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

ObjectivesQualitatively describe the adoption of strategies and challenges experienced by intervention facilities participating in a study targeted to improve quality of care in nursing homes “in need of improvement”. To describe how staff use federal quality indicator/quality measure (QI/QM) scores and reports, quality improvement methods and activities, and how staff supported and sustained the changes recommended by their quality improvement teams.Design/setting/participantsA randomized, two-group, repeated-measures design was used to test a 2-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.ResultsA qualitative analysis revealed a subgroup of homes likely to continue quality improvement activities and readiness indicators of homes likely to improve: (1) a leadership team (nursing home administrator, director of nurses) interested in learning how to use their federal QI/QM reports as a foundation for improving resident care and outcomes; (2) one of the leaders to be a “change champion” and make sure that current QI/QM reports are consistently printed and shared monthly with each nursing unit; (3) leaders willing to involve all staff in the facility in educational activities to learn about the QI/QM process and the reports that show how their facility compares with others in the state and nation; (4) leaders willing to plan and continuously educate new staff about the MDS and federal QI/QM reports and how to do quality improvement activities; (5) leaders willing to continuously involve all staff in quality improvement committee and team activities so they “own” the process and are responsible for change.ConclusionsResults of this qualitative analysis can help allocate expert nurse time to facilities that are actually ready to improve. Wide-spread adoption of this intervention is feasible and could be enabled by nursing home medical directors in collaborative practice with advanced practice nurses.     

CHI. Who nose best? Commission for Health Improvement

CHI is the fastest growing institution in the NHS. It has been generally well accepted by the NHS. Its methodology is a compromise between looking at mechanisms and testing whether they deliver in practice. There is no consistency in the basic data provided in CHI reports. It remains to be seen what effect CHI reports have on improving patient care.     

Continuous Quality Improvement: Does It Make a Difference?

A corporate benefits consultant suggests that dynamic leadership is needed to bring about a serious commitment to continuous quality improvement in the health care field.     

Quality Rating and Improvement Systems and Children’s Cognitive Development

Background

Providing enriched learning environments is important to stimulating children’s development in early childhood. Early child-care policymakers in many states in the US have adopted Quality Rating and Improvement Systems (QRIS) as a way to verify quality of child care and to support children’s school readiness.

Objective

The purpose of this study was to examine associations between QRIS, a statewide government-funded early childhood care and education policy which integrates structural quality of child-care, and children’s cognitive skills.

Methods

A sample of randomly selected 313 children (mean age = 54.9 months, SD = 6.7) from 36 QRIS-participating early child-care programs was included in this study.

Results

Multilevel analysis with a latent variable (i.e., observed cognitive skills consisting of vocabulary, phonological awareness, and mathematical skills) revealed that children in the highest level of QRIS programs demonstrated better cognitive skills after controlling for child demographics, and home and neighborhood environments. In addition, QRIS moderated a negative association between family socioeconomic risk and children’s cognitive skills.

Conclusions

The results suggest that policymakers may expect positive returns on QRIS investments in terms of children’s early cognitive achievements that support their school readiness in later life.

     

From Adversary to Partner: Have Quality Improvement Organizations Made the Transition?

OBJECTIVE: To describe the perceived impact of the Centers for Medicare and Medicaid Services Quality Improvement Organizations (QIOs) on quality of care for patients hospitalized with acute myocardial infarction, in the context of new efforts to work more collaboratively with hospitals in the pursuit of quality improvement. DATA SOURCE: Primary data collected from a national random sample of 105 hospital quality management directors interviewed between January and July 2002. STUDY DESIGN: We interviewed quality management directors concerning their interactions with the QIO interventions, the helpfulness of QIO interventions and the degree to which they helped or hindered their hospital quality efforts, and their recommendations for improving QIO effectiveness. PRINCIPLE FINDINGS: More than 90% of hospitals reported that their QIO had initiated specific interventions, the most common being the provision of educational materials, benchmark data, and hospital performance data. Many respondents (60%) rated most QIO interventions as helpful or very helpful, although only one-quarter of respondents believed quality of care would have been worse without the QIO interventions. To increase QIO efficacy, respondents recommended that QIOs appeal more directly to senior administration, target physicians (not just hospital employees), and enhance the perceived validity and timeliness of data used in quality indicators. CONCLUSIONS: Our study demonstrates that the QIOs have overcome, to some degree, the previously adversarial and punitive roles of Peer Review Organizations with hospitals. The generally positive view among most hospital quality improvement directors concerning the QIO interventions suggests that QIOs are potentially poised to take a leading role in promoting quality of care. However, the full potential of QIOs will likely not be realized until QIOs are able to engender greater engagement from senior hospital administration and physicians.     

