An empirical test of the structure, process, and outcome quality paradigm using resident-based, nursing facility assessment data.

This study distinguishes between organizational characteristics, regarded as exogenous structural indicators of quality, and those identified as endogenous indicators 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 measures include: licensed and unlicensed staffing, licensed therapists, and case mix-adjusted direct care expenditures. In addition, seven (four process and three outcome) facility-level, risk-adjusted process, and outcome quality scales are developed from 39 resident-level quality indicators. A causal mode of NF quality arranged according to the structure, process and outcome paradigm is specified and estimated using path analysis. Organizational data derive from the 1991 Medicaid Cost Report; process and outcome quality measures were developed from the Minimum Data Set Plus Resident Assessment 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 unconfirmed. 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 (versus direct) effects on process or outcome quality indicators. The path analysis implies that the structure-process-outcome paradigm may not accurately capture the way NF health care is delivered. Research which considers alternate NF quality paradigms needs to be done with samples that are more representative of national proportions of each ownership mode.