October 9, 2012 part 2


Health Care Administration and Organization
Health Care Innovation and Quality Assurance

Health Care Administration & Organization

A four-year, systems-wide intervention promoting interprofessional collaboration.
Braithwaite J, Westbrook M, Nugus P, Greenfield D, Travaglia J, Runciman W, Foxwell AR, Boyce RA, Devinney T, Westbrook J.
BMC Health Serv Res. 2012 Apr 20;12:99.

A four-year action research study was conducted across the Australian Capital Territory health system to strengthen interprofessional collaboration (IPC) though multiple intervention activities. METHODS: We developed 272 substantial IPC intervention activities involving 2,407 face-to-face encounters with health system personnel. Staff attitudes toward IPC were surveyed yearly using Heinemann et al’s Attitudes toward Health Care Teams and Parsell and Bligh’s Readiness for Interprofessional Learning scales (RIPLS). At study’s end staff assessed whether project goals were achieved. RESULTS: Of the improvement projects, 76 exhibited progress, and 57 made considerable gains in IPC. Educational workshops and feedback sessions were well received and stimulated interprofessional activities. Over time staff scores on Heinemann’s Quality of Interprofessional Care subscale did not change significantly and scores on the Doctor Centrality subscale increased, contrary to predictions. Scores on the RIPLS subscales of Teamwork & Collaboration and Professional Identity did not alter. On average for the assessment items 33% of staff agreed that goals had been achieved, 10% disagreed, and 57% checked neutral. There was most agreement that the study had resulted in increased sharing of knowledge between professions and improved quality of patient care, and least agreement that between-professional rivalries had lessened and communication and trust between professions improved. CONCLUSIONS: Our longitudinal interventional study of IPC involving multiple activities supporting increased IPC achieved many project-specific goals. However, improvements in attitudes over time were not demonstrated and neutral assessments predominated, highlighting the difficulties faced by studies targeting change at the systems level and over extended periods.

Nursing assistant views on nursing home regulatory inspection: Knowledge and attitudes regarding the state nursing home survey
Chung G.
Journal of Applied Gerontology. 2012;31(3):336-53.

Nursing assistants provide more than 80% of direct care to residents. However, it is unknown whether or not they clearly understand the purpose of nursing home regulation and incorporate regulatory standards in their care delivery process. This study uses qualitative methods to explore their experiences with nursing home inspection. Findings suggest that the subtle nuances of human interaction between nursing assistants and residents tend to be overlooked in the midst of enforcing highly strict and detailed regulatory standards that mainly focus on visible outcomes of care. In addition, the state survey might deepen the chasm between nursing assistants and nursing home administration so that the hierarchical culture of mistrust and ritualism continues in nursing homes. To resolve such problems, it is critical to rethink the impact of nursing home regulation at the level of direct interactions between nursing assistants and residents and to consider increasing nursing assistant involvement in the inspection process. © 2012 The Author(s).

Job satisfaction in birth cohorts of nurses.
Klaus SF, Ekerdt DJ, Gajewski B.
Journal of nursing management 2012 May;20(4):461-471

The aim of the present study was to investigate which hospital, unit and individual characteristics predict job satisfaction in four age cohorts of registered nurses (RNs). BACKGROUND: Adequate supply of direct care nurses in hospitals is paramount to the provision of safe patient care. While recruitment is important, interventions to retain experienced nurses in the work force should also be undertaken. METHODS: Cross-sectional survey data from the 2004 National Database of Nursing Quality Indicators(®) (NDNQI(®) ) RN Survey with Job Satisfaction Scales(©) were used. The sample included 53 851 RNs age 20-59 years divided into four age cohorts. Data were analysed using three-level hierarchical linear modelling. RESULTS: Overtime demand and involuntary floating resulted in significantly lower job satisfaction in all age cohorts. The oldest two cohorts reported higher job satisfaction with increased unit tenure whereas the youngest cohort reported decreased job satisfaction with increased unit tenure. Higher job satisfaction was reported in all cohorts within Magnet hospitals; however, the relationship was only significant in 40-49 year olds. CONCLUSIONS: Some factors are associated with job satisfaction in all age cohorts. Other factors differentially influence job satisfaction based on the cohort group. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse leaders should consider retention strategies congruent with the job satisfaction predictors of different age groups. © 2011 Blackwell Publishing Ltd.

Professional caregivers’ mental health problems and burnout in small-scale and traditional long term care settings for elderly people with dementia in the Netherlands and Belgium.
de Rooij AH, Luijkx KG, Declercq AG, Emmerink PM, Schols JM.
Journal of the American Medical Directors Association 2012 Jun;13(5):486.e7-486.11

The aim of this study was to provide an insight into burnout and mental health problems of professional caregivers working in traditional and small-scale long term care settings for elderly residents with dementia in the Netherlands and Belgium. DESIGN: This study was part of a larger study investigating similarities and differences between traditional and small-scale long term care settings for elderly residents with dementia. In this article, the perspective of the professional caregiver is of central importance. A survey was conducted among professional caregivers of residents with dementia, older than 65 years, at 2 measurement moments (at baseline and after 12 months). SETTING: The questionnaire was administered to professionals working in traditional and small-scale long term care settings in the Netherlands and Belgium. PARTICIPANTS: Professional caregivers (n = 80) working in 5 different care settings completed a questionnaire. MEASUREMENTS: The questionnaire included items on personal data, mental health problems (GHQ-12), and burnout (UBOS-C, divided into emotional exhaustion, depersonalization, and personal accomplishment). Analyses were conducted using Mixed Models analysis. RESULTS: Although mental health problems and emotional strain increased significantly over time in both types of settings and countries, overall levels of health problems and burnout were low. As regards emotional strain, professional caregivers in small-scale living facilities showed significantly increased levels in comparison with traditional units. Two significant differences between the countries were also found, with less “depersonalization” and more “personal accomplishment” in Dutch settings compared with Belgian settings. No differences emerged for type of setting or over time on “depersonalization” and “personal accomplishment.”

