The Omnibus Reconciliation Act of 1987 (OBRA), was the federal legislation that included the Nursing Home Reform Act of 1987. OBRA was a fundamental shift for the nursing home industry since it changed the focus for evaluating nursing homes from inputs to outcomes.
The inputs, which were the focus of nursing home surveyors prior to OBRA, were the “three P's”: paper, personnel, and property. “Paper” signifies the policies, procedures, and documentation of care, which surveyors reviewed in great detail for compliance with requirements. Under “Personnel” surveyors focused largely on the numbers and qualifications of employees, the structure under which they were organized; the assumption being that if a nursing home had the required number of properly qualified employees organized as defined in the regulations, the desired results would be achieved. In evaluating “Property”, surveyors looked primarily at resident safety as defined under the various state and federal building codes applicable to nursing homes.
Under OBRA, nursing home surveyors had to shift their focus to outcomes. The quality of life and the quality of care of each resident became the two basic points of analysis. Under quality of life, the concept of maintaining or improving the residents' “well-being” was introduced. In addition to physical and mental health, well-being includes functional status, self-esteem, relationships, and appearance. For each nursing home resident to have a sense of well-being, the living environment must meet their social, psychological, and spiritual needs, as well as their physical needs.
While OBRA was not written to address the built environment, the SAGE planning committee identified that the OBRA philosophy applied to the built environment as much as to operations. If the built environment is not in alignment with the operational aspects of the environment, then the built environment creates a major barrier to achieving the desired outcomes. On the other hand, if all aspects of the environment, including the built environment, are in alignment with the resident-centered OBRA philosophy, then the objectives of OBRA will be a natural outcome.
Because OBRA focuses on providing the highest quality of life and quality of care for the residents of nursing homes, it is logical that this would be the common ground where nursing home providers, design professionals, educators, researchers, government officials, manufacturers, and consumers meet.