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Williams C, Joshi A. The Greenhouse Model of Nursing Home Care: A Scoping Review. J Appl Gerontol 2024; 43:803-813. [PMID: 38029726 DOI: 10.1177/07334648231216005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
The study aimed to comprehensively review and assess evidence-based outcomes of the Greenhouse model. We systematically reviewed, assessed, and reported on relevant literature using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines for the scoping review. We identified qualitative or quantitative studies that met our inclusion criteria from PubMed, Medline, CINAHL, and EBSCOhost. The review yielded 41,515 articles published between January 2015 and December 2022; eleven articles met the inclusion criteria and were included in the analysis. The emerging themes were organizational culture, clinical outcomes, and business effects. The Greenhouse model offers a favorable organizational culture with opportunities to enhance clinical and business outcomes. The scoping review was registered in Prospero: CRD42023389048.
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Tocco Tussardi I, Cazzoletti L, Zanolin ME, Comini A, Visentin D, Torri E, Tardivo S, Moretti F. Patient Safety Subcultures among Nursing Home Staff in Italy: A Cross-Sectional Study. Healthcare (Basel) 2023; 11:1962. [PMID: 37444796 DOI: 10.3390/healthcare11131962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
Nursing home (NH) residents are vulnerable subjects and highly susceptible to adverse events. Knowledge of patient safety culture (PSC) is essential for an organization to ensure patient safety. However, research on PSC in NHs, and its variability among staff, is still scarce. This study aimed to explore whether and how PSC differed among NH staff (Managers, Nurses, Direct Care Staff, Support Staff, Administrative Staff and Other Providers) in the Autonomous Province of Trento, Italy. This study employed a cross-sectional design and collected data from 1145 NH providers using the Nursing Home Survey on Patient Safety Culture (NHSPSC). Data were analyzed using linear mixed models, with each of the 12 NHSPSC domains as a response variable. The majority of the respondents (61.6%) were Direct Care Staff members. 'Feedback and Communication about Incidents' and 'Overall Perceptions of Resident Safety' were the domains with the highest proportions of positive answers (PPAs). For most staff categories, 'Staffing' was the domain with the lowest PPA. Support Staff showed significantly lower scores in the majority of domains (8/12). Shorter job tenure, fewer weekly working hours, working mostly during the day and working in highly specialized areas were associated with higher scores in several domains. Interventions to improve PSC must consider the differences between professional groups. Further research is needed to explore the relationship between job-related features and perceptions of patient safety among NH workers.
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Affiliation(s)
- Ilaria Tocco Tussardi
- Department of Diagnostics and Public Health, Section of Hygiene, University of Verona, 37134 Verona, Italy
| | - Lucia Cazzoletti
- Department of Diagnostics and Public Health, Section of Epidemiology and Medical Statistics, University of Verona, 37134 Verona, Italy
| | - Maria Elisabetta Zanolin
- Department of Diagnostics and Public Health, Section of Epidemiology and Medical Statistics, University of Verona, 37134 Verona, Italy
| | - Annarita Comini
- Department of Diagnostics and Public Health, Section of Hygiene, University of Verona, 37134 Verona, Italy
| | - Donatella Visentin
- Department of Prevention, Healthcare Trust of the Autonomous Province of Trento, 38123 Trento, Italy
| | - Emanuele Torri
- Clinical Governance Service, Healthcare Trust of the Autonomous Province of Trento, 38123 Trento, Italy
| | - Stefano Tardivo
- Department of Diagnostics and Public Health, Section of Hygiene, University of Verona, 37134 Verona, Italy
| | - Francesca Moretti
- Department of Neurosciences, Biomedicine and Movement, University of Verona, 37134 Verona, Italy
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3
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Lei KC, Loi CI, Cen Z, Li J, Liang Z, Hu H, Chan TF, Ung COL. Adopting an electronic medication administration system in long-term care facilities: a key stakeholder interview study in Macao. Inform Health Soc Care 2023:1-15. [PMID: 36650719 DOI: 10.1080/17538157.2023.2165084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To improve medication safety for residents in long-term care facilities (LTCFs), electronic medication administration records (eMARs) are widely adopted in Macao. This study aimed to (1) develop a logic model for adopting eMAR in LTCFs and (2) explore the contextual factors relevant to the implementation. Semi-structured interviews were conducted with key stakeholders (managers, doctors, nurses, pharmacy staff and other frontline workers) experienced with eMAR in LTCFs in Macao between February and March 2021. Purposive sampling was used for recruitment and thematic analysis followed the theoretical framework of the logic model. All 57 participants were positive about eMAR. Financial and nonfinancial resources were critical to adopting eMAR. eMAR was mostly used for its functions in documentation, e-prescribing and monitoring. Immediate output included simplified working process, reduced errors, closer monitoring of residents' conditions, and timely communication among staff. The outcomes mainly related to efficiency, safety and quality of care, workload redundancy, and data unification. Key influencing factors included eMAR flexibility, stability, and technical support. Adopting eMARs is highly consuming and the benefits in improving quality of care can only be realized with appropriate implementation, precise execution, regular evaluation and responsive adjustment. The proposed logic model framework serves as a roadmap for LTCFs, both current and future users of eMAR.
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Affiliation(s)
- Ka Cheng Lei
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China
| | - Cheng I Loi
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China
| | - Zhifeng Cen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China
| | - Junlei Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China
| | - Zuanji Liang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China.,Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macao, SAR, China
| | - Tek Fai Chan
- Macao Society for Medicinal Administration, Macao, SAR, China
| | - Carolina Oi Lam Ung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, SAR, China.,Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macao, SAR, China
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Gaur S, Kumar R, Gillespie SM, Jump RLP. Integrating Principles of Safety Culture and Just Culture Into Nursing Homes: Lessons From the Pandemic. J Am Med Dir Assoc 2022; 23:241-246. [PMID: 34958744 PMCID: PMC8709783 DOI: 10.1016/j.jamda.2021.12.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 11/01/2022]
Abstract
Decades of concerns about the quality of care provided by nursing homes have led state and federal agencies to create layers of regulations and penalties. As such, regulatory efforts to improve nursing home care have largely focused on the identification of deficiencies and assignment of sanctions. The current regulatory strategy often places nursing home teams and government agencies at odds, hindering their ability to build a culture of safety in nursing homes that is foundational to health care quality. Imbuing safety culture into nursing homes will require nursing homes and regulatory agencies to acknowledge the high-risk nature of post-acute and long-term care settings, embrace just culture, and engage nursing home staff and stakeholders in actions that are supported by evidence-based best practices. The response to the COVID-19 pandemic prompted some of these actions, leading to changes in nursing survey and certification processes as well as deployment of strike teams to support nursing homes in crisis. These actions, coupled with investments in public health that include funds earmarked for nursing homes, could become the initial phases of an intentional renovation of the existing regulatory oversight from one that is largely punitive to one that is rooted in safety culture and proactively designed to achieve meaningful and sustained improvements in the quality of care and life for nursing home residents.
