Job and organizational determinants of nursing home employee commitment, job satisfaction and intent to turnover.

The purpose of this study was to examine whether job characteristics, the work environment, participation in quality improvement activities and facility quality improvement environment predicted employee commitment and job satisfaction in nursing homes, and whether those same predictors and commitment and satisfaction predicted turnover intention. A total of 6,584 nursing home employees from 76 nursing homes in a midwestern state participated. A self-administered questionnaire was used to collect the data. The results supported the hypotheses that job and organizational factors predicted commitment and satisfaction while commitment and satisfaction predicted turnover intentions. The implications for retaining nursing home employees are discussed.

Applying quality improvement principles to achieve healthy work organizations.

BACKGROUND: Health care has used total quality management (TQM)/quality improvement (QI) methods to improve quality of care and patient safety. Research on healthy work organizations (HWOs) shows that some of the same work organization factors that affect employee outcomes such as quality of life and safety can also affect organizational outcomes such as profits and performance. An HWO is an organization that has both financial success and a healthy workforce. For a health care organization to have financial success it must provide high-quality care with efficient use of scarce resources. To have a healthy workforce, the workplace must be safe, provide good ergonomic design, and provide working conditions that help to mitigate the stress of health care work. INTEGRATING TQM/QI INTO THE HWO PARADIGM: If properly implemented and institutionalized, TQM/QI can serve as the mechanism by which to transform a health care organization into an HWO. To guide future research, a framework is proposed that links research on QI with research on HWOs in the belief that QI methods and interventions might be an effective means by which to create an HWO. Specific areas of research should focus on identifying the work organization, cultural, technological, and environmental factors that affect care processes; affect patient health, safety, and satisfaction; and indirectly affect patient health, safety, and satisfaction through their effects on staff and care process variables. SUMMARY: Integrating QI techniques within the paradigm of the HWO paradigm will make it possible to achieve greater improvements in the health of health care organizations and the populations they serve.

Measuring post-decision satisfaction.

Measuring satisfaction with a decision after a choice has been made is particularly important for difficult choice situations where there is no "right" decision and/or where long-term consequences are uncertain. While others have developed instruments that primarily focus on clinical decisions, the authors developed a scale-the decision-attitude scale-in the context of consumers' choice of health plan. They examined the reliability and validity of this scale using data from a sample of state employees. While the decision-attitude scale has been applied to a health-plan-choice problem only, it can be applied to a variety of other health-related decision problems, because it shares a core set of items with the existing Satisfaction with Decision Scale. The authors identify and discuss the similarities and differences between the two scales. They also observe that each scale uncovers an additional construct not addressed by the other, suggesting that the concept of post-decision satisfaction is multidimensional. A new instrument combining items from both scales may prove the best measure of decision satisfaction for a variety of health-related decision problems.

A time-tradeoff method for cost-effectiveness models applied to radiology.

PURPOSE: The wait tradeoff (WTO) is a simple time-tradeoff method designed for temporary health states that uses a realistic and intuitive interface for the patient/subject. This method was tested by assessing patients' preferences for magnetic resonance angiography (MRA) versus x-ray angiography (XRA). MATERIALS AND METHODS: The WTO was tested by telephone interview in 38 patients with atherosclerotic peripheral vascular disease, all having previously undergone both MRA and XRA. At indifference point, patients were ambivalent about having MRA or XRA and immediate treatment, versus having a waiting period for test results and treatment after a hypothetical "ideal test" that entailed no pain or risk. RESULTS: The patients were willing to wait a mean of 42.1 days after the ideal test for results and treatment, as opposed to XRA. They were willing to wait only 16.1 days as opposed to MRA. This difference in waiting times was significant (p = 0.0001) and indicates a clear preference for MRA, in agreement with known literature. CONCLUSION: The WTO method assesses preferences for these radiologic tests in an intuitive fashion that does not invoke artificial or irrelevant health states. This approach may also prove useful for other testing situations or short-term treatments being evaluated for cost-effectiveness.

Macroergonomics and total quality management: how to improve quality of working life?

In this paper, we present a macroergonomic model of work design that is applied and tested to examine Total Quality Management (TQM) in the public sector. According to the model, TQM can influence different aspects of work design and quality of working life (QWL). Questionnaire data collected in 2 public sector organizations in the USA show that TQM can have both positive and negative impact on work design and QWL. The main positive impact of TQM was found on job content, job control and participation, and social relationships. The main negative impact of TQM was on workload, uncertainty, and clarity of job duties. The impact of TQM on QWL was mixed. Our results show that the impact of TQM on work design and QWL varied very much across the 6 participating departments, as well as within the departments. Further research is warranted to assess the human impact of TQM, in particular research on the linkage between various aspects of TQM, on one hand, and work design and QWL, on the other hand.

