Quality improvement implementation in the nursing home

Health Services Research, Feb, 2003 by Dan R. Berlowitz, Gary J. Young, Elaine C. Hickey, Debra Saliba, Brian S. Mittman, Elaine Czarnowski, Barbara Simon, Jennifer J. Anderson, Arlene S. Ash, Lisa V. Rubenstein, Mark A. Moskowitz

BACKGROUND AND HYPOTHESES

The VA operates a federally financed health care system for eligible veterans. The system comprises more than 150 medical centers, many of which have associated nursing homes. Although part of a larger medical center, VA nursing homes have a separate administrative structure consisting of a medical director and a director of nursing. Nursing home units within the VA are also often physically separated from the rest of the medical center, occupying separate buildings or campuses. Beginning in the early 1990s, VA headquarters began to encourage its hospital directors to adopt QI as "an essential management method and an organizational imperative" (Kizer 1999; Young, Chains, and Shortell 2001). Yet previous research suggests that the implementation of QI is a gradual process and considerable differences have been found among VA medical centers, as well as private sector hospitals, regarding the extent to which QI practices are being followed (Parker et al. 1999; Shortell et al. 1995). Additionally, questions hav e been raised as to whether QI can be successfully implemented in nursing homes (Kane 1998; Institute of Medicine 2001). We specifically test the hypothesis:

[H.sub.1]: Veterans Affairs nursing homes differ in their implementation of QI practices.

Determinants of quality improvement implementation have been actively investigated. Zinn and colleagues (1998) have hypothesized that nursing homes adopt QI as a management tool in response to environmental pressures as conceptualized by resource dependence and institutional theory. They found that perceived competition, the Medicare share of hospital discharges in the market, and the Medicare census within the nursing home were associated with QI adoption. These factors, though, are likely to be less important in the VA.

Studies from nonnursing home settings have demonstrated that organizational culture, those values, beliefs, and norms of an organization that shape its behavior, is an important determinant of QI implementation (Parker et al. 1999; Shortell et al. 1995). Shortell et al. reported that the implementation of QI practices among hospitals is associated with a group! developmental culture, that is, a culture where innovation, risk-taking, and teamwork are highly valued. This finding makes sense intuitively since in health care delivery organizations, QI represents a substantial departure from traditional quality assurance methods. For a health care organization to implement QI successfully, employees must be willing to take chances and learn new ways of doing their work. Moreover, because QI in health care settings requires communication among employees from different clinical disciplines, a culture that emphasizes teamwork also seems essential. The generalizability of this earlier research to nursing homes, where much care is provided by aides with little formal education and clinical training, is uncertain. We therefore test the hypothesis:

[H.sub.2]: A greater degree of QI implementation will be seen in those nursing homes with the strongest group/developmental culture.

In concept, QI implementation empowers employees to be actively involved in all aspects of care. It encourages staff to develop innovative practices that may improve care. In hospital settings, QI implementation has been associated with managements' perception of improved human resource development, which included ability to recruit and retain staff, physician commitment to the hospital, and nursing staff satisfaction (Shortell et al. 1995). Similar effects are likely in the nursing home. We hypothesize that:

[H.sub.3]: Quality improvement implementation is positively associated with employee satisfaction.

Quality improvement implementation is closely related to clinical practice guidelines (James 1993; Mittman, Tonesk, and Jacobson 1992; Burns et al. 1992). Guidelines are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific circumstances" (Field and Lohr 1990). Quality improvement encourages an analytic, evidence-based approach to medical care. Important steps in the QI process include identifying appropriate guidelines to solve problems and removing barriers to their implementation. Guidelines provide the initial description of best practices while QI supplies a set of tools to iteratively implement and customize them to a particular setting (James 1993). Nursing homes that are further along in implementing QI practices may be more likely to be using guidelines and to have adopted the best practices that they recommend. We now test the hypothesis:

[H.sub.4]: Quality improvement implementation is positively associated with guideline adoption and the performance of best practices.

Considerable uncertainty exists regarding the association between QI and patient outcomes (Shortell, Bennett, and Byck 1998). There have been few randomized clinical trials of QI and the results have generally been disappointing. Moreover, questions are increasingly being raised regarding the feasibility and generalizability of such studies (Samsa and Matchar 2000; Goldberg 2000). Consequently, most hospital-based studies either have evaluated QI as a method for generating interventions or have examined observationally the association between extent of QI implementation and outcomes.