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Affiliation(s)
- Swati Gaur
- New Horizons Nursing Facilities, Gainesville, GA, USA
| | - Rajeev Kumar
- Symbria, Warrenville, IL, USA; Humana I-SNP, Chicago, IL, USA
| | - Suzanne M Gillespie
- Geriatrics, Extended Care & Rehabilitation, VA Finger Lakes Healthcare System, Bath, NY, USA; Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, USA; Division of Infectious Diseases and HIV Medicine, Department of Medicine and the Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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Wu AW, McIntyre J. Patient safety in long-term care facilities and the COVID-19 pandemic. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2021. [DOI: 10.1177/25160435211059871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Albert W. Wu
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John McIntyre
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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6
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Buljac-Samardžić M, Dekker-van Doorn C, Van Wijngaarden J. Detach Yourself: The Positive Effect of Psychological Detachment on Patient Safety in Long-Term Care. J Patient Saf 2021; 17:490-496. [PMID: 29485520 DOI: 10.1097/pts.0000000000000479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Delivering health care is emotionally demanding. Emotional competencies that enable caregivers to identify and handle emotions may be important to deliver safe care, as it improves resilience and enables caregivers to make better decisions. A relevant emotional competence could be psychological detachment, which refers to the ability to psychologically detach from work and patients in off-duty hours. The objective of this study was to examine the relationship between psychological detachment and patient safety. In addition, the ability of teams to create a safe environment to discuss errors and take personal risks, i.e., psychological safety, was explored as an underlying condition for psychological detachment. METHODS A total of 1219 caregivers (response rate = 44%) from 229 teams in two long-term care organizations completed a survey on psychological safety and psychological detachment at T0. Team managers rated patient safety of those teams at two points in time (T0 and T1). RESULTS Two-level regression analysis showed that both psychological safety (β = 0.72, P < 0.01) and psychological detachment (β = 0.54, P < 0.05) relate directly to patient safety. Psychological safety relates positively to psychological detachment (β = 0.48, P < 0.01) but was, however, not an underlying condition. CONCLUSIONS Perceived patient safety is enhanced by emotional competencies, at individual level by psychological detachment and at team level by psychological safety. Caregivers should be aware of the important influence emotional competencies have on patient safety and be trained to develop these competencies. Future research should focus on exploring underlying conditions for emotional competencies.
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Affiliation(s)
| | | | - Jeroen Van Wijngaarden
- From the Erasmus University Rotterdam, Erasmus School of Health Policy Management (ESHPM)
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7
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Safety Climate Associated With Adverse Events in Nursing Homes: A National VA Study. J Am Med Dir Assoc 2020; 22:388-392. [PMID: 32698990 DOI: 10.1016/j.jamda.2020.05.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Adverse events in nursing homes are leading causes of morbidity and mortality, prompting facilities to investigate their antecedents. This study examined the contribution of safety climate-how frontline staff typically think about safety and act on safety issues-to adverse events in Veterans Affairs (VA) nursing homes or Community Living Centers (CLCs). DESIGN Cross-sectional study. SETTING AND PARTICIPANTS A total of 56 CLCs nationwide, 1397 and 1645 CLC staff (including nurses, nursing assistants, and clinicians/specialists), respectively, responded to the CLC Employee Survey of Attitudes about Resident Safety (CESARS) in 2017 and 2018. METHODS Adverse events (pressure ulcers, falls, major injuries from falls, and catheter use) were measured using the FY2017-FY2018 Minimum Data Set (MDS). Safety climate was defined as 7 CESARS domains (safety priorities, supervisor commitment to safety, senior management commitment to safety, personal attitudes toward safety, environmental safety, coworker interactions around safety, and global rating of CLC). The associations between safety climate domains and each adverse event were determined separately for each frontline group, using beta-logistic regression with random effects. RESULTS Better ratings of supervisor commitment to safety were associated with lower rates of major injuries from falls [odds ratio (OR) 0.33, 95% confidence interval (CI) 0.11-0.97, clinicians] and catheter use (OR 0.42, 95% CI 0.21-0.85, nurses), and better ratings of environmental safety were associated with lower rates of pressure ulcers (OR 0.23, 95% CI 0.09-0.61, clinicians), major injuries from falls (OR 0.48, 95% CI 0.24-0.93, nurses), and catheter use (OR 0.55, 95% CI 0.32-0.93, nursing assistants). Better global CLC ratings were associated with higher rates of catheter use. No other safety climate domains had significant associations. CONCLUSIONS AND IMPLICATIONS Nursing homes may reduce adverse events by fostering supportive supervision of frontline staff and a safer physical environment.
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Perceived Patient Safety Culture in Nursing Homes Associated With "Nursing Home Compare" Performance Indicators. Med Care 2019; 57:641-647. [PMID: 31259786 DOI: 10.1097/mlr.0000000000001142] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The safety and quality of care provided to nursing home residents is a significant concern. Little is known whether fostering patient safety culture helps improve the safety and quality of nursing home care. METHODS This study determined the associations of nursing home patient safety culture performance, as reported by administrators, directors of nursing, and unit leaders in a large national sample of free-standing nursing homes, with several "Nursing Home Compare" performance indicators. We conducted the survey in 2017 using the Agency for Healthcare Research and Quality Survey on Patient Safety Culture for nursing homes to collect data on 12 core domains of safety culture scores. Survey data were linked to other nursing home files for multivariable regression analyses. RESULTS Overall, 818 of the 2254 sampled nursing homes had at least 1 completed survey returned for a response rate of 36%. After adjustment for nursing home, market, and state covariates, every 10 percentage points increase in overall positive response rate for safety culture was associated with 0.56 fewer health care deficiencies (P=0.001), 0.74 fewer substantiated complaints (P=0.004), reduced fines by $2285.20 (P=0.059), and 20% increased odds of being designated as 4-star or 5-star (vs. 1 to 3 star) facilities (odds ratio roughly=1.20, P<0.05). CONCLUSIONS Efforts to improve nursing home performance in patient safety culture have the potential to improve broad safety and quality of care measures encapsulated in the Nursing Home Compare publication.
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9
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Edwards NC, Smith Higuchi K. Process Evaluation of a Participatory, Multimodal Intervention to Improve Evidence-Based Care in Long-Term Care Settings. Worldviews Evid Based Nurs 2018; 15:361-367. [PMID: 30022601 DOI: 10.1111/wvn.12313] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Evidence-based improvements in long-term care (LTC) are challenging due to human resource constraints. AIMS To evaluate implementation of a multimodal, participatory intervention aimed at improving evidence-based care. METHODS Using a qualitative descriptive design, we conducted and inductively analyzed individual interviews with staff at midpoint and end-point to identify action plan implementation processes and challenges. The 9-month intervention engaged professional and unregulated staff in an on-site workshop and provided support for their development and implementation of site-specific action plans. RESULTS Ten of 12 enrolled sites participated for the full study period. Interviews were conducted with 44 and 69 participants at midpoint and end-point, respectively. Seven of 10 sites focused their action plan on team functioning and communication. Main achievements described at end-point were improved team communication, better staff engagement, and improved teamwork. Internal and external supports for action plan implementation were described as critical for success. DISCUSSION Three factors influenced change: vertically and horizontally linked teams, external facilitator support for action plan implementation, and coaching by Best Practice Coordinators that emphasized organizational change and normalization of evidence-based practice. IMPLICATIONS Team functioning and communication are forerunners of clinical practice changes in LTC. An off-site model of facilitation is promising and may provide a more efficient means to reach a wider array of LTC settings. LINKING EVIDENCE TO ACTION Practice changes need engagement of all staff.
