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By Daniel Brauner, Rachel M. Werner, Tetyana P. Shippee, John Cursio, Hari Sharma, and
R. Tamara Konetzka
AGING
&
HEALTH
Does Nursing Home Compare
Reflect Patient Safety In
Nursing Homes?
ABSTRACT
The past several decades have seen significant policy efforts
to improve the quality of care in nursing homes, but the patient safety
movement has largely ignored this setting. In this study we compared
nursing homes’performance on several composite quality measures
from Nursing Home Compare, the most prominent recent example of a
national policy aimed at improving the quality of nursing home care, to
their performance on measures of patient safety in nursing homes such
as pressure sores, infections, falls, and medication errors. Although
Nursing Home Compare captures some aspects of patient safety, we
found the relationship to be weak and somewhat inconsistent, leaving
consumers who care about patient safety with little guidance. We
recommend that Nursing Home Compare be refined to provide a
clearer picture of patient safety and quality of life, allowing consumers
to weight these domains according to their preferences and priorities.
The Institute of Medicine (IOM)
inspired the quality improvement
movement for US nursing homes
with its 1986 report titled Improving
the Quality of Care in Nursing
Homes.1The report noted the “shockingly defi-
cient”care that people were receiving in many
government-licensed nursing homes. This re-
port led to the Nursing Home Reform Act of
1987, which mandated extensive regulatory con-
trols; regular inspections; and the development
of a resident-level assessment, data collection,
and care planning system.
It wasn’t until 1999 that another groundbreak-
ing report by the IOM, To Err Is Human, ignited
the patient safety movement.2Focusing on the
prevention of medical errors in acute care, the
patient safety movement inspired a proliferation
of attention focused on creating evidence-based
methods for improving the safety of care,3,4 along
with systems analysts calling for an “integrated
framework”to create a universally applicable
and coherent approach to quality and patient
safety.5
However, until recently, attention to patient
safety in nursing homes remained conspicuously
absent. A 2015 review of evidence on patient
safety in nursing homes concluded that patient
safety outcomes in such facilities have not been
well studied and that patient safety measures
taken from the hospital setting are unlikely to
apply to the nursing home context, with its
unique set of resident characteristics and regu-
latory environment.6A related article noted the
weak and mixed evidence base on interventions
for improving patient safety in nursing homes.7
At the time when patient safety in acute care
was gaining momentum, policy makers re-
mained focused on improving the quality of care
in nursing homes and did not define these efforts
as promoting patient safety. Notably, in 2002 the
Centers for Medicare and Medicaid Services
(CMS) substantially expanded its quality im-
provement efforts by launching Nursing Home
Compare (NHC), a national effort to publicly
report the quality of care in all US nursing
doi: 10.1377/hlthaff.2018.0721
HEALTH AFFAIRS 37,
NO. 11 (2018): 1770–1778
©2018 Project HOPE—
The People-to-People Health
Foundation, Inc.
Daniel Brauner is an associate
professor in the Department
of Medicine, University of
Chicago, in Illinois.
Rachel M. Werner is a
professor of medicine in the
Division of General Internal
Medicine at the Perelman
School of Medicine and a
professor of health care
management at the Wharton
School of Business, both
at the University of
Pennsylvania, and core
faculty at the Center for
Health Equity Research
and Promotion, Corporal
Michael J. Crescenz Veterans
Affairs Medical Center, in
Philadelphia.
Tetyana P. Shippee is an
associate professor in the
Division of Health Policy
and Management, School of
Public Health, University of
Minnesota, in Minneapolis.
John Cursio is a research
assistant professor in the
Department of Public Health
Sciences, University of
Chicago.
Hari Sharma is an assistant
professor in the Department
of Health Management and
Policy, University of Iowa, in
Iowa City. At the time this
research was conducted,
Sharma was a doctoral
student in the Department
of Public Health Sciences,
University of Chicago.
R. Tamara Konetzka
(konetzka@uchicago.edu) is a
professor in the Department
of Public Health Sciences
and in the Department of
Medicine, University of
Chicago.