Effect of Clinical Decision-Support Systems: A Systematic Review.
Bright TJ, Wong A, Dhurjati R, Bristow E, Bastian L, Coeytaux RR, et al.
Annals of Internal Medicine 2012 Apr 23

Background: Despite increasing emphasis on the role of clinical decision-support systems (CDSSs) for improving care and reducing costs, evidence to support widespread use is lacking. Purpose: To evaluate the effect of CDSSs on clinical outcomes, health care processes, workload and efficiency, patient satisfaction, cost, and provider use and implementation. Data Sources: MEDLINE, CINAHL, PsycINFO, Web of Science, and the Cochrane Database of Systematic Reviews through January 2011. Study Selection: Investigators independently screened reports to identify randomized trials published in English of electronic CDSSs that were implemented in clinical settings; used by providers to aid decision making at the point of care; and reported clinical, health care process, workload, relationship-centered, economic, or provider use outcomes. Data Extraction: Investigators extracted data about study design, participant characteristics, interventions, outcomes, and quality. Data Synthesis: 148 randomized, controlled trials were included. A total of 128 (86%) assessed health care process measures, 29 (20%) assessed clinical outcomes, and 22 (15%) measured costs. Both commercially and locally developed CDSSs improved health care process measures related to performing preventive services (n = 25; odds ratio [OR], 1.42 [95% CI, 1.27 to 1.58]), ordering clinical studies (n = 20; OR, 1.72 [CI, 1.47 to 2.00]), and prescribing therapies (n = 46; OR, 1.57 [CI, 1.35 to 1.82]). Few studies measured potential unintended consequences or adverse effects. Limitations: Studies were heterogeneous in interventions, populations, settings, and outcomes. Publication bias and selective reporting cannot be excluded. Conclusion: Both commercially and locally developed CDSSs are effective at improving health care process measures across diverse settings, but evidence for clinical, economic, workload, and efficiency outcomes remains sparse. This review expands knowledge in the field by demonstrating the benefits of CDSSs outside of experienced academic centers. Primary Funding Source: Agency for Healthcare Research and Quality.

Measuring administrators’ and direct care workers’ perceptions of the safety culture in assisted living facilities.
Castle NG, Wagner LM, Sonon K, Ferguson-Rome JC.

Joint Commission journal on quality and patient safety / Joint Commission Resources 2012 Aug;38(8):375-382
BACKGROUND: Further understanding of patient safety in health care is still needed. This is particularly evident in long term care settings, where relatively little information exists. Safety culture has emerged as a critical component of efforts to improve patient safety; it is strongly associated with iniatatives that influence patient safety and quality of care. The safety culture of a large sample of assisted living (AL) facilities was examined. METHODS: The Nursing Home Survey on Patient Safety Culture (NHPSC) was modified and used to examine safety culture. A random sample of AL settings from all 50 states was selected to participate. Respondents were AL administrators and direct care workers (DCWs) who completed the modified safety culture survey. The applied properties of the instrument are examined. A summary score for administrators and DCWs for each NHPSC item is also presented. These summary scores have a range from 0 to 100, with low scores representing a poor safety culture (and vice versa). RESULTS: Information was received from 572 administrators (response rate = 57%) and 3,620 DCWs (response rate = 51%). The scores, using the 0-100 scale, fell into the 48-72 range for administrators and the 40-68 range for DCWs. Many of the scores were similar to those previously found in nursing homes. CONCLUSIONS: AL is recognized as one of the fastest-growing institutional components of the long term care industry. The modified NHPSC performed well. Some areas of safety culture were perceived less favorably than in nursing homes. As such, some further attention to safety culture in AL is warranted. This study provides a first step toward assessing safety culture in this underexamined setting.

Nursing practice environment and registered nurses’ job satisfaction in nursing homes.
Choi J, Flynn L, Aiken LH.
The Gerontologist 2012 Aug;52(4):484-492

PURPOSE: Recruiting and retaining registered nurses (RNs) in nursing homes is problematic, and little research is available to guide efforts to make nursing homes a more attractive practice environment for RNs. The purpose of this study was to examine relationships between aspects of the nursing practice environment and job satisfaction among RNs in nursing homes. DESIGN AND METHODS: The sample included 863 RNs working as staff RNs in 282 skilled nursing facilities in New Jersey. Two-level hierarchical linear modeling was used to account for the RNs nested by nursing homes. RESULTS: Controlling for individual and nursing home characteristics, staff RNs’ participation in facility affairs, supportive manager, and resource adequacy were positively associated with RNs’ job satisfaction. Ownership status was significantly related to job satisfaction; RNs working in for-profit nursing homes were less satisfied. IMPLICATIONS: A supportive practice environment is significantly associated with higher job satisfaction among RNs working in nursing homes. Unlike other nursing home characteristics, specific dimensions of the nursing practice environment can be modified through administrative actions to enhance RN job satisfaction.

District nurses’ perceptions of the concept of delegating administration of medication to home care aides working in the municipality: A discrepancy between legal regulations and practice.
Craftman AG, von Strauss E, Rudberg SL, Westerbotn M.
Journal of clinical nursing 2012 Sep 17

Aims and objectives. To describe district nurses’ perceptions of the concept of delegating medication management to unlicensed personnel working in municipal social care. Background. The delegation of medical tasks involves responsibility and is regulated by law to avoid damage and injuries and to protect the patient. The delegation of the administration of medication is a multifaceted task. The delegating district nurse is responsible for the outcome and should also follow up the delegated task. Design. A descriptive qualitative study, involving semi-structured interviews and content analysis. Methods. Twenty district nurses were interviewed. The interviews were audio taped. The data were collected from April 2009-August 2010 and analysed using content analysis. Results. The findings revealed that the statutes of delegation appear to be incompatible with practice, however, mostly due to lack of time. Communication between district nurses and home care aides, as well as tutoring, was regarded as important. The district nurses found it imperative to be available to the home care aides and made an effort to create a trusting atmosphere. Conclusions. District nurses cannot manage their workload without delegating the administration of medication in the present organisational model of health care and social care. The statutes regarding delegating medicine tasks are also cumbersome and difficult to incorporate for district nurses who are responsible for the delegation. Relevance to clinical practice. The findings elucidate the current situation as regards district nurses and the need to delegate the administration of medication. Health care and social care for home-dwelling older patients, as well as statutes, needs to be evaluated and updated to meet and be prepared for the increasing demands of care. © 2012 Blackwell Publishing Ltd.

A taxonomy of nursing care organization models in hospitals.
Dubois CA, D’Amour D, Tchouaket E, Rivard M, Clarke S, Blais R.
BMC health services research 2012 Aug 28;12(1):286

BACKGROUND: Over the last decades, converging forces in hospital care, including cost-containment policies, rising healthcare demands and nursing shortages, have driven the search for new operational models of nursing care delivery that maximize the use of available nursing resources while ensuring safe, high-quality care. Little is known, however, about the distinctive features of these emergent nursing care models. This article contributes to filling this gap by presenting a theoretically and empirically grounded taxonomy of nursing care organization models in the context of acute care units in Quebec and comparing their distinctive features. METHODS: This study was based on a survey of 22 medical units in 11 acute care facilities in Quebec. Data collection methods included questionnaire, interviews, focus groups and administrative data census. The analytical procedures consisted of first generating unit profiles based on qualitative and quantitative data collected at the unit level, then applying hierarchical cluster analysis to the units’ profile data. RESULTS: The study identified four models of nursing care organization: two professional models that draw mainly on registered nurses as professionals to deliver nursing services and reflect stronger support to nurses’ professional practice, and two functional models that draw more significantly on licensed practical nurses (LPNs) and assistive staff (orderlies) to deliver nursing services and are characterized by registered nurses’ perceptions that the practice environment is less supportive of their professional work. CONCLUSIONS: This study showed that medical units in acute care hospitals exhibit diverse staff mixes, patterns of skill use, work environment design, and support for innovation. The four models reflect not only distinct approaches to dealing with the numerous constraints in the nursing care environment, but also different degrees of approximations to an ideal|| nursing professional practice model described by some leaders in the contemporary nursing literature. While the two professional models appear closer to this ideal, the two functional models are farther removed.

