Health Care Innovation and Quality Assurance

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

Changes in US Nursing Home Infection Prevention and Control Programs From 2014 to 2018
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Agarwal M, Dick AW, Sorbero M, Mody L, Stone PW.
J Am Med Dir Assoc 2020 Jan;21(1):97-103.
OBJECTIVE: Burgeoning rates of antibiotic resistance have resulted in a shift in national focus to improve infection prevention and control programs in US nursing homes (NHs). We sought to evaluate the changes in nursing home infection prevention and control programs over time. DESIGN: Retrospective comparative analysis of national nursing home survey data from 2014 and 2018. SETTING AND PARTICIPANTS: We used survey data from 2 nationally representative samples of US nursing homes (945 NHs in 2014 and 888 in 2018). METHODS: Three indices measuring antibiotic stewardship, outbreak control, and urinary tract infection prevention (ranging from 0 to 100) were developed to measure the change in infection prevention and control programs. Multivariable linear regression models were used to identify facility and infection preventionist characteristics associated with each index. Decomposition models were used to identify contributions of factors on the differences in each index over time. RESULTS: From 2014 to 2018, we saw strengthening of antibiotic stewardship practices by 33 percentage points, outbreak control practices by 13 percentage points, and urinary tract infection prevention practices by 6 percentage points. Although we found several predictors of these improvements, much of the improvement was due to the difference in time. CONCLUSIONS AND IMPLICATIONS: Policy mandates and greater national attention are likely important factors in improving nursing home infection prevention and control practices. Further work is needed to evaluate the effect of these programs on resident outcomes.

Why is Quality Improvement so Challenging? A Viable Systems Model Perspective to Understand the Frustrations of Healthcare Quality Improvement Managers
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Akmal A, Podgorodnichenko N, Foote J, Greatbanks R, Stokes T, Gauld R.
Health Policy 2021 Apr 3.
The challenges facing Quality Improvement Managers (QIMs) are often understood and addressed in isolation from wider healthcare organisation within which quality improvement initiatives are embedded. We draw on Stafford Beer’s Viable System Model (VSM) to shed light on how the viability of quality improvement depends on the effective functioning of five critical quality improvement systems and the extent to which these systems are integrated within the healthcare organisation. These systems are System 1 (Operations), System 2 (Coordination), System 3 (Operational Control), System 4 (Development) and System 5 (Policy). Our analysis draws on interviews with 56 QIMs working in 15 of New Zealand’s 20 District Health Boards. We use VSM to identify the sources of problems in QI implementation. These include changes in direction for QI initiatives; myopic behaviour resulting from fragmented systems of care; difficulties in managing and monitoring QI activities given variable staff engagement and inadequate resourcing; pressure for quick results rather developing QI capabilities; and a lack of strategic embeddedness. A viable QI system requires QI approaches that are (1) implemented at an organisation-wide level; (2) well-resourced and carefully monitored; (3) underpinned by a long-term vision; and (4) supported by QIMs with the necessary power and influence to integrate QI subsystem within the wider healthcare organisation.

Topical antimicrobial prescribing patterns in residents of Australian aged-care facilities: use of a national point prevalence survey to identify opportunities for quality improvement
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Bennett N, Walker K, Buising K, Cheah R, Fang X, Ingram R, et al.
Am J Infect Control 2021 Apr 1.
BACKGROUND: Australian residential aged care facilities (RACFs) are encouraged to participate in an annual Aged Care National Antimicrobial Prescribing Survey. This data source was analysed to describe patterns of topical antimicrobial prescribing and thereby provide insight into antimicrobial stewardship (AMS) changes that might be required. METHODS: 2018 and 2019 survey data was analysed. RESULTS: The overall prevalence of the 52,431 audited residents (629 facilities) who were prescribed one or more topical antimicrobials was 2.9%. Of all prescribed antimicrobials (n=4899), 33.0% were for topical application. Most frequently prescribed topical antifungals were clotrimazole (85.3%) and miconazole (9.1%), and antibacterials chloramphenicol (64.1%) and mupirocin (21.8%). Tinea (38.3%) and conjunctivitis (23.8%) were the two most common indications. Topical antimicrobials were sometimes prescribed for prn administration (38.8%) and greater than six months (11.3%). The review or stop date was not always documented (38.7%). CONCLUSIONS: To reduce the possibility of adverse consequences associated with antimicrobial use, AMS programs in Australian RACFs should at least ensure mupirocin is appropriately used, first line antimicrobial therapy is prescribed for tinea, chloramphenicol is prescribed for conjunctivitis only if necessary, prn orders for prescriptions are discouraged and to avoid prolonged duration of prescriptions, review or stop dates are always documented.

