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

Table 1


Sample Items for Each of the Five Subscales of the Quality Improvement
Implementation Survey. Each Item is Rated on a 5-point Scale from
Strongly Disagree (1) to Strongly Agree (5)


MANAGEMENT ROLE

My immediate supervisor makes quality a priority.

INFORMATION AND ANALYSIS

In my service, we routinely collect quality data related to most of
 our important work.

PLANNING FOR QUALITY

In my facility, nonmanagerial employees are playing a key role in
 setting priorities for quality improvement.

HUMAN RESOURCES UTILIZATION

Employees in my service serve or have served on quality improvement
 teams with employees from other services and/or other facilities.

QUALITY ASSURANCE OF PRODUCTS AND SERVICE

The quality management staff effectively coordinates their efforts with
 other employees to improve the quality of services the facility
 provides.

Table 2

Response Rate on the Survey by Employee Category

                                   Licensed
               Nurse   Registered  Practical  Nursing
              Manager    Nurse       Nurse     Aide    Physician

No. sent        88        441         424       573       88
No. returned    72        266         247       314       48
Response        82%       60%         58%       55%       54%



              Other *

No. sent        167
No. returned    118
Response        71%

* Other includes dieticians, physical therapists, and nurse
practitioners

Table 3

Results of Regression Models Examining Associations between QI
Implementation and the Other Study Variables at 35 VA Nursing Homes

                                                    B Coefficient
                                                    (Std. Error)

QI Implementation as Dependent Variable  
 Group/developmental culture score *            0.0173[  or -]0.0043
QI Implementation as Independent Variable *
 Employee satisfaction                           0.828[  or -]0.123
 Staff-reported guideline adoption &             0.280[  or -]0.070
 Adherence to 15 guideline recommendations $    -0.0405[  or -]0.0444
 Observed minus expected pressure ulcer rate #  - 1.713[  or -]1.304


                                                P-value

QI Implementation as Dependent Variable  
 Group/developmental culture score *            <.001
QI Implementation as Independent Variable *
 Employee satisfaction                          <.001
 Staff-reported guideline adoption &            <.001
 Adherence to 15 guideline recommendations $    0.37
 Observed minus expected pressure ulcer rate #  0.19

  Scored on a 1 to 5 scale.

* Scored on a 0 to 100 scale; higher scores indicate greater
group/developmental culture.

& Percent of nursing home staff reporting guideline adoption.

$ Proportion of indicated recommendations documented in the medical
record.

# Based on a random effects model with 12,679 patient-observations.

ACKNOWLEDGMENTS

The study team gratefully acknowledges the contribution of Boris Kader, Ph.D., in performing the analyses, Cheryl Burton, R.N., in performing chart abstractions, and Bruce Ferrell, M.D., in assisting in the creation of the medical records abstraction instrument.