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Can Apples & Oranges Be Compared?

Published June 30, 2008 10:20 AM by Brian Garavaglia
The Bush administration advocated the need to rate nursing homes on a similar ranking system to that found in the hotel and restaurant industry. At first blush this seems an intuitively simple and consumer friendly system. Why not have consumers that are looking to place their loved ones in nursing homes have a simple system of one through five stars to help with their search. It appears to be a completely simple and adequate system that can be put in place quickly to assist the public with nursing home quality. However, remember when your algebra teacher said you cannot add apples and oranges? Can the rules be overlooked here? Can nursing homes be ranked similarly to hotels and restaurants? I think this question begs further consideration.

Currently there are a number of tools that are used to rank nursing homes. Probably the best known is the Medicare site that compares nursing homes on the basis of their number and type of citations. The information for this site is compiled from surveys of nursing homes conducted by surveyors. Yet, what is known about the system as it exists is it is far from perfect. In fact, there is a considerable level of subjectivity that is found in the survey process. Surveyors often make judgments about facilities prior to entering the facility. Furthermore, there is considerable variation from one surveyor to another as well as from one survey team as compared to another. In addition, states demonstrate a considerable level of variation among their surveyors. Surveys and the level of stringency found to exist in the survey process from one state to another differ considerably. Therefore, the system as a whole is filled with considerable variability that often is difficult to account for and would dramatically influence a supposed standardized rating system. 

Another problem that exists is that hotels and restaurants do not have to rely on Medicare and Medicaid funding, or other third party funding, as do most nursing care facilities. Consumers in these other industries often pay up front with a fee set by the establishments. This allows hotels and restaurants to know their revenues and cash flows up front. However, in the nursing home industry, state and federal entities and third party insurance regulations place great restrictions on what earnings are actually realized. Most nursing homes operate on very small margins and therefore, many fail to have the funds to engage in extensive renovations as well as have the comfort to pay out large amounts of money for extensive and specialized staffing. In fact, there is also considerable statistical variability between nursing homes and the companies that own them, with larger companies often able to incur much greater capital expenditures to achieve the homelike environment that many seek.        

So you may ask, what does all of this have to do with ranking nursing homes? As I hope has been illustrated so far, the complexity for a simple rating system is simply, not that simple. Even with hotels and restaurants, this simple five star system is not so simple. First, how many of us have been in supposed five star restaurants and hotels, only to come away quite disappointed in the food or service we encountered. Also, how many of us have come away saying that I wish I would have went instead to the smaller community restaurant or hotel where I get better quality and more food to eat for the money or better and higher quality customer service. 

Yet, these hotels and restaurants, which are smaller and less spacious, are often viewed as the red-headed stepchild of the hotel and restaurant industry, especially when compared with their four and five star competitors. The same holds true for the nursing home industry, where the commodious environment of new, modernized, and large-scale facilities hold a primacy effect on those that rate these facilities. 

For a true nursing home rating system to work, the rating system must be multifaceted and use many different indices for measurement. If the rating system is only going to be based on facility survey results, a less than true picture of the facilities that are being rated will result. This is not to say survey results should not be used. For sure survey results are an important indicator of the health of a nursing home facility. However, as was mentioned above, it does have its flaws and our current survey system, which has improved over the pre-OBRA years, is still predominately a subjective system. So with the subjective nature of the survey process, coupled with considerable differences found among state survey agencies as it relates to the level of nursing home survey stringency, other factors have to be considered in ranking nursing homes. 

One important consideration is the type of people working in the facility and not just the number. Often, facilities are examined for having an adequate number of staff to residents. However, the quality of the staff is also important. What is the level of training, years experience, education, and level of specialization found among nursing home staff. Just as hospitals are viewed as progressive environments, predicated on the quality of their staff, so to should nursing care facilities be examined in the same manner. 

In addition, how does acuity play a role in rating nursing homes? For instance, a facility that provides more extensive and intensive services such as bariatric care, dialysis, or ventilator care often have more critical residents with concerns that are more easily targeted during the survey process. However, they also typically have a clinical skill base that is higher as well. This also needs to be factored into the rating system of any nursing facility. 

Moreover, is the nursing care facility a learning, teaching and training environment? Is it a place for training physicians, nurses or other long-term care professionals? Is research conducted among individuals within the long-term care environment? Is it a progressive environment that explores new strategies and techniques, especially toward advancing the care of long-term care residents? Many at this point may be saying you have to be kidding; these are nursing homes and not hospitals. However, many long-term care environments are now involved in many of these areas as well.   

There can be more that can be targeted in creating a nursing home rating system with greater levels of legitimacy to help assist consumer knowledge in this area. However, just using survey results is not enough and I hope I was able to emphasize the importance in creating a multifaceted rating scale for nursing homes. Furthermore, I hope I was able to demonstrate that creating a rating system for nursing homes, based on and similar to the one used in the hotel and restaurant industry, would be very difficult.  These industries are apples and oranges, and as your elementary algebra teacher explained to you early on, apples and oranges cannot be added together. 

That being said, a system of rating nursing homes can be created, however in doing so one cannot create a valid system that is overly simplistic and based on a one-dimensional scale of measurement.  It must be a system that adequately captures and reflects the complexity of the long-term care environment. Because of the complexity of the systemic nature of long-term care environments, capturing the complexity in creating a valid rating instrument for measuring nursing homes will be more difficult than for rating hotels and restaurants.    

For more information: New Rating System in the Works for Nursing Homes



In my June 30, 2008 blog post " Can Apples and Oranges be Compared ?" I wrote about the anticipated implementation

January 19, 2009 10:59 AM

Nice article, why do you even try to educate these politicians, they want to rate long term care and nursing homes like hotels and restaurants, it is incomprehensible for an industry that is over regulated, underfunded and overburdened with staff burnout. I suggest they first start with a menu system before the star rating system.

Dr. Ben Kukoyi,Ph.D., Healthcare - US Dept. of Veterans Affairs July 28, 2008 7:21 AM
Dallas TX

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About this Blog

    Brian Garavaglia, PhD
    Occupation: Long-term care administrator
    Setting: Sterling Heights, Mich.
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