Age-Friendly Health Systems and Meeting the Principles of High Reliability Organizations in the VHA.

Background: The Veterans Health Administration (VHA) is the largest integrated health care system in the US, providing care to more than 9 million enrolled veterans. In February 2019, the VHA identified key actionable steps to become a high reliability organization (HRO), transforming how employees think about patient safety and care quality. The VHA is also working toward becoming the largest age-friendly health system in the US to be recognized by the Institute for Healthcare Improvement for its commitment to providing care guided by the 4Ms (what matters, medication, mentation, and mobility), causing no harm, and aligning care with what matters to older veterans. Observations: In this article, we describe how the Age-Friendly Health Systems (AFHS) movement supports the culture shift observed in HROs. AFHS use the 4Ms as a framework to be implemented in every care setting. The 4Ms are used in conjunction with the 3 pillars (leadership commitment, culture of safety, and continuous process improvement) and 5 principles (sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to clinical expertise, and commitment to resilience) that guide an HRO. We also share an HRO case study that is representative of many Community Living Centers involved in AFHS. Conclusions: AFHS empower VHA teams to honor veterans' care preferences and values, supporting their independence, dignity, and quality of life across care settings. The adoption of AFHS brings evidence-based practices to the point of care by addressing common pitfalls in the care of older adults, drawing attention to, and calling for action on inappropriate medication use, physical inactivity, and assessment of the vulnerable brain. The 4Ms also serve as a framework to continuously improve care and cause zero harm, reinforcing HRO pillars and principles across the VHA and ensuring that older adults reliably receive the evidence-based, high-quality care they deserve.

Electronic surveillance criteria for non-ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity.

OBJECTIVE: Surveillance of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is complicated by subjectivity and variability in diagnosing pneumonia. We compared a fully automatable surveillance definition using routine electronic health record data to manual determinations of NV-HAP according to surveillance criteria and clinical diagnoses. METHODS: We retrospectively applied an electronic surveillance definition for NV-HAP to all adults admitted to Veterans' Affairs (VA) hospitals from January 1, 2015, to November 30, 2020. We randomly selected 250 hospitalizations meeting NV-HAP surveillance criteria for independent review by 2 clinicians and calculated the percent of hospitalizations with (1) clinical deterioration, (2) CDC National Healthcare Safety Network (CDC-NHSN) criteria, (3) NV-HAP according to a reviewer, (4) NV-HAP according to a treating clinician, (5) pneumonia diagnosis in discharge summary; and (6) discharge diagnosis codes for HAP. We assessed interrater reliability by calculating simple agreement and the Cohen κ (kappa). RESULTS: Among 3.1 million hospitalizations, 14,023 met NV-HAP electronic surveillance criteria. Among reviewed cases, 98% had a confirmed clinical deterioration; 67% met CDC-NHSN criteria; 71% had NV-HAP according to a reviewer; 60% had NV-HAP according to a treating clinician; 49% had a discharge summary diagnosis of pneumonia; and 82% had NV-HAP according to any definition according to at least 1 reviewer. Only 8% had diagnosis codes for HAP. Interrater agreement was 75% (κ = 0.50) for CDC-NHSN criteria and 78% (κ = 0.55) for reviewer diagnosis of NV-HAP. CONCLUSIONS: Electronic NV-HAP surveillance criteria correlated moderately with existing manual surveillance criteria. Reviewer variability for all manual assessments was high. Electronic surveillance using clinical data may therefore allow for more consistent and efficient surveillance with similar accuracy compared to manual assessments or diagnosis codes.

Non-ventilator associated hospital acquired pneumonia (NV-HAP) risk among hospitalized veterans before and during the COVID-19 pandemic.