Eliciting consumer preferences for health plans.

OBJECTIVE: To examine (1) what people say is important to them in choosing a health plan; (2) the effect, if any, that giving health plan information has on what people say is important to them; and (3) the effect of preference elicitation methods on what people say is important. DATA SOURCES/STUDY SETTINGS: A random sample of 201 Wisconsin state employees who participated in a health plan choice experiment during the 1995 open enrollment period. STUDY DESIGN: We designed a computer system to guide subjects through the review of information about health plan options. The system began by eliciting the stated preferences of the subjects before they viewed the information, at time 0. Subjects were given an opportunity to revise their preference structures first after viewing summary information about four health plans (time 1) and then after viewing more extensive, detailed information about the same options (time 2). At time 2, these individuals were also asked to rate the relative importance of a predefined list of health plan features presented to them. DATA COLLECTION/EXTRACTION METHODS: Data were collected on the number of attributes listed at each point in time and the importance weightings assigned to each attribute. In addition, each item on the attribute list was content analyzed. PRINCIPAL FINDINGS: The provision of information changes the preference structures of individuals. Costs (price) and coverage dominated the attributes cited both before and after looking at health plan information. When presented with information on costs, quality, and how plans work, many of these relatively well educated consumers revised their preference structures; yet coverage and costs remained the primary cited attributes. CONCLUSIONS: Although efforts to provide health plan information should continue, decisions on the information to provide and on making it available are not enough. Individuals need help in understanding, processing, and using the information to construct their preferences and make better decisions.

Stability of nursing home quality indicators over time.

BACKGROUND: Nursing home quality indicators (QIs) provide a way to support quality assurance and improvement activities and to help ensure that cost savings are based on increased efficiency and not on decreased quality of care. OBJECTIVES: QIs values are expected to change over time. However, to be good indicators of quality, they should be reasonably stable over "short" periods. This paper discusses theoretical and measurement issues affecting stability and examines the stability of QIs over each of two 3-month periods and one 6-month period. SUBJECTS: The study sample included 512 nursing facilities from two states, Kansas and South Dakota. QIs were measured for the first 3 quarters of 1996. MEASURES: Facility level QIs were constructed using three different metrics that each provide a unique perspective of facility performance as follows: the proportion of residents in the facility with the QI condition; the facility's percentile rank in its state; and a variable indicating whether the facility's rank exceeded the 90th percentile in its state. QI stability was assessed using Pearson correlation coefficients, Spearman rank order correlation coefficients, and Cohen's Kappa, as appropriate for the metric. RESULTS: Results indicated high levels of stability for most QIs, with lower levels of stability found to be in keeping with theoretical and measurement considerations. CONCLUSIONS: QIs are reasonably stable over short periods of time. Quality improvement efforts may best be focused on facilities that are consistently poor performers over time, and those that show a large decrease in quality from one quarter to the next.

Disease progression and cost of insulin dependent diabetes mellitus: development and application of a simulation model.

This paper presents the development and application of a Markov model that simulates the onset and progression of insulin dependent diabetes mellitus (IDDM) and its sequelae. The model estimates direct medical costs resulting from different patterns of health states during the course of the disease. The model is user-friendly and allows for changes in the input variables to be specified, thereby providing a frame-work for sensitivity analysis. The Markov process moves a cohort of individuals through six different health states: Healthy, IDDM without chronic microvascular complications, IDDM with retinopathy alone, IDDM with neuropathy alone or with retinopathy, IDDM with nephropathy, and death. Epidemiologic data were obtained from governmental sources as well as the medical literature. Transition probabilities were estimated using data from the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR). Direct medical costs were estimated from actual charges from a local health maintenance organization in Wisconsin. The validity of the model was tested in several ways including a comparison with an independent cost estimate made by the Wisconsin Department of Health and Family Services. The model appears to be useful in estimating the progression and associated costs of IDDM for any large population over any period of time and in allowing changes in the inputs to evaluate their impact thus providing pertinent information to healthcare decision-makers and health planners.

Development and application of a model to estimate the impact of type 1 diabetes on health-related quality of life.

