Identifying star performers: the relationship between ambitious targets and nursing home quality improvement

Setting Targets--Achieving Results (STAR) is a Web-based tool that helps nursing home leadership select annual performance goals, or targets, for a subset of publicly reported quality measures. Previous results demonstrate that nursing homes whose staff implement STAR targets demonstrate greater improvement on the related outcomes. In this analysis, the authors hypothesized that nursing homes whose staff select the most ambitious targets (reflecting large improvement over their current performance) may be more successful in their related quality improvement efforts than homes with less-ambitious targets (reflecting lesser improvement). The authors analyzed data from 7,091 Medicare- or Medicaid-certified nursing homes that set STAR targets in 2005 or 2006 for two quality measures: the proportion of residents who were physically restrained daily and the proportion of high-risk residents with pressure ulcers. Targets were classified as ambitious or less ambitious based on the 75th and 50th rank-ordered percentiles, respectively. Improvement was calculated using four-quarter averages for baseline (the year ending when the target was set) and remeasurement (the subsequent year). The results indicate that nursing homes with ambitious targets demonstrate greater improvement than their peers selecting less-ambitious targets. With limited federal and local resources to assist providers with quality improvement, target values may be a used as a "flag" to help agencies allocate scarce resources to nursing homes committed to quality improvement efforts and with the organizational capacity to improve.