BACKGROUND: Among hospitalized US Veterans, the rate of non-ventilator associated hospital acquired pneumonia (NV-HAP) decreased between 2015 and 2020 then increased following the onset of 2019-nCoV (COVID-19). METHODS: Veterans admitted to inpatient acute care for ≥48 hours at 135 Department of Veterans Affairs Medical Centers between 2015 and 2021 were identified (n = 1,567,275). Non-linear trends in NV-HAP incidence were estimated using generalized additive modeling, adjusted for seasonality and patient risk factors. RESULTS: The incidence rate (IR) of NV-HAP decreased linearly by 32% (95% CI: 63-74) from 10/1/2015 to 2/1/2020, translating to 337 fewer NV-HAP cases. Following the US onset of the COVID-19 pandemic in February 2020, the NV-HAP IR increased by 25% (95% CI: 14-36) among Veterans without COVID-19 and 108% (95% CI: 178-245) among Veterans with COVID-19, resulting in an additional 50 NV-HAP cases and $5,042,900 in direct patient care costs 12-months post admission. DISCUSSION: This increase in NV-HAP rates could be driven by elevated risk among Veterans with COVID-19, decreased prevention measures during extreme COVID-19 related system stress, and increased patient acuity among hospitalized Veterans during the first year of the pandemic. CONCLUSIONS: Basic nursing preventive measures that are resilient to system stress are needed as well as population surveillance to rapidly identify changes in NV-HAP risk.

A mixed-methods evaluation of the national implementation of the Hospital-Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) initiative.

OBJECTIVE: To describe healthcare provider, veteran, and organizational barriers to, challenges to, and facilitators of implementation of the oral care Hospital-Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) initiative to prevent non-ventilator-associated hospital-acquired pneumonia (NV-HAP). DESIGN: Concurrent mixed methods. Qualitative interviews of staff and patients were conducted in addition to a larger survey of VA employees regarding implementation. SETTING: Medical surgical or extended care units in 6 high-complexity (01a-c) VA hospitals. PARTICIPANTS: Between January 2020 and February 2021, we interviewed 7 staff and 7 veterans, and we received survey responses from 91 staff. INTERVENTION: Provide education, support, and oral care supplies to prevent NV-HAP. RESULTS: Barriers to HAPPEN implementation and tracking at the pilot sites included maintaining oral care supplies and completion of oral care documentation. Facilitators for HAPPEN implementation included development of supportive formal and informal nurse leaders, staff engagement, and shared beliefs in the importance of care quality and infection prevention. Nurses worked together as a team to provide consistent oral care. Oral care was viewed as an essential infection control practice (not just "a task") and was considered part of the "culture" and "mission" in caring for veterans. CONCLUSIONS: Nurse leaders and direct-care staff were engaged throughout HAPPEN implementation, and most reported feeling supported and well prepared as they walked through the steps. Veterans reported positive experiences and increased knowledge about prevention of pneumonia. Lessons learned included building a community of practice and sharing expertise, which led to the successful replication of the HAPPEN initiative nationwide, improving patient safety and care quality and influencing health policy.

Recommendations for change in infection prevention programs and practice.

Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.

The association between non-ventilator associated hospital acquired pneumonia and patient outcomes among U.S. Veterans.

BACKGROUND: Non-ventilator associated hospital acquired pneumonia (NV-HAP) affects approximately 1 in 100 hospitalized patients yet risk-adjusted outcomes associated with developing NV-HAP are unknown. METHODS: Retrospective cohort study with propensity score matched populations (NV-HAP vs no NV-HAP), using ICD-10 codes for bacterial pneumonia not present on admission. Outcomes included the patient level probability of NV-HAP developing among acute care non-transfer admissions in 133 Veterans Affairs hospitals and subsequent mortality, length of stay, inpatient sepsis, and 12-month costs. RESULTS: NV-HAP occurred in 0.6% of Veteran admissions. Among admissions that developed NV-HAP, the mean length of stay of 26.3 days (6.72 days among non-NV-HAP), 30-day mortality was 18.4% (4.5% among non-NV-HAP), 1-year mortality was 47.8% (21.4% among non-NV-HAP), and total median 12-month direct medical costs were $138,136.32 ($64,357.21 among non-NV-HAP). Inpatient sepsis occurred in approximately 20% of NV-HAP admissions (0.7% among non-NV-HAP). Data available at admission was insufficient to identify high and low risk patient groups. CONCLUSIONS: NV-HAP is associated with severely worse patient outcomes and increased costs of care up to 12 months post-episode. Since population risk stratification is not feasible, prevention efforts should be directed at the full population of hospitalized Veterans.