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homes, thereby informing consumers and in-
centing the improvement of quality. NHC was
modified to feature a five-star composite rating
system for overall quality in late 2008, assigning
each nursing home a rating of one to five stars
(with more stars indicating higher quality).
The notions of health care quality and patient
safety are often conflated. Although they over-
lap, patient safety—in the IOM’s sense of preven-
tion of harm to patients from medical errors2—
may be considered a subdomain of quality that is
associated with distinct approaches, processes,
and outcomes. The emphasis in patient safety is
on identifying errors, determining their cause,
and preventing them from happening again, of-
ten by addressing gaps or failures in the relevant
system of care. In the nursing home setting, res-
ident falls are a good example of a typical patient
safety target. If a nursing home finds that fall
rates are high, a patient safety approach would
examine the circumstances that lead to the falls.
For example, a fall might result from a loss of
balance that may be due to the side effects of
medications, environmental hazards, or lack of
appropriate staffing to provide oversight and
assistance. To prevent future falls, each of these
items might be addressed. Ultimately, these ef-
forts can result in improved patient safety.
A quality improvement perspective, on the
other hand, would consider avoiding adverse
events from errors as one of a broader set of
goals. Quality improvement efforts also work
to enable positive health outcomes beyond im-
proving safety. For nursing homes, some of these
other goals have been defined as improving or
maintaining functional status, treating pain,
maintaining weight, avoiding incontinence and
catheter use, avoiding depression, avoiding
physical restraints and the inappropriate use of
antipsychotic medications, and improving vacci-
nation rates. There has been little attention
placed on differentiating patient safety from oth-
er types of quality outcomes in tools designed to
measure nursing home quality.
Our goal was to examine the relationship be-
tween nursing homes’performance on standard
quality measures overall and on measures spe-
cific to patient safety in nursing homes. To do so,
we focused on quality measures from NHC, a
national, policy-driven public reporting system.
Prior research has established that providers
monitor their ratings and attempt to improve
them,8,9 and NHC scores have generally im-
proved over time.10 Yetit is unclear whether nurs-
ing homes that score well on NHC also perform
well from a patient safety perspective.While NHC
was intended first and foremost to help consum-
ers choose high-quality nursing homes, arguably
it is the extreme examples of poor patient safety
outcomes, sometimes associated with neglect,
that consumers fear most when considering
nursing home placement.
NHC star ratings are based on three domains
of quality: state regulatory health inspections,
staffing ratios, and clinical quality. Each facility
is assigned a star rating for each domain. The
health inspections domain rating is based on the
number, scope, and severity of health deficien-
cies found at state inspections and the number of
repeat visits needed to confirm the correction of
deficiencies, all relative to other facilities in the
state. One key area of patient safety, medication
errors, appears in several potential health defi-
ciencies in this domain. The staffing domain rat-
ing is based on case-mix-adjusted measures of
total nurse hours per resident day and registered
nurse hours per resident day, relative to specific
national thresholds. The clinical quality domain
rating is based on meeting national thresholds
across a group of individual outcome measures,
some of which are patient safety measures.
The overall star rating combines the three do-
mains, using the health inspection star rating as
a base and potentially adjusting the rating up or
down depending on the staffing and clinical
quality star ratings. The health inspections do-
main is given the greatest weight, as it is based on
the results of inspections by state surveyors rath-
er than facility self-reported data and is therefore
considered the most objective. The three individ-
ual domain star ratings are reported on NHC in
addition to the overall star rating. Details of the
process for calculating the star ratings can be
found on the NHC website.11
NHC does include some patient safety mea-
sures, such as pressure sores and injurious falls,
that are often associated in the minds of consum-
ers with neglect. However, because NHC mea-
sures many factors, its signal in terms of patient
safety performance may be weak. How much
NHC reflects patient safety and what consumers
can learn from NHC scores about patient safety
have not been established.
