Health Care Innovation and Quality Assurance

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

Effects of a Multicomponent Program on Fall Incidence, Fear of Falling, and Quality of Life among Older Adult Nursing Home Residents.
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M. Bastami and A. Azadi.
Ann Geriatr Med Res 2020 Nov 11
Falling is one of the most common problems in older adults and can lead to additional health problems. This study aimed to determine the effects of a multicomponent program on fall incidence and quality of life in older adult nursing home residents. METHODS: This was a quasi-experimental study with a pretest and post-test design. The study population comprised 55 older adults residing in nursing homes. The intervention was a multicomponent program including physical activities, training sessions, and physical environment modifications in nursing homes that was conducted for 8 weeks. The data collection tools included a socio-demographic characteristics form and questionnaires pertaining to the quality of life and fear of falls, which were completed by the participants before and after the intervention. RESULTS: The mean age of the participants was 68.48 years, and most (90%) were illiterate. We observed a significant difference between the mean number of falls and the scores for fear of falling before and after the intervention (p<0.001). We also observed a significant difference between the total quality of life scores and all of the related dimensions before and after the intervention, indicating that the quality of life of the older adults had improved after the intervention (p<0.001). CONCLUSION: The results of this study indicated that the multicomponent fall prevention program was effective in improving the quality of life, fall rate, and fear of falling among older residents in nursing homes. Further studies are needed to explore the long-term effects of these interventions.

An Algorithm for Comprehensive Medication Management in Nursing Homes: Results of the AMBER Project.
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S. Erzkamp, J. Köberlein-Neu and O. Rose.
Drug Saf 2020 Oct 31
There are several barriers to conducting medication management in nursing homes. Our project aimed to develop an algorithm that guides and supports pharmacists to perform this clinical service. METHODS: Phase I of the project examined the practitioner and patient perspectives on the medication process in nursing homes. The mixed methods approach consisted of interviews with qualitative content analysis and a quantitative questionnaire. Phase IIa scoped existing research and comprised a three-stepped systematic review. It was registered in the International Prospective Register of Systematic Reviews (CRD42017065002). Results of the first two steps were assessed for quality. Phase IIb was performed as a Delphi survey. The developed algorithm was tested in nursing homes. The primary endpoint was the number and type of detected drug-related problems. The study was conducted between June 2016 and December 2018 (Deutsches-Register-Klinischer-Studien-ID: DRKS00010995). RESULTS: Interviews were held with 21 healthcare practitioners and six patients. Frequent and relevant aspects of the medication process in nursing homes were identified. The systematic reviews included 28 reviews, 12 interventional studies and 1450 non-interventional studies. As a result of the Delphi survey, two new aspects were added. Testing of the drafted algorithm was done in 73 nursing home residents. A mean of 6.3 drug-related problems were detected. Sample cases were executed in a mean time of 21 min by community pharmacists. CONCLUSIONS: The developed and consented algorithm can guide pharmacists in conducting medication management in a timely and effective manner. It might serve as a facilitator to improve collaboration and quality of medication in nursing home residents.

Certificate-Of-Need Regulation and Healthcare Service Quality: Evidence from the Nursing Home Industry.
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B. Fayissa, S. Alsaif, F. Mansour, T. E. Leonce and F. G. Mixon Jr.
Healthcare (Basel) 2020 Oct 23;8(4):E423. doi: 10.3390/healthcare8040423
This quantitative study investigates the effect of certificate-of-need (CON) regulation on the quality of care in the nursing home industry. It uses county-level demographic data from the 48 contiguous US states that are extracted from the American Community Survey (ACS) and cover the years 2012, 2013, and 2014. In doing so, it employs a new set of service quality variables captured from a variety of county-level data sources. Instrumental variables results indicate that health survey scores for nursing homes that are computed by healthcare professionals are about 18-24% lower, depending on the type of nursing home under consideration, in states with CON regulation. We also find that the presence of CON regulation leads to a substitution of lower-quality certified nursing assistant care for higher-quality licensed practical nurse care, regardless of the type of nursing home under consideration.

