Defense Date


Document Type


Degree Name

Doctor of Philosophy


Health Administration

First Advisor

Yasar Ozcan


Determinants of nursing home performance: examining the relationship between quality and efficiency By Nailya O. DeLellis, MPH, Ph.D. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University. Virginia Commonwealth University, 2010 Director: Dr. Yasar Ozcan, Professor, Department of Health Administration To assess the relationship between quality of care and efficiency of nursing homes this study used 10% random sample of non-hospital based nursing homes of size 20-360 beds and occupancy rate of 5-100% in OSCAR database 2008 (n=1430). Data Envelopment Analysis was used to calculate efficiency score and Structural Equations Modeling was used to assess the effect of environmental factors on efficiency score and quality measures as well as relationship between efficiency and quality of care. Logistic regression was performed to find the factors that affect high performance, defined as high efficiency and high quality. In the study’s sample, 149 facilities (10.4%) had an efficiency score of 1, which indicates perfect efficiency. The average efficiency score of nursing homes in the sample was 0.854 (0.079 min; 0.145 std). Competition positively affects efficiency, with a path coefficient 0.09 (t-value = 2.65). Although the path coefficients relating competition with process and with outcome quality were positive (0.08 and 0.04, respectively), the results were not statistically significant. Stronger position of payers in the market positively affects process quality of care (path coefficient = 0.15, (t-value = 2.48). Higher efficiency of nursing homes is associated with higher outcome quality (path coefficient of 0.06, t-value = 1.99), but lower process quality (path coefficient of –0.20 , t-value = –2.95). Only 7.4% of nursing homes in the sample could efficiently provide high quality services, which was defined as high performance in the study. Among the factors that demonstrated statistically significant coefficients in the regression were the size of a facility, the availability of registered nurses, excess demand, and for-profit status. The study provides evidence of the trade-off between efficiency and process quality, in which higher efficiency of a nursing home is associated with lower process quality of care. Findings in the study also suggested that higher efficiency is associated with higher outcome quality.


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