Non-ventilator associated hospital acquired pneumonia incidence and health outcomes among U.S. veterans from 2016-2020.

Among 1,635,711 Veteran acute care admissions (FY2016-2020), the risk of non-ventilator associated hospital acquired pneumonia (NV-HAP) was 1.26 cases per 1,000 hospitalized days and decreased linearly over time with an uptick in cases in the last year coinciding with the onset of the covid-19 pandemic. Veterans who develop NV-HAP experience remarkably higher 30-day and 1-year mortality, longer length of stay, and higher rates of inpatient sepsis. Monitoring and prevention measures may substantially reduce negative outcomes.

Implementing Oral Care as a Nursing Intervention to Reduce Hospital-Acquired Pneumonia Across the United States Department of Veterans Affairs Healthcare System.

Hospital-acquired pneumonia is a preventable complication. The primary source of pneumonia among hospitalized and long-term care residents is aspiration of bacteria present in the oral biofilm. Reducing the bacterial burden in the mouth through consistent oral care is associated with a reduction in the incidence of hospital-acquired pneumonia. Following a significant reduction in pneumonia among non-ventilated patients in the research pilots, the Veterans Health Administration deployed the evidence-based, nurse-led oral care intervention called Hospital Acquired Pneumonia Prevention by Engaging Nurses as quality improvement nationwide. In this article, nursing informatics experts on the team describe the design and implementation of process and outcome measures of Hospital-Acquired Pneumonia Prevention by Engaging Nurses and outline lessons learned. The team used standardized terms and observations embedded within the EHR documentation templates to measure the oral care intervention in acute care areas. They also developed a tracking system for hospital-acquired pneumonia cases among non-ventilated patients. In addition to improving patient safety and care quality, Hospital-Acquired Pneumonia Prevention by Engaging Nurses links evidence-based practice with nursing informatics principles to generate numerous opportunities to measure the value of nursing at the point of care. This initiative was reported using SQUIRE 2.0: Standards for QUality Improvement Reporting Excellence.

Nonventilator hospital-acquired pneumonia: A call to action.

In 2020 a group of U.S. healthcare leaders formed the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) to issue a call to action to address non-ventilator-associated hospital-acquired pneumonia (NVHAP). NVHAP is one of the most common and morbid healthcare-associated infections, but it is not tracked, reported, or actively prevented by most hospitals. This national call to action includes (1) launching a national healthcare conversation about NVHAP prevention; (2) adding NVHAP prevention measures to education for patients, healthcare professionals, and students; (3) challenging healthcare systems and insurers to implement and support NVHAP prevention; and (4) encouraging researchers to develop new strategies for NVHAP surveillance and prevention. The purpose of this document is to outline research needs to support the NVHAP call to action. Primary needs include the development of better models to estimate the economic cost of NVHAP, to elucidate the pathophysiology of NVHAP and identify the most promising pathways for prevention, to develop objective and efficient surveillance methods to track NVHAP, to rigorously test the impact of prevention strategies proposed to prevent NVHAP, and to identify the policy levers that will best engage hospitals in NVHAP surveillance and prevention. A joint task force developed this document including stakeholders from the Veterans' Health Administration (VHA), the U.S. Centers for Disease Control and Prevention (CDC), The Joint Commission, the American Dental Association, the Patient Safety Movement Foundation, Oral Health Nursing Education and Practice (OHNEP), Teaching Oral-Systemic Health (TOSH), industry partners and academia.

Answering the question: Is the Doctor of Philosophy or Doctor of Nursing Practice right for me?

