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

In examining the results of these analyses, two limitations of our methods should be considered. First, our data were all cross-sectional, capturing the process of QI implementation at one point in time. Thus, caution is required in assuming causal direction among study variables, and the associations reported in the paper may have occurred through different mechanisms than the ones we assumed to exist in advancing our hypotheses. Second, the employees that responded to our survey completed several instruments contained in the same questionnaire that potentially addressed overlapping concepts. Accordingly, our measures may have been vulnerable to response set bias. Efforts to replicate our results with measures obtained from independent data sources will be valuable contributions to the literature.

RESULTS

A total of 1,781 clinical staff of VA nursing homes were surveyed. Completed surveys were received from 1,065 staff, for an overall response rate of 60 percent. Response rates by position in the nursing home are described in Table 2. The response rate was highest for nurse managers, with 72 of 88 (82 percent) completing the survey, and lowest for physicians, with only 48 of 88 (54 percent) completing the survey. The overall response rate by nursing home ranged from 39 to 85 percent with 31 of the 35 nursing homes having a response rate of 50 percent or greater. Respondents were typically experienced health care workers; 96 percent of the nurse managers, 75 percent of the nurses, and 71 percent of the nursing aides reported more than 10 years experience in the field.

There were considerable differences among nursing homes regarding their extent of QI implementation, which supports hypothesis 1. The mean ([ or -]SD) score on the 42-item QI implementation survey was 3.55 [ or -] 0.72. However, mean scores at individual nursing homes ranged from a low of 2.98 to a high of 4.08 (p< .001). Quality improvement implementation was significantly greater (p = .003) among nursing homes located in the West compared to the South and East (mean scores 3.93, 3.61, and 3.50, respectively). No differences in QI implementation was evident based on facility size, teaching status, or urban versus rural location.

Nursing homes also differed considerably in their organizational culture. Their mean ([ or -] SD) culture score, which as noted combines the group and developmental scores from the instrument, was 44.9 [ or -] 23.1 with a range from 29.3 to 64.9. In support of hypothesis 2, those nursing homes with a stronger group/developmental culture had a greater degree of QI implementation. In the linear regression model, a 10-point increase in the organizational culture score was associated with a 0.17 increase in the QI implementation score (model [R.sup.2] = 0.31; p< .00 1) (Table 3).

Employees were generally satisfied regarding their jobs. The mean ([ or -] SD) satisfaction score on the 5-point scale was 3.68 [ or -] 1.03 and the range among nursing homes was from 3.19 to 4.18. Nursing homes with a greater degree of QI implementation also had on average a higher level of satisfaction among their employees, supporting hypothesis 3. A 1-point increase in the QI implementation score was associated with a 0.83 increase in the satisfaction score (model [R.sup.2] = 0.57, p<.001) (Table 3).