Provincial legislative and regulatory standards for pain assessment and management in long-term care homes: a scoping review and in-depth case analysis.
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N. L. Gallant, A. Peckham, G. Marchildon, T. Hadjistavropoulos, B. Roblin and R. J. N. Stopyn.
BMC Geriatr 2020 Nov 9;20(1):458-020-01758-7
Among Canadian residents living in long-term care (LTC) facilities, and especially among those with limited ability to communicate due to dementia, pain remains underassessed and undermanaged. Although evidence-based clinical guidelines for the assessment and management of pain exist, these clinical guidelines are not widely implemented in LTC facilities. A relatively unexplored avenue for change is the influence that statutes and regulations could exert on pain practices within LTC. This review is therefore aimed at identifying the current landscape of policy levers used across Canada to assess and manage pain among LTC residents and to evaluate the extent to which they are concordant with evidence-based clinical guidelines proposed by an international consensus group consisting of both geriatric pain and public policy experts. METHODS: Using scoping review methodology, a search for peer-reviewed journal articles and government documents pertaining to pain in Canadian LTC facilities was carried out. This scoping review was complemented by an in-depth case analysis of Alberta, Saskatchewan, and Ontario statutes and regulations. RESULTS: Across provinces, pain was highly prevalent and was associated with adverse consequences among LTC residents. The considerable benefits of using a standardized pain assessment protocol, along with the barriers in implementing such a protocol, were identified. For most provinces, pain assessment and management in LTC residents was not specifically addressed in their statutes or regulations. In Alberta, Saskatchewan, and Ontario, regulations mandate the use of the interRAI suite of assessment tools for the assessment and reporting of pain. CONCLUSION: The prevalence of pain and the benefits of implementing standardized pain assessment protocols has been reported in the research literature. Despite occasional references to pain, however, existing regulations do not recommend assessments of pain at the frequency specified by experts. Insufficient direction on the use of specialized pain assessment tools (especially in the case of those with limited ability to communicate) that minimize reliance on subjective judgements was also identified in current regulations. Existing policies therefore fail to adequately address the underassessment and undermanagement of pain in older adults residing in LTC facilities in ways that are aligned with expert consensus.

Unintended consequences: a qualitative study exploring the impact of collecting implementation process data with phone interviews on implementation activities.

Inga Gruß, Arwen Bunce, James Davis and Rachel Gold.
Implementation Science Communications 2020 11/04;1(1):101
Qualitative data are crucial for capturing implementation processes, and thus necessary for understanding implementation trial outcomes. Typical methods for capturing such data include observations, focus groups, and interviews. Yet little consideration has been given to how such methods create interactions between researchers and study participants, which may affect participants’ engagement, and thus implementation activities and study outcomes. In the context of a clinical trial, we assessed whether and how ongoing telephone check-ins to collect data about implementation activities impacted the quality of collected data, and participants’ engagement in study activities.

Consistent practice for pressure ulcer prevention in long-term older people care: A quasi-experimental intervention study.
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S. Mäki-Turja-Rostedt, H. Leino-Kilpi, T. Korhonen, T. Vahlberg and E. Haavisto.
Scand J Caring Sci 2020 Nov 8
Consistent practice, an agreed clinical practice based on evidence, has been considered as a base for effective provision of quality and safety of care. As a result, patients have an equal quality of care regardless of the organisation or worker. However, despite the international guidelines, pressure ulcer prevention practices vary in long-term older people care. AIM: To develop, implement and evaluate the impact of renewed, consistent practice for pressure ulcer prevention, in long-term older people care. DESIGN: A quasi-experimental intervention study. METHODS: Two long-term older people care facilities chosen with convenience sampling were randomly allocated to intervention or comparison group. Registered and practical nurses, in total 141/112, participated in the study. The renewed consistent practice based on international guidelines for pressure ulcer prevention was developed and implemented using the Operational Model for Evidence-Based Practices (OMEBP). Frequencies and agreement of PU prevention practices in line with international guidelines in the care facilities were measured using the PUPreP instrument. RESULTS: In the intervention facility, improvement in line with international guidelines was seen in the frequency of PU prevention practices in risk assessment, nutrition, pressure-relieving devices and documentation. Furthermore, improvement was seen in the intervention facility in all six areas of agreement on practices. CONCLUSIONS: The results of this study support the implementation of PU prevention guidelines in long-term older people care (LOPC) and more widely in healthcare settings for older people to promote consistent practice, and safety and equal quality of care.

