The fault in our (5) stars

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Jacqueline Vance, RN
Jacqueline Vance, RN

So, let me start off by saying that I am sure a lot of us have our own rating systems. For example, my sisters and I have a tissue-box rating system for tearjerker books and movies. The book the “Fault in Our Stars” (excellent in my opinion) was a 5-tissue-box book. The movie “Terms of Endearment” a 5-tissue-box movie, for sure.

We have our own ratings for meals, shoes, etc. and even hotels. We don't go by the “Hotels.com” ratings because we know it all depends on what people like. Love breakfast and you're more liable to rate higher the hotel that has free breakfast than, say, someone who stays only at Ritz Hotels would.

So we find the general Five Star nursing home rating thing confusing unless we're willing to read all of the reviews. In other words, you can't just look at the stars.

So what am I fussing about today?

Well, CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes, supposedly easily. (Or, so that was the thought behind it.) Then, they created a website featuring a “star rating” system.

This system assigns each nursing home a rating between one and five stars. The idea is that nursing homes with five stars are considered to have above-average quality, compared to other nursing homes in that state. Nursing homes with one star have quality are considered much below the average in that state.

But, like other ratings, you can't just look at the stars on face value. There's a problem with what the ratings are based on, and that is where some of the fault lies. Now for sure, a 5-star home is a great home and a 1 is underperforming. But what about the 3's?  Are they average? Good? Bad? Ugly? 

The rating system is based on the star ratings assigned in three separate categories: Health inspections, Quality Measures, and staffing.

Let's start with health inspections (surveys). Almost anyone who has been through an inspection knows that guidance for inspectors is just that, leaving a lot to interpretation and lacking, especially when you have a surveyor with no idea related to clinical geriatrics. Inspection veterans also know that the posting of these results can be extremely delayed. So this rating has the ability to be a bit biased (“love the hot breakfast bar”, or “If it doesn't measure up to a Ritz, I'm gonna' get ya!”).

 Or you may been a lousy home, have turned over management, and now just had a perfect survey but, you have last year's survey results bringing you down. Like a hotel, the 2014 reviews can be outstanding since the hotel has been under new management, but the 2013 reviews are still posted, and those still get average in. But at least with hotels.com, and the hotel management can respond with something like, “Thanks for all the great reviews since the new management. We're committed to quality!  On the CMS 5 star rating system, no such luck.

Quality measures - Even CMS will agree there are some faults there. Take pressure ulcers, for example. Let's say you are KNOWN for providing amazing chronic wound and pressure ulcer management. The nastiest wounds all come to you. Census is always full. 

All these stage 4 ulcers show up on the first MDS, but in the first quarter, they magically convert to you owning them. And, you can't back-stage, so you now own dozens of stage 4 ulcers, making it look like you are a home of horrors in the quality ratings yet you are the most advanced wound provider around. So, if this were a hotel, there would be a chance for the hotel management to say, we are the best at XYZ. On the CMS Five Star rating system, no such luck.

Staffing — don't get me started.  We still haven't figured out how to staff according to acuity so how can we know what average we need.

I know the rating system states it is “considered,” but not to a mathematical extent. You can't say, “Hey, we had a lot of light care residents when we were rated. We didn't need a ton of staff.” It would be like counting the staff at a sky resort in the summer.  You just didn't need full staff but what if that was what the hotel got rated on for the whole year?

So all I am saying is, I think the best job we can do is educate consumers to get out there, visit nursing homes, ask questions (this IS what the rating system is supposed to inspire consumers to do) ask friends, relatives etc. and look beyond our faulty stars when considering where to place a loved one.

But if you have five stars, go ahead and brag!!

Just keeping it real,

Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.


The Real Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, an APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.

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