Psychosocial work environment and prediction of job satisfaction among Swedish registered nurses and physicians – a follow-up study.
Jonsson S.
Scandinavian journal of caring sciences 2012 Jun;26(2):236-244

In Sweden, the health care sector was subject to considerable changes during the 1990s: decreased costs, related staff redundancies and high rates of sick leave. The situation has now changed, and the sector is not facing the same all-embracing and turbulent changes. In addition, there is a shortage of nurses and physicians and a difficulty in retaining qualified staff. Regarding the psychosocial work environment, there is a lack of studies where both physicians and nurses are in focus. It is from a managerial perspective important to take a holistic approach towards questions regarding the work environment in general and the psychosocial work environment in particular. The aims of this study were to analyse similarities and differences in Registered Nurses and physicians’ experience of quantitative and qualitative demands, control, role conflicts, role clarity, social support and job satisfaction in 2002 and 2009 and to analyse the stability in the prediction of job satisfaction over time. Questionnaires regarding psychosocial work environment aspects were distributed in 2002 and 2009, and a total of 860 nurses and 866 physicians answered the questionnaire. Independent t tests and linear stepwise regression analyses were conducted. The results indicate that the work environment has improved between 2002 and 2009 and that nurses experience their psychosocial working environment as more satisfactory than physicians. Social support, control, role conflicts, role clarity and qualitative demands were the best predictors of job satisfaction in 2002 and 2009. Quantitative demands did not contribute to predicting job satisfaction. Variables predicting job satisfaction are quite stable over time and are quite comparable for both nurses and physicians. © 2011 The Author. Scandinavian Journal of Caring Sciences © 2011 Nordic College of Caring Science.

The weather-stains of care: Interpreting the meaning of bad weather for front-line health care workers in rural long-term care.
Joseph GM, Skinner MW, Yantzi NM.
Social science & medicine (1982) 2012 Aug 18

This paper addresses the gap in health services and policy research about the implications of everyday weather for health care work. Building on previous research on the weather-related challenges of caregiving in homes and communities, it examines the experiences of ‘seasonal bad weather’ for health care workers in long-term care institutions. It features a hermeneutic phenomenology analysis of six transcripts from interviews with nurses and personal support workers from a qualitative study of institutional long-term care work in rural Canada. Focussing on van Manen’s existential themes of lived experience (body, relations, space, time), the analysis reveals important contradictions between the lived experiences of health care workers coping with bad weather and long-term care policies and practices that mitigate weather-related risk and vulnerability. The findings contribute to the growing concern for rural health issues particularly the neglected experiences of rural health providers and, in doing so, offer insight into the recent call for greater attention to the geographies of health care work. Copyright © 2012 Elsevier Ltd. All rights reserved.

Job satisfaction among hospital nurses revisited: a systematic review.
Lu H, Barriball KL, Zhang X, While AE.
International journal of nursing studies 2012 Aug;49(8):1017-1038

BACKGROUND: The current nursing shortage and high turnover is of great concern in many countries because of its impact upon the efficiency and effectiveness of any healthcare delivery system. Recruitment and retention of nurses are persistent problems associated with job satisfaction. OBJECTIVE: To update review paper published in 2005. DESIGN: This paper analyses 100 papers relating to job satisfaction among hospital nurses derived from systematic searches of seven databases covering English and Chinese language publications 1966-2011 (updating the original paper with 46 additional studies published 2004-2011). FINDINGS: Despite varying levels of job satisfaction across studies, sources and effects of job satisfaction were similar. Hospital nurse job satisfaction is closely related to working conditions and the organizational environment, job stress, role conflict and ambiguity, role perception and role content, organizational and professional commitment. CONCLUSIONS: More research is required to understand the relative importance of the many identified factors relating to job satisfaction of hospital nurses. It is argued that the absence of a robust causal model reflecting moderators or moderator is undermining the development of interventions to improve nurse retention.

Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: a literature review.
McGahan M, Kucharski G, Coyer F, Winner ACCCN Best Nursing Review Paper 2011 sponsored by Elsevier.
Australian Critical Care : Official Journal of the Confederation of Australian Critical Care Nurses 2012 May;25(2):64-77

BACKGROUND: Studies have shown that nurse staffing levels, among many other factors in the hospital setting, contribute to adverse patient outcomes. Concerns about patient safety and quality of care have resulted in numerous studies being conducted to examine the relationship between nurse staffing levels and the incidence of adverse patient events in both general wards and intensive care units. AIM: The aim of this paper is to review literature published in the previous 10 years which examines the relationship between nurse staffing levels and the incidence of mortality and morbidity in adult intensive care unit patients. METHODS: A literature search from 2002 to 2011 using the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Australian digital thesis databases was undertaken. The keywords used were: intensive care; critical care; staffing; nurse staffing; understaffing; nurse-patient ratios; adverse outcomes; mortality; ventilator-associated pneumonia; ventilator-acquired pneumonia; infection; length of stay; pressure ulcer/injury; unplanned extubation; medication error; readmission; myocardial infarction; and renal failure. A total of 19 articles were included in the review. Outcomes of interest are patient mortality and morbidity, particularly infection and pressure ulcers. RESULTS: Most of the studies were observational in nature with variables obtained retrospectively from large hospital databases. Nurse staffing measures and patient outcomes varied widely across the studies. While an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found in this review, most studies concluded that a trend exists between increased nurse staffing levels and decreased adverse events. CONCLUSION: While an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found in this review, most studies demonstrated a trend between increased nurse staffing levels and decreased adverse patient outcomes in the intensive care unit which is consistent with previous literature. While further more robust research methodologies need to be tested in order to more confidently demonstrate this association and decrease the influence of the many other confounders to patient outcomes; this would be difficult to achieve in this field of research. Copyright © 2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

An inpatient rehabilitation model of care targeting patients with cognitive impairment.
McGilton KS, Davis A, Mahomed N, Flannery J, Jaglal S, Cott C, et al.
BMC geriatrics 2012 May 25;12:21

