70% of the time. Surprisingly the use of a standardized cognitive performance test (i.e., the Mini-Mental State Exam) did not improve upon the predictive value of the MDS Recall subscale. The authors write: "Based on the results of this study, the most time-efficient and simple approach to identify incontinent NH residents capable of accurately describing the care that they receive would be to calculate the MDS Recall subscale score and include all residents in the interview who score 2 or higher on this scale. This calculation could be completed quickly if one has access to the MDS information, which is available for all NH residents." The use of the highly efficient MDS Recall scale to identify residents capable of accurate self-report is preferable to the subjective approaches to screening often used in nursing homes. Moreover, it is even preferable to use of the MDS-derived CPS scale, which is much more difficult to calculate. (Back to top)
Improving Nursing Home Quality Assessment: Capturing the Voice of Cognitively Impaired Elders
John F. Schnelle, 2003, in J. Gerontol. A Biol. Sci. Med. Sci., 58:M238-M239.
In this editorial, a commentary on a research report by Kane, et al. in the same issue (1), Dr. Schnelle argues that " the current quality assessment process should bolster efforts to obtain information directly from nursing home (NH) residents, partly because no one is better positioned to comment on quality than residents themselves, but also because their reports will provide balance to the extensive information currently obtained from staff reports. As it now stands, the state and federal survey process for evaluating NH home care is biased against resident assessments of the care they receive. Although some NH residents are interviewed about their care during on-site survey visits …many more residents could be interviewed than is currently the case." He identifies a need for further work to ensure that quality assessments based on resident interviews are time- and cost-efficient to implement, do not unduly burden residents, and are designed so as to minimize acquiescence response bias. But noting that specific guidelines for selecting residents to interview are now available (see the first two studies on this page [bookmark to top of page]), he concludes: "The question now is not, 'Should we improve the quality assessment process by interviewing more residents?' but rather, 'How do we interview more residents within the cost constraints of the quality assessment process?'" (Back to top)
DESIGNING AND ANALYZING INTERVIEW QUESTIONS
Strategies to Measure Nursing Home Residents' Satisfaction and Preferences Related to Incontinence and Mobility Care: Implications for Evaluating Intervention Effects
Sandra F. Simmons and John F. Schnelle, 1999, in The Gerontologist, 39(3):1-11.
This study compared four different interview strategies to measure 111 incontinent nursing home residents' "met needs" related to incontinence and mobility care. In one method-perhaps the most commonly used strategy in nursing homes-residents were asked direct satisfaction questions (e.g., "Overall, are you satisfied with how often someone helps you to walk?"). A second method asked residents about their preferences for care (e.g., "Would you like for someone to help you walk more often?" "How many times during the day would you like someone to help you to walk?") The last two methods compared resident reports about how often they preferred to receive care to how often they actually did receive care based first on research staff observations (Method 3) and then on their own reports (Method 4). Incontinent residents who passed a simple responsiveness screen (residents were asked to state their name or identify two common items) were interviewed. Each resident was interviewed on two occasions to evaluate the stability of their responses. Results showed that 75% of the residents provided logically consistent responses, a finding that dispels the widespread assumption that only a small subset of cognitively intact residents can provide meaningful information about the care they receive.
A Comparison of Methods to Assess Nursing Home Residents' Unmet Needs
Of the four methods tested, the third method proved superior with respect to response stability. Method 1 yielded the most unstable responses. The third method also revealed comparatively higher levels of "unmet need," but by doing so, is considered more useful for guiding improvement efforts. The authors acknowledge that Method 3 is the most time-consuming to implement because it requires objective, direct observations of the care actually provided to residents. They argue, however, that this type of monitoring should be conducted at least annually in any case. (Back to top)
Lené Levy-Storms, John F. Schnelle, and Sandra F. Simmons, 2002, in The Gerontologist, 42(4):454-461.
