Randomized clinical trial of a quality improvement intervention in nursing homes

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork

Leadership, communication, and teamwork are essential elements of organizational capacity and are linked to organizational performance. How those organizations actually achieve improved performance, however, is not clearly understood. In this comparative case study, nursing leadership who facilitated open communication and teamwork achieved improvement while nursing leadership who impeded open communication and teamwork did not.

The use of data for process and quality improvement in long term care and home care: a systematic review of the literature

BACKGROUND

Standardized resident or client assessments, including the Resident Assessment Instrument (RAI), have been available in long term care and home care settings (continuing care sector) in many jurisdictions for a number of years. Although using these data can make quality improvement activities more efficient and less costly, there has not been a review of the literature reporting quality improvement interventions using standardized data.

OBJECTIVES

To address 2 questions: (1) How have RAI and other standardized data been used in process or quality improvement activities in the continuing care sector? and (2) Has the use of RAI and similar data resulted in improvements to resident or other outcomes?

DATA SOURCES

Searches using a combination of keyword and controlled vocabulary term searches were conducted in MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, the Cochrane Library, and PsychINFO. ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: English language publications from database inception to October 2008 were included. Eligibility criteria included the following: (1) set in continuing care (long-term care facility or home care), (2) involved some form of intervention designed to improve quality or process of care, and (3) used standardized data in the quality or process improvement intervention.

STUDY APPRAISAL AND SYNTHESIS METHODS

After reviewing the articles, we grouped the studies according to the type of intervention used to initiate process improvement. Four different intervention types were identified. We organized the results and discussion by these 4 intervention types.

RESULTS

Key word searches identified 713 articles, of which we excluded 639 on abstract review because they did not meet inclusion criteria. A further 50 articles were excluded on full-text review, leaving a total of 24 articles. Of the 24 studies, 10 used a defined process improvement model, 8 used a combination of interventions (multimodal), 5 implemented new guidelines or protocols, and 1 used an education intervention.

CONCLUSIONS/IMPLICATIONS

The most frequently cited issues contributing to unsuccessful quality improvement interventions were lack of staff, high staff turnover, and limited time available to train staff in ways that would improve client care. Innovative strategies and supporting research are required to determine how to intervene successfully to improve quality in these settings characterized by low staffing levels and predominantly nonprofessional staff. Research on how to effectively enable practitioners to use data to improve quality of care, and ultimately quality of life, needs to be a priority.

Culture change models and resident health outcomes in long-term care

PURPOSE

To examine the scientific evidence for the effect of comprehensive culture change model implementation on resident health outcomes in long-term care.

DESIGN

In this integrated review, an electronic literature search was conducted for studies that examined the effect of comprehensive culture change models on long-term care residents' physical and psychosocial health.

METHODS

Eleven articles were thoroughly reviewed for outcomes related to resident health, and findings were integrated across models. Each study was assigned a level of evidence rating using the Scottish Intercollegiate Guidelines Network guidelines and an overall recommendation grade was determined.

FINDINGS

Evaluation of the literature indicates that results are conflicting, although potential resident benefits as a result of model implementation may exist, particularly in regard to psychosocial health outcomes.

CONCLUSIONS

Evidence regarding long-term care residents' health outcomes after comprehensive culture change model implementation is inconsistent, and the grade of the evidence makes practice recommendations difficult at this time. However, integrated findings across studies demonstrate potential psychosocial benefits to long-term care residents.

CLINICAL RELEVANCE

Nurses working in long-term care play a crucial role in the success of culture change initiatives as well as the health outcomes of residents. Empirical evidence for the effect of comprehensive culture change models on resident health outcomes supports reasonable expectations of their implementation and indicates areas for future research and translation into practice.

Aging issues: nursing imperatives for healthcare reform

The people of the United States sent a clear message in November 2008 that they wanted a change in the nation's priorities, including healthcare. The question is whether healthcare reform will extend to the care of older adults, especially in the face of complex needs in the last years of their lives. This article addresses this question by examining the demographics of the older adult population, the eldercare workforce, and the current inadequate patchwork of financing. Some aging issues, such as chronic care, are being addressed in the broad context of healthcare reform, whereas health information technology and others remain marginal. The window of opportunity for a clear and coherent voice in a reformed/reshaped healthcare system is narrow. Now is the time for the "trusted" profession to advocate for meaningful change that will meet the current and future needs of older adults. The article concludes with strategies and Web-based resources for nurses to bring aging issues to the healthcare reform debate at both the national and local levels.

Data for improvement and clinical excellence: protocol for an audit with feedback intervention in long-term care

Background

There is considerable evidence about the effectiveness of audit coupled with feedback, although few audit with feedback interventions have been conducted in long-term care (LTC) settings to date. In general, the effects have been found to be modest at best, although in settings where there has been little history of audit and feedback, the effects may be greater, at least initially. The primary purpose of the Data for Improvement and Clinical Excellence (DICE) Long-Term Care project is to assess the effects of an audit with feedback intervention delivered monthly over 13 months in four LTC facilities. The research questions we addressed are:

1. What effects do feedback reports have on processes and outcomes over time?

2. How do different provider groups in LTC and home care respond to feedback reports based on data targeted at improving quality of care?

Methods/design

The research team conducting this study comprises researchers and decision makers in continuing care in the province of Alberta, Canada. The intervention consists of monthly feedback reports in nine LTC units in four facilities in Edmonton, Alberta. Data for the feedback reports comes from the Resident Assessment Instrument Minimum Data Set (RAI) version 2.0, a standardized instrument mandated for use in LTC facilities throughout Alberta. Feedback reports consist of one page, front and back, presenting both graphic and textual information. Reports are delivered to all staff working in the four LTC facilities. The primary evaluation uses a controlled interrupted time series design both adjusted and unadjusted for covariates. The concurrent process evaluation uses observation and self-report to assess uptake of the feedback reports. Following the project phase described in this protocol, a similar intervention will be conducted in home care settings in Alberta. Depending on project findings, if they are judged useful by decision makers participating in this research team, we plan dissemination and spread of the feedback report approach throughout Alberta.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

Although the evidence to support influenza vaccination is poor, it is promoted by many health authorities. There is uncertainty about the effectiveness of interventions to increase influenza vaccination rates in those 60 years or older.

