Organizational Structural and Cultural Variables as Predictors of Quality in Federally Approved ...

113 Pages·2015·0.54 MB·English

by  Lorraine V. Desormeaux

East Tennessee State University
Digital Commons @ East
Tennessee State University
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12-2002
Organizational Structural and Cultural Variables as
Predictors of Quality in Federally Approved
Nursing Homes.
Lorraine V. Desormeaux
East Tennessee State University
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Desormeaux, Lorraine V., "Organizational Structural and Cultural Variables as Predictors of Quality in Federally Approved Nursing
Homes." (2002).Electronic Theses and Dissertations.Paper 716. https://dc.etsu.edu/etd/716
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Organizational Structural and Cultural

Variables as Predictors of Quality in Federally Approved Nursing Homes

________________

A dissertation
presented to
the faculty of the Department of Educational Leadership and Policy Analysis
East Tennessee State University

In partial fulfillment
of the requirements for the degree
Doctor in Education
________________

by

Lorraine V. Desormeaux

December 2002
________________

Dr. Russell West, Chair
Dr. Hal Knight
Dr. Terrence Tollefson
Dr. Richard Wissell

Keywords: Long- term Care Systems, Quality Indicators, Long-term Care Insurance, Alternative
Leadership, and Culture in Long-term Care
ABSTRACT

Organizational Structure and Cultural Variables as Predictors of Quality
in Federally Approved Nursing Homes

by
Lorraine V. Desormeaux

The purpose of this study was to determine the extent to which nursing home organizational
structure and cultural variables were related to the outcomes reported by the Health Care Finance
Administration public use data set (HCFA-NHCD). A second purpose was to examine the
effects of a new style of nursing home management called the Eden Alternative  concept. A
related purpose was to test the usefulness of the HCFA-NHCD in predicting the quality of care
for residents in federally approved nursing homes. Secondary data analysis was conducted on
the HCFA-NHCD, as published in December 2001. Descriptive statistics and measures of
association were used to assess the degree of relationship between the organizational structure
and culture variables and the eight clinical health indicators of the HCFA-NHCD. Multiple
regression analyses were conducted to measure the impact of the organizational structure and
culture variables on the quality of care for residents in federally approved nursing homes.

When compared with previously collected statistics, these findings suggest that there is a
nationwide trend towards smaller nursing homes; smaller Eden homes were associated with a
higher level of individualized attention. Smaller Eden homes with council representation had
better scores on a majority of the eight clinical health indicators when compared to their
counterparts with no council representation. Council representation was inversely related to a
nursing homes’ reliance on RN and LPLVN services. However, a regression model assessing the
impact of organizational structure and cultural variables on the quality of care for residents in
federally approved nursing homes had very limited predictive power (R2=2.2%). The findings of
this study suggest that quality improvements in the HCFA-NHCD are needed in order to better
serve families.

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DEDICATION

This dissertation is dedicated to my loving family: my husband Robert Jules
Desormeaux; my son Wyatt Jules Desormeaux, in memory of my son Robert John Desormeaux,
and to my friend and colleague Dr. H. C. "Bud" Meece.

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ACKNOWLEDGMENTS
This dissertation could not have been possible without the help and patience of many
people.

First, I would like to thank my loving husband, Robert Jules Desormeaux, for having the
patience to lose me to my computer for many long months and for tolerating my innovative
cooking style wherein I treated him as a god and served him three burnt offerings a day. At the
completion of this thesis I know my husband will be proud of my accomplishments and thankful
that the "starving season" is over!

Second, I would like to thank my son Wyatt for proofreading the text of this thesis and
promising not to ever send his mother to one of those "bad homes"!

Third, I would like to thank my friend and colleague, Dr. H. C. "Bud" Meece, for being
my friend and mentor throughout my entire doctoral program. He inspired me to stay with the
program and opened my mind to many innovative leadership styles.

Fourth, I would like to thank the Chairman of my advisory committee, Dr. Russell West,
whose patience and kindness have made this dissertation an enjoyable experience.

Finally, I would like to thank the members of my advisory committee: Dr. Hal Knight,
Dr. Terrence Tollefson, and Dr. Richard Wissell and the Departments of Public Health and
Educational Leadership and Policy Analysis for all of the guidance and assistance they have
provided me throughout this process.

