Health Care Innovation and Quality Assurance

Collection of articles on Health Care Innovation and Quality Assurance is available here.

Health economic evaluation of a nurse-led care model from the nursing home perspective focusing on residents’ hospitalisations.
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Bartakova J, Zúñiga F, Guerbaai RA, Basinska K, Brunkert T, Simon M, et al.
BMC geriatrics. 2022 Jun;22(1):496.
BACKGROUND: Health economic evaluations of the implementation of evidence-based interventions (EBIs) into practice provide vital information but are rarely conducted. We evaluated the health economic impact associated with implementation and intervention of the INTERCARE model-an EBI to reduce hospitalisations of nursing home (NH) residents-compared to usual NH care. METHODS: The INTERCARE model was conducted in 11 NHs in Switzerland. It was implemented as a hybrid type 2 effectiveness-implementation study with a multi-centre non-randomised stepped-wedge design. To isolate the implementation strategies’ costs, time and other resources from the NHs’ perspective, we applied time-driven activity-based costing. To define its intervention costs, time and other resources, we considered intervention-relevant expenditures, particularly the work of the INTERCARE nurse-a core INTERCARE element. Further, the costs and revenues from the hotel and nursing services were analysed to calculate the NHs’ losses and savings per resident hospitalisation. Finally, alongside our cost-effectiveness analysis (CEA), a sensitivity analysis focused on the intervention’s effectiveness-i.e., regarding reduction of the hospitalisation rate-relative to the INTERCARE costs. All economic variables and CEA were assessed from the NHs’ perspective. RESULTS: Implementation strategy costs and time consumption per bed averaged 685CHF and 9.35 h respectively, with possibilities to adjust material and human resources to each NH’s needs. Average yearly intervention costs for the INTERCARE nurse salary per bed were 939CHF with an average of 1.4 INTERCARE nurses per 100 beds and an average employment rate of 76% of full-time equivalent per nurse. Resident hospitalisation represented a total average loss of 52% of NH revenues, but negligible cost savings. The incremental cost-effectiveness ratio of the INTERCARE model compared to usual care was 22’595CHF per avoided hospitalisation. As expected, the most influential sensitivity analysis variable regarding the CEA was the pre- to post-INTERCARE change in hospitalisation rate. CONCLUSIONS: As initial health-economic evidence, these results indicate that the INTERCARE model was more costly but also more effective compared to usual care in participating Swiss German NHs. Further implementation and evaluation of this model in randomised controlled studies are planned to build stronger evidential support for its clinical and economic effectiveness. TRIAL REGISTRATION: clinicaltrials.gov ( NCT03590470 ).

Identifying Quality Indicators for Nursing Home Residents with Dementia: A Modified Delphi Method.
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Burgess JG, Maust DT, Myron Chang MU, Zivin K, Gerlach LB.
Journal of geriatric psychiatry and neurology. 2022 Jun;8919887221106446.
BACKGROUND: We convened a two-round, modified Delphi panel to identify and reach consensus on additional potential quality indicators (QIs) for nursing home residents with dementia. METHODS: The study team identified 12 potential QIs for nursing home dementia care and treatment of behavioral disturbances based on review of the literature. All proposed QIs were readily available in administrative claims data. Panelists rated each QI on importance, usefulness, and feasibility (a total of 36 items) using a 9-point Likert scale. Data were collected using an online survey platform and virtual group discussion. We defined consensus as ≥70% of the panelists responding within a three-point range surrounding the median. A QI achieved relevance on a domain (importance, usefulness, feasibility) when the panel reached consensus and a median rating of 7-9. RESULTS: The study had a 100% response rate for both survey rounds. Twenty-four items achieved consensus, with 15 reaching relevance with a median >7. Three QIs (percent of long-stay residents with dementia prescribed APs, percent with physical restraint use, and percent with a positive behavioral symptom score) reached consensus at the highest median score (9) for importance. Only 2 of the 12 proposed QIs reached relevance on all three domains: percent of long-stay residents with dementia prescribed antipsychotics (APs) and percent prescribed benzodiazepines. CONCLUSIONS: Of the proposed QIs, our panel of dementia care experts only reached consensus on two QIs: measuring long-stay resident prescriptions of APs and benzodiazepines. Challenges remain in identifying QIs that meet threshold of all three areas and accurately reflect quality nursing home dementia care.