This study compared three interview methodologies to assess nursing home residents' unmet needs for daily care. The researchers interviewed 70 residents across seven Activity of Daily Living (ADL) care domains using three types of questions:
Nursing Home Residents' Perceptions of Care: A Method for Coding Their Comments into Unmet and Met Needs
Estimates of the proportion of residents with unmet needs were significantly higher with the discrepancy and open-ended measures as compared to the direct satisfaction measures across most ADL care domains. The analysis of residents' responses to open-ended questions produced the most useful information for individualizing aspects of technical care and assessing the interpersonal quality of care, whereas the discrepancy questions elicited specific information useful for changing the frequency or occurrence of ADL care. Interview methodologies that directly ask residents questions about satisfaction with ADL care are the least useful for designing improvement interventions.
- direct satisfaction questions about ADL care (e.g., "Overall, are you satisfied with how often someone helps you to walk?"),
- questions that compared residents' preferences for ADL care frequency to their perceptions of the ADL care actually delivered (discrepancy measure, e.g., "How many times during the day would you like staff to help you walk?" vs. "How many times during the day do staff help you to walk?"), and
- open-ended questions that asked what residents wanted changed about ADL care.
The authors underscore the importance of including open-ended questions in nursing home care assessments, while acknowledging that these questions require significantly more time and skill to record and code than closed-ended questions. They recommend asking open-ended questions at the start of an improvement project, and converting the information they elicit into closed-ended preference questions, which can then be asked at regular intervals to continuously monitor care quality. (Back to top)
Lené Levy-Storms, Sandra F. Simmons, Veronica F. Gutierrez, Dana Miller-Martinez, Kelly Hickey, and John F. Schnelle. Under review at The Gerontologist.
This study reports on a reliable method for coding nursing home residents' comments about the care they receive and the care they would like to receive. Nursing homes-and the researchers who study them-often use close-ended questions to assess residents' satisfaction with care. Recent studies, however, suggest that answers to these questions may be skewed by response acquiescence, or the tendency of residents to provide mostly satisfied responses, even when problems with the quality of care are known to exist. Open-ended questions and spontaneous remarks by residents during interviews have not been analyzed systematically in most studies, in part because a standardized coding protocol has been lacking.
NURSING HOME REPORT CARDS
In this study, 67 residents in one nursing facility were asked both closed- and open-ended questions about their perceptions of care in eight domains: social activities, walking, mealtime, dressing, showering, getting in and out of bed, toileting, and pad changes. Their comments were then codified as to whether they indicated a desire for change. If the comment did not indicate a desire for change, then it was assessed for indicators of reduced expectation (e.g., "They do the best they can."). Overall, 66% of the residents made comments indicative of unmet needs in at least one care domain. Of these residents, 52% and 84% had unmet emotional support (ES) or instrumental support (IS) needs, respectively, in at least one of the eight domains. Among residents with met needs, 26% had reduced expectations for care.
Coding and analyzing residents' comments supplements information from closed-ended questions in several ways. First, over 30% of the residents provided comments to only open-ended questions, so their viewpoints would have been missed had only closed-ended questions been used. Second, by recording residents' own words, subtle but often specific aspects of both technical and interpersonal aspects of care delivery were assessed. And finally, this study's methodology was sensitive enough to identify reduced expectations among residents who otherwise reported only met needs.(Back to top)
Designing a Report Card for Nursing Facilities: What Information is Needed and Why
Charlene Harrington, Janis O'Meara, Martin Kitchener, Lisa Payne Simon, and John F. Schnelle, 2003, in The Gerontologist, 43: 47-57.
Abstract from the paper: "This article presents a rationale and conceptual framework for making comprehensive consumer information about nursing facilities available. Such information can meet the needs of various stakeholder groups, including consumers, family/friends, health professionals, providers, advocates, ombudsman, payers, and policy makers. The rationale and framework are based on a research literature review of key quality indicators for nursing facilities. The findings show six key areas for information: (a) facility characteristics and ownership; (b) resident characteristics; (c) staffing indicators; (d) clinical quality indicators; (e) deficiencies, complaints, and enforcement actions; and (f) financial indicators. This information can assist in selecting, monitoring, and contracting with nursing facilities. Model information systems can be designed using existing public information, but the information needs to be enhanced with improved data." (Back to top)
The Minimum Data Set Weight Loss Quality Indicator: Does it Reflect Differences in Care Processes Related to Weight Loss?
