title: The effectiveness of quality systems in nursing homes: a review.
abstract: BACKGROUND
  The need for quality improvement and increasing concern about the costs and appropriateness of health care has led to the implementation of quality systems in healthcare organisations. In addition, nursing homes have made significant investments in their development. The effects of the implementation of quality systems on health related outcomes are not yet clear.
  
  
  OBJECTIVE
  To examine evidence in the literature on whether quality systems have an impact on the care process and the satisfaction and health outcomes of long term care residents.
  
  
  METHODS
  Review of the literature.
  
  
  RESULTS
  The 21 empirical studies identified concerned quality system activities such as the implementation of guidelines; providing feedback on outcomes; assessment of the needs of residents by means of care planning, internal audits and tuition; and an ombudsman for residents. Only four articles described controlled studies. The selected articles were grouped according to five focal areas of quality. The opinion of residents was seldom used to evaluate the effectiveness of quality systems. The effects on care processes and the health outcomes of long term care residents were inconsistent, but there was some evidence from the controlled studies that specific training and guidelines can influence the outcomes at the patient level.
  
  
  CONCLUSIONS
  The design of most of the studies meant that it was not possible to attribute the results entirely to the newly implemented quality system. As it is difficult in practice to design a randomised controlled study, future research into the effectiveness of quality systems should not only focus on selected correlates of quality, but should also include a qualitative and quantitative (multivariate and multilevel) approach. The methods used to measure quality need to be improved.
authors.affiliation: NIVEL, Netherlands Institute of Health Services Research, P O Box 1568, 3500 BN Utrecht, The Netherlands. c.wagner@nivel.nl
authors.forename: C
authors.initials: C
authors.lastname: Wagner
authors.forename: G
authors.initials: G
authors.lastname: van der Wal
authors.forename: P P
authors.initials: PP
authors.lastname: Groenewegen
authors.forename: D H
authors.initials: DH
authors.lastname: de Bakker
mesh_terms: D000368:Aged; D005069:Evaluation Studies as Topic; D019983:Guideline Adherence; D006302:Health Services Research; D006801:Humans; D008134:Long-Term Care / Q000592:standards*; D008330:Management Audit; D008485:Medical Audit; D009426:Netherlands; D009735:Nursing Homes / Q000458:organization & administration / Q000592:standards*; D017063:Outcome Assessment, Health Care; D011785:Quality Assurance, Health Care / Q000458:organization & administration*