Exploration of Symptom Scale as an Outcome for Deprescribing: A Medication Review Study in Nursing Homes.
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Dalin DA, Frandsen S, Madsen GK, Vermehren C.
Pharmaceuticals (Basel, Switzerland). 2022 Apr;15(5).
The use of inappropriate medication is an increasing problem among the elderly, leading to hospitalizations, mortality, adverse effects, and lower quality of life (QoL). Deprescribing interventions (e.g., medication reviews (MRs)) have been examined as a possible remedy for this problem. In order to be able to evaluate the potential benefits and harms of a deprescribing intervention, quality of life (QoL) has increasingly been used as an outcome. The sensitivity of QoL measurements may, however, not be sufficient to detect a change in specific disease symptoms, e.g., a flair-up in symptoms or relief of side effects after deprescribing. Using symptom assessments as an outcome, we might be able to identify and evaluate the adverse effects of overmedication and deprescribing alike. The objective of this study was to explore whether symptom assessment is a feasible and valuable method of evaluating outcomes of MRs among the elderly in nursing homes. To the best of our knowledge, this has not been investigated before. We performed a feasibility study based on an experimental design and conducted MRs for elderly patients in nursing homes. Their symptoms were registered at baseline and at a follow-up 3 months after performing the MR. In total, 86 patients, corresponding to 68% of the included patients, received the MR and completed the symptom questionnaires as well as the QoL measurements at baseline and follow-up, respectively. Forty-eight of these patients had at least one deprescribing recommendation implemented. Overall, a tendency towards the improvement of most symptoms was seen after deprescribing, which correlated with the tendencies observed for the QoL measurements. Remarkably, deprescribing did not cause a deterioration of symptoms or QoL, which might otherwise be expected for patients of this age group, of whom the health is often rapidly declining. In conclusion, it was found that symptom assessments were feasible among nursing home residents and resulted in additional relevant information about the potential benefits and harms of deprescribing. It is thus recommended to further explore the use of symptom assessment as an outcome of deprescribing interventions, e.g., in a controlled trial.

Changing Care: Applying the Transtheoretical Model of Change to Embed Equity, Diversity, and Inclusion in Long-Term Care Research in Canada
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Finnegan HA, Daari L, Jaiswal A, Sinn CJ, Ellis K, Kallan L, et al.
Societies. 2022.
Healthcare policy reform is evident when considering the past, present and future of long-term care (LTC) in Canada. Some of the most pressing issues facing the LTC sector include the changing demographic composition in Canadian LTC homes, minimal consideration for the role of intersectionality in LTC data collection and analysis, and the expanding need to engage diverse participants and knowledge users. Using the Transtheoretical Model of Change (TTMC) as a framework, we consider opportunities to address intersectionality in LTC research. Engaging diverse knowledge users in LTC (e.g., unpaid caregivers, paid care staff), community (e.g., advocacy groups, service providers) and policy decision-makers (e.g., provincial government) is crucial. Empowering individuals to participate, modifying environments to support engagement, and facilitating ongoing partnerships with knowledge users are critical aspects of change efforts. Addressing structural barriers (e.g., accessibility, capacity, jurisdictional policies, and mandates) to research in LTC is also essential. The TTMC offers a framework for planning and enacting individual, organizational, and system-level changes for the future of LTC.

Nurses’ experiences of an outreach interprofessional mental health service for nursing homes: a qualitative descriptive study.
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Fuchs K, Vögeli S, Schori D, Haendler-Schuster D.
Journal of psychiatric and mental health nursing. 2022 May.
INTRODUCTION: Outreach interprofessional mental health services for nursing homes can increase the quality of care for residents experiencing mental health issues but research on how nurses in nursing homes experience such a service is lacking worldwide. AIM: To describe how nurses experience the involvement of an outreach interprofessional mental health team in the care for older people experiencing mental health issues in nursing homes and to identify barriers to and facilitators of interprofessional collaboration. METHOD: Qualitative descriptive analysis based on 13 semi-structured interviews. Framework analysis and complex adaptive systems theory were applied. RESULTS: One core theme with two main categories: Nurses experienced relief from burden through inclusive support provided by the mental health team. Main categories were feeling accompanied and confident as a nurse and partnership-based collaboration. DISCUSSION: Results showed for the first time that nurses felt supported by the mental health team and were encouraged to find new ways of coping with challenging situations. IMPLICATIONS FOR PRACTICE: To empower nurses, mental health teams should take into account nurses’ perceptions in the treatment process, value and respect their role as nurses, transfer knowledge in both formal and informal settings, establish a steady and reliable contact person, and define processes and responsibilities.

