Off-campus UMass Amherst users: To download dissertations, please use the following link to log into our proxy server with your UMass Amherst user name and password.

Non-UMass Amherst users, please click the view more button below to purchase a copy of this dissertation from Proquest.

(Some titles may also be available free of charge in our Open Access Dissertation Collection, so please check there first.)

An organizational perspective on quality of care in nursing homes

Carter Cleveland Rakovski, University of Massachusetts Amherst


In this dissertation, I studied organizational characteristics of nursing home facilities (NHs) and the health outcomes of their residents. Organizational features of nursing homes, such as the category of ownership (either profit or nonprofit), facility size (number of beds), and chain affiliation (chain or independent) were linked to resident outcomes (quality indicators). The analyses were informed by theory from the sociology of organizations. This study had four objectives: (1) analyze the extent of homogenization in the current field of NH care; (2) measure quality of care using new and existing indicators; (3) impact of NH organizational structures on quality of care; and (4) changes in organizational structure and outcomes of NHs over time. The primary data for this study are from the National Nursing Home Survey (NNHS). The survey was conducted in 1973, 1995, 1997, and 1999. Data from 1995, 1997, and 1999 are publicly available and were downloaded for use from the National Center of Health Statistics website, which is part of the Center for Disease Control and Prevention ( )(2003). There were two types of data collected at each occurrence of the survey, facility-level and resident-level. A high amount of homogeneity was present across NHs by organizational type (i.e., ownership and affiliation). NHs were similar according to resident characteristics, types and amounts of services offered, presence of specialty units, source of payment, and use of volunteers. Facilities varied substantially in their daily and monthly charges by organizational type and size of facility. Quality indicators (QIs) were obtained from previous research funded by the Centers for Medicaid and Medicare. These “existing” QIs were prevalence of three conditions: bowel or bladder incontinence, urinary tract infection, and use of indwelling catheters. New QIs were flu, pneumonia, and Tetanus-Diphtheria vaccination rates. No significant differences were found across facility types using existing QIs. More variation was found across types using immunization rates. Nonprofit NHs had better quality than for-profit NHs using immunization rates. Several theories from the sociology of organizations were supported by examining changes in the industry of NHs over time. There was generally homogenization in the NHs. When there was change in facilities, it was in the direction of NHs emulating the most successful types of NHs, which were nonprofit, chain-affiliated homes.

Subject Area


Recommended Citation

Rakovski, Carter Cleveland, "An organizational perspective on quality of care in nursing homes" (2004). Doctoral Dissertations Available from Proquest. AAI3165629.