Sandra F. Simmons, Emily T. Garcia, Mary P. Cadogan, N.R. Al-Samarrai, Lené Levy-Storms, Dan Osterweil, and John F. Schnelle, in Journal of the American Geriatrics Society, 2003;51(10):1410-1418.
Federal regulations require nursing homes to complete resident assessments periodically using the Minimum Data Set (MDS) assessment protocol. Results are used to generate quality indicators (QI) for each facility as a means of identifying poor outcomes in a number of clinical areas. But the use of QIs as a measure of quality of care is controversial due in part to concerns about the accuracy of staff-generated MDS data.
A Minimum Data Set (MDS) Prevalence of Pain Quality Indicator: Is it Accurate and Does it Reflect Differences in Care Processes?
This study collected independent data that showed that the MDS-derived "prevalence of weight loss" QI does indeed discriminate between nursing homes with a high percentage of residents at risk for weight loss and those with a much lower percentage of at-risk residents. A desirable, low score on this QI, however, did not mean that the facility provided qualitatively better feeding assistance to its residents. In fact, results indicated that all the facilities needed to improve the adequacy and quality of their feeding assistance. The one consistent, between-group difference in care quality was that staff in low-weight loss prevalence homes were more likely to interact socially and verbally prompt residents to eat than staff in high-weight loss prevalence homes. Other studies have shown that verbal encouragement to eat and social interaction at mealtimes leads to increased food consumption among the elderly. (Back to top)
Mary P. Cadogan, John F. Schnelle, Noriko Yamamoto-Mitani, Georgina Cabrera, and Sandra F. Simmons, accepted for publication in J Gerontology: Medical Sciences;59A; M281-M285.
This study, conducted in 16 nursing homes, collected independent data that showed that the MDS quality indicator (QI) for "prevalence of pain" accurately discriminates between facilities. Interpretation of the pain indicator requires caution, however. Rather than reflecting poor quality, a high prevalence of pain according to the MDS was associated with better pain assessment and treatment. This study reports results from eight nursing homes that scored in the upper 75th percentile on the prevalence of pain QI and eight nursing homes that scored in the lower 25th percentile for the same QI. Research staff collected data through interviews with 255 residents and medical record reviews.
The Minimum Data Set (MDS) Urinary Incontinence Quality Indicators: Do They Reflect Differences in Care Processes Related to Incontinence?
In high prevalence homes, 47% of the participating residents had pain documented on their most recent MDS and the same percentage reported symptoms of chronic pain during interviews with research staff. By contrast, in low prevalence homes, 9% of the participating residents had pain documented on their most recent MDS, but 27% reported chronic pain symptoms in interviews. On every measure of pain-related care quality independently evaluated in this study (detection, assessment, treatment, and documentation), nursing homes with a high reported prevalence of pain on the MDS performed better than nursing homes with low MDS pain prevalence. One explanation, according to the authors, is that a higher prevalence of pain among residents sensitizes nursing home staff to the need for better overall care for pain. (Back to top)
John F. Schnelle, Mary P. Cadogan, June Yoshii, Nahla R. Al-Samarrai, Dan Osterweil, Barbara M. Bates-Jensen, and Sandra F. Simmons, 2003, in Medical Care, 41(8):909-922.