OBJECTIVES

To assess effects of interventions to increase influenza vaccination rates in those 60 or older.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 3), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1950 to July 2010), PubMed (January 1950 to July 2010), EMBASE (1980 to 2010 Week 28), AgeLine (1978 to July 2010), ERIC (1965 to July 2010) and CINAHL (1982 to July 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) to increase influenza vaccination rates in those aged 60 years and older, recording influenza vaccination status either through clinic records, billing data or local/national vaccination registers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data.

MAIN RESULTS

Forty-four RCTs were included. All included RCTs studied seniors in the community and in high-income countries. No RCTs of society-level interventions were included. Heterogeneity was marked and meta-analysis was limited. Only five RCTs were graded at low and six at moderate risk of bias. They included three of 13 personalized postcard interventions (all three with the 95% confidence interval (CI) above unity), two of the four home visit interventions (both with 95% CI above unity, but one a small study), three of the four reminder to physicians interventions (none with 95% CI above unity) and three of the four facilitator interventions (one with 95% CI above unity, and one P < 0.01). The other 33 RCTs were at high risk of bias and no recommendations for practice can be drawn.

AUTHORS' CONCLUSIONS

Personalized postcards or phone calls are effective, and home visits, and facilitators, may be effective. Reminders to physicians are not. There is insufficient good evidence for other interventions.

Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports

OBJECTIVE

To design and facilitate implementation of practice-based evidence changes associated with decreases in pressure ulcer (PrU) development in long-term-care (LTC) facilities and promote these practices as part of routine care.

DESIGN

Pre/post observational study.

SETTINGS AND PARTICIPANTS

Frail older adult residents in 11 US LTC facilities.

INTERVENTION

Project facilitators assisted frontline multidisciplinary teams (certified nurse aides [CNAs], nurses, and dietitians/dietary aides) to develop streamlined standardized CNA documentation and weekly reports to identify high-risk residents and to integrate clinical reports into day-to-day practice and clinical decision making. The program was called "Real-Time Optimal Care Plans for Nursing Home QI" (Real-Time).

MAIN OUTCOME MEASURES

Prevalence of PrUs using Centers for Medicare & Medicaid Services (CMS) quality measures (QMs), number of in-house-acquired PrUs, and number and completeness of CNA documentation forms.

MAIN RESULTS

Seven study LTC facilities that reported data to CMS experienced a combined 33% (SD, 36.1%) reduction in the CMS high-risk PrU QM in 18 months and reduction in newly occurring PrUs (number of ulcers in the fourth quarter of 2003: range, 2-19; and in the third quarter of 2005: range, 1-6). Five of these LTC facilities that fully implemented Real-Time experienced a combined 48.1% (SD, 23.4%) reduction in the CMS high-risk PrU QM. Ten facilities reduced by an average of 2 to 5 their number of CNA documentation forms; CNA weekly documentation completeness reached a consistent level of 90% to 95%, and 8 facilities integrated the use of 2 to 4 weekly project reports in routine clinical decision making.

CONCLUSIONS

Quality improvement efforts that provide access to focused and timely clinical information, facilitate change, and promote staff working together in multidisciplinary teams impacted clinical outcomes. Prevention of PrUs showed a trend of improvement in facilities that fully integrated tools to identify high-risk residents into day-to-day practice. CNA documentation facilitated better information for clinical decision making. More than 70 additional LTC facilities across the United States are implementing this QI program.

Adjustment of nursing home quality indicators

Background

This manuscript describes a method for adjustment of nursing home quality indicators (QIs) defined using the Center for Medicaid & Medicare Services (CMS) nursing home resident assessment system, the Minimum Data Set (MDS). QIs are intended to characterize quality of care delivered in a facility. Threats to the validity of the measurement of presumed quality of care include baseline resident health and functional status, pattern of comorbidities, and facility case mix. The goal of obtaining a valid facility-level estimate of true quality of care should include adjustment for resident- and facility-level sources of variability.

Methods

We present a practical and efficient method to achieve risk adjustment using restriction and indirect and direct standardization. We present information on validity by comparing QIs estimated with the new algorithm to one currently used by CMS.

Results

More than half of the new QIs achieved a "Moderate" validation level.

Conclusions

Given the comprehensive approach and the positive findings to date, research using the new quality indicators is warranted to provide further evidence of their validity and utility and to encourage their use in quality improvement activities.

Care of nursing home residents by advanced practice nurses. A review of the literature

The complexity of care in nursing homes has steadily increased during the past several years. Many nursing homes now provide care for both short-stay and long-stay patients who range in age from young to very old. At the same time, there has been a shortage of primary care physicians to provide care while nursing homes have been under intense scrutiny and pressure to improve the quality of care provided. Advanced practice nurses (APNs) are increasingly evident members of the nursing home workforce, providing both primary care to individual residents in collaboration with physicians and consultative services to nursing homes. This article reviews the research that documents the relationship between APNs and improved quality of care and begins a discussion of what constitutes APN best practices in the nursing home setting.

Interventions for preventing falls in older people in nursing care facilities and hospitals

BACKGROUND

Falls in nursing care facilities and hospitals are common events that cause considerable morbidity and mortality for older people.

OBJECTIVES

To assess the effectiveness of interventions designed to reduce falls by older people in nursing care facilities and hospitals.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2009); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 2); MEDLINE, EMBASE, and CINAHL (all to November 2008); trial registers and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials of interventions to reduce falls in older people in nursing care facilities or hospitals. Primary outcomes were rate of falls and risk of falling.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.

