The Importance of Standardized Observations to Evaluate Nutritional Care Quality in the Survey Process
published online 04 September 2009.
Objective
Guidelines written for government surveyors who assess nursing home (NH) compliance with federal standards contain instructions to observe the quality of mealtime assistance. However, these instructions are vague and no protocol is provided for surveyors to record observational data. This study compared government survey staff observations of mealtime assistance quality to observations by research staff using a standardized protocol that met basic standards for accurate behavioral measurement. Survey staff used either the observation instructions in the standard survey process or those written for the revised Quality Improvement Survey (QIS).
Methods
Trained research staff observed mealtime care in 20 NHs in 5 states during the same time period that survey staff evaluated care in the same facilities, although it could not be determined if survey and research staff observed the same residents during the same meals. Ten NHs were evaluated by government surveyors using the QIS survey instructions and 10 NHs were evaluated by surveyors using the standard survey instructions.
Results
Research staff observations using a standardized observation protocol identified a higher proportion of residents receiving inadequate feeding assistance during meals relative to survey staff using either the standard or QIS survey instructions. For example, more than 50% of the residents who ate less than half of their meals based on research staff observation were not offered an alternative to the served meal, and the lack of alternatives, or meal substitutions, was common in all 20 NHs. In comparison, the QIS survey teams documented only 2 instances when meal substitutes were not offered in 10 NHs and the standard survey teams documented no instances in 10 NHs.
Conclusions
Standardized mealtime observations by research staff revealed feeding assistance care quality issues in all 20 study NHs. Surveyors following the instructions in either the standard or revised QIS surveys did not detect most of these care quality issues. Survey staff instructions for observation of nutritional care are not clearly written; thus, these instructions do not permit accurate behavioral measurement. These instructions should be revised in consideration of basic principles that guide accurate behavioral measurement and shared with NH providers to enable them to effectively implement quality improvement programs.
aVanderbilt University, School of Medicine, Division of General Internal Medicine and Public Health, Center for Quality Aging, Nashville, TN
cGeriatric Research, Education, and Clinical Center, VA Medical Center, Nashville, TN
dUniversity of California, Los Angeles, School of Medicine, Division of Geriatrics, Los Angeles, CA
Address correspondence to John F. Schnelle, PhD, Center for Quality Aging, 1161 21st Avenue South, S-1121 Medical Center North, Vanderbilt University Medical Center, Nashville, TN 37232–2400.
The analyses on which this publication is based were performed under Contract Number 500-00-0032, Task Order #7, entitled “Evaluation of the Quality Indicator Survey,” sponsored by the Centers for Medicare and Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.
ABSTRACT