Study Data And Methods
Data Sou rc e We merged data for the first quar-
ter of 2017 from the Nursing Home Compare
archives with data from Certification and Survey
Provider Enhanced Reporting (CASPER) to cre-
ate a nursing home–level data set. The archives, a
historical compilation of ratings published on
the NHC website, provided us with each home’s
overall and domain-specific star ratings and
facility-level performance on individual patient
safety measures that appear in the quality mea-
sures domain. CASPER is a compilation of data
collected by surveyors during regular inspec-
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tions of nursing facilities for Medicare and Med-
icaid certification. From CASPER, we obtained
profit status, payer mix, and chain status, as well
as whether the nursing home was cited for medi-
cation errors in its most recent prior health
inspection—information not published as part
of the NHC archives.
Methods We examined six key measures
of patient safety in nursing homes: injurious
falls, urinary tract infections, and pressure sores
among long-stay residents; pressure sores
among short-stay residents; and two measures
of medication errors. Applying the IOM’s sense
of safety as the prevention of harm to patients
from medical errors,2which we took to include
acts of omission and commission, we defined the
domain of nursing home measures of safety as
negative outcomes that were potentially avoid-
able. These measures have been identified as
safety concerns in the literature as well.6Al-
though the distinction is not always sharp, other
types of NHC quality measures (such as pain
control, functional status, and vaccination rates)
are typically not considered patient safety mea-
sures. Each of our selected outcomes is impor-
tant in that it potentially leads to hospitalization
and subsequent health consequences that are
costly in terms of health care use, morbidity,
and mortality. Some evidence (though mixed)
exists on interventions that could help avoid
each of these outcomes.7Falls could be avoided
through education programs, mobility aids, re-
ducing polypharmacy, and increased or more
consistent staffing levels.12,13 Urinary tract infec-
tions could be reduced through minimizing the
use of urinary catheters and ensuring their prop-
er use, including through better hygiene.14,15
Pressure sores could be reduced through fre-
quent turning of mobility-limited residents and
ensuring proper nutrition and hydration.16 Fi-
nally, medication errors could be reduced
through medication review and improved com-
munication across care providers.17,18
The first four measures (injurious falls, uri-
nary tract infections, and the two pressure sore
measures) were originally based on federally
mandated assessments of residents’condition at
regular intervals, the data from which are com-
piled into the Minimum Data Set 3.0. The data
are reported by the nursing homes and reviewed
by nursing home inspectors. Following technical
specifications for each measure,19 CMS uses
the data to define the cohort at risk. Long-stay
residents are defined as those who have been
residing in the facility for at least 100 days, and
short-stay residents as those with shorter lengths-
of-stay, primarily for post–acute care rehabilita-
tion. In addition, a resident must be considered
at risk for the outcome being measured. For ex-
ample, for the long-stay pressure sore measure,
residents at risk are those with mobility limita-
tions. Each resident who qualifies for the cohort
is then coded as having had the adverse outcome
or not, with regression-based risk adjustment
incorporated into some measures. The resi-
dent-level binary outcomes are aggregated into
a facility-level percentage that is averaged over
four quarters and reported on NHC. We used
these facility-level percentages in our analysis.
The two measures of medication errors are
based on deficiency citations from health inspec-
tions. Each nursing home in the US that qualifies
for Medicare, Medicaid, or both must be in-
spected by state surveyors at least once every
fifteen months to ensure compliance with regu-
lations.When a facility is found to be out of com-
pliance, it is cited with a deficiency that needs to
be corrected. There are hundreds of possible de-
ficiencies. We focused on two related to medica-
tion errors, as these errors are prototypical safe-
ty failures across health care settings. The first
identifies significant medication errors among
one or more residents; the second is for a medi-
cation error rate of more than 5 percent of all
doses prescribed, at any level of significance.
These deficiencies are each defined as equal
to 1 (cited) or 0 (not cited) at the facility level.
Each deficiency is also assigned a score for the
scope and severity of the violation. We ignored
this information because its use complicated
the measure without substantively changing our
results.
Analysis Our primary goal was to examine
the relationship between nursing homes’perfor-
mance on standard quality measures overall and
on measures specific to patient safety in nursing
homes. We first tested the Pearson correlation
between performance on each patient safety
Our results highlight
the differences
between patient
safety and quality
improvement, two
related but distinct
approaches to
improving health care.
