An Empirical Test of the Structure, Process, and Outcome Quality Paradigm Using Resident-Based, Nursing Facility Assessment Data

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Abstract
This study distinguishes between organizational char acteristics, regarded as exogenous structural indicators of quality, and those identified as endogenous indica tors of structural care (SC), and investigates the degree to which measures of SC vary by ownership mode (defined by four combinations of chain affiliation and profit status) for 142 certified and licensed nursing facilities (NFs) in a southern state. Structural care mea sures include: licensed and unlicensed staffing, licensed therapists, and case mix-adjusted direct care expendi tures. In addition, seven (four process and three out come) facility-level, risk-adjusted process, and outcome quality scales are developed from 39 resident-level qual ity indicators. A causal model of NF quality arranged according to the structure, process and outcome para digm is specified and estimated using path analysis. Or ganizational data derive from the 1991 Medicaid Cost Report; process and outcome quality measures were de veloped from the Minimum Data Set Plus Resident As sessment Instrument. Using the percentage of Medicaid and private pay residents as covariates, there was a significant overall multivariate effect due to ownership mode on the SC measures. Although there were several significant direct effects, the overall path model was disconfirmed. The multivariate results suggest that some organizational characteristics of structure quality may be more appropriately considered exogenous to causal quality models and therefore have indirect (ver sus direct) effects on process or outcome quality indica tors. The path analysis implies that the structure-pro cess-outcome paradigm may not accurately capture the way NF health care is delivered. Research which consid ers alternate NF quality paradigms needs to be done with samples that are more representative of national proportions of each ownership mode.