BACKGROUND: The course and outcomes of hip fracture patients are often complicated by the presence of dementia and delirium, referred to as cognitive impairment (CI), which limits access to in-patient rehabilitation. In response to this concern, members of our team developed and piloted an in-patient rehabilitation model of care (Patient-Centred Rehabilitation Model; PCRM) targeting patients with hip fracture and CI (PCRM-CI). We are now conducting a 3-year study comparing an inpatient rehabilitation model of care for community dwelling individuals with hip fracture and CI (PCRM-CI) to usual care to determine whether it results in improved mobility at the time of discharge from inpatient rehabilitation. METHODS/DESIGN: A non-equivalent pre-post design is being used to evaluate the PCRM-CI compared to usual care. All community dwelling (private home or retirement home) patients following a hip fracture are eligible to participate. Recruitment of both cohorts is taking place at two facilities. Target accrual is 70 hip fracture patients in the PCRM-CI cohort and 70 patients in the usual care cohort. We are also recruiting 70 health care providers (HCPs), who are being trained to implement the PCRM-CI, and their unit managers. Patient data are collected at baseline, discharge, and 6 months post-discharge from an inpatient rehabilitation program. Evaluations include mobility, physical function, and living arrangement. Additional outcome variables are being collected from medical records and from the patients via their proxies. Data on the prevalence and severity of dementia and delirium are being collected. Staff data are collected at baseline and one year after implementation of the model to determine change in staff knowledge and attitudes toward patients with hip fracture and CI. Bi-monthly semi-structured interviews with unit managers have been conducted to examine factors and barriers influencing the model implementation. Data collection began in 2009 and is expected to be completed in 2012. The control cohort of 70 patients has been recruited, and 45 patients have been accrued to the intervention group to date. DISCUSSION: Evaluation of this model of care is timely given the increasing proportion of persons with cognitive impairment and hip fractures. TRIAL REGISTRATION: The study is registered at http://clinicaltrials.gov, Identifier NCT01566136.

Manitoba: enhanced orientation for nurses new to long-term care.
O’Rourke D.
Nursing leadership (Toronto, Ont.) 2012 Mar;25 Spec No 2012:64-70

The Manitoba pilot project, Enhanced Orientation for Nurses New to Long-Term Care, lasted 18 months and involved three sites in the Winnipeg Regional Health Authority. It was developed to address the reality that individuals entering long-term care have more complex needs than in the past and that it is often difficult to recruit and retain nurses to work in this care setting. This mentorship program included 11 mentors and 12 proteges. As well, six clinical workshops were developed and held for a total of 390 participants. Proteges reported a positive effect on their transition to the workplace and their confidence levels, and mentors reported building their mentorship skills. The program has been expanded within the Winnipeg Region and to other health regions in the province and in Canada.

An exploratory study about meaningful work in acute care nursing.
Pavlish C, Hunt R.
Nursing forum 2012 Apr-Jun;47(2):113-122

OBJECTIVE: To develop deeper understandings about nurses’ perceptions of meaningful work and the contextual factors that impact finding meaning in work. BACKGROUND: Much has been written about nurses’ job satisfaction and the impact on quality of health care. However, scant qualitative evidence exists regarding nurses’ perceptions of meaningful work and how factors in the work environment influence their perceptions. The literature reveals links among work satisfaction, retention, quality of care, and meaningfulness in work. METHODS: Using a narrative design, researchers interviewed 13 public health nurses and 13 acute care nurses. Categorical-content analysis with Atlas.ti data management software was conducted separately for each group of nurses. This article reports results for acute care nurses. RESULTS: Twenty-four stories of meaningful moments were analyzed and categorized. Three primary themes of meaningful work emerged: connections, contributions, and recognition. Participants described learning-focused environment, teamwork, constructive management, and time with patients as facilitators of meaningfulness and task-focused environment, stressful relationships, and divisive management as barriers. Meaningful nursing roles were advocate, catalyst and guide, and caring presence. CONCLUSIONS: Nurse administrators are the key to improving quality of care by nurturing opportunities for nurses to find meaning and satisfaction in their work. Study findings provide nurse leaders with new avenues for improving work environments and job satisfaction to potentially enhance healthcare outcomes. © 2012 Wiley Periodicals, Inc.

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.
Payne CE, Stein JM, Leong T, Dressler DD.
BMJ quality & safety 2012 Jun 16

BACKGROUND: Handover of patient information represents a critical time period during a patient’s hospitalisation. While recent guidelines promote standardised communication during these patient care transitions, significant variability in structure and practice persists among hospitals and providers. METHODS: The authors surveyed internal medicine residents regarding handover practices before and after introduction of a structured, web-based handover application. The handover application standardised patient data in a format suitable for both patient handovers and day-to-day patient management. RESULTS: A total of 80 residents were surveyed prior to the intervention (80% response rate) and 161 residents during the intervention (average 68% response rate for all surveys distributed). At baseline, residents perceived deficits in handover practices related to the variability of information transferred and correlated that variability to near-miss events. After introduction of the handover application, 100% of handovers contained an updated problem list, active medications, and code status (compared to <55% at baseline, p<0.01); residents perceived approximately half as many near-miss events on call (31.5% vs 55%; p=0.0341) and were twice as likely to respond that they were confident or very confident in their patient handovers compared to traditional practices (93% vs 49%; p=0.01). CONCLUSION: Standardisation of information transmitted during patient handovers through the use of a structured, web-based application led to consistent transfer of vital patient information and was associated with improved resident confidence and fewer perceived near-miss events on call.

Blending evidence and innovation: improving intershift handoffs in a multihospital setting.
Thomas L, Donohue-Porter P.
Journal of nursing care quality 2012 Apr-Jun;27(2):116-124

Ineffective handoffs have been identified as a barrier to patient safety and quality and as a key area for improvement. Handoffs require a process for effective transfer of critical information. A redesigned nurse-to-nurse intershift handoff was implemented in 7 hospitals of a multisite system. The redesign included combining evidence and an innovative approach developed by nurse managers to improve intershift report. Results included an increase in nurse and patient satisfaction.

Health Care Innovation and Quality Assurance
Benchmarking: A Method for Continuous Quality Improvement in Health.
Amina Ettorchi-Tardy, Marie Levif and,Philippe Michel.
Healthcare Policy 2012 11/05;7(4):101-e119

Benchmarking, a management approach for implementing best practices at best cost, is a recent concept in the healthcare system. The objectives of this paper are to better understand the concept and its evolution in the healthcare sector, to propose an operational definition, and to describe some French and international experiences of benchmarking in the healthcare sector. To this end, we reviewed the literature on this approach’s emergence in the industrial sector, its evolution, its fields of application and examples of how it has been used in the healthcare sector.
Benchmarking is often thought to consist simply of comparing indicators and is not perceived in its entirety, that is, as a tool based on voluntary and active collaboration among several organizations to create a spirit of competition and to apply best practices. The key feature of benchmarking is its integration within a comprehensive and participatory policy of continuous quality improvement (CQI). Conditions for successful benchmarking focus essentially on careful preparation of the process, monitoring of the relevant indicators, staff involvement and inter-organizational visits.
Compared to methods previously implemented in France (CQI and collaborative projects), benchmarking has specific features that set it apart as a healthcare innovation. This is especially true for healthcare or medical–social organizations, as the principle of inter-organizational visiting is not part of their culture. Thus, this approach will need to be assessed for feasibility and acceptability before it is more widely promoted.

