Is Patient Safety Culture Related to Nursing Home Quality? Linking Nursing Home

1. Is Patient Safety Culture Related to Nursing Home Quality? Linking Nursing Home SOPS Scores With CMS Five-Star Quality Ratings Naomi Dyer, Westat Joann Sorra, Westat Kabir Khanna, Princeton University

2. Challenge to change culture of healthcare organizations. Focus has been on hospital patient safety and quality Diagnostic tool: AHRQNursing Home Survey on Patient Safety Culture focuses on Nursing Homes Background

3. Research Objective • Examine relationship between resident safety culture and nursing home quality, as measured by: • AHRQ Nursing Home Survey on Patient Safety Culture • http://www.ahrq.gov/qual/patientsafetyculture/nhsurvindex.htm • Nursing Home Compare Five-Star Quality Ratings • http://www.medicare.gov/NHCompare/ • Hypothesis: Facilities with higher patient safety culture scores will have higher Five-Star Quality Ratings.

4. AHRQ Nursing Home SOPS(NH SOPS) Measures • Twelve composites • Three or four items each • 5-point Likert scale • Average composite score • Average of the 12 composites • Two overall ratings • Overall recommendation: Yes, Maybe, No • Overall rating: Poor, Fair, Good, Very good, Excellent

5. Nursing Home Compare Five-Star Quality Ratings • Released by Centers for Medicare and Medicaid Services (CMS) in December 2008 • Provides snapshot of quality of care in facility • Consists of four ratings (from one to five stars) • Health Inspections • Staffing • Quality Measures • Overall Rating

6. Health Inspections Rating • Health Inspections Rating based on annual inspections assessing over 180 items designed to protect residents • Examples: • “Keep all essential equipment working safely” • “Properly mark drugs and other similar products” • “Try to resolve each resident’s complaints quickly”

7. Staffing Rating • Staffing Rating is based on staffing hours per resident per day. • Total nursing hours per resident day • RN hours per resident day. • Note: These numbers represent staffing levels for a two-week period prior to the time of the state inspection.

8. Quality Measures Rating • Quality Measures Rating based on self-reported clinical/physical measure of quality • Percent of residents: • With pressure ulcers • In moderate to severe pain • Who were physically restrained • With a urinary tract infection • Whose ability to move worsened • Who had a catheter inserted and left in their bladder • With delirium • Needing increased help with daily activities

9. Overall Rating • The Overall Rating combines: • Health Inspections Rating • Staffing Rating • Quality Measures Rating

10. Method • Five-Star Rating data identified for 219 of 226 nursing homes from NH SOPS Database. • Used the following 15 NH SOPS scores: • 12 composite scores, • Average composite score (mean across the 12 composites), and • 2 overall ratings • Recommend the Nursing Home (Yes) • Overall rating (Excellent/Very Good). • 4 Five-Star Quality Ratings

11. Method • Matched the Five-star rating time frame to the culture survey administration dates • Time difference between measures: • Average = 129 days (~ 4 months) • Minimum = 0 days • Maximum = 399 days (~13 months) • * Special thanks to Frank Nagy and Edward Mortimore at CMS for sending us Five-Star Quality Ratings data from 2008 to 2011.

12. Analysis • Relationships between NH SOPS and the 4 Five-Star Ratings. • Examined correlations for potential confounding variables (e.g., nursing home size, ownership) • Performed regressions controlling for • Number of beds (a proxy for size), • Ownership (For profit, Nonprofit), and • Facility owned/leased by multi-facility organization

13. Control Variable Relationships • Smaller nursing homes were more positive on 5 of the 15 NH SOPS measures and 3 of the 4 NH Five-Star Ratings • Nonprofit nursing homes were more positive on 9 of the 15 NH SOPS measures and 3 of the 4 NH Five-Star Ratings • Multi-facility nursing homes were less positive on 9 of the 15 NH SOPS measures and 3 of the 4 NH Five-Star Ratings • Note: None of the control variables were related to the Quality Measures Rating

14. Results • All 15 NH SOPS measures positively related with • Overall Five-Star Rating • Health Inspections Rating • None of the NH SOPS measures were significantly related with • Quality Measures • Staffing

15. Health Inspection Rating Regression Results *p<.01

16. Results Health Inspections Rating vs. Average NH SOPS Composite Score

17. Conclusions • Important analysis attempting to link patient safety culture and measures of nursing home quality. • Nursing homes with more positive patient safety culture tend to have higher Overall and Health Inspections Five-Star Ratings. • Staffing and Quality Measures Five-Star Ratings not associated with patient safety culture.

18. Future Directions • AHRQ funded national comparativedatabase for NH SOPS and recently published the Nursing Home Comparative Database Report. • http://www.ahrq.gov/qual/patientsafetyculture • Further studies needed to… • Replicate study or examine potential linkages with other measures of nursing home quality; • Examine validity of Nursing Home Compare Five-Star Rating System; and • Study relationship between improvements in patient safety culture and the impact on quality of nursing home care.