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10
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Impact of Nursing Home Palliative Care Teams on End-of-Life Outcomes: A Randomized Controlled Trial. Med Care 2017; 56:11-18. [PMID: 29068904 DOI: 10.1097/mlr.0000000000000835] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Deficits in end-of-life care in nursing homes (NHs) are reported, but the impact of palliative care teams (PCTeams) on resident outcomes remains largely untested. OBJECTIVE Test the impact of PCTeams on end-of-life outcomes. RESEARCH DESIGN Multicomponent strategy employing a randomized, 2-arm controlled trial with a difference-in-difference analysis, and a nonrandomized second control group to assess the intervention's placebo effect. SUBJECTS In all, 25 New York State NHs completed the trial (5830 decedent residents) and 609 NHs were in the nonrandomized group (119,486 decedents). MEASURES Four risk-adjusted outcome measures: place of death, number of hospitalizations, self-reported moderate-to-severe pain, and depressive symptoms. The Minimum Data Set, vital status files, staff surveys, and in-depth interviews were employed. For each outcome, a difference-in-difference model compared the pre-post intervention periods using logistic and Poisson regressions. RESULTS Overall, we found no statistically significant effect of the intervention. However, independent analysis of the interview data found that only 6 of the 14 treatment facilities had continuously working PCTeams throughout the study period. Decedents in homes with working teams had significant reductions in the odds of in-hospital death compared to the other treatment [odds ratio (OR), 0.400; P<0.001), control (OR, 0.482; P<0.05), and nonrandomized control NHs (0.581; P<0.01). Decedents in these NHs had reduced rates of depressive symptoms (OR, 0.191; P≤0.01), but not pain or hospitalizations. CONCLUSIONS The intervention was not equally effective for all outcomes and facilities. As homes vary in their ability to adopt new care practices, and in their capacity to sustain them, reforms to create the environment in which effective palliative care can become broadly implemented are needed.
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Banaszak-Holl J, Reichert H, Todd Greene M, Mody L, Wald HL, Crnich C, McNamara SE, Meddings J. Do Safety Culture Scores in Nursing Homes Depend on Job Role and Ownership? Results from a National Survey. J Am Geriatr Soc 2017; 65:2244-2250. [PMID: 28846129 DOI: 10.1111/jgs.15030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify facility- and individual-level predictors of nursing home safety culture. DESIGN Cross-sectional survey of individuals within facilities. SETTING Nursing homes participating in the national Agency for Healthcare Research and Quality Safety Program for Long-Term Care: Healthcare-Associated Infections/Catheter-Associated Urinary Tract Infections Project. PARTICIPANTS Responding nursing home staff (N = 14,177) from 170 (81%) of 210 participating facilities. MEASUREMENTS Staff responses to the Nursing Home Survey on Patient Safety Culture (NHSOPS), focused on five domains (teamwork, training and skills, communication openness, supervisor expectations, organizational learning) and individual respondent characteristics (occupation, tenure, hours worked), were merged with data on facility characteristics (from the Certification and Survey Provider Enhanced Reporting): ownership, chain membership, percentage residents on Medicare, bed size. Data were analyzed using multivariate hierarchical models. RESULTS Nursing assistants rated all domains worse than administrators did (P < .001), with the largest differences for communication openness (24.3 points), teamwork (17.4 points), and supervisor expectations (16.1 points). Clinical staff rated all domains worse than administrators. Nonprofit ownership was associated with worse training and skills (by 6.0 points, P =.04) and communication openness (7.3 points, P =.004), and nonprofit and chain ownership were associated with worse supervisor expectations (5.2 points, P =.001 and 3.2 points, P =.03, respectively) and organizational learning (5.6 points, P =.009 and 4.2 points, P = .03). The percentage of variation in safety culture attributable to facility characteristics was less than 22%, with ownership having the strongest effect. CONCLUSION Perceptions of safety culture vary widely among nursing home staff, with administrators consistently perceiving better safety culture than clinical staff who spend more time with residents. Reporting safety culture scores according to occupation may be more important than facility-level scores alone to describe and assess barriers, facilitators, and changes in safety culture.
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Affiliation(s)
- Jane Banaszak-Holl
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan.,Institute of Gerontology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Heidi Reichert
- Division of General Medicine, Department of Internal Medicine, Medical School, University of Michigan, Ann Arbor, Michigan
| | - M Todd Greene
- Division of General Medicine, Department of Internal Medicine, Medical School, University of Michigan, Ann Arbor, Michigan.,Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, Medical School, University of Michigan, Ann Arbor, Michigan.,Geriatric Research, Education, and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Heidi L Wald
- Division of Health Care Policy and Research, School of Medicine, University of Colorado, Aurora, Colorado
| | - Christopher Crnich
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin.,William S. Middleton Veterans Affairs Hospital, Madison, Wisconsin
| | - Sara E McNamara
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Jennifer Meddings
- Division of General Medicine, Department of Internal Medicine, Medical School, University of Michigan, Ann Arbor, Michigan.,Department of Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan.,Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, Medical School, University of Michigan, Ann Arbor, Michigan.,School of Medicine, University of Colorado, Aurora, Colorado
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12
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Improving palliative care through teamwork (IMPACTT) in nursing homes: Study design and baseline findings. Contemp Clin Trials 2017; 56:1-8. [PMID: 28315478 DOI: 10.1016/j.cct.2017.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND The 2014 Institute of Medicine report recommended that healthcare providers caring for individuals with advanced illness have basic palliative care competencies in communication, inter-professional collaboration, and symptom management. Nursing homes, where one in three American decedents live and die, have fallen short of these competency goals. We implemented an intervention study to examine the efficacy of nursing home-based integrated palliative care teams in improving the quality of care processes and outcomes for residents at the end of life. METHODS/DESIGN This paper describes the design, rationale, and challenges of a two-arm randomized controlled trial of nursing home-based palliative care teams in 31 facilities. The impact of the intervention on residents' outcomes is measured with four risk-adjusted quality indicators: place of death (nursing home or hospital), number of hospitalizations, and self-reported pain and depression in the last 90-days of life. The effect of the intervention is also evaluated with regard to staff satisfaction and impact on care processes (e.g. palliative care competency, communication, coordination). Both secondary (e.g. the Minimum Data Set) and primary (e.g. staff surveys) data are employed to examine the effect of the intervention. DISCUSSION Several challenges in conducting a complex, nursing home-based intervention have been identified. While sustainability of the intervention without research funding is not clear, we surmise that without changes to the payment model that put palliative care services in this care setting on par with the more "skilled" care, it will not be reasonable to expect any widespread efforts to implement facility-based palliative care services.