Service Guidelines Based on Resource Utilization Groups Version III for Home Care Provide Decision-Making Support for Case Managers.
Barbara Collister, Glenda Stein, Deborah Katz, Joan DeBruyn, Linda Andrusiw and, Sheila Cloutier.
Healthcare Quarterly 2012 02/04;15(2):75-81

Increasing costs and budget reductions combined with increasing demand from our growing, aging population support the need to ensure that the scarce resources allocated to home care clients match client needs. This article details how Integrated Home Care for the Calgary Zone of Alberta Health Services considered ethical and economic principles and used data from the Resident Assessment Instrument for Home Care (RAI-HC) and case mix indices from the Resource Utilization Groups Version III for Home Care (RUG-III/HC) to formulate service guidelines. These explicit service guidelines formalize and support individual resource allocation decisions made by case managers and provide a consistent and transparent method of allocating limited resources.

Large-system transformation in health care: a realist review.
Best A, Greenhalgh T, Lewis S, Saul JE, Carroll S, Bitz J.
The Milbank quarterly 2012 Sep;90(3):421-456

Context: An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation (LST) and health care reform. Fundamental conceptual and methodological challenges also must be addressed. The Saskatchewan Ministry of Health in Canada requested a six-month synthesis project to guide four major policy development and strategy initiatives focused on patient- and family-centered care, primary health care renewal, quality improvement, and surgical wait lists. The aims of the review were to analyze examples of successful and less successful transformation initiatives, to synthesize knowledge of the underlying mechanisms, to clarify the role of government, and to outline options for evaluation. Methods: We used realist review, whose working assumption is that a particular intervention triggers particular mechanisms of change. Mechanisms may be more or less effective in producing their intended outcomes, depending on their interaction with various contextual factors. We explain the variations in outcome as the interplay between context and mechanisms. We nested this analytic approach in a macro framing of complex adaptive systems (CAS). Findings: Our rapid realist review identified five “simple rules” of LST that were likely to enhance the success of the target initiatives: (1) blend designated leadership with distributed leadership; (2) establish feedback loops; (3) attend to history; (4) engage physicians; and (5) include patients and families. These principles play out differently in different contexts affecting human behavior (and thereby contributing to change) through a wide range of different mechanisms. Conclusions: Realist review methodology can be applied in combination with a complex system lens on published literature to produce a knowledge synthesis that informs a prospective change effort in large-system transformation. A collaborative process engaging both research producers and research users contributes to local applications of universal principles and mid-range theories, as well as to a more robust knowledge base for applied research. We conclude with suggestions for the future development of synthesis and evaluation methods. © 2012 Milbank Memorial Fund.

The Urban-Rural Disparity in Nursing Home Quality Indicators: The Case of Facility-Acquired Contractures.
Bowblis JR, Meng H, Hyer K.
Health services research 2012 Jun 7

OBJECTIVE: To identify and quantify the sources of the urban-rural disparity in facility-acquired contracture rates in nursing homes. DATA SOURCES: Survey inspection data of U.S. nursing homes from 1999 to 2008 and standardized national rural definition file from the Rural-Urban Commuting Area Codes. STUDY DESIGN: We estimated regressions of facility-level contracture rate as a function of urban-rural categories (urban, micropolitan, small rural town, and isolated small rural town) and other related facility characteristics to identify size of the urban-rural disparity. We used Blinder-Oaxaca decomposition techniques to determine the extent to which the disparity is attributable to the differences in facility and aggregate resident characteristics. PRINCIPAL FINDINGS: Rural nursing homes have higher contracture rates than urban nursing homes. About half of the urban-rural disparity is explained by differences in observable characteristics among urban and rural nursing homes. Differences in staffing levels explain less than 5 percent of the disparity, case-mix explains 6-8 percent, and structure and operational characteristics account for 10-22 percent of the disparity. CONCLUSION: While a lower level and quality of staffing are a concern for rural nursing homes, facility structure and funding sources explain a larger proportion of the urban-rural disparity in the quality of care. © Health Research and Educational Trust.

Overview of systematic reviews of the effectiveness of reminders in improving healthcare professional behavior.
Cheung A, Weir MC, Mayhew A, Kozloff N, Brown K, Grimshaw J.
Systematic reviews 2012 Aug 16;1(1):36

OBJECTIVE: The purpose of this project was to conduct an overview of existing systematic reviews to evaluate the effectiveness of reminders in changing professional behavior in clinical settings.Materials and methodsRelevant systematic reviews of reminder interventions were identified through searches in MEDLINE, EMBASE, DARE and the Cochrane Library in conjunction with a larger project examining professional behavioral change interventions. Reviews were appraised using AMSTAR, a validated tool for assessing the quality of systematic reviews. As most reviews only reported vote counting, conclusions about effectiveness for each review were based on a count of positive studies. If available, we also report effect sizes. Conclusions were based on the findings from higher quality and current systematic reviews. RESULTS: Thirty-five reviews were eligible for inclusion in this overview. Ten reviews examined the effectiveness of reminders generally, 5 reviews focused on specific health care settings, 14 reviews concentrated on specific behaviors and 6 reviews addressed specific patient populations. The quality of the reviews was variable (median = 3, range = 1 to 8). Seven reviews had AMSTAR scores >5 and were considered in detail. Five of these seven reviews demonstrated positive effects of reminders in changing provider behavior. Few reviews used quantitative pooling methods; in one high quality and current review, the overall observed effects were moderate with an absolute median improvement in performance of 4.2% (IQR: 0.5% to 6.6%). DISCUSSION: The results support that modest improvements can occur with the use of reminders. The effect size is consistent with other interventions that have been used to improve professional behavior. CONCLUSION: Reminders appear effective in improving different clinical behaviors across a range of settings.

Nursing assistant views on nursing home regulatory inspection: Knowledge and attitudes regarding the state nursing home survey.
Chung G.
Journal of Applied Gerontology 2012;31(3):336-353

Nursing assistants provide more than 80% of direct care to residents. However, it is unknown whether or not they clearly understand the purpose of nursing home regulation and incorporate regulatory standards in their care delivery process. This study uses qualitative methods to explore their experiences with nursing home inspection. Findings suggest that the subtle nuances of human interaction between nursing assistants and residents tend to be overlooked in the midst of enforcing highly strict and detailed regulatory standards that mainly focus on visible outcomes of care. In addition, the state survey might deepen the chasm between nursing assistants and nursing home administration so that the hierarchical culture of mistrust and ritualism continues in nursing homes. To resolve such problems, it is critical to rethink the impact of nursing home regulation at the level of direct interactions between nursing assistants and residents and to consider increasing nursing assistant involvement in the inspection process. © 2012 The Author(s).

