Critical Review of Resident Assessment Protocols

OBJECTIVES: To evaluate the quality of all 18 federally mandated Resident Assessment Protocols (RAPs) by measuring their adherence to established criteria for clinical practice guidelines (CPGs). DESIGN: Analytical evaluation. SETTING: United States nursing homes. PARTICIPANTS: Eighteen federally mandated RAPs. MEASUREMENTS: Each RAP was evaluated using review criteria based on the 1992 Institute of Medicine criteria for measuring the quality of clinical practice guidelines. Criteria included measurements of RAP validity, reliability/reproducibility, clinical applicability, clinical flexibility, clarity/format, scheduled review, expertise needed to complete, multidisciplinary process, and resources needed to complete. Two reviewers, each a geriatrician with expertise in nursing home medicine, evaluated each RAP on the degree of compliance with each criterion using a 2‐point scale for each criterion. RESULTS: Overall, no individual RAP met all of the review criteria. The Urinary Incontinence RAP best approximated all the review criteria. The Pressure Ulcer RAP received the lowest score. Notable deficiencies in most of the RAPs included poor validity, documentation, reliability, clinical flexibility, and clinical applicability. CONCLUSION: The RAPs synthesize large amounts of information into key points and recommendations. Nevertheless, RAPs perform poorly when held to formal standards expected for CPGs. Based on these findings, the authors and a technical expert panel convened by the Agency for Health Care Research and Quality generated recommendations that might improve the use and quality of future RAPs.