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CONTENTS

Page

ABSTRACT……………………………………………………………………….. 2
DEDICATION…………………………………………………………………….. 3
ACKNOWLEDGEMENTS……………………………………………………….. 4
LIST OF TABLES………………………………………………………………… 8

Chapter
1. INTRODUCTION………………………………………………………….. 12
Statement of the Problem………………………………………………. 17
Importance of the Study……………………………………..…………. 17
Research Questions…………………………………………………….. 19
Limitations……………………………………………………………… 19
Definition of Terms……………………………………………………. 20
Overview of the Study…………………………………………………. 21
2. REVIEW OF LITERATURE………………..…………………………….. 22
Growing Need for Long-term Care……………………………………. 22
Long-term Care Related Law and Amendments………………………. 23
Population Expansion, Long-term Care Costs, and Insurance………… 26
Clinical Indicators for Care Accountability……………………….…… 28
Residents with Physical Restraints……………………………..… 29
Residents with Reported Pressure Sores…………….…………… 30
Residents with Bowel and Bladder Problems…..………………… 31
Residents who are Very Dependent in Eating……………………. 32
Residents who are Bedfast……………………………………….. 33
Residents with Restricted Joint Movement………………………. 34
Residents with Unplanned Weight Gain or Loss………….……… 35
Residents who Exhibit Behavioral Symptoms. …………………. 35
Organizational Culture and Structure in Nursing Homes…………..….. 36
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Chapter Page

Resident Councils and Family Councils.……………….…….…... 36
Staffing Patterns………………………………………………... 37
Alternative Long-term Care and Cultural Change…………………….. 38
The Eden Alternative…………………………………………… 38
The Person Centered Alternative…………………………………. 42
The Medicare+Choice Alternative……………………………….. 43
Costs, Ownership, and Alternatives…………………………………… 43
Summary…………………………………………………………..….. 45
3. RESEARCH METHODOLOGY………….…………………………………. 47
Description of the Study………………………………………………... 47
Rationale of Using Secondary Analysis of Data……………………….. 48
Population of HCFA Nursing Homes………………………………….. 48
The HCFA National Data Set - Justification for Use………………….. 49
Procedures for Obtaining and Organizing the Data……………….…… 50
Measurement of Variables. ……………………………………………. 50
Organizational Structure Indicators……………………….………… 50
Size……………………………………….…………………… 50
Staffing Patterns……………………………………………… 51
Type of Ownership……………………………….………….. 51
Organizational Culture Variables…………………………………… 51
Eden vs. Non-Eden Facility…………………………………… 51
Use of Advisory Council vs. No Advisory Council…………... 51
Clinical Healthcare Indicators…………………………………………. 52
Quality of Care Index…………………………………………………... 52
Need for a Non-subjective Method……………………………….. 53
The Method for Constructing the Quality of Care Index…………. 53
Weighting Scale………………………………………………….... 54

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Chapter Page

Hypotheses……………………………………………………………… 55
Data Analysis Procedures……………………………………………… 55
4. ANALYSIS OF DATA………………………………………………………. 56
Research Question #1…………………………….…………………..... 56
Research Question #2…………….….……………………………….... 79
Research Question #3………………………………………………….. 89
Summary of Chapter 4……………………………………………….… 91
5. SUMMARY, DISCUSSION, AND CONCLUSIONS……………………… 92
Category 1 Descriptive Characteristics………………………………… 92
Descriptive Characteristics of Clinical Indicators by Organizational
Structure and Cultural Variables………………………………………. 94
Category 2 Relationship Analysis……………………………………... 98
Category 3 Predictability of the Quality of Care Index from the
Organizational Structure and Cultural Variables…………..………….. 98
Conclusions……………………………………………………………. 99
Recommendations……………………………………………………... 100
REFERENCES………………………………………………..……….. 102
APPENDICES
APPENDIX A: Variables Used in Analysis………………….…… 108
APPENDIX B: Populations Used to Compare Quality Indicators
at Nursing Facilities in the United States………………….………. 109
APPENDIX C: Calculations for the Quality of Care Index………. 110
APPENDIX D: Point-Bi-Serial Formula………………………….. 111
VITA………………..…………………………………………………. 112

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LIST OF TABLES
Table Page

1. National Mean Percentage on each of the Eight Clinical Indicators …………… 53

2. Quality of Care Index Weights Calculated to the First Significant
Digit…...………………………………………………………………………… 54

3. Frequency and Percentage of Federally Approved (HCFA) Nursing Homes, by
Type of Home (All HCFA, Eden Only, and Non-Eden Only), and Type of
Ownership (For Profit, Non-Profit, and Government)……….…………………. 57