Over the past decade, leading health care organizations have recommended doubling the number of doctorally prepared nurses to meet the future demands of health care. In 2018, the National Organization of Nurse Practitioner Faculties committed to move all nurse practitioner degree programs to the Doctor of Nursing Practice degree by 2025. As more and more doctorally prepared nurses enter the workforce, other nurses are considering returning to school for a terminal degree. This column will review options for doctoral education in nursing and the strength, focus, and program requirements for PhD and DNP degrees.

Research productivity following nursing research initiative grants.

BACKGROUND: In 1995, VA's Office of Research and Development launched the Nursing Research Initiative (NRI), to encourage nurses to apply for research funding and to increase the role of nurse investigators in the VA's research mission. This program provides novice nurse researchers the opportunity to further develop their research skills with the guidance of a mentor. PURPOSE: Since the NRI's inception, its impact on the research career trajectory of budding nurse researchers had never been fully explored. METHODS: An electronic quality improvement survey was developed to collect information about the scope of work and research trajectory of VA nurse researchers undertaken since they received NRI funding. FINDINGS: NRI awardees demonstrated research productivity in several areas including research funding, peer-reviewed publications; participation on journal editorial boards and grant review committees; and mentorship. The majority of past NRI grant recipients (78%) have maintained employment within the VA system and benefit from the expertise, mentoring, and support of other nurse researchers. NRI grant recipients confirm the value of the VA NRI mentored grant funding mechanism and its association with a productive research trajectory with survey respondents demonstrating an average return on investment of $7.7 million in research funding per person. CONCLUSION: The experiences derived from the NRI accelerated the professional growth and research productivity of this group and it guided future opportunities to design, implement, and test nurse-led interventions.

A model of successful DNP and PhD collaboration.

BACKGROUND AND PURPOSE: Within nursing education, the existence of two graduate-level programs has created some challenges. Role confusion between the practice-focused Doctor of Nursing Practice (DNP) and the research-focused Doctor of Philosophy (PhD) is compounded by competition for similar positions. Collaboration between DNP and PhD nurses, however, benefits the health care system and patients. METHODS: The complementary skills of these two groups of nurses are detailed, and a model for building PhD-DNP partnerships is presented based on a collaborative PhD-DNP project that resolved a negative trend in outcomes from cardiac surgery. The clinical pathway created by the project met national benchmarks, improved interprofessional staff communication, and resulted in uniform and improved patient care. CONCLUSIONS: Although role differentiation for doctoral nurses can be challenging, role integration is critical. Building collaborative partnerships between these groups of nurses benefits the health care system, as well as patients, and this partnership is sustainable through successful collaborative projects. IMPLICATIONS FOR PRACTICE: Doctoral-prepared nurses must understand each other's background and education and focus on what each can contribute. In the beginning, as with any collaborative relationship, collaborators must discuss and agree on ground rules, team roles, responsibilities, and time line for projects.

Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans Affairs.

Consistently delivered, effective oral care targets bacterial multiplication reducing the risk of non-ventilator associated hospital acquired pneumonia (NV-HAP). AIM: Determine the effect of a twice daily oral care initiative on the incidence and cost of NV-HAP. METHODS: This single arm intervention study used pre/post population data to determine the effectiveness of a universal, standardized oral care protocol vs. usual care in preventing NV-HAP. This phase followed a retrospective study of 14,396 patient days (2002-2012) that determined the pre-intervention levels of nursing care provided, and the overall disease prevalence. RESULTS: The pilot incidence rate on the geriatric units decreased from 105 to 8.3 cases per 1,000 patient days (by 92%) in the first year. The intervention yielded an estimated cost avoidance of $2.84 million and 13 lives saved in 19 months post-implementation. Expansion of this study as quality improvement is in progress at 8 VA hospitals with plans for national VA deployment. CONCLUSIONS: While oral care may seem deceptively simple in terms of base care provision, hospital and nursing services struggle to provide effective oral care delivery with high-reliability. Barriers to oral care include: (1) the perception that oral care is an optional daily care activity for patient's comfort, (2) hospitals supply inadequate, poorly designed oral care materials, and (3) hospitals are not required to monitor the incidence of NV-HAP. The impact of consistently delivered oral care is substantial in terms of Veteran health, quality of life, and well-being in addition to considerable cost avoidance.