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13
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Wagner LM. Improving the Patient Safety Culture in Nursing Homes Through WalkRounds. Jt Comm J Qual Patient Saf 2016; 42:543-544. [DOI: 10.1016/s1553-7250(16)30105-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Frey R, Boyd M, Foster S, Robinson J, Gott M. What's the diagnosis? Organisational culture and palliative care delivery in residential aged care in New Zealand. HEALTH & SOCIAL CARE IN THE COMMUNITY 2016; 24:450-462. [PMID: 25808936 DOI: 10.1111/hsc.12220] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/27/2015] [Indexed: 06/04/2023]
Abstract
Organisational culture has been shown to impact on resident outcomes in residential aged care (RAC). This is particularly important given the growing number of residents with high palliative care needs. The study described herein (conducted from January 2013 to March 2014) examined survey results from a convenience sample of 46 managers, alongside interviews with a purposively selected sample of 23 bereaved family members in order to explore the perceptions of organisational culture within New Zealand RAC facilities in one large urban District Health Board. Results of the Organisational Culture Assessment Instrument (OCAI) completed by managers indicated a preference for a 'Clan' and the structured 'Hierarchy' culture. Bereaved family interviews emphasised both positive and negative aspects of communication, leadership and teamwork, and relationship with residents. Study results from both managers' OCAI survey scores and next of kin interviews indicate that while the RAC facilities are culturally oriented towards providing quality care for residents, they may face barriers to adopting organisational processes supportive of this goal.
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Affiliation(s)
- Rosemary Frey
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Michal Boyd
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Waitemata District Health Board, Auckland, New Zealand
| | - Sue Foster
- Waitemata District Health Board, Auckland, New Zealand
| | - Jackie Robinson
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Merryn Gott
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Li Y, Berkowitz L, Noskin G, Mehrotra S. Detection of patient's bed statuses in 3D using a Microsoft Kinect. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2014:5900-3. [PMID: 25571339 DOI: 10.1109/embc.2014.6944971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Patients spend the vast majority of their hospital stay in an unmonitored bed where various mobility factors can impact patient safety and quality. Specifically, bed positioning and a patient's related mobility in that bed can have a profound impact on risks such as pneumonias, blood clots, bed ulcers and falls. This issue has been exacerbated as the nurse-per-bed (NPB) ratio has decreased in recent years. To help assess these risks, it is critical to monitor a hospital bed's positional status (BPS). Two bed positional statuses, bed height (BH) and bed chair angle (BCA), are of critical interests for bed monitoring. In this paper, we develop a bed positional status detection system using a single Microsoft Kinect. Experimental results show that we are able to achieve 94.5% and 93.0% overall accuracy of the estimated BCA and BH in a simulated patient's room environment.
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16
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Understanding organizational and cultural premises for quality of care in nursing homes: an ethnographic study. BMC Health Serv Res 2015; 15:508. [PMID: 26566784 PMCID: PMC4643525 DOI: 10.1186/s12913-015-1171-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 11/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Internationally, there are concerns about the quality of care in nursing homes. The concept of 'corporate culture' as an internal variable could be seen as the means to improve quality of care and quality of life for the residents. The aim of this article was to describe the nursing home culture from the staff's perspective and to include how the residents describe quality of care. METHODS An ethnographic design was employed. A purposive sample of four municipal public nursing homes in Norway with long-term care residents was included in the study. Data were collected by participant observation including informal conversation with the staff, and in-depth interviews with 15 residents using a narrative approach. RESULTS The main findings were that organizational cultures could be seen as relatively stable corporate cultures described as 'personalities' with characteristics that were common for all nursing homes (conformity) and typical traits that were present in some nursing homes, but that they were also like no other nursing home (distinctiveness). Conformity ('Every nursing home is like all other nursing homes') meant that nursing home organizations formed their services according to a perception of what residents in general need and expect. Trait ('Every nursing home is like some other nursing homes') expressed typologies of nursing homes: residency, medical, safeguard or family orientation. The distinctness of each nursing home ('Every nursing home is like no other nursing home') was expressed in unique features of the nursing home; the characteristics of the nursing home involved certain patterns of structure, cultural assumptions and interactions that were unique in each nursing home. Nursing home residents experienced quality of care as 'The nursing home as my home' and 'Interpersonal care quality'. The resident group in the different types of nursing homes were unique, and the experience of quality of care seemed to depend on whether their unique needs and expectations were met or not. CONCLUSION In order to create a sustainable nursing home service the service needs to be characterized by learning and openness to change and must actually implement practices that respond to the resident and his or her family's values.
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Abrahamson K, Miech E, Davila HW, Mueller C, Cooke V, Arling G. Pay-for-performance policy and data-driven decision making within nursing homes: a qualitative study. BMJ Qual Saf 2015; 24:311-7. [PMID: 25749027 DOI: 10.1136/bmjqs-2014-003362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 02/19/2015] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Health systems globally and within the USA have introduced nursing home pay-for-performance (P4P) programmes in response to the need for improved nursing home quality. Central to the challenge of administering effective P4P is the availability of accurate, timely and clinically appropriate data for decision making. We aimed to explore ways in which data were collected, thought about and used as a result of participation in a P4P programme. METHODS Semistructured interviews were conducted with 232 nursing home employees from within 70 nursing homes that participated in P4P-sponsored quality improvement (QI) projects. Interview data were analysed to identify themes surrounding collecting, thinking about and using data for QI decision making. RESULTS The term 'data' appeared 247 times in the interviews, and over 92% of these instances (228/247) were spontaneous references by nursing home staff. Overall, 34% of respondents (79/232) referred directly to 'data' in their interviews. Nursing home leadership more frequently discussed data use than direct care staff. Emergent themes included using data to identify a QI problem, gathering data in new ways at the local level, and measuring outcomes in response to P4P participation. Alterations in data use as a result of policy change were theoretically consistent with the revised version of the Promoting Action on Research Implementation in Health Services framework, which posits that successful implementation is a function of evidence, context and facilitation. CONCLUSIONS Providing a reimbursement context that facilitates the collection and use of reliable local evidence may be an important consideration to others contemplating the adaptation of P4P policies.
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Affiliation(s)
| | - Edward Miech
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Christine Mueller
- School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA
| | - Valerie Cooke
- Minnesota Department of Human Services, Minneapolis, Minnesota, USA
| | - Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana, USA
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Temkin-Greener H, Ladwig S, Caprio T, Norton S, Quill T, Olsan T, Cai X, Mukamel DB. Developing palliative care practice guidelines and standards for nursing home-based palliative care teams: a Delphi study. J Am Med Dir Assoc 2015; 16:86.e1-7. [PMID: 25481748 DOI: 10.1016/j.jamda.2014.10.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 10/17/2014] [Accepted: 10/20/2014] [Indexed: 11/19/2022]
Abstract
CONTEXT Lack of nursing home (NH)-specific palliative care practice guidelines has been identified as a barrier to improving palliative and end-of-life (EOL) quality of care. OBJECTIVES The objectives of this study were to (1) assess which of the guidelines developed by the National Consensus Project, and the corresponding preferred care practices endorsed by the National Quality Forum, are important and feasible to implement in NHs; and (2) identify the operational standards for palliative care teams in NHs. METHODS Two-round mail Delphi study. Based on the existing literature, a set of 7 domains with associated 22 palliative practice guidelines was drafted. We invited 48 NH leaders, including clinicians, to review the importance (10-point Likert scale) and the feasibility (5-point Likert scale) of these guidelines. Participants were also asked about palliative care team composition rounding frequency. RESULTS The response rate to both rounds was 85%. With regard to importance, the mean rating for all guidelines was 8 or higher (ie, highly important), but there was variability in agreement with regard to 5 of the guidelines. The same 5 guidelines were also considered more difficult to implement (eg, costly, unrealistic). Overall, 17 palliative care guidelines were identified for use by NH palliative care teams. Five disciplines (social work, certified nurse assistant, nurse, physician, and nurse practitioner or physician assistant) were identified as comprising a core team and 3 were proposed as extended or ad hoc members. CONCLUSION The palliative care guidelines and team standards identified in this study may be helpful in providing practical direction to NH administrators and staff looking to improve palliative care practice for their residents.