Does Public Reporting of Staffing Ratios and Nursing Home Compare Ratings Matter?
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de Cordova PB, Johansen ML, Zha P, Prado J, Field V, Cadmus E.
Journal of the American Medical Directors Association 2021/04.
Objective Public reporting is a policy to improve quality and increase data transparency. The objective was to examine the association between publicly available staffing ratios and the Five-Star Quality Ratings from Nursing Home Compare over time.; ObjectivePublic reporting is a policy to improve quality and increase data transparency. The objective was to examine the association between publicly available staffing ratios and the Five-Star Quality Ratings from Nursing Home Compare over time.

A systematic review of measures of implementation players and processes: Summarizing the dearth of psychometric evidence
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Dorsey CN, Mettert KD, Puspitasari AJ, Damschroder LJ, Lewis CC.
Implementation Research and Practice 2021;2:26334895211002474.
Measurement is a critical component for any field. Systematic reviews are a way to locate measures and uncover gaps in current measurement practices. The present study identified measures used in behavioral health settings that assessed all constructs within the Process domain and two constructs from the Inner setting domain as defined by the Consolidated Framework for Implementation Research (CFIR). While previous conceptual work has established the importance social networks and key stakeholders play throughout the implementation process, measurement studies have not focused on investigating the quality of how these activities are being carried out. Methods: The review occurred in three phases: Phase I, data collection included (1) search string generation, (2) title and abstract screening, (3) full text review, (4) mapping to CFIR-constructs, and (5) “cited-by” searches. Phase II, data extraction, consisted of coding information relevant to the nine psychometric properties included in the Psychometric And Pragmatic Rating Scale (PAPERS). In Phase III, data analysis was completed. Results: Measures were identified in only seven constructs: Structural characteristics (n=13), Networks and communication (n=29), Engaging (n=1), Opinion leaders (n=5), Champions (n=5), Planning (n=5), and Reflecting and evaluating (n=5). No quantitative assessment measures of Formally appointed implementation leaders, External change agents, or Executing were identified. Internal consistency and norms were reported on most often, whereas no studies reported on discriminant validity or responsiveness. Not one measure in the sample reported all nine psychometric properties evaluated by the PAPERS. Scores in the identified sample of measures ranged from “-2” to “10” out of a total of “36.” Conclusions: Overall measures demonstrated minimal to adequate evidence and available psychometric information was limited. The majority were study specific, limiting their generalizability. Future work should focus on more rigorous measure development and testing of currently existing measures, while moving away from creating new, single use measures.

Relationship between Nursing Home Compare Improvement in Function Quality Measure and Physical Recovery after Hip Replacement
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Downer B, Reistetter TA, Kuo YF, Li S, Karmarkar A, Hong I, et al.
Arch Phys Med Rehabil 2021 Apr 1.
OBJECTIVE: To determine if patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016. DESIGN: Pre (1/1/2015-6/30/2016) versus post (7/1/2016-12/31/2017) design. SETTING: Skilled Nursing Facilities (n=12,829). PARTICIPANTS: Medicare fee-for-service beneficiaries discharged from acute hospitals to SNF following hip replacement between 01/01/2015 and 12/31/2017 (N=106,832). MAIN OUTCOME MEASURES: The 5-day and 14-day Minimum Data Set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10-days and any improvement between the 5-day and 14-day assessments. RESULTS: The average adjusted changer per 10-days for the quality measure total score for patients admitted before July 2016 and after July 2016 were 1.00 points (standard error [SE]=0010) and 1.06 points (SE=0.010), respectively (p<0.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (SE=0.06) had any improvement in the quality measure total score compared to 45.5% (SE=0.23) of patients admitted after July 2016 (p<0.01). This was a relative increase of 2.5%. The adjusted change per 10-days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016. CONCLUSIONS: Patients admitted to a SNF following a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.