OBJECTIVE: To develop a simulation model to assess the impact of type 1 diabetes and its associated complications on health-related quality of life of a population. RESEARCH DESIGN AND METHODS: The methodology builds upon 1) an existing population model of type 1 diabetes progression, 2) an empirical study designed to measure state- and age-specific health statuses of type 1 diabetes, and 3) existing literature to quantify quality of life of the corresponding health status. Health statuses were measured in a group of type 1 diabetic patients using the Medical Outcomes Study short form 36 (SF-36). A published empirical regression equation was then used to predict corresponding Quality of Well-Being Index (QWB) scores from these assessments. The QWB scores were incorporated into a previously developed type 1 diabetes progression and cost simulation model. Sensitivity analyses on key parameters were performed, and the model was found to be robust. RESULTS: The augmented model can estimate quality-adjusted life years (QALYs) as well as costs associated with type 1 diabetes on any population of interest over any period of time. The model is used to compare intensive versus conventional treatment strategies using a simplified set of assumptions regarding the relative effects of these alternative treatments. With these assumptions, intensive strategy produces more QALYs than does conventional strategy and is cost-beneficial after 5 years. CONCLUSIONS: The model enables health planners to perform cost-effectiveness analyses to compare alternative treatment strategies for type 1 diabetes and support subsequent decision making.

Risk adjustment of nursing home quality indicators.

The purpose of this study was to develop a method for risk adjusting nursing home quality indicators (QI's). The QI's measure incidence and prevalence of resident-level care processes and outcomes which are indicative of care quality. Risk adjustment was carried out by stratifying residents into risk groups (high and low), calculating QI rates within groups, and then drawing comparisons across facilities. The method was examined through analysis of data from over 800 nursing homes in four states. Results showed that facilities differed substantially in QI rates even after risk had been taken into account. Also, results suggested differences in care quality which may not have been apparent without controlling for risk.

Judgments of quality of life of individuals with severe mental disorders: Patient self-report versus provider perspectives.

OBJECTIVE: This study was an investigation of judgments regarding quality of life of individuals with severe mental disorders from two different perspectives: patient self-report versus provider. METHOD: Judgments on several dimensions of quality of life were collected from a convenience sample of 37 schizophrenic patients and their primary clinicians by using the well-known Quality of Life Index of Spitzer et al. and the more recently developed Quality of Life Index-Mental Health. Both indexes capture judgments on a number of dimensions. Patterns of concordance for the patient-provider pairs were tested by using Cohen's kappa and Pearson correlation coefficients. RESULTS: The results suggest that patients' and providers' judgments are more likely to coincide on clinical aspects, such as symptoms and function, than on social aspects. Specifically, there was moderate agreement on symptoms and function, less agreement on physical health, and little to no agreement on social relations and occupational aspects of quality of life. CONCLUSIONS: Such differences support the notion that treatment strategies and mental health services should address a wide range of needs reflecting different aspects of quality of life perceived as important by different patients.

Role of information in consumer selection of health plans.

Considerable efforts are underway in the public and private sectors to increase the amount of information available to consumers when making health plan choices. The objective of this study was to examine the role of information in consumer health plan decisionmaking. A computer system was developed which provides different plan descriptions with the option of accessing varying types and levels of information. The system tracked the information search processes and recorded the hypothetical plan choices of 202 subjects. Results are reported showing the relationship between information and problem perception, preference structure, choice of plan, and attitude towards the decision.

Conceptual and methodological sources of variation in the measurement of nursing facility quality: an evaluation of 24 models and an empirical study.

Whereas many researchers have developed sophisticated instruments to assess quality of care in nursing facilities (NFs), the concept of quality, its measurement, and its relationship to organizational characteristics remain important issues that are characterized by inconsistent findings across studies. The conceptualization and methodologies used in twenty-four NF quality studies are compared. The review identifies four main sources of variation hypothesized to be important bases of inconsistency in the NF quality literature: (1) differences in conceptualization and operationalization, (2) differences in the unit of analysis (resident vs. facility), (3) differences in sampling method and sample constitution, and (4) differences in the main method of analysis. As an empirical test of three of these sources of variation, the authors investigated relationships between primary organizational characteristics and various measures of quality using a sample of 104 Wisconsin NFs. From both the comparative and Wisconsin analyses, implications for research are drawn.

An empirical test of the structure, process, and outcome quality paradigm using resident-based, nursing facility assessment data.

