Original Study| Volume 11, ISSUE 7, P500-505, September 2010

Beyond CMS Quality Measure Adjustments: Identifying Key Resident and Nursing Home Facility Factors Associated With Quality Measures


      This quality improvement (QI) project was initiated to understand what differentiates nursing homes (NHs) that perform well on publicly reported Centers for Medicare and Medicaid Services (CMS) Quality Measures (QMs). The intent was to assist NH staff to direct QI efforts to positively impact QM rates. A key step was to determine if any resident or facility characteristics might account for some of the variability in QMs of high-risk pressure ulcers (HRPrUs), low-risk incontinence (LRI), and Activities of Daily Living (ADL) decline, beyond those already adjusted for by CMS.


      Observational Study.

      Setting and Participants

      The setting was 147 NHs across 12 northeast states owned by 1 for-profit, multifacility organization in 2006 and 2007.




      Minimum Data Set (MDS), patient admission information, facility staffing metrics, and CMS QM data.


      Relationships of facility and resident characteristics to QMs were evaluated using regression analyses performed separately for 2006 and 2007. Among factors found consistently to be significant (P ≤ .05) for HRPrUs were percent admissions with pressure ulcers and percent residents with end-stage disease. For LRI, there was significant association with percent residents readmitted and percent incontinent of bladder on admission. ADL decline showed significant associations with licensed nurse turnover and facilities in specific states.


      Several resident and facility factors were associated with QMs beyond those previously adjusted for by CMS. With introduction of MDS 3.0, we suggest further exploration of resident and facility factors identified in this study.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Centers for Medicare and Medicaid Services. Data Compendium. 2007 Edition. Available at: Accessed June 30, 2008.

      2. Centers for Medicare and Medicaid Services. 2008 Action Plan for (further Improvement of) Nursing Home Quality. Available at: Accessed June 30, 2008.

        • Saliba D.
        • Solomon D.
        • Rubenstein L.
        • et al.
        Feasibility of quality indicators for the management of geriatric syndromes in nursing home residents.
        J Am Med Dir Assoc. 2005; 6: S50-S59
        • Rantz M.J.
        • Popejoy L.
        • Mehr D.R.
        • et al.
        Verifying nursing home care quality using minimum data set quality indicators and other quality measures.
        J Nurs Care Qual. 1997; 12: 54-62
        • Arling G.
        • Kane R.L.
        • Lewis T.
        • et al.
        Future development of nursing home quality indicators.
        Gerontologist. 2005; 45: 147-156
        • Schnelle J.F.
        • Bates-Jensen B.M.
        • Levy-Storms L.
        • et al.
        The Minimum Data Set prevalence of restraint quality indicators: Does it reflect differences in Care?.
        Gerontologist. 2004; 44: 245-255
        • Simmons S.F.
        • Cadogan M.P.
        • Cabrera G.R.
        • et al.
        The Minimum Data Set depression quality indicator: Does it reflect differences in care processes?.
        Gerontologist. 2004; 44: 554-564
        • Grando V.T.
        • Rantz M.J.
        • Maas M.
        Nursing home staff's views on quality improvement interventions: A follow-up study.
        J Gerontol Nurs. 2007; 33: 40-47
        • Goodson J.
        • Jang W.
        • Rantz M.
        Nursing home care quality: Insights from a Bayesian network approach.
        Gerontologist. 2008; 48: 338-348
        • Arling G.
        • Lewis T.
        • Kane R.L.
        • et al.
        Improving quality assessment through multilevel modeling: The case of nursing home compare.
        Health Serv Res. 2007; 42: 1177-1199
        • Solomon D.H.
        • Wenger N.S.
        • Saliba D.
        • et al.
        Appropriateness of quality indicators for older patients with advanced dementia and poor prognosis.
        J Am Geriatr Soc. 2003; 51: 902-907
        • Mukamel D.B.
        • Glance L.G.
        • Li Y.
        • et al.
        Does risk adjustment of the CMS quality measures for nursing homes matter?.
        Med Care. 2008; 46: 532-541
        • Rantz M.J.
        • Hicks L.
        • Petroski G.F.
        • et al.
        Stability and sensitivity of nursing home quality indicators.
        J Gerontol A Biol Sci Med Sci. 2004; 59: 79-82
      3. The National Voluntary Consensus Standards for Nursing Home Care project. Available at: Accessed June 30, 2008.

        • Zimmerman D.R.
        Improving nursing home quality of care through outcomes data: The MDS quality indicators.
        Int J Geriatr Psychiatry. 2003; 18: 250-257
        • Berg K.
        • Mor V.
        • Morris J.
        • et al.
        Identification and evaluation of existing nursing homes quality indicators.
        Health Care Finance Rev. 2002; 23: 19-36
        • Zinn J.
        • Spector W.
        • Hsieh L.
        • et al.
        Do trends in the reporting of quality measures on the nursing home compare web site differ by nursing home characteristics?.
        Gerontologist. 2005; 45: 720-730
        • Mor V.
        • Berg K.
        • Angelelli J.
        • et al.
        The quality of quality measurement in US nursing homes.
        Gerontologist. 2003; 43: 37-46
        • Grabowski D.C.
        • Angelelli J.J.
        • Mor V.
        Medicaid payment and risk-adjusted nursing home quality measures.
        Health Aff. 2004; 23: 243-252
        • Mukamel D.B.
        • Watson N.M.
        • Meng H.
        • et al.
        Development of a risk-adjusted urinary incontinence outcome measure of quality for nursing homes.
        Med Care. 2003; 41: 467-478
        • Phillips C.D.
        • Shen R.
        • Chen M.
        • et al.
        Evaluating nursing home performance indicators: An illustration exploring the impact of facilities on ADL change.
        Gerontologist. 2007; 47: 683-689
        • Bates-Jensen B.M.
        • Simmons S.F.
        • Schnelle J.F.
        • et al.
        Evaluating the accuracy of minimum data set bed-mobility ratings against independent performance assessments: Systematic error and directions for improvement.
        Gerontologist. 2005; 45: 731-738
      4. RAND report on MDS 3.0. Available at: Accessed June 30, 2009.

        • Connor M.J.
        • Gillings D.
        An empiric study of ecological inference.
        Am J Public Health. 1984; 74: 555-559
        • Castle N.G.
        • Degenholtz H.
        • Engberg J.
        State variability in indicators of quality of care in nursing facilities.
        J Gerontol A Biol Sci Med Sci. 2005; 60A: 1173-1179
        • Castle N.G.
        • Engberg J.
        • Men A.
        Nursing home staff turnover: Impact on Nursing Home Compare quality measures.
        Gerontologist. 2007; 47: 650-666
        • Castle N.G.
        • Engberg J.
        Further examination of the influence of caregiver staffing levels on nursing home quality.
        Gerontologist. 2008; 48: 464-476