Continuous Quality Improvement in Nursing Homes: Public Relations or a Reality?

Abstract

This article makes the case that many nursing home programs labeled as continuous quality improvement (CQI) efforts do not use trademark methods that have made CQI so effective in other settings. Confusion about the distinction between quality assurance and quality improvement is one barrier to implementing effective CQI programs in nursing homes. Another is that federal regulations and reporting systems prompt nursing homes to focus on outcomes as opposed to care processes. Indeed, data available about care process quality in nursing homes are useful only for regulatory compliance and, perhaps, quality assurance activities designed to avoid survey deficiencies. A radical change in how care processes are documented is needed if CQI is to become a reality in nursing homes, rather than an empty program label. This article discusses how care processes related to daily care provision can be efficiently measured and the data used in CQI programs. It focuses especially on daily care processes implemented by nurse aides because of their paramount importance for enhancing quality of care and life and because research suggests that consumers view this care as both important and problematic. CQI is widely considered the paradigm that guides quality improvement efforts in long-term care settings, at least partly because of its credibility as an effective approach to improving work quality in other settings. However, one of the most important components of CQI—a focus on process measurement—is often absent in nursing home programs, even those labeled as CQI efforts. A major reason why so-called CQI programs in many nursing homes fail to actually use CQI methods is confusion about the difference between quality assurance and quality improvement. Although nursing home providers have a long history of conducting quality assurance activities, they may fail to understand the important distinction between quality assurance and quality improvement because of the common use of the word “quality.” In fact, the approaches are quite different, and failure to understand their differences can be a barrier to implementing effective CQI programs. A first step toward