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Affiliation(s)
- Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, NY.
| | - Susan Ladwig
- Department of Medicine, University of Rochester School of Medicine, Rochester, NY
| | - Tom Caprio
- Department of Medicine, University of Rochester School of Medicine, Rochester, NY
| | - Sally Norton
- University of Rochester, School of Nursing, Rochester, NY
| | - Timothy Quill
- Department of Medicine, University of Rochester School of Medicine, Rochester, NY
| | - Tobie Olsan
- University of Rochester, School of Nursing, Rochester, NY
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine, Rochester, NY
| | - Dana B Mukamel
- Department of Medicine, Health Policy and Research Center, University of California, Irvine, Irvine, CA
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Yoon SH, Kim SY, Wu X. Perception of Workers on Patient Safety Culture and Degree of Patient Safety in Nursing Homes in Korea. ACTA ACUST UNITED AC 2014. [DOI: 10.11111/jkana.2014.20.3.247] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sook Hee Yoon
- Department of Nursing · Institute of Health Science, Inje University, Korea
| | - Se Young Kim
- Department of Nursing, Changwon National University, Korea
| | - XiangLian Wu
- Department of Nursing, Graduate School of Inje University, Korea
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Wagner LM, Roup BJ, Castle NG. Impact of infection preventionists on Centers for Medicare and Medicaid quality measures in Maryland nursing homes. Am J Infect Control 2014; 42:2-6. [PMID: 24388467 PMCID: PMC7132677 DOI: 10.1016/j.ajic.2013.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/17/2013] [Accepted: 07/17/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Health care-associated infections are the leading cause of morbidity and mortality in US nursing homes (NHs). The objective of the research is to assess the impact of Maryland NH infection preventionists (IPs) on NH quality measures. METHODS Two hundred thirty-four NHs were queried through mailed survey. These survey data were then linked with 2008 quality data from Nursing Home Compare and the On-line Survey Certification of Automated Records. RESULTS Three of the 8 quality measures examined-influenza vaccination for both short- and long-stay residents and pressure ulcer prevention in high-risk residents-were significantly associated with the number of IPs. None of the quality measures were shown to be significant with IPs who received specialized training on infection prevention and management compared with those who did not receive specialized training. CONCLUSION IPs play a critical role in preventing and managing health care-associated infections in nursing homes, especially in the areas of influenza vaccination and pressure ulcer prevention among high-risk nursing home residents. Quality measures that reflect the effects of IP training may not have been elucidated yet. Further research is needed to support the IP role in order for policy to advocate for increased IP funding.
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Affiliation(s)
- Laura M Wagner
- University of California, San Francisco, School of Nursing, Department of Community Health Systems, San Francisco, CA.
| | - Brenda J Roup
- Department of Infection Prevention and Control, Prevention and Health Promotion Administration, Infectious Disease Bureau, Office of Infectious Disease Epidemiology and Outbreak Response, Maryland Department of Health and Mental Hygiene, Baltimore, MD
| | - Nicholas G Castle
- Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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Sax S, Marx M. Local perceptions on factors influencing the introduction of international healthcare accreditation in Pakistan. Health Policy Plan 2013; 29:1021-30. [PMID: 24226171 DOI: 10.1093/heapol/czt084] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
One contributor to poor health outcomes in developing countries is weak health systems; key to strengthening them are interventions to improve quality of health services. Though the value of healthcare accreditation is increasingly recognized, there are few case studies exploring its adaptation in developing countries. The aim of our study in Pakistan was to identify perceived factors influencing the adaptation of international healthcare accreditation within a developing country context. We used qualitative methods including semi-structured interviews, a structured group discussion, focus groups and non-participant observation of management meetings. Data analysis used a grounded theory approach and a conceptual framework adapted from implementation science. Using our conceptual framework categories of 'inner' and 'outer' setting, we found six perceived inner health system factors that could influence the introduction of healthcare accreditation and two 'outer' setting factors, perceived as external to the health system but able to influence its introduction. Our research identified that there is no 'one size fits all' approach to introducing healthcare accreditation as a means to improve healthcare quality. Those planning to support healthcare accreditation, such as national and provincial ministries and international development partners, need to understand how the three components of healthcare accreditation fit into the local health system and into the broader political and social environment. In our setting this included moving to supportive and transparent external evaluation mechanisms, with a first step of using locally developed and agreed standards. In addition, sustainable implementation of the three components was seen as a major challenge, especially establishment of a well-managed, transparent accreditation agency able to lead processes such as training and support for peer surveyors. Consideration of local change mechanisms and cultural practices is important in designing a local accreditation approach. The results of our study are important for health systems strengthening in Pakistan and in other developing countries.
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Affiliation(s)
- Sylvia Sax
- Institute of Public Health, University of Heidelberg, INF 324 69120 Heidelberg, Germany
| | - Michael Marx
- Institute of Public Health, University of Heidelberg, INF 324 69120 Heidelberg, Germany
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Schwendimann R, Zúñiga F, Ausserhofer D, Schubert M, Engberg S, de Geest S. Swiss Nursing Homes Human Resources Project (SHURP): protocol of an observational study. J Adv Nurs 2013; 70:915-26. [PMID: 24102650 DOI: 10.1111/jan.12253] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2013] [Indexed: 11/26/2022]
Abstract
AIM To explore the relationships among various nursing homes characteristics including work environment, careworker outcomes and resident outcomes in Swiss nursing homes. BACKGROUND In Switzerland, a growing number of older people live in nursing homes. Although research has addressed the issue of quality of nursing care in such facilities, few have integrated a range of interrelated factors that may influence the quality and safety of residential care. The Swiss Nursing Homes Human Resources Project will comprehensively assess key organizational factors, their interrelationships and the associations between these factors and careworker and resident outcomes. DESIGN Cross-sectional design. METHODS Three-year multi-centre study (2011-2013) including a representative sample of approximately 160 nursing homes across the three language regions in Switzerland. Survey data will come from approximately 6000 careworkers and 160 administrators. Survey questionnaires will include variables on organizational facility characteristics and resident outcomes, careworker socio-demographic and professional characteristics, the quality of their work environments, resident safety climates and careworker outcomes. Appropriate descriptive and comparative analysis will be used and multivariate and multilevel analyses will be applied to examine the relationships among the various factors including quality of the work environment, safety climate, work stressors, rationing of care, workload, careworker and resident characteristics, as well as resident and careworker outcomes. DISCUSSION The study results will contribute to a comprehensive understanding of the interrelationships between key organizational factors and resident/careworker outcomes and will also support planning and conducting interventions to improve quality of care concerning organizational factors affecting careworkers in daily practice.