Implementation and Dissemination of a Department of Veterans Affairs Oral Care Initiative to Prevent Hospital-Acquired Pneumonia Among Nonventilated Patients.

Implementation and dissemination of an oral care initiative enhanced the safety and well-being of Veterans at the Salem VA Medical Center by reducing the risk of non-ventilator-associated hospital-acquired pneumonia (NV-HAP). The incidence rate of non-ventilator-associated hospital-acquired pneumonia decreased from 105 cases to 8.3 cases per 1000 patient-days (by 92%) in the initial VA pilot, yielding an estimated cost avoidance of $2.84 million and 13 lives saved in 19 months postimplementation. The team was successful in translating this research into a meaningful quality improvement intervention in 8 VA hospitals (in North Carolina, Texas, and Virginia) that has promoted effective and consistent delivery of oral care across hospital service lines and systems, improved the health of Veterans, and driven down health care costs associated with this largely preventable illness. The steps needed for successful replication and dissemination of this nurse-led, evidence-based practice are summarized in this article.

Barriers and Health Beliefs Related to Weight Management Among Veterans With Human Immunodeficiency Virus.

INTRODUCTION: The success of antiretroviral therapy has led to dramatic changes in causes of morbidity and mortality among U.S. Veterans with human immunodeficiency virus (HIV). Among the 25,000 Veterans treated for HIV, 70% are over age 50 and the rate of obesity has doubled in this population. Veterans with HIV have a 50% increased risk of myocardial infarction yet have limited presence in prevention-related programs designed to lower cardiovascular disease risk. METHODS: This mixed methods study (focus groups, Schwarzer and Renner physical activity, and nutrition self-efficacy questionnaires) was used to explore factors related to health behavior and identify barriers that overweight Veterans with HIV face in enrolling in the MOVE weight management program. Institutional review board approval was granted before the start of the study. All participants were recruited from the Infectious Disease clinic if they met national inclusion criteria for the MOVE weight management program and had not previously participated in the program. Transcribed audio recordings were independently analyzed and coded by four of the researchers using an exploratory process to obtain consensus regarding themes. An interrater reliability analysis for the Kappa statistic was performed to determine consistency among raters. The relationship between physical activity self-efficacy scores and nutrition self-efficacy scores was tested using Spearman's correlation coefficient. RESULTS: The median age of the sample was 56 with high rates of diabetes (36%), hypertension (73%), hyperlipidemia (36%), and tobacco use history (82%). External barriers to participation were discussed in addition to 8 other themes, which influence treatment engagement for Veterans with obesity and HIV including adaptation, stigma, self-management, and support. Veterans held strong beliefs about responsibility and commitment to their health and wanted to assume an active and informed role in their health care. Veterans with high levels of perceived self-efficacy indicated intention to overcome barriers to improve their nutrition and increase their physical activity. Refer to the full manuscript online to see the results in tables. CONCLUSIONS: Despite the chronic life-threatening nature of their condition, Veterans with HIV display a remarkable ability to adapt and commit to their treatment regimen. However, the dual stigma of obesity and HIV was a significant barrier to participation in weight management. This group placed high value on exercise over eating healthier and the importance of social support particularly from their Veteran peers. Focus groups allowed for fluid interaction between group members and researchers, rich conversation, and allowed additional clarification and exploration of topics. One unanticipated effect of the focus groups was that participants may feel less isolated after being a part of the discussion and may develop supportive relationships with their peers. It is possible that participants demonstrated more positive behavioral adaptation or other possible sources of bias. The study findings provide insight into health beliefs and barriers to weight management for all populations struggling with chronic disease and stigma. Data collected will inform future recruitment and retention strategies to engage Veterans with HIV in prevention-related programs designed to enhance long-term health and wellness.