The “State of Implementation” Progress Report (SIPREP): a pilot demonstration of a navigation system for implementation.

Edward J. Miech, Angela Larkin, Julie C. Lowery, et al.
Implementation Science Communications 2020 11/05;1(1):102
Implementation of new clinical programs across diverse facilities in national healthcare systems like the Veterans Health Administration (VHA) can be extraordinarily complex. Implementation is a dynamic process, influenced heavily by local organizational context and the individual staff at each medical center. It is not always clear in the midst of implementation what issues are most important to whom or how to address them. In recognition of these challenges, implementation researchers within VHA developed a new systemic approach to map the implementation work required at different stages and provide ongoing, detailed, and nuanced feedback about implementation progress.

Receiving a diagnosis of young onset dementia: Evidence-based statements to inform best practice.
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M. O’Malley, J. Parkes, J. Campbell, et al.
Dementia (London) 2020 Oct 30:1471301220969269
Better understanding of patient experience is an important driver for service improvements and can act as a lever for system change. In the United Kingdom, the patient experience is now a central issue for the National Health Service Commissioning Board, clinical commissioning groups and the providers they commission from. Traditionally, dementia care in the United Kingdom has focused predominantly on the individual experience of those with late onset dementia, while the voice of those with young onset dementia has been, comparatively, unheard. This study aims to improve the understanding of the personal experience of younger people undergoing investigation for dementia. METHODS: A modified Delphi approach was undertaken with 18 younger people with dementia and 18 supporters of people with young onset dementia. Questions were informed by a scoping review of the literature (O’Malley, M., Carter, J., Stamou, V., Lafontaine, J., & Parkes, J. (2019a). Receiving a diagnosis of young onset dementia: A scoping review of lived experiences. Ageing & Mental Health, 0(0), 1-12). Summary individual statements were refined over two rounds to a final list of 29 key statements. RESULTS: Twenty-seven of these statements were rated as absolutely essential or very important and included (1) for the general practitioner to identify dementia in younger people, (2) clinicians should be compassionate, empathic and respectful during the assessment and particularly sensitive when providing information about a diagnosis, and (3) remembering that receiving the diagnosis is a lot to absorb for a person with dementia and their supporter. Statistical analyses found no difference in the scoring patterns between younger people with dementia and supporters, suggesting similar shared experiences during the diagnostic process. CONCLUSION: Understanding the uniquely personal experience of young people going through the process of diagnosis for dementia is essential to provide person-centred, needs-led, and cost-effective services. Patient’s values and experiences should be used to support and guide clinical decision-making.

Multifaceted intervention to Reduce Antimicrobial Prescribing in Care Homes: a process evaluation of a UK-based non-randomised feasibility study.
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R. Potter, A. Campbell, D. R. Ellard, et al.
BMJ Open 2019 Nov 21;9(11):e032185-2019-032185
To explore the facilitators and obstacles to the development and implementation of the Reduce Antimicrobial Prescribing in Care Homes intervention. DESIGN: We used a mixed-methods approach. We conducted focus groups with care home staff and relatives of residents, and interviews with general practitioners (GPs) and home managers, completed observational visits and collected demographic data, training attendance records and data on the use of a decision-making algorithm. We used normalisation process theory to inform topic guides and interpretation of the data. SETTING: Six care homes, three in Northern Ireland and three in the West Midlands, England. INTERVENTION: A decision-making algorithm for urinary tract, respiratory tract and skin and soft-tissue infections, plus small group interactive training for care home staff. RESULTS: We ran 21 training sessions across the six homes and trained 35/42 (83%) of nurses and 101/219 (46%) of all care staff. Care home staff reported using the decision-making algorithm 81 times. Postimplementation, staff reported being more knowledgeable about antimicrobial resistance but were unsure if the intervention would change how GPs prescribed antimicrobials. The pressures of everyday work in some homes meant that engagement was challenging at times. Staff felt that some of the symptoms included in decision-making algorithm, despite being evidence based, were not easy to detect in residents with dementia or urinary incontinence. Some staff did not use the decision-making algorithm, noting that their own knowledge of the resident was more important. CONCLUSION: We delivered a training package to a substantial number of key staff in care homes. A decision-making algorithm for common infections in care homes empowered staff but was challenging to operationalise at times. A future study should consider the findings from the process evaluation to help ensure the successful implementation on a larger scale.