Aging
&
Health
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measure and both the NHC overall star rating
and the NHC health inspection star rating. Next,
we tested the correlation between patient safety
measures and NHC ratings graphically by strati-
fying nursing homes on overall star level and
displaying the average percentage for each mea-
sure. The average percentage was calculated as
the unweighted average across facilities in each
star category of the reported percentage of res-
idents who trigger each measure—that is, the
average of facility-level percentages.The medica-
tion error measures represent the average per-
centage of facilities cited for the deficiency.
We used analysis-of-variance tests to test for
groupwise differences. If NHC serves as a good
marker for patient safety, the means should be
highest for one-star homes and lowest for five-
star homes, with a monotonic trend in between.
The patient safety measures we studied are in-
cluded in NHC, so some correlation is to be ex-
pected. At the same time, their role in the overall
score may be limited. Medication errors are cap-
tured only to the extent that nursing homes are
cited with a regulatory deficiency for having iso-
lated or frequent errors and are just two possible
deficiencies among hundreds that feed into a
complex formula for the health inspection score.
That score and associated star rating do not iden-
tify which deficiencies had an impact on the
score. One can find the full health inspection
results, including specific deficiencies cited, on
the NHC website, but these are far less promi-
nent than the star ratings and require multiple
clicks through the website. The other four pa-
tient safety measures we studied (injurious
falls, urinary tract infections, and pressure sores
among long-stay residents; and pressure sores
among short-stay post–acute care residents) are
included as separate measures within the clinical
quality domain on NHC. Although all four mea-
sures are included in the star rating for clinical
quality, they constitute a minority of the twenty-
four measures (sixteen of which are included in
the star rating). Thus, the extent to which patient
safety is reflected in NHC depends on whether
patient safety variation drives, or is correlated
with, overall variation in quality.
Our secondary goal was to identify the types of
nursing homes in which patient safety was likely
to present the greatest challenges. To do this, we
compared rates of patient safety outcomes by
key nursing home characteristics: profit status,
chain status, and payer mix (whether the facility
is dominated by Medicaid, using 90 percent of
residents on Medicaid as our threshold).20
Li mi tati on s Our approach was subject to sev-
eral limitations. First, it is possible that neither
the NHC ratings nor the individual patient safety
measures reflect true quality or safety. Our goal
was to examine the relationships among types of
measures, not to assess their underlying validity.
Second, we examined six typical measures of
patient safety that were available in our data, but
these measures might not provide a complete
picture of patient safety and might not be equally
important.
Third, the relationships we studied might not
be causal and could be the result of unobservable
factors that were correlated with both quality
and safety, such as the ability of facility manag-
ers. We were mainly interested in whether the
NHC ratings acted as a signal for performance
in patient safety and did not intend to explore the
underlying mechanisms.
Study Results
Our national sample of nursing homes in the
first quarter of 2017 is summarized in online
appendix exhibit 1.21 We analyzed data on 15,652
nursing homes, which includes all nursing
homes in the country certified for Medicare,
Medicaid, or both.
We expected measures of patient safety (all of
which were constructed as adverse outcomes,
so that lower rates are better) to have a negative
correlation with the Nursing Home Compare
overall star rating, in which more stars are
better. Exhibit 1 shows that this expected nega-
tive relationship was the norm (with some ex-
ceptions), but the correlations were quite low.
The highest correlation (in absolute value) was
for pressure sores among long-stay residents
(−0.21), and the lowest was for urinary tract
infections among the same population (−0.05).