This study, conducted in 14 nursing homes, collected independent data that showed that the only two currently used MDS incontinence quality indicators (QIs)--"prevalence of incontinence" and "prevalence of incontinence without a toileting plan"-- do not reflect real differences in the quality of incontinence care provided to residents. None of the facilities, for example, evaluated residents' responsiveness to toileting assistance. Residents who received toileting assistance were comparatively less cognitively and physically impaired, which suggests that staff used invalid resident characteristics to determine who received scheduled toileting assistance. Although facilities with better scores on both MDS incontinence QIs were more likely to document in medical records that residents received toileting assistance, there were no difference between homes in resident reports of the assistance they actually received. Across all facilities, participants capable of accurate self-report said they received an average of 1.8 toileting assists per day (range 1.6-2.0), which is insufficient to improve urinary incontinence but consistent with the findings from previous studies. There also were no differences in reports of received assistance between residents noted in the MDS as being on scheduled toileting and those who were not. This finding points to disturbing discrepancies between the toileting assistance care documented in medical charts and the care actually provided. (Back to top)
The Minimum Data Set Pressure Ulcer Indicator: Does it Reflect Differences in Care Processes Related to Pressure Ulcer Prevention and Treatment in Nursing Homes
Barbara M. Bates-Jensen, Mary Cadogan, Dan Osterweil, Lené Levy-Storms, Jennifer Jorge, Nahla Al-Samarrai, Valena Grbic, and John F. Schnelle, 2003, in J Am Geriatrics Society, 51(9): 1203-12.
This study showed that, despite assumptions to the contrary, nursing homes with low prevalence rates for pressure ulcers (PU) do not provide better PU care than homes with high prevalence rates. In general, all 16 nursing homes in this study performed poorly on screening and preventing PUs, though they did better at management once a PU was present.
OTHER QUALITY-OF-LIFE STUDIES
The study examined 16 quality indicators related to PU care in two groups of nursing homes: Six homes with a high prevalence of PU and 10 with a low prevalence of PU. At the time of the study, prevalence of PU as reported in Minimum Data Set (MDS) resident assessments was a publicly reported quality indicator for nursing homes. (This quality indicator has since been revised.) The researchers observed care, interviewed caregivers, reviewed medical records, and obtained data from wireless thigh movement monitors.
They found few differences between the two study groups. Homes with low PU prevalence rates-and low scores on the MDS PU quality indicator-did not provide better care. Nursing homes with higher rates of PU, however, were more likely to use pressure-reduction surfaces and were better at documenting wound characteristics.
None of the facilities documented PU risk on admission and once a week for four weeks, though most clinical guidelines recommend periodic reassessments for high risk residents. Also of concern was a wide discrepancy between medical record documentation and actual care delivery. For example, neither high- nor low-prevalence homes routinely repositioned PU risk residents every two hours, as recommended in clinical practice guidelines, even through two-hour repositioning was documented in the medical record for nearly all participating residents.
"These data raise questions about the usefulness of this (PU quality) indicator for improvement, survey, or consumer education purposes," the investigators conclude. "In particular, it should not be assumed that homes that score well (low prevalence) on the MDS PU quality indicators are providing good or better care than homes that report a high prevalence. A more accurate interpretation is that all homes provide relatively poor preventive care and that improvement is needed in most care process areas other than treatment once a PU is present." (Back to top)
Family Members' Preferences for Nutrition Interventions to Improve Nursing Home Residents' Oral Food and Fluid Intake
Sandra F. Simmons, Helene Y. Lam, Geetha Rao, and John F. Schnelle, 2003, in Journal of the American Geriatrics Society, 51(1):69-74.
What nutrition interventions do family members prefer for relatives in nursing homes who are at risk for undernutrition and weight loss? Given a choice of six possible interventions, the 105 resident representatives, mostly family members, who completed this study's written questionnaire, rated them, in order of preference, as follows:
Quality Assessment in Nursing Homes by Systematic Direct Observation: Feeding Assistance
These findings indicate a clear preference among residents' significant others for behavioral and environmental approaches over the use of supplements or pharmacological approaches to improve food and fluid intake. The authors point out that resident preferences could not be assessed directly in this study due to the questionnaire's rather complex design, but future studies should attempt to correct this shortcoming. (Back to top)
- Improve quality of food
- Improve quality of feeding assistance
- Provide multiple small meals and snacks throughout the day
- Place resident in preferred dining location
- Provide oral liquid nutritional supplements
- Provide an appetite stimulant medication
Sandra F. Simmons, Sarah Babineau, Emily Garcia, and John F. Schnelle, 2002, in Journal of Gerontology: Medical Sciences, 57 (10): M665-M671.
