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Siegel EO, Young HM. Assuring Quality in Nursing Homes: The Black Box of Administrative and Clinical Leadership—A Scoping Review. THE GERONTOLOGIST 2020; 61:e147-e162. [DOI: 10.1093/geront/gnaa175] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Indexed: 01/18/2023] Open
Abstract
Abstract
Background and Objectives
Licensed nursing home administrators (NHA) and directors of nursing (DON) are responsible for nursing home quality and assuring optimal performance and job satisfaction/retention of their nursing home workforce. NHA/DON-focused studies have generated important foundational knowledge over the last three decades; yet, targeted research is needed to understand and apply the complexities of the black box of this top management team. This scoping review identifies, reviews, synthesizes, and maps the topical areas of research in NHA/DON positions in U.S. nursing homes.
Research Design and Methods
We conducted searches of 5 databases, yielding 3,479 records; screening/review yielded 88 unique records. We used thematic analysis to code the primary foci of the studies and the variables associated with the concepts of interest.
Results
Most papers (n = 40) focused on role characteristics, 23 examined approaches to management and leadership, 24 focused on perceptions about the role, and the remaining 12 examined role structure. The role-related themes linked to outcomes (n = 42), processes (n = 27), and structures (n = 30).
Discussion and Implications
We highlight important gaps for future research and offer a call to action for research, policy, practice, and education collaborations to accelerate the rate of research and translate the findings into best practices for NHA/DON to lead and manage the nursing home workforce and build capacity to ensure person-centered, high-quality care. Based on foundational descriptive studies, it is time to use what is known to design and implement interventions that enhance the capacity of NHA/DON to improve the structures, processes, and outcomes of nursing homes.
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Affiliation(s)
- Elena O Siegel
- Betty Irene Moore School of Nursing, University California, Davis, Sacramento, USA
| | - Heather M Young
- Betty Irene Moore School of Nursing, University California, Davis, Sacramento, USA
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Kokkonen K, Rissanen S, Hujala A. The match between institutional elderly care management research and management challenges - a systematic literature review. Health Res Policy Syst 2012; 10:35. [PMID: 23137416 PMCID: PMC3542075 DOI: 10.1186/1478-4505-10-35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 10/29/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Elderly care practice and its management together with policy and research play a crucial role in responding to increasing challenges in institutional care for elderly people. Successful dialogue between these is necessary. The purpose of this systematic literature review is to compare how institutional elderly care management research meets the care challenges currently emphasized in international long-term care policy documents. METHODS This paper was based on a systematic literature review. After screening 1971 abstracts using inclusion/exclusion criteria, 58 refereed articles published between 2000 and 2010 remained for analysis. The articles were analyzed using theory-based content analysis by comparing the results to the framework based on analysis of international long-term care management policy documents. RESULTS The current challenges of long-term care management identified from policy documents were Integrated Care Management, Productivity Management, Quality Management, Workforce Management and ICT Management. The research on institutional elderly care management responded somewhat to the challenges mentioned in policy documents. However, some of the challenges were studied broadly and some were paid only minor attention. Further, only few studies focused on the core items of challenges addressed in policy documents. CONCLUSIONS Institutional care management research needs to focus more on challenges in integrated care, productivity, ICT and division of labor. Managers, researchers and policy-makers should assume more active collaborative roles in processes of research, policymaking and policy implementation. In addition managers' and policymakers' scientific literacy needs to be enhanced.
