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CMS star rating system should be based on quality, not compliance

November 1, 2008
by Terrence P. Sullivan, MS, LNHA
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Editor's Note: This article was originally sent to the Centers for Medicare & Medicaid Services and appeared in the Illinois Council on Long Term Care's newsletter. Adapted with permission.

The Centers for Medicare & Medicaid Services (CMS) has announced that it will soon launch a five-star rating system for nursing homes, and requested comments and suggestions. We want to express our appreciation for the opportunity to have some genuine input on this initiative, both in the June 25 Open Door Forum this past summer and in this editorial.

We believe that a five-star rating system, properly constructed, is an excellent idea that can be very helpful to consumers. As with restaurants and hotels, a star rating system can assist consumers in finding quality nursing homes, motivate nursing facilities to strive to be the best, and encourage identified priority areas of quality that CMS wants to emphasize. It can be a win-win-win situation for everyone.

During the Open Door Forum, CMS's Thomas Hamilton mentioned that the current proposed plan was to base the five stars on a combination of three factors: the facility's compliance surveys of the past three years, a selection of quality measures, and staffing levels. There are two problems with the selection of these three criteria:

  1. CMS is offering no new information to consumers. CMS would be basing the five stars on information already available on its Web site's Nursing Home Compare. If we truly want to offer some new helpful information for consumers, let's not just rehash already posted information.

  2. These identified components do not measure quality; they measure violations. They may help consumers avoid bad nursing homes, but they don't help consumers find a good one. Violations measure compliance; they don't measure quality. Will five stars for a nursing home mean only that it didn't do anything wrong? As was mentioned in the Open Door Forum, this is a lot like giving restaurants five stars because they didn't poison anyone in the last year.

A good facility is not just defined by the absence of violations, but by the presence of quality. Quality is a proactive commitment to improvement and resident-centered service, not just compliance. Both the compliance surveys and the quality measures evaluate practices and conditions that indicate lack of quality. For a five-star rating system to be effective in helping consumers find a good nursing home, let's base the stars on positive and progressive measures, not just the absence of negative outcomes. There are more proactive indicators of quality available to CMS from collected MDSs—for example:

  • Healed Pressure Ulcers (MDS Section M3). The rate of pressure ulcers healed is a greater indication of a facility's aggressive commitment to quality wound management than the actual number of pressure ulcers. As we are all well aware, the facilities that specialize in aggressive wound management and admit fragile high-risk residents will always have a greater number of pressure ulcers than the facility with no pressure ulcers that primarily admit a healthier residential population. Focusing only on the current pressure ulcer quality measure would seem to indicate that the residential facility with restricted admissions does a better job with pressure ulcers than the facility with a specialized wound management program, when in fact, the opposite is true. The true measure of quality in this critical benchmark care area is not just the absence of pressure ulcers, but the history of resolved pressure ulcers.

  • Pressure Ulcer Prevention Services (MDS Sections M5 and M6). Another benchmark indicator of quality and commitment is the facility that is aggressively protecting residents from pressure ulcers. The practices and treatments in MDS Sections M5 and M6 are effective in preventing pressure ulcers. The facilities that progressively pursue these practices with residents who do not have pressure ulcers are promoting resident quality of life and quality of care, not just reacting to deteriorating conditions.

  • Nursing Rehabilitation/Restorative Care Programs and Services (MDS Section P3). The number of restorative programs per resident is an excellent indicator of the facility's commitment to keeping its residents as active and independent as possible. This basic area of resident functionality improves a resident's quality of care, quality of life, attitude, motivation, and involvement. Not only do rehabilitation and restorative programs improve resident independence and prevent functional deterioration, they also contribute positively to the health and well-being of residents with more serious problems such as heart disease, pressure ulcers, Parkinson's Disease, arthritis, degenerative joint disease, respiratory diseases, depression, and even Alzheimer's disease. An active restorative care program underscores a facility's commitment not to just accept the chronic conditions of aging as inevitable, but to reverse these conditions and improve a resident's involvement in living.

  • Improvement in Activities of Daily Living (ADLs) (MDS Section G1 and G9). Regardless of diagnosis, the greatest predictor of morbidity is ADL decline. The facility that is improving residents' ADL functionality is breathing life into its residents. ADL improvement doesn't happen naturally—it takes that extra effort and a facility-wide motivation to improve the residents' capabilities in daily living tasks. Improvement in ADLs is a quality indicator of a facility attitude not to accept the inevitable, but to fight for the health and overall well-being of its residents.

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