Exhibit 1
Correlations between patient safety measures and Nursing Home Compare overall and
health inspection star ratings in the first quarter of 2017
Nursing Home Compare star
rating
Safety measure Overall Health inspection
Pressure sores (long-stay residents only) −0.21 −0.13
Pressure sores (short-stay residents only) −0.12 −0.05
Urinary tract infections (long-stay residents only) −0.05 0.04
Injurious falls (long-stay residents only) −0.06 0.02
Medication error rate >5% (all residents) −0.15 −0.17
Significant medication error(s) (all residents) −0.13 −0.14
SOURCE Authors’analysis of data from Nursing Home Compare and Certification and Survey Provider
Enhanced Reporting (CASPER). NOTESThe Nursing Home Compare health inspection star rating is for
the health inspections domain only, which is one of the three components used to calculate the
Nursing Home Compare overall star rating. Long-stay residents are defined as people who have been
residing in the nursing home for at least a hundred days. Short-stay residents are defined as people
with a shorter length-of-stay, usually for post–acute care purposes. All correlations were significant
(p<0:05). Although we focused our analysis on a single quarter for ease of exposition, similar results
were obtained for 2012–16.
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This means that nursing homes with higher star
ratings generally had lower rates of both pres-
sure sores and urinary tract infections, but these
relationships were quite weak. Pearson correla-
tion coefficients in general run from 0 to 1 in
absolute value, with 0 indicating no relationship
between two variables and 1 indicating the stron-
gest possible relationship. The correlations be-
tween patient safety measures and the star rating
for the health inspections domain, which is one
of three components used in the overall star rat-
ing, were generally even lower.
Nursing homes’performance on patient safety
measures appears to track somewhat with the
overall star rating. Notably, for the nondefi-
ciency measures (injurious falls, urinary tract
infections, and the two pressure sore measures),
the differences were most pronounced at the
extremes (one-star versus five-star ratings), with
little meaningful difference between nursing
homes with ratings in the two- to four-star range
(exhibit 2). The one exception was pressure
sores among long-stay residents, which exhib-
ited a more monotonic trend by star rating,
with the difference from one star (7.1 percent)
to five stars (4.2 percent) constituting a clinically
meaningful magnitude. In contrast to most of
the nondeficiency measures, the relationship be-
tween the overall star rating and deficiency cita-
tions for medication errors was more consistent.
The difference between the pattern for medi-
cation-related deficiencies and other patient
safety measures is likely due to the fact that defi-
ciencies inherently affect the health inspection
rating (even if medication-related deficiencies
are only two of many), and the health inspection
rating is weighted more heavily than the other
domains in the overall star rating. Toexplore this
explanation, exhibit 3 displays the relationship
between mean patient safety outcomes and the
star rating in the health inspection domain. Oth-
er than pressure sores, the clinical outcomes had
little relationship with the health inspection star
rating, with two measures (urinary tract infec-
tions and injurious falls) even suggesting a posi-
tive relationship. However, medication-related
deficiency rates still reflected the expected down-
ward slope. Deficiencies for this classic patient
safety issue—medication errors—appeared to be
better correlated with health inspection ratings
Exhibit 2
Nursing homes’performance on patient safety measures in the first quarter of 2017, by Nursing Home Compare overall
star rating
SOURCE Authors’analysis of data from Nursing Home Compare and Certification and Survey Provider Enhanced Reporting. NOTES The
average percentages are calculated as the unweighted average across facilities in each star category of the reported percentage of
residents who trigger each measure—that is, the average of facility-level percentages. The medication error measures represent the
average percentage of facilities cited for the deficiency. Long-stay residents (LS) and short-stay residents (SS) are defined in the notes
to exhibit 1.
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&
Health
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and therefore with overall NHC ratings.
Our exploration of heterogeneity by nursing
home type (profit or nonprofit, independent
or chain, and high or low Medicaid) revealed
no substantial differences in the relationship
between the NHC ratings and patient safety mea-
sures, but at least one nursing home character-
istic was associated with worse absolute perfor-
mance on several of the patient safety measures:
For-profit facilities had higher rates of both de-
Exhibit 3
Nursing homes’performance on patient safety measures in the first quarter of 2017, by Nursing Home Compare health
inspection star rating
SOURCE Authors’analysis of data from Nursing Home Compare and Certification and Survey Provider Enhanced Reporting. NOTES The
average percentages are calculated as explained in the notes to exhibit 2.The Nursing Home Compare health inspection star rating is
for the health inspections domain only, which is one of the three components used to calculate the Nursing Home Compare overall star
rating. Long-stay residents (LS) and short-stay residents (SS) are defined in the notes to exhibit 1.