This study showed that a standardized protocol that calls for direct observations of care can be used to accurately measure the adequacy and quality of feeding assistance in nursing homes. The observational protocol, designed for routine use by licensed nursing home staff, is a practical alternative to reviewing medical chart information to monitor quality of care. Prior studies have shown that chart information is unreliable in that it consistently overestimates residents' food and fluid intake. The observational protocol assesses the ability of nurse aides to accomplish four tasks deemed critical to the delivery of adequate feeding assistance. These tasks include: 1) accurately identifying residents with clinically significant low oral food and fluid intake during mealtimes; 2) providing feeding assistance to at-risk residents during mealtimes; 3) providing feeding assistance to residents identified in the Minimum Data Set as requiring staff assistance to eat; and 4) providing a verbal prompt to residents who receive physical assistance at mealtimes. The study showed that the protocol is reliable, replicable, and feasible to implement. One staff person can use it to reliably observe 6 to 8 residents during one mealtime period. (Back to top)
Urinary Incontinence Treatment Preferences in Long-Term Care
Theodore M. Johnson, Joseph G. Ouslander, Gwen C. Uman, and John F. Schnelle, 2001, in Journal of the American Geriatrics Society, 49:710-718.
What treatments for urinary incontinence are preferred for nursing home residents? This study asked this question of frail older adults, family members of nursing home residents, and long-term-care nursing staff. Among all respondents, 85% "definitely" or "probably" preferred diapers, and 77% "definitely" or "probably" preferred prompted voiding to indwelling catheterization. There were, however, differences among the respondent groups. Nurses preferred prompted voiding to diapers more than did older adults or family members. Older adults, compared with family and nurse respondents, more strongly preferred medications to diapers. In open-ended responses, older adults (nine of them nursing home residents and 70 residential care residents) said they would choose a treatment based in part upon criteria of feeling dry, being natural, not causing embarrassment, being easy, and not resulting in dependence. The comments also indicated that older adults and family members did not believe nursing home staff would provide prompted voiding often enough to improve continence. Because of the divergence of opinions among different proxy respondents, the researchers recommend that, when possible, nursing home residents be asked first for their treatment preference. (Back to top)
A Cost and Value Analysis of Two Interventions with Incontinent Nursing Home Residents
John F. Schnelle, Emmett Keeler, Ron D. Hays, Sandra F. Simmons, Joseph G. Ouslander, and Albert L. Siu, 1995, in Journal of the American Geriatrics Society, 43:1112-1117.
In this study, family members of nursing home residents and older board-and-care residents were asked in a written survey to compare the value of interventions that improve continence and mobility to other nursing home perks such as improved meals or moving to a more private room. By wide margins, the respondents rated the functional improvement programs higher than the other, more customary options. The top-rated programs were a physical therapy program that provides 15 additional minutes of supervised activity and exercise a day, an incontinence prevention program that cuts the number of wetness episodes in half for a resident, and a program that improves the amount a resident can walk by a few minutes a day. These services were significantly preferred to any of the bottom-rated, non-rehabilitative services, which included having one additional nurse aide on the unit during the day shift, moving from a triple room to a single, from a triple room to a double, and from double room to a single. The researchers point out that while nursing home consumers often complain about privacy and food issues, they rarely request services that improve continence and walking, most likely because they are unaware of such rehabilitative programs. (Back to top)
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- Kane RA, Kling KC, Bershadsky B, et al.. Quality of life measures for nursing home residents. J Gerontol Med Sci.