Digital Methodology for Mobile Clinical Decision Support Development in Long-Term Care.
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Gallimore MR, Howland C, Chase JAD, Grimsley A, Emezue C, Boles K, et al.
Studies in health technology and informatics. 2022 Jun;290:479–83.
The global COVID-19 pandemic has driven innovations in methods to sustain initiatives for the design, development, evaluation, and implementation of clinical support technology in long-term care settings while removing risk of infection for residents, family members, health care workers, researchers and technical professionals. We adapted traditional design and evaluation methodology for a mobile clinical decision support app – designated Mobile Application Information System for Integrated Evidence (“MAISIE”) – to a completely digital design methodology that removes in-person contacts between the research team, developer, and nursing home staff and residents. We have successfully maintained project continuity for MAISIE app development with only minor challenges while working remotely. This digital design methodology can be implemented in projects where software can be installed without in-person technical support and remote work is feasible. Team skills, experience, and relationships are key considerations for adapting to digital environments and maintaining project momentum.

Implementation of core elements of antibiotic stewardship in nursing homes-National Healthcare Safety Network, 2016-2018.
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Gouin KA, Kabbani S, Anttila A, Mak J, Mungai E, McCray TT, et al.
Infection control and hospital epidemiology. 2022 Jun;43(6):752–6.
OBJECTIVE: To assess the national uptake of the Centers for Disease Control and Prevention’s (CDC) core elements of antibiotic stewardship in nursing homes from 2016 to 2018 and the effect of infection prevention and control (IPC) hours on the implementation of the core elements. DESIGN: Retrospective, repeated cross-sectional analysis. SETTING: US nursing homes. METHODS: We used the National Healthcare Safety Network (NHSN) Long-Term Care Facility Component annual surveys from 2016 to 2018 to assess nursing home characteristics and percent implementation of the core elements. We used log-binomial regression models to estimate the association between weekly IPC hours and the implementation of all 7 core elements while controlling for confounding by facility characteristics. RESULTS: We included 7,506 surveys from 2016 to 2018. In 2018, 71% of nursing homes reported implementation of all 7 core elements, a 28% increase from 2016. The greatest increases in implementation from 2016 to 2018 were in education (19%), reporting (18%), and drug expertise (15%). In 2018, 71% of nursing homes reported pharmacist involvement in improving antibiotic use, an increase of 27% since 2016. Nursing homes that reported at least 20 hours of IPC activity per week were 14% (95% confidence interval, 7%-20%) more likely to implement all 7 core elements when controlling for facility ownership and affiliation. CONCLUSIONS: Nursing homes reported substantial progress in antibiotic stewardship implementation from 2016 to 2018. Improvements in access to drug expertise, education, and reporting antibiotic use may reflect increased stewardship awareness and resource use among nursing home providers under new regulatory requirements. Nursing home stewardship programs may benefit from increased IPC staff hours.

Putting the Nursing and Home in Nursing Homes.
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Grabowski DC.
Innovation in aging. 2022;6(4):igac029.
As the late Robert Kane observed, the term nursing home is often a misnomer. Most U.S. nursing homes lack adequate nursing staff, and they are typically not very homelike in either their physical structure or culture. These problems were magnified during the pandemic. The underlying reasons for these longstanding issues are that most state Medicaid payment systems reimburse nursing homes at a relatively low level and the government does not hold nursing homes accountable for spending dollars on direct resident care. To encourage increased staffing and more homelike models of care, policymakers need to reform how nursing homes are paid and hold facilities accountable for how they spend government dollars. With these reforms, the term nursing home will become more appropriate in the United States.