Exhibit 4
Performance on patient safety measures in the first quarter of 2017, by key nursing home characteristics
Characteristic
For profit Chain High Medicaid
Safety measure Yes No Yes No Yes No
All nursing
homes
Pressure sores (long-stay residents only) 6.0% 5.0% 5.8% 5.8% 6.2% 5.7% 5.7%
Pressure sores (short-stay residents only) 1.1 1.1 1.0 1.2 1.1 1.1 1.1
Urinary tract infections (long-stay residents only) 4.3 5.1 4.4 4.7 3.6 4.6 4.6
Falls (long-stay residents only) 3.2 3.8 3.3 3.4 2.5 3.4 3.4
Medication error rate >5% (all residents) 15.1 9.2 13.8 13.5 15.1 13.6 13.4
Significant medication error(s) (all residents) 7.3 4.0 6.4 6.0 5.7 6.3 6.3
SOURCE Authors’analysis of data from Nursing Home Compare and Certification and Survey Provider Enhanced Reporting (CASPER). NOTES High Medicaid is defined as
having at least 90 percent of residents with Medicaid as their primary payer. Long-stay residents and short-stay residents are defined in the notes to exhibit 1. The
percentages are averages, calculated as explained in the notes to exhibit 2.
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ficiency-based patient safety measures and pres-
sure sores among long-stay residents (exhibit 4).
As for-profit, chain, and high-Medicaid facilities
also tended to score lower on health inspections
and on the NHC star ratings, this result for
for-profit status was consistent with expecta-
tions.22,23 At the same time, rates of urinary tract
infections and falls exhibited the opposite pat-
tern: For-profit, chain, and high-Medicaid facili-
ties reported consistently lower rates than non-
profit and independent facilities did.
Discussion
Our results highlight the differences between
patient safety and quality improvement, two
related but distinct approaches to improving
health care. In nursing homes, quality improve-
ment has been emphasized, with less attention
paid to patient safety. Our results reveal that
Nursing Home Compare, a key policy initiative
aimed at improving quality and empowering
consumers to make better choices, does not pro-
vide them with much information on which to
judge patient safety in nursing homes. Triangu-
lating among several sources of data, we found
that although there was some correlation be-
tween NHC star ratings and patient safety mea-
sures, these tended to be weak—and for many
safety measures, nonexistent. A rating of one
star or five stars seemed to give the most infor-
mation about patient safety, with one-star nurs-
ing homes having higher rates of adverse safety
events and five-star nursing homes having the
lowest rates. However, for nursing homes in the
middle—those with two, three, or four stars—
there was no meaningful difference in adverse
safety events between nursing homes with differ-
ent star ratings. This lack of correlation makes
interpretation more difficult for consumers, as
the difference between a one-star and a two-star
facility is quite different from the difference be-
tween a three-star and a four-star facility. Finally,
nursing home characteristics such as profit and
chain status and payer mix do not serve as con-
sistent proxies for patient safety performance.
Nursing homes that scored well on NHC did
exhibit a more consistent relationship between
the star ratings and two important measures of
patient safety—rates of pressure sores among
long-stay residents and citations for medication
errors—but again, these correlations were small.
Furthermore, a high star rating says little about
the rates of such outcomes as falls and infections.
In fact, we found that those facilities with the
highest star ratings in the health inspections
domain (arguably the most objective domain
we studied) reported more falls and urinary tract
infections. These measures may simply present
different clinical challenges. However, another
possible explanation for this seemingly paradox-
ical finding is that superior facilities may be
better able to identify and track falls and urinary
tract infections, which suggests an ascertain-
ment bias that exposes an inherent problem in
reporting systems such as NHC.
