Quality of care in a Veterans Affairs' nursing home-based hospice unit.

OBJECTIVES: To report on quality of care in a Veterans Affairs (VA) dedicated hospice unit. DESIGN: Mortality follow-back survey of bereaved family members, using a quality of care instrument. SETTING: A VA inpatient hospice unit. PARTICIPANTS: Bereaved family members. MEASUREMENTS: Satisfaction with care as perceived by family members using a telephone survey. RESULTS: 159 family members were contacted with 102 completing full and 37 completing abbreviated surveys. (Overall response rate: 87.4%, complete responses: 64.2%) 98% of all respondents reported overall quality of care as Excellent or Very Good. CONCLUSION: High levels of satisfaction were reported by family members. Implications of this initiative for the provision of hospice care in nursing homes are discussed, including replication of the model in both VA and non-VA nursing home settings.

The effects of changes in nursing home staffing on pressure ulcer rates.

OBJECTIVE: To examine the relationships between various components of nursing home staffing (total staffing levels and staff mix, staff turnover, and changes in staffing patterns) to an important measure of quality, risk-adjusted rates of pressure ulcer development. DESIGN, SETTING, AND MEASUREMENTS: Staffing records from 35 Department of Veterans Affairs (DVA) nursing homes were reviewed and nursing home administrators from each of the facilities were interviewed. Incidence rates for pressure ulcers were obtained from DVA's national long-term care database and risk adjusted using patients' baseline characteristics. The relationships of risk-adjusted pressure ulcer rates to staffing patterns were tested. RESULTS: Although there was no linear association between staffing levels and pressure ulcer rates, data analysis revealed a strong trend (P = .07) that among the nursing homes meeting staffing guidelines, 60% were among the best performing. Ten nursing homes reduced staffing levels from their baseline levels at the beginning of the study and/or changed their staffing mix by replacing licensed personnel with nursing assistants. This change was associated with a 2.1% higher rate of pressure ulcer development (P = .004). CONCLUSION: Changes in nursing home staffing patterns (either a decrease in overall staffing levels or a change in staffing mix) are related to the quality of nursing home care. Staff stability is associated with better outcomes.

Quality improvement implementation in the nursing home.

OBJECTIVE: To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care. DATA SOURCES/STUDY SETTING: Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database. STUDY DESIGN: A cross-sectional analysis of the association among the different measures was performed. DATA COLLECTION/EXTRACTION METHODS: Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database. PRINCIPAL FINDINGS: Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development. CONCLUSIONS: Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.

Adherence to pressure ulcer prevention guidelines: implications for nursing home quality.

OBJECTIVES: This study aims to assess overall nursing home (NH) implementation of pressure ulcer (PU) prevention guidelines and variation in implementation rates among a geographically diverse sample of NHs. DESIGN: Review of NH medical records. SETTING: A geographically diverse sample of 35 Veterans Health Administration NHs. PARTICIPANTS: A nested random sample of 834 residents free of PU on admission. MEASUREMENTS: Adherence to explicit quality review criteria based on the Agency for Healthcare Research and Quality Practice Guidelines for PU prevention was measured. Medical record review was used to determine overall and facility-specific adherence rates for 15 PU guideline recommendations and for a subset of six key recommendations judged as most critical. RESULTS: Six thousand two hundred eighty-three instances were identified in which one of the 15 guideline recommendations was applicable to a study patient based on a specific indication or resident characteristic in the medical record. NH clinicians adhered to the appropriate recommendation in 41% of these instances. For the six key recommendations, clinicians adhered in 50% of instances. NHs varied significantly in adherence to indicated guideline recommendations, ranging from 29% to 51% overall adherence across all 15 recommendations (P <.001) and from 24% to 75% across the six key recommendations (P <.001). Adherence rates for specific indications also varied, ranging from 94% (skin inspection) to 1% (education of residents or families). Standardized assessment of PU risk was identified as one of the most important and measurable recommendations. Clinicians performed this assessment in only 61% of patients for whom it was indicated. CONCLUSIONS: NHs' overall adherence to PU prevention guidelines is relatively low and is characterized by large variations between homes in adherence to many recommendations. The low level of adherence and high level of variation to many best-care practices for PU prevention indicate a continued need for quality improvement, particularly for some guidelines.