Performance Improvement in Practice: Managing Urinary Incontinence in Home Health Patients with the Use of an Evidence-Based Guideline

Home health agency adoption of quality improvement activities and association with performance

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) Home Health Quality Reporting Program (HHQRP) uses performance measurement to spur improvements in home health agencies' (HHAs') quality of care. We examined quality improvement (QI) activities HHAs reported making to improve on HHQRP quality measures, and whether reported QI activities were associated with better measure performance.

METHODS

We used responses (N = 1052) from a Web- and mail-based survey of a stratified random sample of HHAs included in CMS Home Health Compare in October 2019. We estimated national adoption rates for 27 possible QI activities related to organizational culture, health information technology, care process redesign, provider incentives, provider training, changes to staffing responsibilities, performance monitoring, and measure-specific QI initiatives and technical assistance. We used multivariate linear regression to examine the associations between HHA characteristics and QI adoption, and between QI adoption and CMS Home Health Quality of Patient Care Star Rating.

RESULTS

HHAs reported implementing an average of 16 QI activities (interquartile range 11-19 activities). Larger HHA size was associated with adopting 1.6 additional QI activities (p < 0.001). HHAs with higher proportions of disabled, black, or Hispanic patients adopted QI activities at similar or higher rates as other HHAs. Of the 27 QI activities, 23 were considered helpful by more than 80% of adopting HHAs. Compared with adopting 44% of QI activities (10th percentile among HHAs), adopting 89% of QI activities (90th percentile) was associated with a 0.4-star higher Star Rating (95% confidence interval 0.2-0.6).

CONCLUSIONS

HHAs report implementing a significant number of QI activities in response to CMS measurement programs; implementation of a greater number of activities is associated with better performance on publicly reported measures. To guide future HHA QI investments, work is needed to identify the optimal combination of QI activities and the specific QI activities that yield the greatest performance improvements.

Relationship between physician financial incentives and clinical pathway compliance: a cross-sectional study of 18 public hospitals in China

OBJECTIVES

Many strategies have been either used or recommended to promote physician compliance with clinical practice guidelines and clinical pathways (CPs). This study examines the relationship between hospitals' use of financial incentives to encourage physician compliance with CPs and physician adherence to CPs.

DESIGN

A retrospectively cross-sectional study of the relationship between the extent to which patient care was consistent with CPs and hospital's use of financial incentives to influence CP compliance.

SETTING

Eighteen public hospitals in three provinces in China.

PARTICIPANTS

Stratified sample of 2521 patients discharged between 3 January 2013 and 31 December 2014.

PRIMARY OUTCOME MEASURES

The proportion of key performance indicators (KPIs) met for patients with (1) community-acquired pneumonia (pneumonia), (2) acute myocardial infarction (AMI), (3) acute left ventricular failure (heart failure), (4) planned caesarean section (C-section) and (5) gallstones associated with acute cholecystitis and associated cholecystectomy (cholecystectomy).

RESULTS

The average implementation rate of CPs for five conditions (pneumonia, AMI, heart failure, C-section and cholecystectomy) based on 2521 cases in 18 surveyed hospitals was 57% (ranging from 44% to 67%), and the overall average compliance rate for the KPIs for the five conditions was 69.48% (ranging from 65.07% to 77.36%). Implementation of CPs was associated with greater compliance within hospitals only when hospitals adopted financial incentives directed at physicians to promote compliance.

CONCLUSION

CPs are viewed as important strategies to improve medical care in China, but they have not been widely implemented or adhered to in Chinese public hospitals. In addition to supportive resources, education/training and better administration in general, hospitals should provide financial incentives to encourage physicians to adhere to CPs.

Effectiveness of conservative urinary incontinence management among female nursing home residents-A cluster RCT

BACKGROUND

Guideline-compliant conservative management of urinary incontinence (UI) is the first step of the initial management for UI and is recommended for long-term care in older persons. Recent studies have focused on the effects of guideline-compliant UI management. However, most of these studies were tested in another setting than nursing homes and were not focused on conservative management.

AIMS

To measure the effectiveness of 29 evidence-based nursing recommendations regarding the conservative management of UI in Austrian nursing homes.

METHODS

The study is a cluster randomized intervention trial with institution as the unit of randomization. Twelve nursing homes in two Austrian provinces (Styria, Carinthia) were randomly allocated to the intervention group (IG) and control group (CG). Data were collected from participating residents over a three-month period. The intervention consisted of the implementation of recommendations for the conservative management of UI among female nursing home residents. The primary outcome variable was the daily UI experienced by the participating residents.

RESULTS

Residents in the (IG n = 216) had a lower risk (OR = 0.14, p = 0.02) of experiencing daily UI and were less likely to receive absorbent products (OR = 0.01, p = 0.01) than residents in the CG (n = 165). Residents in the IG (OR = 5.16, p = 0.00) were five times more likely to receive recommended interventions (e.g., bladder training) than residents in the CG.

CONCLUSION

Introducing guideline-compliant management into nursing practice can increase the likelihood of evidence-based interventions for the conservative management of UI. The intervention in this study targeted on nurses/nurse managers and can be recommended for the nursing home setting.

Cancer symptom management in the home: A scoping review

The aim of this scoping review was to examine interventions used by nurses in the home setting for symptom management of adults with cancer. Databases were searched (CINAHL, Medline, PubMed, EBM Reviews, Joanna Briggs Institute EBP) with key words cancer, home, nursing, symptom, and protocol. Out of 390 identified citations, five met the inclusion criteria. Studies were conducted from 1989 to 2009. Findings revealed that home care nursing services improved symptom management, promoted independence, maintained quality of life, and decreased use of health care services. Two studies used evidence-based guidelines for cancer symptom management. Although few studies have explored nursing interventions for cancer symptom management in the home setting, their evidence suggests some improved client- and system-level outcomes.

A formative evaluation of nurses' use of electronic devices in a home care setting

The purpose of this study was to evaluate the implementation of a clinical information system (CIS) in a community setting. The researchers used a mixed-method design involving interviews, focus groups, and surveys. An independent cross-sectional sample of nurses was surveyed. At time 1 a total of 118 nurses responded and at time 2 a total of 81. Respondents were moderately satisfied with features of the CIS. User satisfaction was positively associated with access to structural and electronic resources and social capital and negatively associated with nurses' age at time 1. Social capital was positively associated with user satisfaction at time 2. Younger age was associated with overall research use at both time 1 and time 2. Research use was negatively associated with evaluation and feedback but positively associated with formal interactions. This evaluation identified the importance of educational support, user-centred design, and responsiveness to successful implementation of CISs in a community setting.