Quality of care in nursing homes surfaced as a major issue in the early 1960s because many institutions violated fire and health standards. With the enactment of Medicare and Medicaid in 1965, the monitoring of quality became a prerequisite for licensure and reimbursement in nursing homes.

This dissertation examined the foundation on which quality is measured in skilled-nursing homes. Data from 395 skilled-nursing homes in New York State were analyzed, using ordinary least squares regression procedures, to determine the relationship between the determinants of structure and structural characteristics of the nursing home and between structural characteristics and outcomes of care.

The evidence suggests that structural measures, except for costs, are not direct indicators of the outcome of patient care. Further, only one determinant of structure, location (rural area), has a significant effect on the outcome of care. Thus the current emphasis in quality assurance on meeting structural standards should shift to ensuring that the patient's care is compatible with their health status. In fact, the results suggest a need to more stringently apply the policy decisions legislated in OBRA 87 emphasizing the development of patient outcome assessments.

A significant feature of this research was the use of multiple regression procedures to analyze the relationship among the structural characteristics of the nursing home and the outcome of care. The results confirmed prior research and demonstrated the need to develop patient centered outcomes and process criteria for assessing the quality of patient care in skilled-nursing homes.

Further, regulating the assurance process is only one method for measuring quality. Other approaches should be explored: specifically alternatives that reflect an understanding of the continuum of services which comprise long-term care including the financial, organizational and information strategies that link the components of the continuum into a system.