MAIN RESULTS

We included 41 trials (25,422 participants).In nursing care facilities, the results from seven trials testing supervised exercise interventions were inconsistent. This was the case too for multifactorial interventions, which overall did not significantly reduce the rate of falls (rate ratio (RaR) 0.82, 95% CI 0.62 to 1.08; 7 trials, 2997 participants) or risk of falling (risk ratio (RR) 0.93, 95% CI 0.86 to 1.01; 8 trials, 3271 participants). A post hoc subgroup analysis, however, indicated that where provided by a multidisciplinary team, multifactorial interventions reduced the rate of falls (RaR 0.60, 95% CI 0.51 to 0.72; 4 trials, 1651 participants) and risk of falling (RR 0.85, 95% CI 0.77 to 0.95; 5 trials, 1925 participants). Vitamin D supplementation reduced the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; 4 trials, 4512 participants), but not risk of falling (RR 0.98, 95% CI 0.89 to 1.09; 5 trials, 5095 participants).In hospitals, multifactorial interventions reduced the rate of falls (RaR 0.69, 95% CI 0.49 to 0.96; 4 trials, 6478 participants) and risk of falling (RR 0.73, 95% CI 0.56 to 0.96; 3 trials, 4824 participants). Supervised exercise interventions showed a significant reduction in risk of falling (RR 0.44, 95% CI 0.20 to 0.97; 3 trials, 131 participants).

AUTHORS' CONCLUSIONS

There is evidence that multifactorial interventions reduce falls and risk of falling in hospitals and may do so in nursing care facilities. Vitamin D supplementation is effective in reducing the rate of falls in nursing care facilities. Exercise in subacute hospital settings appears effective but its effectiveness in nursing care facilities remains uncertain.

Expanding the knowledge base of resident and facility outcomes of care delivered by advanced practice nurses in long-term care: expert panel recommendations

In 2003, a panel of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care convened to examine and make recommendations about care quality and safety issues related to advanced practice nurses (APNs) in nursing home practice. This article reports on the panel recommendation that addressed expanding the evidence base of resident and facility outcomes of APN nursing home practice. A review of the small but important body of research related to nursing home APN practice suggests a positive impact on resident care and facility outcomes. Recommendations are made for critically needed research in four key areas: (a) APN nursing home practice, (b) relative value unit coding, (c) outcomes related to geropsychiatric and mental health nursing services, and (d) outcomes related to geriatric specialization. The APN role could be significantly enhanced and executed if its specific contribution to resident and facility outcomes was more clearly delineated through the recommended rigorous research.

Caring for persons with Parkinson’s disease in care homes: Perceptions of residents and their close relatives, and an associated review of residents’ care plans

Abstract

Through qualitative in-depth interviews, we collected the views of persons with Parkinson’s disease (pwPD) and their close relatives in care homes to establish their collective views of the effectiveness of care. We also reviewed the corresponding care plans. Drawing on these two forms of data collection, we compared similarities and differences between the qualitative interview data and the care plan analysis to elaborate on the experience of residential care for pwPD. Close relatives of care home residents can be a fruitful source of information for care home staff, throughout the care planning process, especially in relation to the specific needs of a pwPD. Although health and social policy advocate active collaboration between people with long-term conditions, their families, and their formal carers, there is limited evidence of such collaboration in the data examined here. There is an apparent shortfall in the knowledge and understanding of PD among care home staff. There are important pragmatic (e.g. drug administration) as well as psycho-social reasons for flexibility in routine care provision to meet the dynamic needs of pwPD. The findings here support the need for further, larger scale research into the quality of care for pwPD who are care home residents.

Helping nursing homes "at risk" for quality problems: a statewide evaluation

The Quality Improvement Program for Missouri (QIPMO), a state school of nursing project to improve quality of care and resident outcomes in nursing homes, has a special focus to help nursing homes identified as "at risk" for quality concerns. In fiscal year 2006, 92 of 492 Medicaid-certified facilities were identified as "at risk" using quality indicators (QIs) derived from Minimum Data Set (MDS) data. Sixty of the 92 facilities accepted offered on-site clinical consultations by gerontological expert nurses with graduate nursing education. Content of consultations include quality improvement, MDS, care planning, evidence-based practice, and effective teamwork. The 60 "at-risk" facilities improved scores 4%-41% for 5 QIs: pressure ulcers (overall and high risk), weight loss, bedfast residents, and falls; other facilities in the state did not. Estimated cost savings (based on prior cost research) for 444 residents who avoided developing these clinical problems in participating "at-risk" facilities was more than $1.5 million for fiscal year 2006. These are similar to estimated savings of $1.6 million for fiscal year 2005 when 439 residents in "at-risk" facilities avoided clinical problems. Estimated savings exceed the total program cost by more than $1 million annually. QI improvements demonstrate the clinical effectiveness of on-site clinical consultation by gerontological expert nurses with graduate nursing education.

WITHDRAWN: Interventions for preventing falls in elderly people

BACKGROUND

Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care).

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 19), CINAHL (1982 to April 2003), The National Research Register, Issue 2, 2003, Current Controlled Trials (www.controlled-trials.com accessed 11 July 2003) and reference lists of articles. No language restrictions were applied. Further trials were identified by contact with researchers in the field.

SELECTION CRITERIA

Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or falls. Trials reporting only intermediate outcomes were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Data were pooled using the fixed effect model where appropriate.