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Abstract
OBJECTIVES To examine the prevalence of obesity and its relationship with pressure ulcers among nursing home (NH) populations, and whether such relationship varies with certified nursing assistant (CNA) level in NHs. DATA AND STUDY POPULATION: The 1999-2009 nationwide Minimum Data Sets were linked with Online Survey of Certification and Reporting records. We identified newly admitted NH residents who became long-stayers and followed them up to 1 year. ANALYSES The outcome variable was presence of pressure ulcers during the 1-year follow-up period. Residents were categorized as normal [18.5 ≤ body mass index (BMI)<30 kg/m2], mild obesity (30 ≤ BMI <35 kg/m2), and moderate or severe obesity (BMI ≥ 35 kg/m2). Pooled and stratified analyses were performed to examine the relationship between obesity and pressure ulcers, and how it varied by facility CNA level. RESULTS The prevalence of obesity increased from 16.9% to 25.8% among newly admitted NH residents over the last decade. Obesity was associated with higher risks of pressure ulcers among long-stay residents. The relationship between obesity and pressure ulcers persisted after accounting for individual health conditions at the baseline and facility-level variations. Further, the within-facility relationship between obesity and pressure ulcers varied by facility CNA levels. The odds of pressure ulcers were 18.9% higher for residents with moderate or severe obesity than for nonobese residents within NHs with low CNA levels. The percents for medium and high CNA level facilities were 14.0% and 12.8%, respectively. CONCLUSION To prepare for the growing obesity epidemic in NHs, policies should focus on strategies to improve care provided for obese residents.
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Affiliation(s)
- Shubing Cai
- Center for Gerontology and Health Care Research, Brown University, Providence, RI 02912, USA.
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First evidence on the validity and reliability of the Safety Organizing Scale-Nursing Home version (SOS-NH). J Am Med Dir Assoc 2013; 14:616-22. [PMID: 23684122 DOI: 10.1016/j.jamda.2013.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 03/12/2013] [Accepted: 03/18/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Safety Organizing Scale is a valid and reliable measure on safety behaviors and practices in hospitals. PURPOSE OF THE STUDY This study aimed to explore the psychometric properties of the Safety Organizing Scale-Nursing Home version (SOS-NH). DESIGN AND METHODS In a cross-sectional analysis of staff survey data, we examined validity and reliability of the 9-item Safety SOS-NH using American Educational Research Association guidelines. SUBJECTS AND SETTING This substudy of a larger trial used baseline survey data collected from staff members (n = 627) in a variety of work roles in 13 nursing homes (NHs) in North Carolina and Virginia. RESULTS Psychometric evaluation of the SOS-NH revealed good response patterns with low average of missing values across all items (3.05%). Analyses of the SOS-NH's internal structure (eg, comparative fit indices = 0.929, standardized root mean square error of approximation = 0.045) and consistency (composite reliability = 0.94) suggested its 1-dimensionality. Significant between-facility variability, intraclass correlations, within-group agreement, and design effect confirmed appropriateness of the SOS-NH for measurement at the NH level, justifying data aggregation. The SOS-NH showed discriminate validity from one related concept: communication openness. IMPLICATIONS Initial evidence regarding validity and reliability of the SOS-NH supports its utility in measuring safety behaviors and practices among a wide range of NH staff members, including those with low literacy. Further psychometric evaluation should focus on testing concurrent and criterion validity, using resident outcome measures (eg, patient fall rates).
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Temkin-Greener H, Zheng NT, Xing J, Mukamel DB. Site of death among nursing home residents in the United States: changing patterns, 2003-2007. J Am Med Dir Assoc 2013; 14:741-8. [PMID: 23664483 DOI: 10.1016/j.jamda.2013.03.009] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 03/12/2013] [Accepted: 03/12/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT The proportion of US deaths occurring in nursing homes (NHs) has been increasing in the past 2 decades and is expected to reach 40% by 2020. Despite being recognized as an important setting in the provision of end-of-life (EOL) care, little is known about the quality of care provided to dying NH residents. There has been some, but largely anecdotal evidence suggesting that many US NHs transfer dying residents to hospitals, in part to avoid incurring the cost of providing intensive on-site care, and in part because they lack resources to appropriately serve the dying residents. We assessed longitudinal trends and geographic variations in place of death among NH residents, and examined the association between residents' characteristics, treatment preferences, and the probability of dying in hospitals. METHODS We used the Minimum Data Set (NH assessment records), Medicare denominator (eligibility) file, and Medicare inpatient and hospice claims to identify decedent NH residents. In CY2003-2007, there were 2,992,261 Medicare-eligible NH decedents from 16,872 US Medicare- and/or Medicaid-certified NHs. Our outcome of interest was death in NH or in a hospital. The analytical strategy included descriptive analyses and multiple logistic regression models, with facility fixed effects, to examine risk-adjusted temporal trends in place of death. FINDINGS Slightly more than 20% of decedent NH residents died in hospitals each year. Controlling for individual-level risk factors and for facility fixed effects, the likelihood of residents dying in hospitals has increased significantly each year between 2003 through 2007. CONCLUSIONS This study fills a significant gap in the current literature on EOL care in US nursing homes by identifying frequent facility-to-hospital transfers and an increasing trend of in-hospital deaths. These findings suggest a need to rethink how best to provide care to EOL nursing home residents.
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Affiliation(s)
- Helena Temkin-Greener
- Department of Public Health Sciences, Center for Ethics, Humanities and Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY.
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Abstract
The aim of this study was to better understand care protocol implementation, including the influence of organizational-contextual factors on implementation approaches, in long-term care homes operating in Ontario. We surveyed directors of care employed in all 547 Ontario LTC homes, and combined survey data with secondary organizational data on rural/urban location, nursing home size, chain membership, type of ownership, and accreditation status. Motivations for the use/selection of care protocols in nursing homes primarily derived from beliefs in continuous improvement and in evidence-based care. Protocol selection was largely participative, involving management and staff. External information sources were important for protocol implementation, and in-service education was the chief means of training and educating staff. Significant differences in approaches to implementation were evident in association with differences in ownership. Three key success factors for implementation were identified: contextualizing the practice change, adequately resourcing for implementation, and demonstrating connections between practice change and outcomes.