This study distinguishes between organizational characteristics, regarded as exogenous structural indicators of quality, and those identified as endogenous indicators of structural care (SC), and investigates the degree to which measures of SC vary by ownership mode (defined by four combinations of chain affiliation and profit status) for 142 certified and licensed nursing facilities (NFs) in a southern state. Structural care measures include: licensed and unlicensed staffing, licensed therapists, and case mix-adjusted direct care expenditures. In addition, seven (four process and three outcome) facility-level, risk-adjusted process, and outcome quality scales are developed from 39 resident-level quality indicators. A causal mode of NF quality arranged according to the structure, process and outcome paradigm is specified and estimated using path analysis. Organizational data derive from the 1991 Medicaid Cost Report; process and outcome quality measures were developed from the Minimum Data Set Plus Resident Assessment Instrument. Using the percentage of Medicaid and private pay residents as covariates, there was a significant overall multivariate effect due to ownership mode on the SC measures. Although there were several significant direct effects, the overall path model was unconfirmed. The multivariate results suggest that some organizational characteristics of structure quality may be more appropriately considered exogenous to causal quality models and therefore have indirect (versus direct) effects on process or outcome quality indicators. The path analysis implies that the structure-process-outcome paradigm may not accurately capture the way NF health care is delivered. Research which considers alternate NF quality paradigms needs to be done with samples that are more representative of national proportions of each ownership mode.

Development and testing of nursing home quality indicators.

In this article, the authors report on the development and testing of a set of indicators of quality of care in nursing homes, using resident-level assessment data. These quality indicators (QIs) have been developed to provide a foundation for both external and internal quality-assurance (QA) and quality-improvement activities. The authors describe the development of the QIs, discuss their nature and characteristics, address the development of a QI-based quality-monitoring system (QMS), report on a pilot test of the QIs and the system, comment on methodological and current QI validation efforts, and conclude by raising further research and development issues.

A first step in total quality management of nursing facility care: development of an empirical causal model of structure, process and outcome dimensions.

While the structure, process, and outcome taxonomy has long been used in the field of health care quality measurement and evaluation, it has not been used in a true causal model which assesses facility level quality. Total quality management and continuous quality improvement call for routinely assessing facility and resident level quality in a causal framework. This paper presents a causal modeling methodology as a more appropriate method for assessing and understanding the inter-relatedness among each of the quality dimensions of Nursing Facility care, and presents how such a causal model directly relates to the notion of continuous quality improvement. The methodology consists of five steps: (1) sample definition and data collection, (2) data reduction through factor analysis, (3) development and testing of a causal model through path analysis, (4) identification of patterns of care through cluster analysis, and (5) integration of the model to both continuous quality improvement and to complex relationships involving quality and organizational variables. The methodology is fully illustrated by using a sample of 104 nursing facilities in Wisconsin in which quality dimensions have been captured through the Quality Assessment Index. The analysis demonstrates that nursing facilities may be substantially benefited by having access to causal linkages which materially affect outcome quality. Management would then have first-hand knowledge of the structural characteristics and the process activities that they may pursue in order to improve outcome quality.

Evaluation of a DUR intervention: a case study of histamine antagonists.

Drug Utilization Review (DUR) programs aim to control inappropriate prescribing and drug costs, but there are few rigorous studies of their impact. This paper presents the evaluation results of a DUR intervention (excessive duration of full-dose histamine-2 receptor antagonists) using a quasi-experimental design. We observe a greater reduction of H2RA use in the intervention group than in the comparison group, and a reduction in drug expenditures which exceeded the cost of targeting and notifying prescribers. The success of DUR programs depends on both their efficiency and the drug issues under consideration; the use of a comparison group is critical in the evaluation of their impact.

A new patient focused index for measuring quality of life in persons with severe and persistent mental illness.

The quality of life in persons with severe and persistent mental illness is often poor. Most treatment programmes have the goal of increasing quality of life. Unfortunately, existing methods to assess quality of life are cumbersome and oriented towards research rather than clinical settings. This study describes preliminary steps in the development, testing and application of a new patient focused index for measuring quality of life in persons with severe mental illness. The Quality of Life Index for Mental Health (QLI-MH) differs from existing instruments in that it is based on an easy to use, self-administered questionnaire that assesses nine separate domains that together encompass quality of life. Each domain can be individually weighted depending on its relative importance to the patient. Different parts of the instrument solicit information from the patient, the primary clinician, and, when available, the family. The instrument and its scoring system address limitations of previous approaches to quality of life measurement.