Nursing Home Responses to Performance-based Accountability

Results of a National Survey

Published in: Journal of the American Geriatrics Society, Volume 68, Issue 9, pages 1979–1987 (September 2020). doi: 10.1111/jgs.16466

Posted on on April 09, 2021

by Kanaka Shetty, Anagha Alka Tolpadi, Michael W. Robbins, Erin Audrey Taylor, Kyle N. Campbell, Cheryl L. Damberg

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The Centers for Medicare & Medicaid Services (CMS) Nursing Home Quality Initiative aims to improve quality through performance measurement. We describe quality improvement (QI) changes that skilled nursing facilities (SNFs) reported making in response to CMS performance measurements and whether reported QI changes were associated with better performance on CMS performance measures.


Nationally representative survey.


A total of 15,475 SNFs that reported quality performance on Nursing Home Compare in 2016.


A total of 1,182 SNFs (58% of random sample of 2,045 SNFs).


Adoption of 22 possible QI changes, grouped into seven categories (organizational culture, health information technology, care process redesign, provider incentives, changes to staffing responsibilities, performance monitoring, and measure-specific QI initiatives and technical assistance); performance on the CMS Nursing Home Compare Five-Star Quality Rating System's quality measure rating.


SNFs reported making an average of 13 QI changes (interquartile range = 11–16 changes). SNFs mostly commonly reported becoming a learning organization (87%) and providing training to staff on QI strategies (87%). After controlling for patient and facility characteristics, larger SNFs were more likely to obtain assistance on measure reporting from QI organizations and use provider champions than smaller SNFs by 14 and 11 percentage points, respectively. Rural SNFs and SNFs with higher proportions of disabled, black, or Hispanic residents adopted QI changes at similar rates as other SNFs. Of the 22 QI changes, 20 were considered at least somewhat helpful by more than 80% of adopting SNFs. Implementation of all 22 QI changes (vs no changes) was associated with a .48-star higher quality measure rating (95% confidence interval = .003–.98 stars; P = .05).


In response to CMS measurement programs, SNFs reported making substantial QI investments that were associated with better performance on CMS quality measures. To guide future SNF investments in QI, work is needed to identify the QI changes that yield the greatest performance improvements.

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