Survey deficiencies are not reliable for drawing conclusions about aspects of quality.

This issue of the Journal includes a study by Lerner et al seeking to identify any correlations between survey deficiencies and Certified Nursing Assistant (CNA) and Registered Nurse or Licensed Practical Nurse turnover in nursing homes.1 The study selected Online Survey, Certification and Reporting deficiencies from the Quality of Care, Quality of Life and Resident Behavior categories, which were considered to be more closely related to nursing care. The study concludes that high CNA turnover was associated with high numbers of Quality of Care, resident behavior, and total selected deficiencies, and that licensed nurse turnover was significantly related to Quality of Care deficiencies and total selected deficiencies. When both CNA turnover and licensed nurse turnover were included in the same model, high licensed nurse turnover was significantly associated with Quality of Care and total deficiencies whereas CNA turnover was not associated with that category of deficiencies. The study’s authors conclude that turnover in nursing homes for both licensed staff and CNA staff is associated with quality problems as measured by deficiencies. They suggest that more efforts to retain nursing staff are needed. The primary basis for these conclusions is the number of survey deficiencies in various categories. Other studies have also used survey deficiencies as a basis for drawing conclusions; for example, the impact of certified medical directors on facilities.2 Certain criteria must be met if survey deficiencies are to be a meaningful basis for drawing any conclusions about care, including (1) the survey process promotes review of all important aspects of care, or there is evidence that the subset that is reviewed adequately represents all important care aspects; (2) surveyors consistently follow survey protocols and guidelines, which give them clear and consistent criteria for determining compliance; (3) survey protocols and guidelines provide an adequate basis for evaluating related performance and practice; (4) surveyors uniformly apply compliance criteria across facilities and residents/patients; and (5) surveyors consistently and correctly identify compliance and instances of noncompliance. However, for many reasons, none of the above is true. First, the survey process does not cover all important aspects of care. According to the American Health Care Association, the average 100-bed nursing home will serve 189 individuals a year for