Overall, our findings suggest that NHC does
not adequately reflect patient safety in nursing
homes, even though it contains some patient
safety measures. Accordingly, consumers who
prioritize patient safety might not find NHC a
useful tool with which to assess the performance
of nursing homes. This conclusion suggests one
straightforward and plausible solution: Nursing
home performance on patient safety should be
emphasized more in NHC. Specifically, to rectify
the lack of focus on patient safety in NHC, we
recommend that patient safety measures be iden-
tified as a separate subset within the clinical
quality measures. Precedent exists for this type
of grouping of measures in some state report
cards.24 The development and inclusion of a mea-
sure of medication errors would be a helpful
addition to current patient safety measures,
which could be as simple as explicitly reporting
medication-related deficiencies as a new mea-
sure. Despite the importance of medication er-
rors to patient safety, NHC captures this safety
failure only as one deficiency among many used
to calculate the health inspection star rating.
Raising the visibility of patient safety measures
should serve not only to inform consumers but
also to provide a stronger incentive for nursing
homes to improve on these measures.
More broadly, our findings suggest that the
patient safety movement has not been well inte-
To rectify the lack of
focus on patient
safety, we recommend
that patient safety
measures be
identified as a
separate subset within
the clinical quality
measures.
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&
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grated into the nursing home setting. This is a
missed opportunity, but it may also reflect the
challenges of patient safety in nursing homes.
These include the challenges of providing appro-
priate care to older people with long-term care
needs and the potential incompatibility between
patient safety models and the nursing home
setting, as the models were designed largely in
the context of acute care. Not only do nursing
homes serve particularly complex and vulnera-
ble residents, they are also residents’homes.
Thus, care providers must balance patient safety
needs with residents’autonomy and freedom.
Recent criticisms of patient safety models sug-
gest that many aspects of medical care are too
complex to be corrected using the models, which
are based on industrial and occupational safety
methods.25 This criticism may be best exempli-
fied by the lack of correlation we found between
nursing home star ratings and rates of falls. An
outcome such as a fall represents a much more
complex event, the result of myriad combina-
tions of problems—for example, cognitive im-
pairment, arthritis, and lack of balance. In addi-
tion, other positive factors such as becoming
more mobile with therapy and gaining an in-
creasing degree of autonomy are both associated
with an increasing possibility of falling, com-
pared with being confined to one’s bed. Achiev-
ing this possibility with its increased risk of
falling may represent a major improvement in
quality and greater resident autonomy at the
same time it heralds an adverse event.
In the quest to improve patient safety in nurs-
ing homes, the need to reconcile competing pri-
orities for long-stay residents will present an
ongoing challenge in NHC and other contexts.
However, the answer to this challenge is not to
deemphasize important patient safety concerns.
Rather, NHC needs to do a better job of repre-
senting the competing concerns of long-stay
residents by incorporating measures related to
quality of life, such as resident and caregiver
satisfaction. Although this would be inherently
challenging because these measures are not con-
veniently derived from administrative data, it is
feasible. Indeed, some states have made substan-
tial progress in measuring and reporting resi-
dent and caregiver satisfaction.26–28 A public re-
porting system that included both patient safety
concerns and quality of life would be the most
straightforward way to represent these two po-
tentially conflicting goals in NHC, while allow-
ing consumers to weight the domains according
to their preferences and priorities.
The challenges of patient safety in nursing
homes will remain embedded in the much
broader challenges of providing appropriate
care to elderly people with long-term care needs.
At the same time, the predominant focus in nurs-
ing homes is improving selected aspects of the
quality of care, with an emphasis on nursing
home star ratings. While tweaking NHC to more
completely measure and report patient safety
metrics is important, there remains the more
central challenge of addressing the tensions and
potential incompatibilities that exist between
patient safety, quality of care, and quality of
life in nursing homes. Within the limited scope
of what a public reporting system can do, NHC
should strive to achieve a more comprehensive
picture that reflects all important domains of
quality—including patient safety and quality of
life, both of which are currently underrepre-
sented. ▪
The authors are grateful for funding
for this work from the Agency for
Healthcare Research and Quality
(Grant No. R01HS024967).
NOTES
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