Stability of Improvement in Patients Receiving Psychiatric Occupational Therapy—A One-year Follow-up

The purpose of this study was to examine stability of treatment outcome in 20 long-term mentally ill patients receiving occupational therapy at a psychiatric day-care unit. The outcome measures included psychiatric symptoms, global mental health, quality of life, and occupational functioning. The patients improved significantly from admission to a one-year follow-up after discharge in all these measures, with the exception of one aspect of quality of life: external life conditions. From discharge to follow-up the patients improved significantly in global mental health and occupational functioning. For psychiatric symptoms and quality of life, the patients maintained their level of functioning. At discharge 11 patients were clinically significantly improved as indicated by qualitative interviews, and another 4 patients met this criterion at follow-up. Thirteen patients showed clinically significant improvement from a quantitative perspective at discharge and 11 of these at follow-up as well. Furthermore, the patients' use of psychiatric services resulted in a significant decrease in the number of hospital admissions and number of inpatient days during the year following discharge compared with the year before admission, and there was a significant increase in the amount of time spent in work or studies. It is concluded that in all the measures used there was a further improvement or stability of outcome at a one-year follow-up and in no instance a deterioration compared to functioning at discharge.     

The 360° Feedback® Process: A Tool for Continuous Board Improvement

To remain accountable to stakeholders, healthcare governing boards need meaningful and actionable feedback on their performance. In 1998, the Board of Governors of West Park Hospital (now West Park Healthcare Centre) used the 360° feedback® technique for the first time to gather feedback from a range of stakeholders. Board members found the technology accessible and the process valuable. They are using the individual results to improve individual performance, and have developed work plans to address areas for continued board development.     

Improvement of quality of life following 6 months of methadone maintenance therapy in Malaysia

ABSTRACT: BACKGROUND: Methadone Maintenance Therapy (MMT) is one of the popular choices for drug substitution therapy and is fairly new in Malaysia. Aside from its role in harm reduction against HIV infection, MMT programme may potentially enhances clients' quality of life. This study aims to identify the impact of MMT programme on clients' quality of life after 6 months in treatment and to explore factors that may be associated with changes in their quality of life. METHODS: In this retrospective report review, 122 subjects from 2 government MMT clinics were selected from the district of Tampin, Negeri Sembilan, Malaysia. The raw score from the WHO Quality of Life questionnaire (WHOQOL-BREF), at baseline and 6 months after therapy were collected and converted to 0-100 scale form to give quality of life scores for four domains; physical, psychological, social relationships and environment. Other variables of interest were socio-demography, age when joining MMT programme, age and duration of illicit drug use, HIV and Hepatitis C status, and the Opiate Treatment Index (OTI) score on drug use, sexual and social aspect at the baseline. Statistical analysis used the SPSS version 16. RESULTS: There was significant improvement in all four domains of quality of life, after 6 months of MMT. The largest improvement was for psychological domain (mean score difference 15.54 +/- 20.81). Multivariable linear regression analysis showed that, for the physical domain, there was no significant predictor. For both the psychological and social domains, having tertiary education is a significant predictor for improvement in both aspects of quality of life. Negative HIV status is associated with improvement for the environment domain. CONCLUSIONS: There was a significant short term improvement in the quality of life of MMT clients who stayed in the programme for at least 6 months in the district of Tampin, Negeri Sembilan, Malaysia.     

Design of Implementation Studies for Quality Improvement Programs: An Effectiveness–Cost-Effectiveness Framework

