Date of Award


Degree Name

Doctor of Philosophy


Public Affairs and Administration

First Advisor

Dr. Peter Kobrak

Second Advisor

Dr. Kathleen Reding

Third Advisor

Dr. Lyke Thompson


This study reviews the history of the legislative process that led to the passage of the Nursing Home Reform Act of 1987 and the implementation of the regulations. The analysis uses the model of Masmanian and Sabatier to identify the variables and assess their impact on the implementation process. The content of the regulations in terms of various statutory and nonstatutory variables is assessed, and an estimate is made of their effect on the program.

Three aspects of the regulations are examined. First, the relative importance of how compliance is to be determined--subjectively, objectively, or clinically. Second, the design and implementation of the means to assess the quality of care over time, the Resident Assessment Instrument, is discussed. Third, the variation in how the regulations are being applied by survey teams in Wisconsin is reviewed, and data from Michigan are statistically analyzed. This analysis shows that there is a significant difference in how the seven Michigan teams applied the regulations in three of four major categories, as well as the total number of citations made. Of particular importance is the finding that the area with the greatest degree of variation was in the area of Quality of Care, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. which will be used to assess very heavy financial and other penalties against facilities.

The multifaceted effort that became the Nursing Home Reform Act was based on the finding that the certification system in place in 1973 failed to meet the mandate of the Social Security Act that the certification system should ensure that residents of certified facilities actually receive high-quality medical care. This assessment of the program identified several problems which indicate that the program has not been successful in designing and implementing such a system.

Access Setting

Dissertation-Open Access