Leading Improvements in the Delivery of Nursing Care for Older Adults with Frailty in Long-Term Care Using Mitchell’s Quality Health Outcome Model and Health Outcome Data.
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Gray-Miceli D, de Cordova PB, Rogowski JA, Grealish L.
The Nursing clinics of North America. 2022 Jun;57(2):287–97.
Protecting frail older residents from adverse health outcomes associated with preventable illnesses and conditions, such as geriatric syndromes within the long-term care (LTC) health system requires attention by the health care team, led by professional nurse leaders, to all of the operant contextual factors influencing health outcomes. Mitchell’s Health Outcomes Model helps to frame these operant contextual factors to help understand how the person and the situation are viewed, which then directs professional nurse leaders’ interventions. Utilization of the LTC facilities Quality Metrics data can shape and inform nurses leaders as to the gaps which can be filled to meet resident care needs operant among these modifiable contextual factors.

Implementation of a Sense of Home in High-Density Multicultural Singapore Nursing Homes: Challenges and Opportunities.
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Lee JJ, Ng TP, Nasution IK, Eng JY, Christensen RD, Fung JC.
International journal of environmental research and public health. 2022 May;19(11).
Many studies have introduced principles for creating a sense of home in nursing homes, yet they mostly feature cases from low-density developments in Western countries. This raises a question about how those principles are interpreted and implemented in other cultural contexts, especially in high-density, multicultural environments such as Singapore. This paper examines how a sense of home is implemented in Singapore nursing homes, with a specific focus on the role of the built environment. Participant observations were conducted in five nursing homes in Singapore comprising various architectural design typologies, with the focus on the residents’ everyday interactions with their built environment. The study identified the extent of the presence of a sense of home in Singapore’s nursing homes and the prevalence of an institutional care model. More specifically, the study explicates Singapore nursing home residents’ management of privacy and personalization in shared spaces, illuminates the need for holistic implementation of homelike environments integrated with building designs and care programs and reiterates the pivotal role of social relationships in fostering a sense of home for the residents in the nursing homes.

Integrating oral care into nursing practice in care homes.
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Oda K, Boyd M, Parsons J, Smith M.
Nursing older people. 2022 Jun.
This article details a narrative review that explored the barriers to and facilitators of integration of oral care into nursing practice in care homes to enhance nurses’ delivery of oral care. Three themes were identified: gaps in oral care protocols and the complexity of nursing oral care; how interprofessional collaboration and education can improve oral care; and limitations and unresolved issues in nurses’ oral care training. The review found that interprofessional collaboration and education were important in normalising oral care practice and nurse leadership in care homes. Nurse-led interprofessional oral care could enhance the quality of care in care homes by advancing interprofessional collaboration and education, coordinating care and improving organisational support.

Implementation fidelity, attitudes, and influence: a novel approach to classifying implementer behavior.
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Swindle T, Rutledge JM, Martin J, Curran GM.
Implementation science communications. 2022 Jun;3(1):60.
BACKGROUND: The current study sought to (1) describe a new classification approach for types of implementer behavior and (2) explore the implementer behavior change in response to tailored implementation facilitation based on the classifications. METHODS: A small-scale, cluster-randomized hybrid type III implementation trial was conducted in 38 early care and education classrooms that were part of the Together, We Inspire Smart Eating (WISE) program. WISE focuses on 4 evidence-based practices (EBPs), which are implemented by teachers to promote nutrition. External facilitators (N = 3) used a modified Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) to complete immersion (i.e., observations) and thematic content analyses of interviews to identify the characteristics of teachers’ behavior at varying levels of implementation fidelity. Three key factors-attitudes toward the innovation, fidelity/adaptations, and influence-were identified that the research team used to classify teachers’ implementation behavior. This process resulted in a novel classification approach. To assess the reliability of applying the classification approach, we assessed the percent agreement between the facilitators. Based on the teachers’ classification, the research team developed a tailored facilitation response. To explore behavior change related to the tailored facilitation, change in fidelity and classification across the school year were evaluated. RESULTS: The classifications include (1) enthusiastic adopters (positive attitude, meeting fidelity targets, active influence), (2) over-adapting adopters (positive attitude, not meeting fidelity targets, active influence), (3) passive non-adopters (negative attitude, not meeting fidelity targets, passive influence), and (4) active non-adopters (negative attitudes, not meeting fidelity targets, active influence). The average percent agreement among the three facilitators for classification was 75%. Qualitative data support distinct patterns of perceptions across the classifications. A positive shift in classification was observed for 67% of cases between the mid-point and final classification. Finally, we generated an expanded classification approach to consider additional combinations of the three factors beyond those observed in this study. CONCLUSIONS: Data from this study support the ability to apply the classification approach with moderate to high reliability and to use the approach to tailor facilitation toward improved implementation. Findings suggest the potential of our approach for wider application and potential to improve tailoring of implementation strategies such as facilitation.

