This study distinguishes between organizational char acteristics, regarded as exogenous structural indicators of quality, and those identified as endogenous indica tors of structural care (SC), and investigates the degree to which measures of SC vary by ownership mode (defined by four combinations of chain affiliation and profit status) for 142 certified and licensed nursing facilities (NFs) in a southern state. Structural care mea sures include: licensed and unlicensed staffing, licensed therapists, and case mix-adjusted direct care expendi tures. In addition, seven (four process and three out come) facility-level, risk-adjusted process, and outcome quality scales are developed from 39 resident-level qual ity indicators. A causal model of NF quality arranged according to the structure, process and outcome para digm is specified and estimated using path analysis. Or ganizational data derive from the 1991 Medicaid Cost Report; process and outcome quality measures were de veloped from the Minimum Data Set Plus Resident As sessment Instrument. Using the percentage of Medicaid and private pay residents as covariates, there was a significant overall multivariate effect due to ownership mode on the SC measures. Although there were several significant direct effects, the overall path model was disconfirmed. The multivariate results suggest that some organizational characteristics of structure quality may be more appropriately considered exogenous to causal quality models and therefore have indirect (ver sus direct) effects on process or outcome quality indica tors. The path analysis implies that the structure-pro cess-outcome paradigm may not accurately capture the way NF health care is delivered. Research which consid ers alternate NF quality paradigms needs to be done with samples that are more representative of national proportions of each ownership mode.
Get full access to this article
View all access options for this article.
References
1.
Davis M.On nursing home quality: a review and analysis. Med Care Rev1991;48:129-166.
2.
Sainfort F., Ramsay JD, Monato H.Conceptual and methodological sources of variation in the measurement of nursing home quality: an evaluation of 24 models and an empirical study . Med Care Rev (in press).
3.
Sainfort F., Ramsay, JD, Ferreira PL, Mezghani, L.A first step in total quality management of nursing facility care: development of an empirical causal model of structure, process and outcome dimensions . Am J Med Qual1994;9:74-86.
4.
Gustafson DH , Sainfort F., Van Koningsveld R., Zimmerman D.The quality assessment index (QAI) for measuring nursing home quality. Health Serv Res1990;25:97-127.
5.
Morris J., Hawes C., Fries B., et al. Designing the national resident assessment instrument for nursing homes. Gerontologist, 1990;30:293-307.
6.
TheMultistate Nursing Home Case Mix and Quality Demonstration. Description of the Resource Utilization Group, Version III (RUG III) System, Version 3/7/92. A Working Document bythe University of Michigan, Rensselaer Polytechnic Institute and The Circle, March 1992.
7.
Donabedian A.Explorations in Quality Assessment and Monitoring: The Definitions of Quality and Approaches to Its Assessment, Vol.1. Ann Arbor, MI, Health Administration Press, 1980.
8.
Johnson R., Wichern D.Applied Multivariate Statistical Analysis. Englewood Cliffs, NJ, Prentice Hall, 1988.
9.
Jones DJ, Ziegenfuss JTThe administrative and clinical rationale for the total organization approach to continuous improvement. Qual Assur Utilization Rev1993;8:112-116.
10.
Institute of Medicine.Improving the Quality of Care in Nursing Homes. The Committee on Nursing Home Regulation (National Academy of Sciences). Washington, DC, National Academy Press, 1986 .
11.
Zimmerman D. , Sainfort F., Arling G., et al. The development, analysis and use of resident assessment-based quality indicators. in Rey JC, Tilquin C (eds): Dependency, The Challengefor the Year 2000, Lausanne, Switzerland, Swiss Institute for Public Health Press, 1994, pp 219-225.
12.
Minimum Data Set Plus Training Manual. Natwick, MA, Eliot Press, 1991.
13.
Phillips C.Developing a method of assessing quality of care in nursing homes, using key indicators and population norms. J Aging Health1991;3:407-422.
14.
Blumberg MSRisk adjusting health care outcomes: a methodological review. Med Care Rev1986;43:351-393.
15.
Mausner J., Kramer, S.Epidemiology. An Introductory Text. Philadelphia , W. B. Saunders, 1985.
16.
Engle V., Graney M.Predicting outcomes of nursing home residents: death and discharge to home . J Gerontol1993 ;48:S269-S275.
17.
SAS Institute Inc.SAS User's Guide, Version 6, Vols. 1 and 2, Ed. 4. Cary, NC, SAS Institute Inc., 1990.
18.
Kim J., Mueller C.Introduction to Factor Analysis: What It Is and How to Do It. Newbury Park, CA, Sage Publications, 1987.
19.
Pedhazur E.Multiple Regression in Behavior Research. Explanation and Prediction . Fort Worth, TX, Harcourt Brace Jovanovich, 1982.
20.
James L., Muliak S., and Brett J.Causal Analysis: Assumptions, Models, and Data. Beverly Hills, CA, Sage Publishing, 1982 .
21.
Wright S.The method of path coefficients. Ann Math Stat1934;5:161-215.
22.
Asher H.Causal Modeling. Newbury Park, CA, Sage Publications, 1983.