Translational research applies basic science discoveries in clinical and community settings. Implementation research is often limited by tremendous variability among settings; therefore, generalization of findings may be limited. Adoption of a novel procedure in a community practice is usually a local decision guided by setting-specific knowledge. The conventional statistical framework that aims to produce generalizable knowledge is inappropriate for local quality improvement investigations. We propose an analytic framework based on cost-effectiveness of the implementation study design, taking into account prior knowledge from local experts. When prior knowledge does not indicate a clear preference between the new and standard procedures, local investigation should guide the choice. The proposed approach requires substantially smaller sample sizes than the conventional approach. Sample size formulae and general guidance are provided.It is common in implementation studies to adapt existing procedures, or to improvise new procedures, to accommodate local conditions in a specific community care setting. From an evidence-based principle, these decisions can often be informed by conducting a local investigation or quality improvement study to evaluate the pros and cons for viable options under consideration. For example, within the primary care setting and emerging medical home practices, primary care clinics may implement focused procedures to engage high-risk, high-complexity patients with emotional and medical conditions such as depression and diabetes. Such procedures might include focused physical and emotional health screening and multidisciplinary health care delivery procedures. Before replacing the existing intake and care delivery procedures, the clinic may benefit from pilot testing the new procedure to examine its potential utility and impact on patient care. The results of this pilot investigation can then be used to inform the decision (which intake procedure to use) for future patients including a broader “roll-out” of the successful procedures.The primary purpose of these local investigations is to produce local knowledge (such as which intake procedure is more effective for the specific clinic) to inform local implementation decisions. The pilot testing of these procedures is not intended to produce generalizable knowledge that can be applied universally to other care settings. This underlines the difference between implementation science that aims to produce generalizable knowledge1 and quality improvement projects that aim to produce local knowledge with a focus on an organization’s own delivery system and process.2 As such, quality improvement projects for local knowledge do not meet the criterion for human participants research as defined by the Office for Human Research Protections, the federal agency with oversight over human participants protection and institutional review boards. Research means a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge.3To avoid the confusion with human participants research that aims to produce generalizable knowledge, we use the term local investigation to highlight the distinction, and also to suggest that those investigations might qualify for exemptions from certain human participants regulations. Local investigations often deal with components (“nuts and bolts,” such as a specific intake procedure) of an overall implementation program. Making appropriate nuts-and-bolts decisions is important for the successful assemblage of the overall implementation “engine.” A specific implementation engine might consist of numerous nuts and bolts. Therefore, it is conceivable that multiple local investigations might be conducted in an implementation program for a specific care setting, each addressing the needs for a specific component of the engine.A variety of designs can be used for local investigations, including randomized designs and nonrandomized quasiexperimental designs.4 To illustrate the difference between local investigations that aim primarily to produce local knowledge, and the usual research studies that aim primarily to produce generalizable knowledge, we focused on randomized designs for this type of quality improvement project.     

Appealing to Vanity: Could Potential Appearance Improvement Motivate Fruit and Vegetable Consumption?

Fruit and vegetable consumption is inadequate among adults in the United States; this contributes to preventable morbidity and mortality. More effective dietary intervention strategies are needed.Recently, interventions that advertise the consequences of behavior for appearance have been successful in modifying sun-exposure habits and tobacco use. Such an approach might also facilitate dietary improvement.Consumption of carotenoid-rich fruit and vegetables positively affects skin color, which influences perceptions of health and attractiveness, and promoting such an effect may motivate target audiences to increase consumption of this important food group. This approach represents a novel direction for the field and is potentially suitable for cost-effective, population-level dissemination through the visual media.Inadequate fruit and vegetable consumption is an enduring problem that presents a significant challenge to human well-being, precipitating an estimated 2.6 million deaths per year worldwide1 and placing a preventable burden on health systems, chiefly through incidences of cardiovascular disease,2 diabetes and its complications,3 and possibly some cancers.4 The Produce for Better Health Foundation''s 2010 Gap Analysis revealed considerable discrepancy between the US Department of Agriculture''s 2005 dietary guidelines and recent estimates of fruit and vegetable consumption.5 To redress this balance, it is important to develop new public health strategies to facilitate population-level dietary improvement.Current campaigns with this objective, such as the World Health Organization''s 5-a-day scheme6 and the Fruits and Veggies—More Matters program of the Produce for Better Health Foundation7 predominantly aim to provide individuals with information on the health benefits of fruit and vegetables. As highlighted in the 2010 Gap Analysis, however, recent evidence suggests that fruit and vegetable consumption has declined since the inception of such campaigns, suggesting that health information alone may not be sufficient to motivate adherence to recommendations at a population level. It may be that these campaigns have succeeded in making individuals aware of what constitutes a healthy diet but failed to motivate them to act on this knowledge.8,9     

Prevention Concept in Industry: Improvement in Occupational Safety and Health Protection—An Empirical Study

This prevention concept offers a contribution to the expansion of the set of instruments for occupational safety and health protection within workplace prevention. The concept involves the multilateral analysis of work conditions. The utilized instruments include a strategy group, a survey, a health issue round table, and an analysis of work demands, and lead to synergy effects at the results level. Employees are drawn into the analysis of work conditions and workplace design solutions for the improvement of the work situation. The prevention concept was tested in a large company and its application established in practice. It was accepted by all participants, and the comparison with the previous situation (defined only through the analysis of work demands) demonstrated a significant improvement in health protection.