Audit and feedback: effects on professional practice and healthcare outcomes.
Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al.
Cochrane database of systematic reviews (Online) 2012 Jun 13;6:CD000259

BACKGROUND: Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact. OBJECTIVES: To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. http://www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011). SELECTION CRITERIA: Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included. DATA COLLECTION AND ANALYSIS: All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors. MAIN RESULTS: We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals’ compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention. AUTHORS’ CONCLUSIONS: Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.

Promoting Quality Improvement in Long-Term Care: A multi-site collaboration to improve outcomes with pneumonia, falls, bacteriuria and behavioural issues in dementia.
John Puxty, Rosemary A Brander, Susanne Murphy and,Vaughan Byrnes.
Healthcare Quarterly 2012 02/04;15(2):70-74

The Bridges to Care for Long-Term Care research project aimed to facilitate improvements in outcomes for long-term care residents through the provision of knowledge-to-practice and quality improvement resources by trained facilitators. Point-of-care staff reported improved communication and collaboration, improved use of scope of practice and implementation of best practice knowledge. Overall, participating long-term care homes demonstrated an enhanced capacity for common care issues of the elderly (pneumonia, falls, bacteriuria and behavioural and psychological symptoms of dementia) and the ability to effectively engage in quality improvement processes with efficient and effective use of healthcare resources.

Nursing home medical staff organization and 30-day rehospitalizations.
Lima JC, Intrator O, Karuza J, Wetle T, Mor V, Katz P.
Journal of the American Medical Directors Association 2012 Jul;13(6):552-557

OBJECTIVES: To examine the relationship between features of nursing home (NH) medical staff organization and residents’ 30-day rehospitalizations. DESIGN: Cross-sectional study combining primary data collected from a survey of medical directors, NH resident assessment data (minimum data set), Medicare claims, and the Online Survey Certification and Reporting (OSCAR) database. SETTING: A total of 202 freestanding US nursing homes. PARTICIPANTS: Medicare fee-for-service beneficiaries who were hospitalized and subsequently admitted to a study nursing home. MEASUREMENTS: Medical staff organization dimensions derived from the survey, NH residents’ characteristics derived from minimum data set data, hospitalizations obtained from Part A Medicare claims, and NH characteristics from the OSCAR database and from http://www.ltcfocus.org. Study outcome defined within a 30-day window following an index hospitalization: rehospitalized, otherwise died, otherwise survived and not rehospitalized. RESULTS: Thirty-day rehospitalizations occurred for 3788 (20.3%) of the 18,680 initial hospitalizations. Death was observed for 884 (4.7%) of residents who were not rehospitalized. Adjusted by hospitalization, resident, and NH characteristics, nursing homes having a more formal appointment process for physicians were less likely to have 30-day rehospitalization (b = -0.43, SE = 0.17), whereas NHs in which a higher proportion of residents were cared for by a single physician were more likely to have rehospitalizations (b = 0.18, SE = 0.08). CONCLUSION: This is the first study to show a direct relationship between features of NH medical staff organization and resident-level process of care. The relationship of a more strict appointment process and rehospitalizations might be a consequence of more formalized and dedicated medical practice with a sense of ownership and accountability. A higher volume of patients per physician does not appear to improve quality of care. Copyright © 2012 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.

Improving hospital outcomes in patients admitted from residential aged care: results from a controlled trial.

Mudge AM, Denaro CP, O’Rourke P.

Age and Ageing 2012 Sep;41(5):670-673

Background: residents of aged care are old, frail and frequently require hospital management of intercurrent illness, but hospital outcomes are poor.

OBJECTIVE: to identify the impact of an interdisciplinary care model on medical inpatients admitted from residential aged care (RAC). DESIGN: pre-planned subgroup analysis of controlled trial. SETTING: general medical units of a teaching hospital in Brisbane, Australia. SUBJECTS: consecutive patients aged over 65 admitted from RAC (n = 189) or the community (n = 815). METHODS: all admitted general medical patients were allocated by existing cyclical roster to control (usual care) or intervention units (interdisciplinary care consisting of improved allied health staffing, consistent teams, daily team meetings and early discharge planning). Patient characteristics and outcomes of care were compared between RAC and community subgroups. In the RAC subgroup, outcomes were compared between the control and intervention groups. RESULTS: patients admitted from RAC had much higher in-hospital mortality (13 versus 6%) and 6-month mortality (35 versus 17%) than those from community. RAC residents receiving the intervention had a significant reduction in in-hospital mortality (4 versus 22% P < 0.001) sustained at 6 months (28 versus 44% P = 0.02). CONCLUSIONS: poor hospital outcomes for RAC residents may reflect prevailing models of inpatient care.

Quality of life outcomes for residents and quality ratings of care homes: is there a relationship?

Netten A, Trukeschitz B, Beadle-Brown J, Forder J, Towers AM, Welch E. 

Age and Ageing 2012 Jul;41(4):512-517

BACKGROUND: quality ratings of care homes are used by decision makers in the absence of direct information about outcomes. However, there is little evidence about the relationship between regulators’ ratings of homes and residents’ quality of life outcomes. OBJECTIVES: to capture social care-related quality of life (SCRQoL) outcomes for residents and investigate the relationship between outcomes and regulator quality ratings of homes. METHODS: data were collected for 366 residents of 83 English care homes for older people inspected during 2008. Outcomes were measured using the Adult Social Care Outcomes Toolkit (ASCOT). Multivariate multilevel modelling was used to investigate the relationship between quality of life outcomes and star ratings of homes, controlling for resident and home characteristics. RESULTS: care homes were delivering substantial gains in SCRQoL, but were more successful in delivering ‘basic’ (e.g. personal cleanliness) than higher-order domains (e.g. social participation). Outcomes were associated with quality ratings of residential homes but not of nursing homes. CONCLUSIONS: the approach to providing quality ratings by the regulator in England is currently under review. Future quality indicators need to demonstrate their relationship with quality of life outcomes if they are to be a reliable guide to commissioners and private individuals purchasing care. Published by Elsevier Inc.

Measurement of implementation components ten years after a nationwide introduction of empirically supported programs–a pilot study.
Ogden T, Bjornebekk G, Kjobli J, Patras J, Christiansen T, Taraldsen K, et al.
Implementation science : IS 2012 May 31;7:49

BACKGROUND: Ten years after the nationwide dissemination of two evidence-based treatment programs, the status of the implementation components was evaluated in a cross-sectional study. The aim of the study was to pilot a standardized measure of implementation components by examining the factor structure, the reliabilities of the scores, and their association with implementation outcome variables. The aim was also to compare implementation profiles of the two evidence-based programs based on multi informant assessments. METHODS: The 218 participants in the study were therapists, supervisors, and agency leaders working with Parent Management Training, the Oregon model (PMTO), and Multisystemic Therapy (MST) in Norway. Interviewers filled in an electronic version of the Implementation Components Questionnaire during a telephone interview. RESULTS: The factor analysis of the eight one-dimensional subscales resulted in an individual clinical-level factor and an organizational system-level factor. Age, experience, and number of colleagues in the workplace were negatively correlated with positive ratings of the implementation process, but the number of colleagues working with the same program predicted positive ratings. MST and PMTO had different implementation profiles and therapists, supervisors, and managers evaluated some of the implementation drivers significantly differently. CONCLUSIONS: The psychometric quality of the questionnaire was supported by measures of internal consistency, factor analyses of the implementation components, and the comparisons of implementation profiles between programs and respondent groups. A moderate, but consistent association in the expected direction was found with the implementation outcome variables.