MAIN RESULTS

Sixty two trials involving 21,668 people were included.Interventions likely to be beneficial:Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0.73, 95%CI 0.63 to 0.85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0.86, 95%CI 0.76 to 0.98), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 0.60, 95%CI 0.50 to 0.73) A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98) Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 0.66, 95% CI 0.54 to 0.81) Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -5.20, 95%CI -9.40 to -1.00) A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73). Interventions of unknown effectiveness:Group-delivered exercise interventions (9 trials, 1387 participants) Individual lower limb strength training (1 trial, 222 participants) Nutritional supplementation (1 trial, 46 participants) Vitamin D supplementation, with or without calcium (3 trials, 461 participants) Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants) Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants) Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants) Home hazard modification for older people without a history of falling (1 trial, 530 participants) Hormone replacement therapy (1 trial, 116 participants) Correction of visual deficiency (1 trial, 276 participants).Interventions unlikely to be beneficial:Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants).

AUTHORS' CONCLUSIONS

Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.

Quality improvement in a publicly provided long-term care system: the case of Norway

OBJECTIVE

To explore the extent to which quality improvement activities are implemented in the Norwegian long-term care system for older people, and to determine if variations in the extent and scope of quality improvement activities are associated with the characteristics of the first-line care leaders, the sector or the size of the municipality.

DESIGN

A cross-sectional telephone survey supplemented with information from public records and official municipal websites. Data were organized according to six total quality management components, and a sum score was developed to measure quality improvement. Variations in the extent of quality improvement activities were analysed using multivariate analysis.

SETTING

Thirty-two Norwegian municipalities stratified according to region and population size.

PARTICIPANTS

Sixty-four first-line leaders in nursing homes and home-based care.

MAIN OUTCOME MEASURE

A sum score has been used as a measure of quality improvement activities.

RESULTS

The unit's quality improvement activities varied by quality improvement components and by municipality. The technical component that requires training in tools and techniques was low; the general components as 'leader's involvement' and 'employee participation' were more common. The size of the populations of the municipalities showed a significant independent association with the scope of quality activities.

CONCLUSIONS

The six quality improvement components varied from high to extremely low, and the large municipalities had more quality activities than small- or medium-sized municipalities.

Enhancing geriatric nursing competencies for RNs in nursing homes

The purpose of this review was to determine the best method to deliver education that strengthens geriatric nursing competencies in RNs working in nursing homes to achieve excellent outcomes for a complex population. On the basis of the evidence reviewed, recommendations are made related to the kind of learning activities, structure of educational sessions, and instructor qualifications and consultation activities.

Using principles of diffusion of innovation to improve nursing home care

Principles of diffusion of innovation were used to change care provided to people with dementia in 9 nursing homes. Use of these principles was associated with increased assessment in response to behavior change, increased administration of analgesics, and a significant decrease in resident behavioral symptoms. Results of this study support the emerging consensus that diffusion of innovation is an effective model for making changes in performance of healthcare organizations.

Balancing regulatory controls and incentives: toward smarter and more transparent oversight in long-term care

Government oversight of long-term care involves inspections of patients' records, limited observations of patients and care practices, reviews of policies and procedures, and distribution of publicly available information. Although many providers bemoan the stifling consequences of excessive regulation, oversight in this area remains a highly legitimate endeavor for the public, though the public has limited trust in the existing regulatory regime. This distrust stems from many sources, not least of which includes considerable variation, both within and across states, in the way government oversight occurs. Reforming the current regulatory structure requires that we regulate "smarter" and more consistently. This means improving and maximizing use of the data already being collected, but it also means explicitly rationalizing the regulator's responsibility to review performance and apply sanctions when necessary. Oversight should more closely resemble consultancy, with regulators sharing information with providers about how to improve quality. Ideally, there needs to be an iterative process in which state inspectors identify performance problems and the nation's quality improvement organizations then help providers design quality improvement interventions to ameliorate the problems identified. The benefits of a revised regulatory approach are especially apparent in the aftermath of Hurricane Katrina, where more effective oversight would have identified nursing home residents at risk for low-quality care before the disaster occurred while better identifying those in need of evacuation or assistance afterward.

Initiating person-centered care practices in long-term care facilities

Person-centered care is a key concept guiding efforts to improve long-term care. Elements of person-centered care include personhood, knowing the person, maximizing choice and autonomy, comfort, nurturing relationships, and a supportive physical and organizational environment. The Oregon Health & Science University Hartford Center of Geriatric Nursing Excellence and the state agency that oversees health care for older adults worked in partnership with 9 long-term care facilities. Each developed and implemented person-centered care practices, including those focused on bathing, dining, or gardening. This article describes the processes used to develop and support these practices. Three exemplary facilities made significant practice changes, 4 made important but more moderate changes, and 2 made minimal progress. These facilities differed in terms of existing culture, management practices, staff involvement, and attention to sustainability.

Improving the quality of residential care using goal attainment scaling

OBJECTIVE

To illustrate the potential of goal attainment scaling (GAS) as a means to improve the quality of care provided by residential care facilities to frail older adults.

DESIGN

A pre-test/post-test single-group design.

SETTINGS/PARTICIPANTS

Twenty facilities providing inadequate care to at least one resident. These facilities were identified with a case-finding questionnaire followed by a thorough investigation of the quality of care delivered to a sample of frail older adults.

INTERVENTION

The 6-month intervention was conducted by three interdisciplinary teams of health professionals experienced in caring for frail older adults. The intervention was tailored to the main quality problems identified at baseline in the facility. The first task of the intervention team was to set weighted priority goals in conjunction with the facility manager. Subsequent monthly on-site visits, interspersed with frequent telephone calls, were devoted to assisting the manager and staff implement permanent changes in the areas of care targeted for improvement.

MEASUREMENTS

Pre- and post-intervention GAS scores.

RESULTS

Two facilities were lost to follow-up. A total of 81 facility goals were established at the onset of the study. Goals per facility ranged from 2 to 9 (mean = 4.5, SD = 2.04). GAS scores increased significantly between pre- and post-intervention (P < .001). Goal achievement varied with the manager's own rating of the quality of care provided in the facility (P = .008), his/her education level (P = .037), and the intervention team (P = .049).