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Affiliation(s)
- Kaija Kokkonen
- Department of Health and Social Management, University of Eastern Finland, Kuopio Campus, P.O. BOX 1627, Kuopio, FI, 70211, Finland
| | - Sari Rissanen
- Department of Social Sciences, University of Eastern Finland, Kuopio, Finland
| | - Anneli Hujala
- Department of Health and Social Management, University of Eastern Finland, Kuopio Campus, P.O. BOX 1627, Kuopio, FI, 70211, Finland
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Kjøs BØ, Botten G, Gjevjon ER, Romøren TI. Quality work in long-term care: the role of first-line leaders. Int J Qual Health Care 2010; 22:351-7. [PMID: 20615926 DOI: 10.1093/intqhc/mzq035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To explore the first-line leaders' role in quality work in long-term care in Norway, in order to determine how that work is related to such success characteristics as leadership, staff, patients, performance, information and information technology. DESIGN Cross-sectional telephone survey. The text was analysed using content 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 The clinical microsystem approach is used as a framework by defining and designing measureable variables. RESULTS Thirty-six leaders described how they initiated and motivated employees to be active in quality work; the remaining leaders indicated that they played a passive role. The first-line leaders played a key role in implementing national quality policies and regulations. The quantity of other success characteristics was low. CONCLUSIONS The municipalities delegated the responsibility of implanting national policies to the first-line leaders. Missing were key quality success criteria such as macro- and meso-perspectives for the municipality as a whole and co-operation with other leaders in the organization and fostering of relevant learning. Quality work was fragmented rather than comprehensive and systematic.
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Affiliation(s)
- Bente Ødegård Kjøs
- Centre for Care Research, Gjøvik University College, PO Box 191, 2802 Gjøvik, Norway.
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Stevenson DG, Mor V. Targeting nursing homes under the Quality Improvement Organization program's 9th statement of work. J Am Geriatr Soc 2009; 57:1678-84. [PMID: 19682119 DOI: 10.1111/j.1532-5415.2009.02401.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the Quality Improvement Organization (QIO) program's latest Statement of Work, the Centers for Medicare and Medicaid Services (CMS) is targeting its nursing home activities toward facilities that perform poorly on two quality measures-pressure ulcers and restraint use. The designation of target facilities is a shift in strategy for CMS and a direct response to criticism that QIO program resources were not being targeted effectively to facilities or clinical areas that most needed improvement. Using administrative data, this article analyzes implications of using narrowly defined criteria to identify facilities that need improvement, particularly in light of considerable evidence showing that nursing home quality is multidimensional and may change over time. The analyses show that one in four facilities is targeted for improvement nationally but that approximately half of some states' facilities are targeted while other states have almost none targeted. The analyses also convey deeper limitations to using threshold values on individual measures to identify poorly performing homes. Target facilities can be among the top performers on a range of other quality measures, and their performance on targeted measures themselves may change over time. The implication of these features is that a very different group of facilities would have been chosen had the QIO program targeted other measures or examined performance at a different point in time. Ultimately, CMS has chosen a blunt instrument to identify poorly performing nursing homes, and supplemental strategies-such as soliciting input from state survey agencies and more closely aligning quality improvement and quality assurance efforts-should be considered to address potential limitations.
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Affiliation(s)
- David G Stevenson
- Department of Health Care Policy, Harvard Medical School, Longwood Avenue, Boston, MA 02115, USA.
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Lee RH, Bott MJ, Gajewski B, Taunton RL. Modeling efficiency at the process level: an examination of the care planning process in nursing homes. Health Serv Res 2008; 44:15-32. [PMID: 18783455 DOI: 10.1111/j.1475-6773.2008.00895.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the efficiency of the care planning process in nursing homes. METHODS We collected detailed primary data about the care planning process for a stratified random sample of 107 nursing homes from Kansas and Missouri. We used these data to calculate the average direct cost per care plan and used data on selected deficiencies from the Online Survey Certification and Reporting System to measure the quality of care planning. We then analyzed the efficiency of the assessment process using corrected ordinary least squares (COLS) and data envelopment analysis (DEA). RESULTS Both approaches suggested that there was considerable inefficiency in the care planning process. The average COLS score was 0.43; the average DEA score was 0.48. The correlation between the two sets of scores was quite high, and there was no indication that lower costs resulted in lower quality. For-profit facilities were significantly more efficient than not-for-profit facilities. CONCLUSIONS Multiple studies of nursing homes have found evidence of inefficiency, but virtually all have had measurement problems that raise questions about the results. This analysis, which focuses on a process with much simpler measurement issues, finds evidence of inefficiency that is largely consistent with earlier studies. Making nursing homes more efficient merits closer attention as a strategy for improving care. Increasing efficiency by adopting well-designed, reliable processes can simultaneously reduce costs and improve quality.
