Resident Vignettes for Assessing Care Quality in Nursing Homes

Objectives

Validated process measures that correlate with patient outcomes are needed for research and quality improvement.

Design

Cross-sectional analysis within a cluster-randomized fall prevention study.

Setting

Nursing homes in North Carolina (n = 16).

Participants

Nursing home staff (n = 541) and residents with 1 or more falls in 6 months (n = 597).

Measurements

Fall-prevention process measures in 4 categories derived from Assessing Care of Vulnerable Elders quality indicators were measured in 2 ways: (1) chart abstraction; and (2) staff responses to clinical vignettes of hypothetical residents at risk for falls. Recurrent fall rates (falls/resident/year) were measured. The proportion of the total variation in falls rates explained by the scores for each method (chart abstraction or vignette) was calculated using multilevel adjusted models.

Results

Chart and vignette measures of comorbidity management were moderately correlated (Pearson correlation coefficient 0.43), whereas other process measure categories had low or negative correlation between the 2 methods (psychoactive medication reduction 0.13, environmental modification ?0.42, and exercise/rehabilitation ?0.08). Measures of environmental modification and comorbidity management explained a moderate amount of the total variation in recurrent fall fates, vignettes (7%–10% variation explained) were superior to chart abstraction (2%–6% variation explained). Vignette responses from unlicensed staff (nurse aides and rehabilitation aides) explained more variance than registered nurses, licensed practical nurses, or other licensed staff in these categories. Process measures for psychoactive medication reduction and exercise/rehabilitation did not explain any of the variation in fall outcomes. Overall, vignette process measures explained 3.9% and chart abstraction measures explained 0% of the variation in fall outcomes.

Conclusions

Clinical vignettes completed by nursing home staff had greater association with resident recurrent fall rates than traditional chart abstraction process measures.