CONCLUSIONS

This study shows that quality improvement objectives established with the manager following a thorough evaluation of the quality of care provided in the facility can, on average, be attained with the help of experienced health professionals. It also provides some insight into the types of facilities where preset objectives are more likely to be achieved.

Enriching opportunities for people living with dementia: the development of a blueprint for a sustainable activity-based model

The aim of this paper is to describe the process of building a multi-level intervention called the Enriched Opportunities Programme, the objective of which is to provide a sustainable activity-based model for people with dementia living in long-term care. It is hypothesised that five key elements need to work together to bring about a sustainable activity-based model of care. These elements are specialist expertise-the staff role of Locksmith was developed as part of this programme; individualised assessment and case work; an activity and occupation programme; staff training; and management and leadership. These elements working together are known as the Enriched Opportunities Programme. This paper reports on the processes undertaken to develop Enriched Opportunities from its inception to the present, and focuses on lessons learnt from the literature, an expert working group and action research in four UK study sites. A blueprint for evaluation in other long-term care facilities is described.

Organizational change and quality improvement in nursing homes: approaching success

Nursing home residents' quality of life (QoL) is directly related to the quality improvement (QI) processes mandated by federal law. This article describes a 3-year longitudinal study of QI process innovations in two nursing homes and highlights details of a successful 6-month initiative. The initial QI initiatives were based on the principles of staff empowerment, enhanced ability through training, and financial incentives. After 18 months without measurable success, the QI process was modified to include real-time feedback. Two not-for-profit nursing homes participated in this study to explore the effect of organizational change in nursing homes on residents' quality of care and QoL and staff members' job satisfaction. At 6-month intervals, residents and staff participated in structured assessments of residents' QoL and quality of care and staff members' job satisfaction. When the QI process was modified to include real-time feedback, there was a significant reduction in the rate of new pressure ulcers, stage 2 or greater (p < .05), in one of the facilities that had struggled with this problem for more than 18 months. By examining QI processes in nursing homes, the researchers were able to identify some of the obstacles to improving quality of care and QoL. Only when the element of real-time feedback was introduced, in combination with enhanced staff abilities and financial incentives, were substantial improvements seen in key clinical outcomes.

The behavioral assessment scale: a measure of community living skills

This study reports the development of a community living skills measure of long-term care AIDS residents. Community living skills impact numbers and types of care providers needed. The Behavioral Assessment Scale (BAS) used multiple sources of validity evidence to ensure community living skills construct representation. The BAS was piloted in four diverse long-term care facilities. Nurses rated residents using the BAS and the Nurse Perception Scale (NPS)-another community living skills measure. Researchers rated residents' community living skills through medical record notations (Interdisciplinary Notation Scale [INS]). Reliability coefficients over .6 (p < .001) were reported for the BAS in both the total sample and the individual samples. Evidence-based validity of the BAS was obtained via coefficients from the total sample (.422 [BAS and INS] and .526 [BAS and NPS], with p < .001 for both relationships), Cronbach's alpha (.851 for all community living skills tools), analysis of variance, and regression results. The BAS was substantiated for long-term care practice with AIDS residents.

Description of an advanced practice nursing consultative model to reduce restrictive siderail use in nursing homes

Researchers have demonstrated that the use of physical restraints in nursing homes can be reduced, particularly where advanced practice nurses (APNs) are utilized. We examined the link between APN practice, siderail reduction, and the costs of siderail alternatives in 273 residents in four Philadelphia nursing homes. The majority of participants were cognitively and physically impaired with multiple co-morbidities. APNs recommended a total of 1,275 siderail-alternative interventions aimed at reducing fall risk. The median cost of siderail alternatives to prevent falls per resident was $135. Residents with a fall history experienced a significantly higher cost of recommendation compared to non-fallers. Findings suggest that an APN consultation model can effectively be implemented through comprehensive, individualized assessment without incurring substantial costs to the nursing home.

Consequences of an intervention to reduce restrictive side rail use in nursing homes

OBJECTIVES

To examine the effect of an advanced practice nurse (APN) intervention on restrictive side rail usage in four nursing homes and with a sample of 251 residents. A secondary question explored the association between restrictive side rail reduction and bed-related falls.

DESIGN

Pre- and posttest design.

SETTING

Four urban nursing homes.

PARTICIPANTS

All nursing home residents present in the nursing home at three time points (n=710, 719, and 707) and a subset of residents (n=251) with restrictive side rail use at baseline.

INTERVENTION

APN consultation with individual residents and facility-wide education and consultation.

MEASUREMENTS

Direct observation of side rail status, resident and nurse interview for functional status, mobility, cognition, behavioral symptoms, medical record review for demographics and treatment information, and incident reports for fall data.

RESULTS

At the institutional level, one of the four nursing homes significantly reduced restrictive side rail use (P=.01). At the individual participant level, 51.4% (n=130) reduced restrictive side rail use. For the group that reduced restrictive side rails, there was a significantly (P<.001) reduced fall rate (-0.053; 95% confidence interval (CI)=-0.083 to -0.024), whereas the group that continued restrictive side rail did not demonstrate a significantly (P=.17) reduced fall rate (-0.013; 95% CI=-0.056-0.030).

CONCLUSION

An APN consultation model can safely reduce side rail use. Restrictive side rail reduction does not lead to an increase in bed-related falls. Although side rails serve many purposes, routine use of these devices to restrict voluntary movement and prevent falls is not supported.

Challenges to implementing an APN-facilitated falls management program in long-term care

Although several clinical studies have demonstrated success in reducing falls among nursing home residents, the degree of adherence to these strategies varies widely among studies and facilities, especially following the removal of external consultants or advance practice nurses (APNs). This article identified contextual factors that challenged the effective implementation of a falls reduction program. For nurses, the major problems with implementing the project involved inadequate nursing assessment and clinical decision making. APNs who influence nursing staff behavior via education and individual resident consultation may fill the critical gap in professional nursing care in nursing homes.

