The Rating System

A misleading rating system.

The federal government rates nursing homes on a scale of one to five stars, by comparing each nursing home to state and national averages in three categories: inspection results, staffing, and quality measures. The ratings are the basis of Medicare’s Internet program called Nursing Home Compare.

Of the three categories, “inspection results” are the most revealing. This is where you will find narrative descriptions of any deficiencies assessed during the state surveys or in response to complaints. It is where you can decide for yourself if the complaint was significant, and if the state response was appropriate.

The next category is “quality measures.” These comprise five standards for short term patients (the subacutes) and thirteen for long term. The following examples are the actual figures for two of these measures, from the ratings of the real Winston and Woodglen. Perfect compliance would be 0% for each. Since perfection is nearly impossible for most of these measures, the state or national averages become the de facto minimum standards.

Percent of long-stay residents who were physically restrained:

Winston 8.4%; Woodglen 0%; NJ average 2.5%; national average 1.9%.

Percent of long-stay residents experiencing one or more falls with major injury:

Winston 1.9%; Woodglen 5.6%; NJ average 2.6%; national average 3.3%.

From these figures, you might conclude that Winston is much worse than Woodglen and the state and national averages in the use of restraints, but much better than all three in the incidence of falls with major injury. Could it be that Winston is more likely to use restraints whennecessary, and that restraints can prevent falls?

If you look only at the state and national averages for restraints and falls, the same inverse relationship is evident. It would seem that perfect compliance may not be so perfect after all, at least in the use of restraints.

The third category, “staffing,” is evaluated by measuring nursing staff hours per patient per day. To most people, a five-star rating is an official stamp of approval, meaning excellence. But what does it mean if all nursing homes are understaffed? It would be like a test that the whole class flunked, but the teacher graded “on a curve.”

Furthermore, this metric disregards productivity. While it is easy to count the number of gizmos produced per worker per hour in manufacturing, or the number of artichokes picked per worker per hour in farming, what do you count in health care, where the output is a quality, not a quantity? What is the point of measuring input (hours of nursing), if you can’t measure the resulting output (quality of care)?

Suggestions: Re-examine the standards applied to nursing home care. Discard those which, as in the examples above, are so flawed as to be misleading.

In the case of restraints, for example, there is no doubt that they can be risky, and overuse can be abusive. The potential adverse effects include entanglement, strangulation, muscular deconditioning, pressure sores, agitation, and even, paradoxically, an increased risk of falls. Like all medical and nursing decisions, the decision to restrain has to be individualized and based on an assessment of the benefit vs the risk. It’s the same kind of analysis that takes place every time a doctor prescribes just about any drug. We don’t have 0% standards for the prescription of any drugs that I know, and the potential side effects can be just as harmful as those of restraints.

There is also no doubt that staffing is important, and there is a point where understaffing becomes dangerous. That point will vary from one nursing home to another, and will depend on such factors as work ethic, motivation, morale, job satisfaction, management, and leadership. Staffing turnover rates, which are not part of the federal or state evaluation process and hence not reported, may be a better index of overall quality than staffing alone.

Quality measures, when pursued blindly for compliance, may not be the best indicators of quality of care. Beating a state average is relatively easy with any of these measures, and may result in a five-star seal of approval which is undeserved, or at worst a meaningless seal of mediocrity.

Check out the highest rated senior care agency in the Bay Area here.