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Carter, Janelle. Government releases data on thousands of nursing homes nationwide. The Detroit News. November 12, 2002.HHS Launches National Nursing Home Quality Initiative - Broad Effort to Improve Quality in Nursing Homes Across the Country (News Release) November 12, 2002. www.ltcombudsman.org/ombpublic/40_369_3926.CFMThe VA operates a federally financed health care system for eligible veterans. The system comprises more than 150 medical centers, many of which have associated nursing homes. Although part of a larger medical center, VA nursing homes have a separate administrative structure consisting of a medical director and a director of nursing. Nursing home units within the VA are also often physically separated from the rest of the medical center, occupying separate buildings or campuses. Beginning in the early 1990s, VA headquarters began to encourage its hospital directors to adopt QI as "an essential management method and an organizational imperative" (Kizer 1999; Young, Chains, and Shortell 2001). Yet previous research suggests that the implementation of QI is a gradual process and considerable differences have been found among VA medical centers, as well as private sector hospitals, regarding the extent to which QI practices are being followed (Parker et al. 1999; Shortell et al. 1995). Additionally, questions hav e been raised as to whether QI can be successfully implemented in nursing homes (Kane 1998; Institute of Medicine 2001). We specifically test the hypothesis:

Table 3 shows the selected parameter estimates from the second-stage estimation. As discussed, the adjusted Wald tests of whether the coefficients of the [lambda]''s were zero were the tests for the endogeneity of having a regular doctor or site. The last column of Table 3 reports the result of the joint tests. The endogeneity of having a regular doctor or site was present for flu shots, blood pressure checkups, and cholesterol level checkups. No selection biases were found in the equations of pap smears or mammograms within the past two years.As described before, the effects of having a regular doctor ([I.sub.d]) and having a regular site ([I.sub.s]) conditional on the choice of a usual source of care are [gamma]1 + ([[alpha].sub.d][[lambda].sub.d] - [[alpha].sub.0][[lambda].sub.0]) and [gamma]2 + ([[alpha].sub.s][[lambda].sub.s] - [[alpha].sub.0][[lambda].sub.0]), respectively. These two effects are show in Table 4. Marginal effects of having a regular doctor and a regular site on the probabilities of receiving preventive services were reported. The [lambda]''s were calculated for each individual based on the predicted probabilities from the first-stage estimation. Because the [lambda]''s vary by individuals, the averages of the [lambda]''s were used in calculating the marginal effects.

An individual has a choice between a regular site and a regular doctor (and no usual source of care), as indicated by the two arrows starting at the decision node. This choice is determined by predisposing, enabling, and need factors. The chosen usual source of care, a regular doctor or site, along with predisposing, enabling, and need factors, affects discrete preventive service use (mammogram is shown for illustration purpose). However, the effect of having a regular doctor on service use (solid arrows) may be different from that of having a regular site (dashed arrows). Furthermore, unobservable preferences of the consumers, such as their risk aversion and health conscientiousness, affect both the use of preventive services and the choice of a usual source of care. That is, the consumers who are likely to use prevention may be those who are likely to have a usual source of care, controlling for their observable characteristics. Figure 1 demonstrates that the unobservable preferences cause the endogeneity o f the choice of a usual source of care.

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