Implementation and Evaluation of a Nursing Home Fall Management Program

OBJECTIVES

To evaluate the feasibility and effectiveness of a falls management program (FMP) for nursing homes (NHs).

DESIGN

A quality improvement project with data collection throughout FMP implementation.

SETTING

NHs in Georgia owned and operated by a single nonprofit organization.

PARTICIPANTS

All residents of participating NHs.

INTERVENTION

A convenience sample of 19 NHs implemented the FMP. The FMP is a multifaceted quality improvement and culture change intervention. Key components included organizational leadership buy-in and support, a designated facility-based falls coordinator and interdisciplinary team, intensive education and training, and ongoing consultation and oversight by advanced practice nurses with expertise in falls management.

MEASUREMENTS

Process-of-care documentation using a detailed 24-item audit tool and fall and physical restraint use rates derived from quality improvement software currently used in all Georgia NHs (MyInnerView).

RESULTS

Care process documentation related to the assessment and management of fall risk improved significantly during implementation of the FMP. Restraint use decreased substantially during the project period, from 7.9% to 4.4% in the intervention NHs (a relative reduction of 44%), and decreased in the nonintervention NHs from 7.0% to 4.9% (a relative reduction of 30%). Fall rates remained stable in the intervention NHs (17.3 falls/100 residents per month at start and 16.4 falls/100 residents per month at end), whereas fall rates increased 26% in the NHs not implementing the FMP (from 15.0 falls/100 residents/per month to 18.9 falls/100 residents per month).

CONCLUSION

Implementation was associated with significantly improved care process documentation and a stable fall rate during a period of substantial reduction in the use of physical restraints. In contrast, fall rates increased in NHs owned by the same organization that did not implement the FMP. The FMP may be a helpful tool for NHs to manage fall risk while attempting to reduce physical restraint use in response to the Centers for Medicare and Medicaid Services quality initiatives.

Field testing, refinement, and psychometric evaluation of a new measure of nursing home care quality

The primary aim of this NINR-NIH-funded field test in 407 nursing homes in 3 states was to complete the development of and conduct psychometric testing for the Observable Indicators of Nursing Home Care Quality Instrument (Observable Indicators, OIQ). The development of the OIQ was based on extensive qualitative and iterative quantitative work that described nursing home care quality and did initial validity and reliability field testing of the instrument in 123 nursing homes in 1 state. The scale is meant for researchers, consumers, and regulators interested in directly observing and quickly evaluating (within 30 minutes of observation) the multiple dimensions of care quality in nursing homes. After extensive testing in this study, the Observable Indicators instrument has been reduced to 30 reliable and discriminating items that have a conceptually coherent hierarchical factor structure that describes nursing home care quality. Seven first-order factors group together into two second-order factors of Structure (includes Environment: Basics and Odors) and Process (includes Care Delivery, Grooming, Interpersonal Communication, Environment: Access, and Environment: Homelike) that are classic constructs of Quality, which was the third-order factor. Internal consistency reliability for the 7 first-order factors ranged from .77 to .93. Construct validity analyses revealed an association between survey citations and every subscale as well as the total score of the OIQ instrument. Known groups analysis revealed expected trends in the OIQ scores. The Observable Indicators instrument as a whole shows acceptable interrater and test-retest reliabilities, and strong internal consistency. Scale subscales show acceptable reliability as well. Generalizability Theory analyses revealed that dependability of scores can be improved by including a second site observer, or by revisiting a site. There is a small additional benefit from increasing observers or visits beyond two.

Predictors of resident outcome improvement in nursing homes

The effects of contextual characteristics and nursing-related factors on the overall quality improvement of resident outcomes, measured by a weighted index in incidents of pressure ulcers, physical restraints, and catheter use in nursing homes, were investigated by autoregressive latent trajectory modeling of panel data (1997-2003). Findings show that in the initial study period, nursing homes with a smaller bed size, being for-profit, caring for more Medicare residents, having residents with lower acuity levels, being located elsewhere than the South, having a high level of nurse staffing, and certified with lower frequencies of nursing care deficiencies had better quality. The intercept factor, representing the baseline of quality, was well predicted by six of the eight contextual and facility characteristics variables, and the slope trajectory of quality was only weakly predicted by them. The improved quality in resident outcomes was associated with facilities having fewer nursing care deficiency citations than their counterparts.

Entrepreneurial program of research and service to improve nursing home care

This is a methodological article intended to demonstrate the integration of multiple goals, multiple projects with diverse foci, and multiple funding sources to develop an entrepreneurial program of research and service to directly affect and improve the quality of care of older adults, particularly nursing home residents. Examples that illustrate how clinical ideas build on one another and how the research ideas and results build on one another are provided. Results from one study are applied to the next and are also applied to the development of service delivery initiatives to test results in the real world. Descriptions of the Quality Improvement Program for Missouri and the Aging in Place Project are detailed to illustrate real-world application of research to practice.

Pressure Ulcer Prevention in Black and White Nursing Home Residents:

OBJECTIVE

To determine if educating nursing home staff about pressure ulcer prevention reduces the differential risk of pressure ulcer development in black and white nursing home residents.

DESIGN

Subanalysis of a study designed to monitor the emergence of all pressure ulcers in nursing home residents during 12-week baseline and intervention periods.

PARTICIPANTS

All residents and staff of a not-for-profit, 136-bed nursing home in urban western Pennsylvania.