Learning from large-scale quality improvement through comparisons.
Ovretveit J, Klazinga N.
International journal for quality in health care 2012 Oct;24(5):463-469

OBJECTIVE: To discover lessons from 10 national health and social care quality programmes in the Netherlands. DESIGN: A mixed-methods comparison using a ‘quantitative summarization of evidence for systematic comparison’. Each research team assessed whether there was evidence from their evaluation to support or refute 17 hypotheses about successful implementation of quality programmes. The programme managers carried out a similar assessment. Their assessments were represented as scores which made it possible to carry out a cross-case analysis to assess factors affecting the success of large-scale quality programmes. PARTICIPANTS: The researchers who evaluated each of the programmes and the leaders who organized each programme. SETTING: Health and social care service organizations and national organization, which led the quality improvement programmes. INTERVENTION: This study did not make an intervention but compared experiences and evaluations of interventions carried out by national organization to health and social care service organizations to help these organizations to improve their services. MAIN OUTCOME MEASURE: The success of the national programmes, and the learning achieved by the programme organizations and care service delivery organizations. RESULTS: The method provided a way to summarize and compare complex information. Common factors which appeared to influence success in implementation included understanding of political processes, leader’s influencing skills, as well as technical skills to manage projects and apply improvement and change methods. CONCLUSIONS: Others could use a similar method to make a fast, broad level, but systematic comparison across reports of improvements or programmes. Descriptions, and then comparisons of the programmes, reveal common factors which appeared to influence success in implementation. There were groups of factors which appeared to be more important for the success of certain types of programmes. It is possible that these factors may also be important for the success of large-scale improvement programmes in other countries.

Challenges of Using Quality Improvement Methods in Nursing Homes that “Need Improvement”.
Rantz MJ, Zwygart-Stauffacher M, Flesner M, Hicks L, Mehr D, Russell T, et al.
Journal of the American Medical Directors Association 2012 Oct;13(8):732-738

OBJECTIVES: Qualitatively describe the adoption of strategies and challenges experienced by intervention facilities participating in a study targeted to improve quality of care in nursing homes “in need of improvement”. To describe how staff use federal quality indicator/quality measure (QI/QM) scores and reports, quality improvement methods and activities, and how staff supported and sustained the changes recommended by their quality improvement teams. DESIGN/SETTING/PARTICIPANTS: A randomized, two-group, repeated-measures design was used to test a 2-year intervention for improving quality of care and resident outcomes in facilities in “need of improvement”. Intervention group (n = 29) received an experimental multilevel intervention designed to help them: (1) use quality-improvement methods, (2) use team and group process for direct-care decision-making, (3) focus on accomplishing the basics of care, and (4) maintain more consistent nursing and administrative leadership committed to communication and active participation of staff in decision-making. RESULTS: A qualitative analysis revealed a subgroup of homes likely to continue quality improvement activities and readiness indicators of homes likely to improve: (1) a leadership team (nursing home administrator, director of nurses) interested in learning how to use their federal QI/QM reports as a foundation for improving resident care and outcomes; (2) one of the leaders to be a “change champion” and make sure that current QI/QM reports are consistently printed and shared monthly with each nursing unit; (3) leaders willing to involve all staff in the facility in educational activities to learn about the QI/QM process and the reports that show how their facility compares with others in the state and nation; (4) leaders willing to plan and continuously educate new staff about the MDS and federal QI/QM reports and how to do quality improvement activities; (5) leaders willing to continuously involve all staff in quality improvement committee and team activities so they “own” the process and are responsible for change. CONCLUSIONS: Results of this qualitative analysis can help allocate expert nurse time to facilities that are actually ready to improve. Wide-spread adoption of this intervention is feasible and could be enabled by nursing home medical directors in collaborative practice with advanced practice nurses. Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

Overview of significant changes in the minimum data set for nursing homes version 3.0.
Saliba D, Jones M, Streim J, Ouslander J, Berlowitz D, Buchanan J.
Journal of the American Medical Directors Association 2012 Sep;13(7):595-601

The Minimum Data Set (MDS) is a standardized assessment that is completed on all residents admitted to Medicare certified nursing homes in the US. It is also completed on all residents admitted to Veteran Health Administration Community Living Centers. Its content addresses multiple domains of resident health and function and is intended to facilitate better recognition of each resident’s needs. A new version of the MDS, MDS 3.0, was implemented in October, 2010. This article highlights significant clinical changes found in the MDS 3.0, including new structured resident interviews to assess mood, preferences, pain and cognition; inclusion of the Confusion Assessment Method to screen for delirium; revised psychosis and behavior items; revised balance and falls sections; revised bladder and bowel assessment items; revised pressure ulcer assessment items; revisions to the nutrition items; items reporting on resident expectations for return to the community; and changes to race/ethnicity item and language report. These changes aim to improve the clinical utility of these assessment items.

New quality regulations versus established nursing home practice: a qualitative study.
Sandvoll AM, Kristoffersen K, Hauge S.
BMC nursing 2012 Jun 7;11:7

ACKGROUND: Western governments have initiated reforms to improve the quality of care for nursing home residents. Most of these reforms encompass the use of regulations and national quality indicators. In the Norwegian context, these regulations comprise two pages of text that are easy to read and understand. They focus particularly on residents’ rights to plan their day-to-day life in nursing homes. However, the research literature indicates that the implementation of the new regulations, particularly if they aim to change nursing practice, is extremely challenging. The aim of this study was to further explore and describe nursing practice to gain a deeper understanding of why it is so hard to implement the new regulations. METHODS: For this qualitative study, an ethnographic design was chosen to explore and describe nursing practice. Fieldwork was conducted in two nursing homes. In total, 45 nurses and nursing aides were included in participant observation, and 10 were interviewed at the end of the field study. RESULTS: Findings indicate that the staff knew little about the new quality regulations, and that the quality of their work was guided by other factors rooted in their nursing practice. Further analyses revealed that the staff appeared to be committed to daily routines and also that they always seemed to know what to do. Having routines and always knowing what to do mutually strengthen and enhance each other, and together they form a powerful force that makes daily nursing care a taken-for-granted activity. CONCLUSION: New regulations are challenging to implement because nursing practices are so strongly embedded. Improving practice requires systematic and deeply rooted practical change in everyday action and thinking.