Prioritizing Prevention to Combat Multidrug Resistance in Nursing Homes: A Call to Action
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Jacobs Slifka KM, Kabbani S, Stone ND.
J Am Med Dir Assoc 2020 Jan;21(1):5-7.
Multidrug-resistant organisms (MDROs) do not discriminate—they spread in all health care settings. From our unique vantage point at the Centers for Disease Control and Prevention (CDC), we are witnessing the emergence of novel MDROs across the country, which are causing life-threatening infections, with limited to no available treatments.1 Public health efforts to detect and contain these pathogens have revealed the significant role nursing homes, especially those caring for a medically complex, higher-acuity resident population, are playing in the regional spread of these dangerous pathogens. Although all health care facilities must be prepared to prevent transmission of MDROs, nursing homes face unique challenges in caring for colonized residents. However, these are challenges that can be overcome with a renewed focus on and investment in infection prevention and antibiotic stewardship to protect the older Americans receiving care in these facilities.

The FRAME-IS: a framework for documenting modifications to implementation strategies in healthcare
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Miller CJ, Barnett ML, Baumann AA, Gutner CA, Wiltsey-Stirman S.
Implement Sci 2021 Apr 7;16(1):36-021-01105-3.
BACKGROUND: Implementation strategies are necessary to ensure that evidence-based practices are successfully incorporated into routine clinical practice. Such strategies, however, are frequently modified to fit local populations, settings, and contexts. While such modifications can be crucial to implementation success, the literature on documenting and evaluating them is virtually nonexistent. In this paper, we therefore describe the development of a new framework for documenting modifications to implementation strategies. DISCUSSION: We employed a multifaceted approach to developing the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS), incorporating multiple stakeholder perspectives. Development steps included presentations of initial versions of the FRAME-IS to solicit structured feedback from individual implementation scientists (“think-aloud” exercises) and larger, international groups of researchers. The FRAME-IS includes core and supplementary modules to document modifications to implementation strategies: what is modified, the nature of the modification (including the relationship to core elements or functions), the primary goal and rationale for the modification, timing of the modification, participants in the modification decision-making process, and how widespread the modification is. We provide an example of application of the FRAME-IS to an implementation project and provide guidance on how it may be used in future work. CONCLUSION: Increasing attention is being given to modifications to evidence-based practices, but little work has investigated modifications to the implementation strategies used to implement such practices. To fill this gap, the FRAME-IS is meant to be a flexible, practical tool for documenting modifications to implementation strategies. Its use may help illuminate the pivotal processes and mechanisms by which implementation strategies exert their effects.

The Story as a Quality Instrument: Developing an Instrument for Quality Improvement Based on Narratives of Older Adults Receiving Long-Term Care
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Scheffelaar A, Janssen M, Luijkx K.
Int J Environ Res Public Health 2021 Mar 9;18(5):2773. doi: 10.3390/ijerph18052773.
The individual experiences of older adults in long-term care are broadly recognized as an important source of information for measuring wellbeing and quality of care. Narrative research is a special type of qualitative research to elicit people’s individual, diverse experiences in the context of their lifeworld. Narratives are potentially useful for long-term care improvement as they can provide a rich description of an older adult’s life from their own point of view, including the provided care. Little is known about how narratives can best be collected and used to stimulate learning and quality improvement in long-term care for older adults. The current study takes a theoretical approach to developing a narrative quality instrument for care practice in order to discover the experiences of older adults receiving long-term care. The new narrative quality instrument is based on the available literature describing narrative research methodology. The instrument is deemed promising for practice, as it allows care professionals to collect narratives among older adults in a thorough manner for team reflection in order to improve the quality of care. In the future, the feasibility and usability of the instrument will have to be empirically tested.