MAIN OUTCOME MEASURE

The quality improvement intervention, featuring a computer-based interactive video education program on pressure ulcer prevention and early detection, consisted of 3 components: (1) staff ability enhancement, (2) staff financial incentives, and (3) real-time management feedback. Three specific outcome measures were monitored for differential risk of pressure ulcer development in black and white nursing home residents: (1) the rate of emergent Stage I-IV pressure ulcers identified, (2) the rate of emergent Stage II-IV pressure ulcers identified, and (3) the rate of individual residents developing at least 1 pressure ulcer (Stages II-IV).

RESULTS

At baseline, black residents demonstrated a higher rate of Stage II-IV pressure ulcer emergence. Black residents with any pressure ulcer were also more likely to have multiple Stage II pressure ulcers compared with white residents. During the baseline period, 31.8% of the pressure ulcers detected in white residents were Stage I, whereas no Stage I pressure ulcers were detected in black residents. During the intervention period, the rate of emergence of all pressure ulcers declined for both groups in similar trends.

CONCLUSION

Black residents were more likely to have multiple Stage II-IV pressure ulcers and were less likely to have Stage I pressure ulcers identified at baseline compared with white residents. The education intervention effectively reduced the rate of pressure ulcers for all residents and eliminated the racial disparity noted during the baseline period.

Audit and feedback: effects on professional practice and health care outcomes

BACKGROUND

Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004.

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality.

MAIN RESULTS

Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies.

AUTHORS' CONCLUSIONS

Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.

Ability, Incentives, and Management Feedback: Organizational Change to Reduce Pressure Ulcers in a Nursing Home

OBJECTIVE

Quality improvement (QI) processes in nursing homes are highly variable and often ineffective. This study evaluated an innovative QI process to reduce pressure ulcers (PUs) in a nursing home with a high rate of PUs.

DESIGN

This was a 48-week, longitudinal study comparing the incidence of PUs during 12-week baseline and intervention and post-intervention periods.

SETTING

Not-for-profit, 136-bed nursing home in urban Western Pennsylvania.

PATIENTS OR OTHER PARTICIPANTS

All residents and all staff at the nursing home participated in this study.

INTERVENTIONS

The intervention consisted of 3 components: Ability enhancement, incentivization, and management feedback. To enhance ability, all staff members completed a computer-based interactive video education program on PU prevention and were mandated to use penlights to promote early detection. Incentivization included $75 for each staff member if the desired reduction in PU incidence was achieved. Management feedback provided real-time information of staff"s adherence to the mandated training.

MAIN OUTCOME MEASURES

Outcome measures consisted of staff's adherence to mandated training and the incidence of new PUs during the baseline period compared to the intervention and post-intervention periods.

RESULTS

Management responded to noncompliance with training with both rewards and stepped discipline. Adherence to protocol, as measured by training compliance, was 100%. There was a significant reduction (P < .05) in the incidence of stage 2 or worse PUs during the intervention period. During the post-intervention periods, the effect was lost.

CONCLUSION

An innovative QI initiative resulted in a significant decrease in PUs in 1 facility. This intervention was not sustainable when the 3 components of the QI intervention were no longer actively maintained.

Nursing assistants' behaviour during morning care: effects of the implementation of snoezelen, integrated in 24-hour dementia care

AIM

This paper reports an investigation of the effects of the implementation of snoezelen, or multisensory stimulation, on the quality of nursing assistants' behaviour during morning care.

BACKGROUND

Nursing assistants in long-term dementia care are often unaware of the impact of their behaviour on patient functioning. Snoezelen is a psychosocial intervention that might improve the quality of caregiver behaviour by combining a person-centred approach with the integration of sensory stimuli.

METHODS

A quasi-experimental pre- and post-test design was implemented in 12 wards for older mentally infirm patients at six nursing homes. The experimental group intervention was a 4-day in-house 'snoezelen' training, stimulus preference screening and supervision meetings. The control group received usual nursing home care. The effectiveness of the intervention was studied by analysing 250 video recordings, which were assessed by independent observers using a 4-point measurement scale developed for this study and based on Kitwood's Dialectical Framework.

RESULTS

The results showed a statistically significant increase in 'Positive Person Work' and decrease in 'Malignant Social Psychology' (total scores) after the implementation of snoezelen. Nursing assistants in the experimental group also improved by statistically significant amounts on all subitems of 'Positive Person Work'. The mean number of sensory stimuli, offered explicitly, increased.

CONCLUSION

The implementation of snoezelen succeeded in effecting a change to a more person-centred approach during morning care. The results indicate that nursing assistants' behaviour can be positively changed provided that the new care model has been successfully implemented.

Improving the quality of residential care using goal attainment scaling

OBJECTIVE

To illustrate the potential of goal attainment scaling (GAS) as a means to improve the quality of care provided by residential care facilities to frail older adults.

DESIGN

A pre-test/post-test single-group design.

SETTINGS/PARTICIPANTS

Twenty facilities providing inadequate care to at least one resident. These facilities were identified with a case-finding questionnaire followed by a thorough investigation of the quality of care delivered to a sample of frail older adults.

INTERVENTION

The 6-month intervention was conducted by three interdisciplinary teams of health professionals experienced in caring for frail older adults. The intervention was tailored to the main quality problems identified at baseline in the facility. The first task of the intervention team was to set weighted priority goals in conjunction with the facility manager. Subsequent monthly on-site visits, interspersed with frequent telephone calls, were devoted to assisting the manager and staff implement permanent changes in the areas of care targeted for improvement.

MEASUREMENTS

Pre- and post-intervention GAS scores.

RESULTS

Two facilities were lost to follow-up. A total of 81 facility goals were established at the onset of the study. Goals per facility ranged from 2 to 9 (mean = 4.5, SD = 2.04). GAS scores increased significantly between pre- and post-intervention (P < .001). Goal achievement varied with the manager's own rating of the quality of care provided in the facility (P = .008), his/her education level (P = .037), and the intervention team (P = .049).