Improving the appropriateness of psychotropic prescribing for nursing home residents with dementia: an overview of reviews.
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Wiggin DA, Timmons S, Rukundo A, Walsh KA.
Aging & mental health. 2022 Jun;26(6):1087–94.
OBJECTIVES: Psychotropic medications are commonly inappropriately prescribed for people with dementia (PwD) residing in nursing homes. This population is often multi-morbid, receiving multiple medications and therefore at an increased risk of mortality. This overview aimed to collate all synthesised quantitative, qualitative, and mixed-method evidence pertaining to the effectiveness of interventions aimed at reducing inappropriate psychotropic prescribing for nursing home residents with dementia; the perceived barriers and facilitators to the implementation of these interventions; and the attitudes and experiences of stakeholders toward prescribing. Method: An overview of reviews was conducted (PROSPERO protocol registration CRD42020187288). Five databases were systematically searched from January 2010 through June 2020, supplemented by grey literature searching. Reviews presenting evidence pertaining to either randomised controlled trials (RCT) aiming to reduce inappropriate prescribing or qualitative/mixed method studies of stakeholder views, were included. RESULTS: Of 273 records identified, 11 systematic reviews were included. The quality of reviews ranged from critically low to moderate. There was mixed evidence for the use of education-only interventions. Multicomponent interventions (typically staff education combined with organisational and structural components), medication review, and interventions aimed at cultural change were evidenced as effective compared to care as usual. Stakeholders cited the importance of multidisciplinary collaboration and targeting organisational climate in changing psychotropic prescribing behaviours. CONCLUSIONS: The inappropriate use of psychotropic medications in nursing homes for PwD is a complex issue with many contextual factors. The evidence suggests a comprehensive approach, targeting organisational climate and multidisciplinary collaboration, along with staff education and training, may be an effective strategy.

Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies.
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Wright D, Gabbay J, Le May A.
BMJ quality & safety. 2022 Jun;31(6):450–61.
BACKGROUND: Previous studies have detailed the technical, learning and soft skills healthcare staff deploy to deliver quality improvement (QI). However, research has mainly focused on management and leadership skills, overlooking the skills frontline staff use to improve care. Our research explored which skills mattered to frontline health practitioners delivering QI projects. STUDY DESIGN: We used a theory-driven approach, informed by communities of practice, knowledge-in-practice-in-context and positive deviance theory. We used case studies to examine skill use in three pseudonymised English hospital Trusts, selected on the basis of Care Quality Commission rating. Seventy-three senior staff orientation interviews led to the selection of two QI projects at each site. Snowball sampling obtained a maximally varied range of 87 staff with whom we held 122 semistructured interviews at different stages of QI delivery, analysed thematically. RESULTS: Six overarching ‘Socio-Organisational Functional and Facilitative Tasks’ (SOFFTs) were deployed by frontline staff. Several of these had to be enacted to address challenges faced. The SOFFTs included: (1) adopting and promulgating the appropriate organisational environment; (2) managing the QI rollercoaster; (3) getting the problem right; (4) getting the right message to the right people; (5) enabling learning to occur; and (6) contextualising experience. Each task had its own inherent skills. CONCLUSION: Our case studies provide a nuanced understanding of the skills used by healthcare staff. While technical skills are important, the ability to judge when and how to use wider skills was paramount. The provision of QI training and fidelity to the improvement programme may be less of a priority than the deployment of SOFFT skills used to overcome barriers. QI projects will fail if such skills and resources are not accessed.