Shareholder value and the performance of a large nursing home chain.

OBJECTIVE: To analyze corporate governance arrangements and quality and financial performance outcomes among large multi-facility nursing home corporations (chains) that pursue stakeholder value (profit maximization) strategies. STUDY DESIGN: To establish a foundation of knowledge about the focal phenomenon and processes, we conducted an historical (1993-2005) case study of one of the largest chains (Sun Healthcare Inc.) that triangulated qualitative and quantitative data sources. DATA SOURCES: Two main sets of information were compared: (1) corporate sources including Sun's Security Exchange Commission (SEC) Form 10-K annual reports, industry financial reports, and the business press; and (2) external sources including, legal documents, press reports, and publicly available California facility cost reports and quality data. PRINCIPAL FINDINGS: Shareholder value was pursued at Sun through three inter-linked strategies: (1) rapid growth through debt-financed mergers; (2) labor cost constraint through low nurse staffing levels; and (3) a model of corporate governance that views sanctions for fraud and poor quality as a cost of business. CONCLUSIONS: Study findings and evidence from other large nursing home chains underscore calls from the Institute of Medicine and other bodies for extended oversight of the corporate governance and performance of large nursing home chains.

Case study: development of and stakeholder responses to a nursing home consumer information system.

California Nursing Home Search (www.calnhs.org), launched in October 2002, provides information about nursing home quality to a broad range of stakeholders. This case study discusses the process of developing a consumer-oriented nursing home Web site and presents an analysis of postlaunch responses from a number of sources (i.e., media, outreach, Web site use, correspondence, meetings, interviews) to determine the impact of the site and how it can be improved and used as an example. Consumers found the Web site valuable, but some needed clarification on navigation. Providers had complaints about the use of quality ratings and concerns about public availability of the data. Most discharge planners and care managers do not use Internet resources to find facilities. Feedback, modifications, updates, and outreach are needed on a continuous basis to ensure the site is a helpful tool for all stakeholders.

Nursing indicators of quality in nursing homes. A Web-based approach.

This article is an examination of websites providing consumer information about nursing home quality of care, including existing federal and state websites and a new comprehensive website designed for California nursing homes. The article focuses on research and information related to nursing indicators of quality used for the California nursing home website. It includes staffing levels (e.g., hours, types, turnover rates), financial indicators (e.g., direct care expenditures, wages, benefits), and complaints and deficiencies. Overall, nursing indicators of quality are a major approach for evaluating nursing home quality and can be used by nurses, consumers, and advocates.

Designing a report card for nursing facilities: what information is needed and why.

PURPOSE: This article presents a rationale and conceptual framework for making comprehensive consumer information about nursing facilities available. Such information can meet the needs of various stakeholder groups, including consumers, family/friends, health professionals, providers, advocates, ombudsman, payers, and policy makers. DESIGN AND METHODS: The rationale and framework are based on a research literature review of key quality indicators for nursing facilities. RESULTS: The findings show six key areas for information: (a) facility characteristics and ownership; (b) resident characteristics; (c) staffing indicators; (d) clinical quality indicators; (e) deficiencies, complaints, and enforcement actions; and (f) financial indicators. This information can assist in selecting, monitoring, and contracting with nursing facilities. IMPLICATIONS: Model information systems can be designed using existing public information, but the information needs to be enhanced with improved data.

Federal and state nursing facility websites: just what the consumer needs?

Since the introduction of the Medicare Nursing Home Compare website in 1999, some states have begun to develop their own websites to help consumers compare nursing facilities (NFs). This article presents a brief conceptual framework for the type of information needed for an Internet-based information system and analyzes existing federal and state NF websites, using data collected from a survey completed in 2002. Twenty-four states and the District of Columbia have a variety of information on NFs, similar to the information on the Medicare website. Information on characteristics and deficiencies of a facility is the most commonly available, but a few states have data on ownership, staffing indicators, quality indicators, complaints, and enforcement actions. Other types of data, such as resident characteristics, staff turnover rates, and financial indicators, are generally not available. Although many states are making progress toward providing consumers with information, there are gaps that exist, which if filled, could provide consumers with a better tool for facility selection and monitoring the quality of care.