CONCLUSIONS

This study shows that quality improvement objectives established with the manager following a thorough evaluation of the quality of care provided in the facility can, on average, be attained with the help of experienced health professionals. It also provides some insight into the types of facilities where preset objectives are more likely to be achieved.

Improving the quality of long-term care with better information

Publicly reporting information stimulates providers' efforts to improve the quality of health care. The availability of mandated, uniform clinical data in all nursing homes and home health agencies has facilitated the public reporting of comparative quality data. This article reviews the conceptual and technical challenges of applying information about the quality of long-term care providers and the evidence for the impact of information-based quality improvement. Quality "tools" have been used despite questions about the validity of the measures and their use in selecting providers or offering them bonus payments. Although the industry now realizes the importance of quality, research still is needed on how consumers use this information to select providers and monitor their performance and whether these efforts actually improve the outcomes of care.

Factors Predictive of Increased Influenza and Pneumococcal Vaccination Coverage in Long-term Care Facilities: The CMS-CDC Standing Orders Program Project

BACKGROUND

Between 1999 and 2002, a multistate demonstration project was conducted in long-term care facilities (LTCFs) to encourage implementation of standing orders programs (SOP) as evidence-based vaccine delivery strategies to increase influenza and pneumococcal vaccination coverage in LTCFs.

OBJECTIVE

Examine predictors of increase in influenza and pneumococcal vaccination coverage in LTCFs.

DESIGN

Intervention study. Self-administered surveys of LTCFs merged with data from OSCAR (On-line Survey Certification and Reporting System) and immunization coverage was abstracted from residents' medical charts in LTCFs.

SETTING AND PARTICIPANTS

Twenty LTCFs were sampled from 9 intervention and 5 control states in the 2000 to 2001 influenza season for baseline and during the 2001 to 2002 influenza season for postintervention.

INTERVENTION

Each state's quality improvement organization (QIO) promoted the use of standing orders for immunizations as well as other strategies to increase immunization coverage among LTCF residents.

MAIN OUTCOME MEASURES

Multivariate analysis included Poisson regression to determine independent predictors of at least a 10 percentage-point increase in facility influenza and pneumococcal vaccination coverage.

RESULTS

Forty-two (20%) and 59 (28%) of the facilities had at least a 10 percentage-point increase in influenza and pneumococcal immunizations, respectively. In the multivariate analysis, predictors associated with increase in influenza vaccination coverage included adoption of requirement in written immunization protocol to document refusals, less-demanding consent requirements, lower baseline influenza coverage, and small facility size. Factors associated with increase in pneumococcal vaccination coverage included adoption of recording pneumococcal immunizations in a consistent place, affiliation with a multifacility chain, and provision of resource materials.

CONCLUSIONS

To improve the health of LTCF residents, strategies should be considered that increase immunization coverage, including written protocol for immunizations and documentation of refusals, documenting vaccination status in a consistent place in medical records, and minimal consent requirements for vaccinations.

Sustaining a Best-Care Practice in a Nursing Home

This study tested whether an action research organizational intervention fostering participatory management practices would sustain a nursing best-care practice protocol in a nursing home. An experimental nursing home (EH) and a control nursing home (CH) with similar characteristics were studied over a 4-year period. A pretest/posttest quasi-experimental design was used. Baseline data were co[lected on residents, families, and the staffs at the EH and the CH. Staff turnover rates, demographics of participant groups, and surveys concerning job stress, nursing care, family involvement, and satisfaction of residents and family members served as proximal outcomes to indicate whether organizational changes had occurred in the EH. Sustaining best practices in a nursing home requires not only significant organizational change but also changes in regulatory support for quality care, sufficient staff resources to implement and monitor the practices, and a change coordinator with sufficient formal or informal influence.

Future Development of Nursing Home Quality Indicators

Nursing home quality indicators have been developed over the past 10 years to quantify nursing home quality and to draw systematic comparisons between facilities. Although these indicators have been applied widely for nursing home regulation, quality improvement, and public reporting, researchers and stakeholders have raised concerns about their accuracy and usefulness. We critically evaluate nursing home quality indicators from the standpoint of theory, measurement, and application, and we recommend strategies to make the indicators more valuable as quality assessment tools. We recommend that (a) more comprehensive quality indicators should be developed in conjunction with the new Minimum Data Set 3.0; (b) the validity and reliability of the indicators should be evaluated thoroughly with respect to both measurement and application; (c) statistical criteria should be incorporated explicitly into quality indicator scoring and outlier targeting; (d) the dimensionality and theoretical structure of the quality indicators should be carefully examined; (e) risk adjustment methods should be refined and broadened; and (f) quality indicator reporting systems should be strengthened and tailored to stakeholders' needs.

Continuous quality improvement as an innovation: which nursing facilities adopt it?

PURPOSE

We identify environmental and organizational predictors that best discriminate between formal continuous quality improvement (CQI) adopters and nonadopters in nursing homes (NHs) and create a diagnostic profile for facility administrators and policy makers to promote CQI.

DESIGN AND METHODS

We performed a cross-sectional survey of licensed NH administrators in New Jersey in 1999, using The Nursing Care Quality Improvement Survey ( Zinn, Weech, & Brannon, 1998) and The New Jersey NH Profiles Chart. We also performed a discriminant analysis. Of 350 NHs, 46% returned completed questionnaires.

RESULTS

Using variance innovation, resource dependence, and institutional perspectives for our framework, we found that new requirements, environmental competition, organizational time and structural facilitators, and manager training made statistically significant contributions to discriminating between formal CQI adopters and nonadopters.

IMPLICATIONS

Regardless of size, NHs adopt formal CQI to meet external expectations of new regulations and accreditation criteria. CQI adoption is facilitated by information systems, flexible use of personnel, and team supports, as well as CQI training for managers. This profile of adopters can guide administrators and policy makers in promoting CQI for NHs, and it can help NHs already interested in CQI focus internal resources on key facilitators.