Challenges of Using Quality Improvement Methods in Nursing Homes that “Need Improvement”

Abstract

A randomized, two-group, repeated-measures design was used to test a two year intervention for improving quality of care and resident outcomes in facilities in “need of improvement”. Intervention group (n=29) received an experimental multilevel intervention designed to help them (1) use quality-improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making. A qualitative analysis revealed a subgroup of homes likely to continue quality improvement activities and readiness indicators of homes likely to improve 1) leadership team (NHA, DON) who are interested in learning to use their federal Quality Indicator/Quality Measure (QI/QM) reports to improve resident care and outcomes; 2) one leader who will be the “change champion” and others make sure that current QI/QM reports are consistently shared on each nursing unit; 3) willingness to involve all staff in educational activities to learn about the QI/QM process and federal reports that compare the home with others in the state and nation; 4) plan and continuously educate new staff about the QI/QM process and how to do quality improvement; 5) continuously involve all staff in quality improvement committee and team activities so they “own” the process and are responsible for change.

Competition in collaborative clothing: a qualitative case study of influences on collaborative quality improvement in the ICU

“…Our results suggested a lack of communication and, therefore, engagement at the frontline which likely influenced the overall results of the QI initiative. This finding has been noted by other evaluations of similar QI programmes 23 24. The theory of collaborative advantage suggests that there may be additional gains when something unusually creative is produced synergistically , allowing an overall objective to be achieved more efficiently in multiple institutions compared with what could be achieved by individual institutions working independently 25.…”

The Influence of Teams to Sustain Quality Improvement in Nursing Homes that “Need Improvement”

“…Calculated annual turnover was 83% DONs and 67% NHAs in the “Full Adopters”; 156% DONs and 94% NHAs in the “Partial Adopters”; and 120% DONs and 90% “Non-Adopters”. Facility characteristics other than leadership turnover were not systematically different for the adopter groups (Rantz et al, in press); nor were other study measures of staff retention, staffing, staff mix, organizational working conditions, and costs (Rantz et al, 2012). …”

“…As described in detail previously (Rantz et al, in press), the research team (three PhD researchers, two research nurses, doctoral nursing student, and PhD qualitative research consultant) reviewed each home’s progress in the study and reached consensus about the degree of adoption of the intervention. Six homes were identified as “Full Adopters” because nursing home staff members were receptive to guidance from the research nurse; they worked in teams to plan process changes around a focused clinical topic, and used data such as their federal quality indicator/measure (QI/QM) scores and QI/QM resident level summary reports to monitor improvements.…”

Characteristics of Quality Improvement Champions in Nursing Homes: A Systematic Review With Implications for Evidence‐Based Practice

“…A number of quality improvement (QI) programs have been implemented in a nursing home setting, highlighting positive impacts on outcomes such as hospitalization rates (Ouslander et al., ), pressure ulcers, and weight loss (Rantz, Zwygart‐Stauffacher, Hicks et al., ). However, studies have also highlighted considerable diversity in the engagement of nursing homes with QI initiatives (Ouslander et al., ; Rantz, Zwygart‐Stauffacher, Hicks et al., ) and there are concerns that some nursing homes do not have the mechanisms in place to implement quality assurance and performance improvement programs (Smith, Castle, & Hyer, ).…”