Building policy and service theory from nursing home inspection results: Qualitative Comparative Analysis

Background: Very little has been published on cited deficiencies and harm levels from inspection results in chroni cally underperforming nursing homes, especially from 'whole-of-service' policy and service theory perspectives. This study aimed to explore how an observational small-N method for the social sciences, known as Qualitative Comparative Analysis (QCA), can help fill this gap in the literature.

Methods: All incidences of cited deficiencies and related citations of patient harm in the US Nursing Home Compare database for the period 2007-2011, for all 147 special focus facilities were included in the QCA. The data for deficiency levels in services were considered by comparing services with a relatively 'low level' versus a relatively 'high level' of patient harm.

Results: No particular combination of service deficiency levels characterised observed facilities with higher total harm levels. Policy and service theory must reflect this heterogeneity of deficiencies in 'high harm' services. Contrary to assumptions of deficiency-focused inspection systems, targeting services with higher deficiency levels is not always the same as targeting services with higher patient harm. Yet, in theory, a higher incidence of one kind of deficiency (in pharmacy services or resident rights) may be a sentinel indicator of higher harm levels in a service.

Conclusions: Although this application of QCA is not conventional, it provides a basis for exploring theoretical possibilities in a context where standardised QCA approaches are unsupported by a well-developed body of relevant service theory.