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Wagner LM, Castle NG, Handler SM. Use of HIT for adverse event reporting in nursing homes: Barriers and facilitators. Geriatr Nurs 2013; 34:112-5. [DOI: 10.1016/j.gerinurse.2012.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 10/22/2012] [Accepted: 10/29/2012] [Indexed: 10/27/2022]
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Okunribido OO. Patient Safety During Assistant Propelled Wheelchair Transfers: The Effect of the Seat Cushion on Risk of Falling. Assist Technol 2013; 25:1-8. [DOI: 10.1080/10400435.2012.680658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Siegel EO, Young HM, Leo MC, Santillan V. Managing up, down, and across the nursing home: roles and responsibilities of directors of nursing. Policy Polit Nurs Pract 2012; 13:214-223. [PMID: 23639958 DOI: 10.1177/1527154413481629] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The director of nursing (DON) is an essential member of the top management team in nursing homes and in a key position to improve the quality and value of care. This article describes and examines the roles and responsibilities of DONs as perceived by a convenience sample of current/previous DONs and nursing home administrators (n = 29). Data were collected through in-depth semistructured interviews and analyzed using content analysis and thematic analysis. The findings reveal a broad scope and wide variation in the DON position across settings, with inextricable linkages between clinical care and other aspects of care delivery, such as managing fiscal and human resources (HR). As RN licensure is the only Federal requirement for the DON position, suggesting a clinical focus, the findings highlight a policy-practice gap. Research is needed to address this gap, focusing on the requisite preparation DONs need to effectively and cost-efficiently lead initiatives for quality improvement.
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Affiliation(s)
- Elena O Siegel
- Betty Irene Moore School of Nursing at UC Davis, UC Davis Health System, Sacramento, CA 95817, USA.
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Scandrett KG, Anichini MA, Berdes C, Estabrook S, Boockvar K, Saliba D, Emanuel L, Taylor SL. Patient safety in the nursing home: how nursing staff assess and communicate about change in condition. J Gerontol Nurs 2012; 38:28-37; quiz 38-9. [PMID: 23066680 DOI: 10.3928/00989134-20121003-03] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 05/10/2012] [Indexed: 11/20/2022]
Abstract
Nursing homes must improve quality of care even as it becomes increasingly complex, and patient safety science may provide a helpful paradigm. Training materials are needed to build staff capacity for clinical assessment and communication, thereby improving care processes. Designed to develop curricular materials, this study used focus groups to determine how experienced nurses and aides assess and communicate about resident clinical changes. Four focus groups were conducted, and interviews were analyzed for themes in an iterative process by multidisciplinary team members. Staff reported that consistent caregiving enables detection of subtle clinical changes; aides further noted the importance of affective bonding. Aides and nurses alike regarded all clinical changes as potentially significant, while nursing staff lacked a consistent approach to assessment. Using a patient safety framework, structural changes and process elements were identified as important topics for further training to support clinical communication and improve resident and facility outcomes.
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Drake J, Redfern WS, Sherburne E, Nugent ML, Simpson P. Pediatric skin care: what do nurses really know? J SPEC PEDIATR NURS 2012; 17:329-38. [PMID: 23009045 DOI: 10.1111/j.1744-6155.2012.00342.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to explore pediatric nurses' knowledge of pressure ulcer prevention, investigate their beliefs and practices, and identify the barriers and facilitators to providing evidence-based pressure ulcer preventive practices. DESIGN AND METHODS An exploratory, descriptive, and cross-sectional survey was taken of registered nurses in a freestanding children's hospital. RESULTS Nurses have adequate knowledge of general pressure ulcer prevention; however, they struggle with individualization. Further, analysis revealed that nursing knowledge did not always correlate with nursing practice. PRACTICE IMPLICATIONS Nurses require education on individualized interventions and access to user-friendly, interactive, and comprehensive resources, including unit-based champions and order sets.
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Affiliation(s)
- Jennifer Drake
- Neuroscience Unit, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Casarett D, Spence C, Clark MA, Shield R, Teno JM. Defining patient safety in hospice: principles to guide measurement and public reporting. J Palliat Med 2012; 15:1120-3. [PMID: 22690916 DOI: 10.1089/jpm.2011.0530] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite progress towards safer care in most settings, there has been much less attention to improving safety in hospices, which care for more than 1,500,000 patients every year. In this article, we describe three serious conflicts that arise when safety measures from other settings are applied to hospice. First, safety measures that are imposed in order to reduce morbidity and mortality may be irrelevant for a hospice patient whose goals focus on comfort. Second, safety measures that are defined in patients with a life expectancy of years can be inappropriate for hospice patients whose typical survival is measured in days. Third, it can be very difficult to assign responsibility for the safety of hospice patients, whose care is provided mostly by family and friends. Therefore, generally accepted safety measures are often inappropriate for hospice care, and can lead to unintended consequences if they are applied without critical evaluation or modification. Instead, we suggest three principles that can guide the development of hospice-appropriate safety measures by considering a patient's goals and life expectancy, and the degree to which responsibility for a patient's care is shared.
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Affiliation(s)
- David Casarett
- Division of Geriatric Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
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Temkin-Greener H, Cai S, Zheng NT, Zhao H, Mukamel DB. Nursing home work environment and the risk of pressure ulcers and incontinence. Health Serv Res 2012; 47:1179-200. [PMID: 22098384 PMCID: PMC3290703 DOI: 10.1111/j.1475-6773.2011.01353.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the association between nursing home (NH) work environment attributes such as teams, consistent assignment and staff cohesion, and the risk of pressure ulcers and incontinence. DATA SOURCES/SETTING Minimum dataset for 46,044 residents in 162 facilities in New York State, for June 2006-July 2007, and survey responses from 7,418 workers in the same facilities. STUDY DESIGN For each individual and facility, primary and secondary data were linked. Random effects logistic models were used to develop/validate outcome measures. Generalized estimating equation models with robust standard errors and probability weights were employed to examine the association between outcomes and work environment attributes. Key independent variables were staff cohesion, percent staff in daily care teams, and percent staff with consistent assignment. Other facility factors were also included. PRINCIPAL FINDINGS Residents in facilities with worse staff cohesion had significantly greater odds of pressure ulcers and incontinence, compared with residents in facilities with better cohesion scores. Residents in facilities with greater penetration of self-managed teams had lower risk of pressure ulcers, but not of incontinence. Prevalence of consistent assignment was not significantly associated with the outcome measures. CONCLUSIONS NH environments and management practices influence residents' health outcomes. These findings provide important lessons for administrators and regulators interested in promoting NH quality improvement.
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Affiliation(s)
- Helena Temkin-Greener
- Department of Community and Preventive Medicine, University of Rochester School of Medicine, Rochester, NY 14642, USA.
