Care received in chain-owned nursing homes generally not on par with care received in nonprofit and singly-owned nursing homes

Standard marketing and strategic planning practices can hurt patient care throughout a nursing home chain, but only if too much emphasis is placed on such administrative standards to the detriment of clinical and facility standards, a new study indicates.

Research from the University of Michigan School of Public Health suggests that one of the strengths of a nursing home chain---the ability to standardize and perfect administrative practices throughout the chain---also can hurt patient care.

"Consumers need ways to identify what is a good or bad nursing home when making choices about where to place a loved one," said Jane Banaszak-Holl, corresponding author on the study. "Right now, we have an easier time distinguishing the quality in McDonalds versus Boston Market than we have distinguishing how, for example, a Sun-owned nursing home differs from a Beverly Enterprises nursing home."

Chain-owned nursing homes are the predominant type of institutional care provided in the United States, yet studies have shown that the patient care received in chain-owned nursing homes is generally not on par with the patient care received in nonprofit and singly-owned nursing homes. However, little is known about their management structure other than the fact that chain ownership has a significant impact on patient care. This study examines one aspect of management structure.

"If they (chain-owned nursing homes) are really not as good, we need to think about how to improve them," said Akiko Kamimura, a U-M doctoral student in Health Management and Policy at the School of Public Health, and first author of the study.

The study suggests that corporate standardization of clinical and facility processes improved resident care, but that corporate standardization of administrative processes hurt patient care. The study concludes that chains must balance administrative efficiency with the local needs of the individual chain-owned facilities to optimize patient care. This paper is part of a larger study that was funded by the Blue Cross Blue Shield of Michigan Foundation on how nursing home chains vary in approaches to delivering nursing home care and whether variations impact the quality of care.

For the study, the researchers surveyed 203 nursing homes in Michigan and North Carolina and examined the effects of corporate standards and training in three areas: administrative processes, clinical processes, and facility design. The study looked at impact on the total number of health deficiencies given to facilities on state inspections, and the percentage of residents with bedsores. An example of a health deficiency would be inserting a catheter unnecessarily because it makes care easier.

An example of standardizing administrative processes would be to share common marketing materials. An example of facility standardization would be to use the same facility layout, and an example of standardizing clinical processes might be to implement guidelines for the treatment of resident bedsores throughout the chain.

"Standardization is a way to think about changing service delivery across many areas, including administrative and clinical processes and even within facility layout," said Banaszak-Holl. Chains that over-emphasize administrative processes don't take advantage of how much their staff can learn---and ultimately improve patient care---from the shared knowledge of developing protocols for handling resident needs.

"What we have stressed in the larger project is that chain ownership is not necessarily bad for the quality of health care, Banaszak-Holl said. "What is problematic is a shift away from community values and local needs, and an overly strong emphasis on administrative rather than clinical outcomes. A good corporate chain can implement a set of practices that still attends to local needs and resident outcomes while introducing greater economies of scale and better business practices."