State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Statewide Quality Review [8]


The Statewide Quality Review provides an independent, structured assessment of the appropriateness of care for specific clinical issues identified by the state as quality improvement priorities. This initiative is a legislatively-mandated annual study of quality of care, quality of life, and consumer satisfaction in Texas nursing homes. First conducted in 2000, this survey is designed and analyzed by Dr. Cortes' division with participation by a technical review panel; the survey itself is conducted under a contract with the Texas Nurses Association. State funds (approximately $500,000 per year) support the effort, which includes on-site research in each of Texas' roughly 1,000 homes and data collection regarding a representative sample of 2000 nursing home residents.

The review has four primary purposes:

  • To identify opportunities for improvement in the quality of LTC services.

  • To track statewide trends in quality improvement.

  • To analyze the impact of presumed determinants of quality such as staffing, facility case mix and severity of resident impairment.

  • To provide a means for measuring the outcome of the Quality Outreach Program created by Senate Bill 1839 (SB 1839) from the 77th Legislature.9

The research is designed to help pin-point areas where there are substantial opportunities for improving quality, to provide information about the possible causes of perceived quality problems (including MDS data quality issues), and to provide a means of tracking statewide progress in selected areas of quality. Findings from the research are also now used as important elements of the Quality Monitoring Program, both as the research basis for determining priority areas for technical assistance and as a way to test protocols.

The 2002 Quality Review was based on the on-site assessment of 1972 nursing facility residents, and it focused five specific issues:

  • Appropriate use of toileting plans among residents with urinary incontinence,
  • Appropriate use of indwelling bladder catheters,
  • Use of physical restraints only when these were clinically unavoidable,
  • Appropriate use of anti-psychotic medications, and
  • Consumer satisfaction with various aspects of nursing facility service.

Based on analysis of almost 2,000 nursing home residents, the 2002 report had the following major conclusions:

  • The majority of residents with urinary incontinence would have potentially benefited from toileting. Fewer than 8 percent of these candidates actually had toileting plans. Neither staffing ratios nor facility case mix explained why toileting needs were not met; nor did these factors show any significant relationship to the appropriateness of toileting plans.

  • Inadequate clinical evaluation of the majority of residents with indwelling bladder catheters continued to be a significant opportunity for quality improvement. While chronic indwelling bladder catheters were more frequently used among residents who had greater impairments in Activities of Daily Living (ADL), the use was not necessarily appropriate.

  • During any given week, 19.5 percent of Texas nursing home residents were in waist, trunk or limb restraints. By expert criteria for unavoidable restraint use, 90 percent of all restraint use in Texas nursing facilities was avoidable and unnecessary.

  • The prevalence of anti-psychotic prescribing in Texas nursing facilities is higher than the national average, 29.4 percent versus 16.9 percent.

The Statewide Quality Review has been used to develop several recommendations for the Quality Monitoring program, including:

  • Applying the resources of the Quality Monitoring programs to disseminate restraint reduction information to facilities, physicians and families in order to eliminate needless restraints.

  • Using the Quality Monitors to monitor the management of urinary incontinence care and use of indwelling bladder catheters in order to assist providers whose practices do not meet evidence-based standards for best practice.

  • Supplementing the Quality Monitoring process with evidence-based best practice knowledge resources including training for providers.

  1. Much of the information in this section is taken from the Statewide Quality Review reports. The 2000, 2001, and 2002 Statewide Quality Review Reports are available on-line at the state's Quality Matters web site (

  2. Note that the 2002 Report contain baseline results against which future findings can be compared, thus serving as a basis for a future evaluation of the impact of the program.

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