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Patient Safety Culture and the Association with Safe Resident Care in Nursing Homes. THE GERONTOLOGIST 2012; 52:802-11. [DOI: 10.1093/geront/gns007] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Arnetz JE, Zhdanova LS, Elsouhag D, Lichtenberg P, Luborsky MR, Arnetz BB. Organizational climate determinants of resident safety culture in nursing homes. THE GERONTOLOGIST 2011; 51:739-49. [PMID: 21708985 DOI: 10.1093/geront/gnr053] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE OF THE STUDY In recent years, there has been an increasing focus on the role of safety culture in preventing costly adverse events, such as medication errors and falls, among nursing home residents. However, little is known regarding critical organizational determinants of a positive safety culture in nursing homes. The aim of this study was to identify organizational climate predictors of specific aspects of the staff-rated resident safety culture (RSC) in a sample of nursing homes. DESIGN AND METHODS Staff at 4 Michigan nursing homes responded to a self-administered questionnaire measuring organizational climate and RSC. Multiple regression analyses were used to identify organizational climate factors that predicted the safety culture dimensions nonpunitive response to mistakes, communication about incidents, and compliance with procedures. RESULTS The organizational climate factors efficiency and work climate predicted nonpunitive response to mistakes (p < .001 for both scales) and compliance with procedures (p < .05 and p < .001 respectively). Work stress was an inverse predictor of compliance with procedures (p < .05). Goal clarity was the only significant predictor of communication about incidents (p < .05). IMPLICATIONS Efficiency, work climate, work stress, and goal clarity are all malleable organizational factors that could feasibly be the focus of interventions to improve RSC. Future studies will examine whether these results can be replicated with larger samples.
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Affiliation(s)
- Judith E Arnetz
- Department of Family Medicine and Public Health Sciences, Wayne State University, Detroit, Michigan 48201, USA.
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Abstract
Deficiency citations for safety violations in U.S. nursing homes from 2000 to 2007 are examined (representing a panel of 119,472 observations). Internal (i.e., operating characteristics of the facility), organizational factors (i.e., characteristics of the facility itself), and external factors (i.e., characteristics outside of the influence of the organization) associated with these deficiency citations are examined. The findings show that nursing homes increasingly receive deficiency citations for resident safety issues. Low staffing levels, poor quality of care, and an unfavorable Medicaid mix (occupancy and reimbursement) are associated with the likelihood of receiving deficiency citations for safety violations. In many cases, this likely influences the quality of life and quality of care of residents.
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Affiliation(s)
- Nicholas G Castle
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA.
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van Beek APA, Gerritsen DL. The relationship between organizational culture of nursing staff and quality of care for residents with dementia: questionnaire surveys and systematic observations in nursing homes. Int J Nurs Stud 2010; 47:1274-82. [PMID: 20371058 DOI: 10.1016/j.ijnurstu.2010.02.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 12/27/2009] [Accepted: 02/14/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Since the 1990s, several studies have shown that organizational culture is an important characteristic in long-term care. However, at the moment little is known about organizational culture and its relationship with quality of care. OBJECTIVES In this study, the relationship between organizational culture and quality of care in long-term care was investigated using the competing values framework. Thereto, two independent measurements of quality of care were applied: the perceived quality of care by nursing staff of dementia units and the observed quality of care on the units by researchers. DESIGN The study used a cross-sectional design. SETTINGS Data were collected on 11 dementia units in 11 Dutch nursing homes. PARTICIPANTS All nursing staff on the units were asked to complete a questionnaire, of whom 248 staff members responded. The average response rate on the 11 units was 63%. METHODS Data were collected during two days of field-work on each unit. Systematic observations were performed, and questionnaires were distributed among nursing staff. Data were analyzed using multilevel analyses. RESULTS Organizational culture was related to both perceived and observed quality of care on the units. Units that are characterized by a clan culture provide better quality of care, both in the eyes of the nursing staff as in the eyes of outsiders. Market culture, compared to clan culture, is negatively related to quality of care in this sample. CONCLUSIONS The results indicate that organizational culture in long-term dementia care is important for organizational performance.
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Affiliation(s)
- A P A van Beek
- Netherlands Institute for Health Services Research, Otterstraat 118-124, PO Box 1568, 3500 BN Utrecht, The Netherlands.
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Pressure ulcer prevalence among black and white nursing home residents in New York state: evidence of racial disparity? Med Care 2010; 48:233-9. [PMID: 20182267 DOI: 10.1097/mlr.0b013e3181ca2810] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The occurrence of pressure ulcers (PUs) in nursing homes is a marker for poor quality of care. We examine whether differences in PU prevalence between black and white residents are due to within- or across-facility disparities. METHODS Minimum Data Sets (2006-2007) are linked with the Online Survey Certification and Reporting database. Long-term care residents with high risk for PUs are identified. The dependent variable is dichotomous, indicating PU presence/absence. Individual race and facility race-mix are the main variables of interests.The sample includes 59,740 long-term care high-risk residents (17.4% black and 82.6% white) in 619 nursing homes. We fit 3 risk-adjusted logit models: base, conditional fixed-effects, and random-effects. RESULTS Unadjusted PU prevalence is 14.5% (18.2% for blacks and 13.8% for whites). Overall, blacks are more likely to have PUs than whites, controlling for individual risk factors. We find no such effect within facilities after additional accounting for facility fixed effects. The effect of race is significantly different between the base and the conditional fixed-effects logit model. The random-effects and conditional fixed-effects logit models show similar results, demonstrating that higher PU presence among blacks is associated with greater facility-specific concentration of black residents. CONCLUSION Greater PU occurrence among blacks may not result from differential within-facility treatment of blacks versus whites. Rather, blacks are more likely to reside in facilities with poorer care quality. To improve PU care for blacks, efforts should focus on improving the overall quality of care for facilities with high proportion of black residents.
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van Gaal BGI, Schoonhoven L, Hulscher MEJL, Mintjes JAJ, Borm GF, Koopmans RTCM, van Achterberg T. The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events. BMC Health Serv Res 2009; 9:58. [PMID: 19338655 PMCID: PMC2675519 DOI: 10.1186/1472-6963-9-58] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Accepted: 04/01/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients in hospitals and nursing homes are at risk of the development of, often preventable, adverse events (AEs), which threaten patient safety. Guidelines for prevention of many types of AEs are available, however, compliance with these guidelines appears to be lacking. Besides general barriers that inhibit implementation, this non-compliance is associated with the large number of guidelines competing for attention. As implementation of a guideline is time-consuming, it is difficult for organisations to implement all available guidelines. Another problem is lack of feedback about performance using quality indicators of guideline based care and lack of a recognisable, unambiguous system for implementation. A program that allows organisations to implement multiple guidelines simultaneously may facilitate guideline use and thus improve patient safety.The aim of this study is to develop and test such an integral patient safety program that addresses several AEs simultaneously in hospitals and nursing homes. This paper reports the design of this study. METHODS AND DESIGN The patient safety program addresses three AEs: pressure ulcers, falls and urinary tract infections. It consists of bundles and outcome and process indicators based on the existing evidence based guidelines. In addition it includes a multifaceted tailored implementation strategy: education, patient involvement, and a computerized registration and feedback system. The patient safety program was tested in a cluster randomised trial on ten hospital wards and ten nursing home wards. The baseline period was three months followed by the implementation of the patient safety program for fourteen months. Subsequently the follow-up period was nine months. Primary outcome measure was the incidence of AEs on every ward. Secondary outcome measures were the utilization of preventive interventions and the knowledge of nurses regarding the three topics. Randomisation took place on ward level. The results will be analysed separately for hospitals and nursing homes. DISCUSSION Major challenges were the development of the patient safety program including a digital registration and feedback system and the implementation of the patient safety program. TRIAL REGISTRATION Trial registration: ClinicalTrials.gov ID [NCT00365430].
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