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Affiliation(s)
- Robert H Lee
- Department of Health Policy and Management, School of Medicine, University of Kansas Medical Center, 5004 Student Center, Mail Stop 3044, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
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Kjøs BØ, Botten G, Romøren TI. Quality improvement in a publicly provided long-term care system: the case of Norway. Int J Qual Health Care 2008; 20:433-8. [PMID: 18653584 DOI: 10.1093/intqhc/mzn031] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Bente Ødegård Kjøs
- Center for Care Research, Gjøvik University College, PO Box 191, N-2802 Gjøvik, Norway.
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Affiliation(s)
- Andrea Gruneir
- Department of Community Health, Brown University, Providence, Rhode Island 02912; ,
| | - Vincent Mor
- Department of Community Health, Brown University, Providence, Rhode Island 02912; ,
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Miller EA, Mor V. Balancing regulatory controls and incentives: toward smarter and more transparent oversight in long-term care. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2008; 33:249-279. [PMID: 18325900 DOI: 10.1215/03616878-2007-055] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
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.
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Colón-Emeric CS, Lyles KW, House P, Levine DA, Schenck AP, Allison J, Gorospe J, Fermazin M, Oliver K, Curtis JR, Weissman N, Xie A, Saag KG. Randomized trial to improve fracture prevention in nursing home residents. Am J Med 2007; 120:886-92. [PMID: 17904460 PMCID: PMC2288656 DOI: 10.1016/j.amjmed.2007.04.020] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2006] [Revised: 04/20/2007] [Accepted: 04/27/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Interventions to improve the fracture prevention in nursing homes are needed. METHODS Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n=67) with > or =10 residents with a diagnosis of osteoporosis or recent hip fracture (n=606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering. RESULTS No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant (P=.72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9-12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1-18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models. CONCLUSIONS Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities.
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Castle NG, Engberg J, Liu D. Have Nursing Home Compare quality measure scores changed over time in response to competition? Qual Saf Health Care 2007; 16:185-91. [PMID: 17545344 PMCID: PMC2465007 DOI: 10.1136/qshc.2005.016923] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Currently, the Centers for Medicare and Medicaid Services report on 15 Quality Measures (QMs) on the Nursing Home Compare (NHC) website. It is assumed that nursing homes are able to make improvements on these QMs, and in doing so they will attract more residents. In this investigation, we examine changes in QM scores, and whether competition and/or excess demand have influenced these change scores over a period of 1 year. METHODS Data come from NHC and the On-line Survey Certification And Recording (OSCAR) system. QM change scores are calculated using values from January 2003 to January 2004. A series of regression analyses are used to examine the association of competition and excess demand on QM scores. RESULTS Eight QMs show an average decrease in scores (ie, better quality) and six QMs show an average increase in scores (ie, worse quality). However, for 13 of the 14 QMs these average changes averaged less than 1%. The regression analyses show an association between higher competition and improving QM scores and an association between lower occupancy and improving QM scores. CONCLUSION As would be predicted based on the market-driven mechanism underlying quality improvements using report cards, we show that it is in the most competitive markets and those with the lowest average occupancy rates that improvements in the QM scores are more likely.
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Abstract
The purposes of this study were to characterize the state of quality improvement (QI) in nursing facilities and to identify barriers to improvement from nursing leaders' perspectives. The study employed a non-experimental descriptive design, using closed- and open-ended survey questions in a sample of 51 nursing facilities in a midwestern state. Only two of these facilities had active QI programs. Furthermore, turnover and limited training among these nursing leaders represented major barriers to rapid implementation of such programs. This study is consistent with earlier findings that QI programs are limited in nursing homes.
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Affiliation(s)
- Linda Adams-Wendling
- Gerontological Nursing, Emporia State University, Newman Division of Nursing, Kansas 66801, USA
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Abstract
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.
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Affiliation(s)
- Vincent Mor
- Department of Community Health and Center for Gerontology and Health Care Research, Brown University School of Medicine, Box G-A418, Providence, RI 02192, USA.
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