Barriers and Facilitators to Communicating Nursing Errors in Long-term Care Settings.
Wagner LM, Damianakis T, Pho L, Tourangeau A.
Journal of patient safety 2012 Sep 20

OBJECTIVE: To explore nurses’ perceptions about communicating nursing errors. DESIGN: Cross-sectional, descriptive study. PARTICIPANTS: Approximately 289 nurses working in long-term care facilities in Ontario, Canada. METHODS: A cross-sectional, descriptive study of approximately 289 nurses working in long-term care facilities in Ontario, Canada. Solicited nurses’ perceptions concerning the disclosure of nursing errors and adverse events by including an open-ended item at the conclusion of a 60-item (multiple choice) questionnaire on the same topic. A qualitative content analysis was conducted using a multi-step process. RESULTS: A total of 245 responses were included in the content analysis. The main categories related to error communication that were derived from the analysis were as follows: (1) differences in the definition of terms; (2) the day-to-day working conditions and their impact on defining and reporting errors; (3) organizational factors that both help and hinder the reporting of errors in ensuring both personal and organizational responsibility; (4) communication styles that both help and hinder disclosure and adherence to proper protocols; and (5) external factors such as policies and professional standards and codes of ethics, which can provide clarity of process; and (6) recommendations for implementation of professional standards in long-term care settings to facilitate supportive working conditions. CONCLUSION: Eliminating the barriers to error communication requires moving toward a culture of safety. This involves both top-down and bottom-up approaches that allow nurses to feel comfortable being active participants in the error communication process.

Translation and adaption of the interRAI suite to local requirements in Belgian hospitals.
Wellens NI, Flamaing J, Moons P, Boonen S, Milisen K.
BMC geriatrics 2012 Sep 7;12(1):53

BACKGROUND: The interRAI Suite contains comprehensive geriatric assessment tools designed for various healthcare settings. Although each instrument is developed for a particular population, together they form an integrated health evaluation system. The interRAI Acute Care Minimum Data Set (interRAI AC) is tailored for hospitalized older persons. Our aim in this study was to translate and adapt the interRAI AC to the Belgian hospital context, where it can be used together with the interRAI Home Care (HC) and the interRAI Long Term Care Facility (LTCF). METHODS: A systematic, comprehensive, and rigorous 10-step approach was used to adapt the interRAI AC to local requirements. After linguistic translation by an official translator, five researchers assessed the translation for appropriate hospital jargon. Three researchers double-checked for translation accuracy and proposed additional items. A provisional version was converted into the three official languages of Belgium—Flemish, French, and German. Next, a multidisciplinary panel of nine experts judged item relevance to the Belgian care context and advised which country-specific items should be added. After these suggestions were incorporated into the interRAI AC, hospital staff from nine Flemish hospitals field-tested the tool in their practice. After evaluating field-test results, we compared the interRAI AC with Belgian versions of the interRAI HC and interRAI LTCF. Next, the Flemish, French, and German versions of the Belgian interRAI portfolio were harmonized. Finally, we submitted the Belgian interRAI AC to the interRAI organization for ratification. RESULTS: Eighteen administrative items of the interRAI AC were adapted to the Belgian healthcare context (e.g., usual residence, formal community services prior to admission). Fourteen items assessing the ‘informal caregiver’, and 17 items, including country-specific items, were added (e.g., advanced directive for euthanasia). CONCLUSIONS: The interRAI AC was adapted to local requirements using a meticulous and recursive 10-step approach. As use of the interRAI Suite continues to grow worldwide and as it continues to expand to other care settings and populations, this procedure can guide future translations. This procedure might also be used by others facing similar challenges of complex translation and adaptation situations, where multidimensional instruments are used across multiple care settings in multiple languages.

Psychosocial care in nursing homes in the era of the MDS 3.0: perspectives of the experts.

Zimmerman S, Connolly R, Zlotnik JL, Bern-Klug M, Cohen LW. 
Journal of gerontological social work 2012;55(5):444-461

Meeting psychosocial needs of nursing home residents is increasingly regarded as a critical component of care, and the nationally-mandated nursing home care screening instrument- the Minimum Data Set (MDS) 3.0-was modified and implemented in 2010 to promote better assessment of psychosocial needs and health. Recognizing the importance of psychosocial well-being among nursing home residents, and the promise of MDS 3.0 for improving psychosocial care, this article reports recommendations derived from a conference of stakeholders representing diverse disciplines and organizations regarding next steps following MDS 3.0 screening. Results relate to seven areas of psychosocial care and address cross-cutting recommendations to improve psychosocial care.

Using the Agency for Healthcare Research and Quality patient safety indicators for targeting nursing quality improvement

Zrelak PA, Utter GH, Sadeghi B, Cuny J, Baron R, Romano PS. 

Journal of nursing care quality 2012 Apr-Jun;27(2):99-108

Quantifying the critical impact nurses have on the prevention and early recognition of potential complications and adverse events, such as those identified by the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSI), is becoming increasingly important. In this paper, we describe how the AHRQ PSI may be used to identify nursing-specific opportunities to improve care based on data from the national AHRQ PSI validation pilot project.

A framework for evaluating evidence in evidence-based design.
Pati D.
HERD 2011 Spring;4(3):50-71

A major challenge in the evidence-based design (EBD) practice model has been in determining the degree of credibility of specific (or a body of) evidence. This challenge has remained one of the key impediments to the broader adoption of EBD. Borrowing from evidence-based medicine and evidence-based practice literatures, this paper proposes a framework for evaluating evidence in EBD. Key to the proposed framework is the separation of the evaluation of strength and quality of evidence from the evaluation of appropriateness and feasibility in a specific application context.

AHRQ series paper 5: grading the strength of a body of evidence when comparing medical interventions–agency for healthcare research and quality and the effective health-care program.
Owens DK, Lohr KN, Atkins D, Treadwell JR, Reston JT, Bass EB, et al.
Journal of clinical epidemiology 2010 May;63(5):513-523

OBJECTIVE: To establish guidance on grading strength of evidence for the Evidence-based Practice Center (EPC) program of the U.S. Agency for Healthcare Research and Quality. STUDY DESIGN AND SETTING: Authors reviewed authoritative systems for grading strength of evidence, identified domains and methods that should be considered when grading bodies of evidence in systematic reviews, considered public comments on an earlier draft, and discussed the approach with representatives of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group. RESULTS: The EPC approach is conceptually similar to the GRADE system of evidence rating; it requires assessment of four domains: risk of bias, consistency, directness, and precision. Additional domains to be used when appropriate include dose-response association, presence of confounders that would diminish an observed effect, strength of association, and publication bias. Strength of evidence receives a single grade: high, moderate, low, or insufficient. We give definitions, examples, mechanisms for scoring domains, and an approach for assigning strength of evidence. CONCLUSION: EPCs should grade strength of evidence separately for each major outcome and, for comparative effectiveness reviews, all major comparisons. We will collaborate with the GRADE group to address ongoing challenges in assessing the strength of evidence.

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