The relationship of nursing home price and quality of life.
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S. Raes, S. Vandepitte, D. De Smedt, H. Wynendaele, Y. DeJonghe and J. Trybou.
BMC Health Serv Res 2020 Nov 9;20(1):987-020-05833-y
Knowledge about the relationship between the residents’ Quality of Life (QOL) and the nursing home price is currently lacking. Therefore, this study investigates the relationship between 11 dimensions of QOL and nursing homes price in Flemish nursing homes. METHODS: The data used in this cross-sectional study were collected by the Flemish government from years 2014 to 2017 and originates from 659 Flemish nursing homes. From 2014 to 2016, data on the QOL of 21,756 residents was assessed with the InterRAI instrument. This instrument contains 11 QOL dimensions. Multiple linear regression analyses were conducted to examine the research question. RESULTS: The multiple linear regressions indicated that a 10 euro increase in the daily nursing home price is associated with a significant decrease (P <  0.001) of 0.1 in 5 dimensions of QOL (access to services, comfort and environment, food and meals, respect, and safety and security). Hence, our results indicate that the association between price and QOL is very small. When conducting a subgroup analysis based on ownership type, the earlier found results remained only statistically significant for private nursing homes. CONCLUSION: Our findings show that nursing home price is of limited importance with respect to resident QOL. Contrary to popular belief, our study demonstrates a limited negative effect of price on QOL. Further research that includes other indicators of QOL is needed to allow policymakers and nursing home managers to improve nursing home residents’ QOL.

Assuring Quality in Nursing Homes: The Black Box of Administrative and Clinical Leadership –a Scoping Review.
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E. O. Siegel and H. M. Young.
Gerontologist 2020 Nov 5
Licensed nursing home administrators (NHA) and directors of nursing (DON) are responsible for nursing home quality and assuring optimal performance and job satisfaction/retention of their nursing home workforce. NHA/DON-focused studies have generated important foundational knowledge over the last three decades; yet, targeted research is needed to understand and apply the complexities of the black box of this top management team. This scoping review identifies, reviews, synthesizes and maps the topical areas of research in NHA/DON positions in US nursing homes. RESEARCH DESIGN AND METHODS: We conducted searches of five databases, yielding 3,479 records; screening/review yielded 88 unique records analyzed using Donabedian’s structure-process-outcome model (Donabedian, 2003) as an organizing framework. RESULTS: Most papers (n=40) focused on role characteristics, 23 examined approaches to management and leadership, 24 focused on perceptions about the role, and the remaining 12 examined role structure. The role-related themes linked to outcomes (n=42), processes (n=27) and structures (n=30). DISCUSSION AND IMPLICATIONS: We highlight important gaps for future research and offer a call to action for research, policy, practice, and education collaborations to accelerate the rate of research and translate the findings into best practices for NHA/DON to lead and manage the nursing home workforce and build capacity to ensure person-centered, high quality care. Based on foundational descriptive studies, it is time to use what is known to design and implement interventions that enhance the capacity of NHA/DON to improve the structures, processes and outcomes of nursing homes.

Linking Patient Safety Culture to Quality Ratings in the Nursing Home Setting.
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N. Yount, K. A. Zebrak, T. Famolaro, J. Sorra and R. Birch.
J Appl Gerontol 2020 Nov 6:733464820969283
There is limited evidence on the associations between patient safety culture and measures of health care quality in nursing homes. This study examines the relationship between scores on the Agency for Healthcare Research and Quality (AHRQ) Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey (NH SOPS) and Centers for Medicare and Medicaid Services Nursing Home Five-Star Quality Ratings. Using data from 186 nursing homes, we conducted multiple regression analyses predicting the Five-Star Quality Ratings from the NH SOPS survey measures. Five NH SOPS measures were related to the Overall, Health Inspections, and Quality Five-Star Ratings. Four NH SOPS measures were related to at least two of the four Five-Star Quality Ratings and three SOPS measures were related to one Five-Star Rating. None of the NH SOPS measures were significantly associated with the Staffing Five-Star Rating. Findings generally indicated that stronger patient safety culture is associated with higher quality ratings.