4. Frequency and Percentage of Federally Approved Nursing Homes, by Type of
Home (All HCFA, Eden Only, Non-Eden Only) and Size Category (0-49, 50-
99, 100-199, >200) of Home.…………………………………………………. 58

5. Mean Number of Hours Worked Per Resident Day by Registered Nurses (RN),
Licensed Practical Nurses (LPLVN), and Certified Nursing Assistants (CNA)
in Federally Approved (HCFA) Nursing Homes, by Type of Home (All HCFA,
Eden Only, and Non-Eden Only) and Type of Ownership (For Profit, Non-
Profit, and Government)………………………………………………………… 59

6. Mean Number of Hours Worked Per Resident Day by Registered Nurses (RN),
Licensed Practical Nurses (LPLVN), and Certified Nursing Assistants (CNA)
in Federally Approved (HCFA) Nursing Homes, by Size Category (0-49, 50-
99, 100-199, >200) and Type of Home (All HCFA, Eden Only, and Non-Eden
Only…………………………………………………………………….……….. 60

7. Frequency and Percentage of Advisory Council Representation in Federally
Approved (HCFA) Nursing Homes by Type of Home (All HCFA, Eden Only,
and Non-Eden Only)……………………………………….………………..… 61

8. Mean Number of Hours Worked Per Resident Day by Registered Nurses (RN),
Licensed Practical Nurses (LPLVN), and Certified Nursing Assistants (CNA)
in Federally Approved (HCFA) Nursing Homes, by Type of Home (All HCFA,
Eden Only, and Non-Eden Only) and Advisory Council Representation…….. 62

9. Comparison of the Mean Percentages of Eden Homes Versus Non-Eden
Homes on Each of the Eight (HCFA-NHCD) Clinical Health Indicators……… 63

10. Mean Percentage of Residents with a Health or Quality Need in Federally
Approved (HCFA) Nursing Homes Based on the Clinical Indicator "Percent of
Residents Who are Bedfast" by Type of Home (All HCFA, Eden Only, and
Non-Eden Only) and Type of Ownership (For Profit, Non-Profit, and
Government)……………………………………………………………………. 64
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Table Page

11. Mean Percentage of Residents with a Health or Quality Need Based on the
Clinical Indicator "Percent of Residents Who are Bedfast" in Federally
Approved HCFA) Nursing Homes by Advisory Council Representation of
Home and Type of Home (All HCFA, Eden Only, and Non-Eden Only)..… 65

12. Mean Percentage of Residents with a Health or Quality Need Based on the
Clinical Indicator "Percent of Residents with Joint Problems" in Federally
Approved (HCFA) Nursing Homes by Type of Home (All HCFA, Eden Only
and Non-Eden Only) and Type of Ownership (For Profit, Non-Profit, and
Government)…………………………………………………………………… 66

13. Mean Percentage of Residents with a Health or Quality Need Based on the
Clinical Indicator "Percent of Residents with Joint Problems" in Federally
Approved (HCFA) Nursing Homes by Advisory Council Representation of
Home and Type of Home (All HCFA, Eden Only, and Non-Eden Only)…….. 67

14. Mean Percentage of Residents with a Health or Quality Need Based on the
Clinical Indicator "Percent of Residents with Bowel and Bladder Problems" in
Federally Approved (HCFA) Nursing Homes by Type of Home (All HCFA,
Eden Only, and Non-Eden Only) and Type of Ownership (For Profit, Non-
Profit, and Government)………………………………………………………. 68

15. Mean Percentage of Residents with a Health or Quality Need Based on the
Clinical Indicator "Percent of Residents with Bowel and Bladder Problems" in
Federally Approved (HCFA) Nursing Homes by Advisory Council
Representation of Home and Type of Home (All HCFA, Eden Only, and Non-
Eden Only)…………………………………………………………………….. 69

16. Mean Percentage of Residents with a Health or Quality Need Based on the
Clinical Indicator "Percent of Residents with Physical Restraints" in Federally
Approved (HCFA) Nursing Homes by Type of Home (All HCFA, Eden Only,
and Non-Eden Only) and Type of Ownership (For Profit, Non-Profit, and
Government……………………………………………………………………. 70

17. Mean Percentage of Residents with a Health or Quality Need Based on the
Clinical Indicator "Percent of Residents with Physical Restraints" in Federally
Approved (HCFA) Nursing Homes by Type of Home (All HCFA, Eden Only,
and Non-Eden Only) and Size Category (0-49, 50-99, 100-199, >200) of Home 71

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