Health Care Innovation and Quality Assurance

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

Development, characteristics and impact of quality improvement casebooks: a scoping review.
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Anderson NN, Gagliardi AR.
Health research policy and systems 2021 sep;19(1):123.
BACKGROUND: Quality improvement (QI) casebooks, compilations of QI experiences, are one way to share experiential knowledge that healthcare policy-makers, managers and professionals can adapt to their own contexts. However, QI casebook use, characteristics and impact are unknown. We aimed to synthesize published research on QI prevalence, development, characteristics and impact. METHODS: We conducted a scoping review by searching MEDLINE, EMBASE, CINAHL and SCOPUS from inception to 4 February 2021. We extracted data on study characteristics and casebook definitions, development, characteristics (based on the WIDER [Workgroup for Intervention Development and Evaluation Research] framework) and impact. We reported findings using summary statistics, text and tables. RESULTS: We screened 2999 unique items and included five articles published in Canada from 2011 to 2020 describing three studies. Casebooks focused on promoting positive weight-related conversations with children and parents, coordinating primary care-specialist cancer management, and showcasing QI strategies for cancer management. All defined casebooks similarly described real-world experiences of developing and implementing QI strategies that others could learn from, emulate or adapt. In all studies, casebook development was a multistep, iterative, interdisciplinary process that engages stakeholders in identifying, creating and reviewing content. While casebooks differed in QI topic, level of application and scope, cases featured common elements: setting or context, QI strategy details, impacts achieved, and additional tips for implementing strategies. Cases were described with a blend of text, graphics and tools. One study evaluated casebook impact, and found that it enhanced self-efficacy and use of techniques to improve clinical care. Although details about casebook development and characteristics were sparse, we created a template of casebook characteristics, which others can use as the basis for developing or evaluating casebooks. CONCLUSION: Future research is needed to optimize methods for developing casebooks and to evaluate their impact. One approach is to assess how the many QI casebooks available online were developed. Casebooks should be evaluated alone or in combination with other interventions that support QI on a range of outcomes.

Feasibility of a Nursing Home Antibiotic Stewardship Intervention.
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Baier RR, Jump RLP, Zhang T, Kabbani S, Gifford DR, Gravenstein S.
Journal of the American Medical Directors Association 2021 sep.
OBJECTIVE: To evaluate a bundled electronic intervention to improve antibiotic prescribing practices in US nursing homes. DESIGN: Prospective mixed-methods quality improvement intervention. SETTING AND PARTICIPANTS: Nursing staff and residents in 13 nursing homes, and residents in 8 matched-control facilities (n = 21 facilities total, from 2 corporations). METHODS: This study involved a 2-month design period (n = 5 facilities) focused on the acceptability and feasibility of a bundled electronic intervention consisting of 3 tools, followed by a 15-month implementation period (n = 8 facilities) during which we used rapid-cycle quality improvement methods to refine and add to the bundle. We used mixed-methods data from providers, intervention tools, and health records to assess feasibility and conduct a difference-in-difference analysis among the 8 intervention sites and 8 pair-matched controls. RESULTS: Nurses at 5 pilot sites reported that initial versions of the electronic tools were acceptable and feasible, but barriers emerged when 8 different facilities began implementing the tools, prompting iterative revisions to the training and bundle. The final bundle consisted of 3 electronic tools and training that standardized digital documentation to document and track a change in resident condition, infections, antibiotic prescribing, and antibiotic follow-up. By the end of the implementation phase, all 8 facilities were using at least 1 of the 3 tools. Early antibiotic discontinuation increased 10.5% among intervention sites, but decreased 10.8% among control sites. CONCLUSIONS AND IMPLICATIONS: The 3 tools in our bundled electronic intervention capture clinical and prescribing data necessary to assess changes in antibiotic use and were feasible for nurses to adopt. Achieving this required modifying the tools and training before the intervention reached its final form. Comparisons of rates of antibiotic use at intervention and control facilities showed promising improvement in antibiotic discontinuation, demonstrating that the intervention could be evaluated using secondary electronic health record data.

Facilitated reflection meetings as a relational approach to problem-solving within long-term care facilities
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Banerjee A, Taylor D, Stranz A, Wahl A.
Journal of Aging Studies 2021;59:100965.
Care workers have valuable knowledge to contribute to the improvement of their work environments. Yet incorporating their perspectives into organizational decision-making within long-term care facilities (LTCFs) has been an ongoing challenge. In this article we investigate a promising practice that brought workers and management together in weekly and bimonthly facilitated reflection meetings to identify and resolve problems. Drawing on observations as well as individual and group interviews, we sought to understand whether and how this intervention worked from the perspective of participants. Our study found that one of the main achievements was creating a safe space for workers to speak honestly. They felt heard and treated with respect. In this context, they were willing to surface concerns, failures, and problems for collective deliberation and action. The inclusion of a range of occupational groups ensured that the solutions developed were sensitive to context, including organizational and occupational realities. While the outcomes of the process were impressive, this paper highlights the relational work that created trust, respect, and a spirit of collaboration. We suggest that such facilitated reflection processes may serve as an important strategy to improve the organization of work in LTCFs, one that is particularly well-suited to the dynamic and relational nature of care.

Targeted gown and glove use to prevent Staphylococcus aureus acquisition in community-based nursing homes: A pilot study.
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Lydecker AD, Osei PA, Pineles L, Johnson JK, Meisel J, Stine OC, et al.
Infection control and hospital epidemiology 2021 apr;42(4):448-454.
OBJECTIVE: To test the feasibility of targeted gown and glove use by healthcare personnel caring for high-risk nursing-home residents to prevent Staphylococcus aureus acquisition in short-stay residents. DESIGN: Uncontrolled clinical trial. SETTING: This study was conducted in 2 community-based nursing homes in Maryland. PARTICIPANTS: The study included 322 residents on mixed short- and long-stay units. METHODS: During a 2-month baseline period, all residents had nose and inguinal fold swabs taken to estimate S. aureus acquisition. The intervention was iteratively developed using a participatory human factors engineering approach. During a 2-month intervention period, healthcare personnel wore gowns and gloves for high-risk care activities while caring for residents with wounds or medical devices, and S. aureus acquisition was measured again. Whole-genome sequencing was used to assess whether the acquisition represented resident-to-resident transmission. RESULTS: Among short-stay residents, the methicillin-resistant S. aureus acquisition rate decreased from 11.9% during the baseline period to 3.6% during the intervention period (odds ratio [OR], 0.28; 95% CI, 0.08-0.92; P = .026). The methicillin-susceptible S. aureus acquisition rate went from 9.1% during the baseline period to 4.0% during the intervention period (OR, 0.41; 95% CI, 0.12-1.42; P = .15). The S. aureus resident-to-resident transmission rate decreased from 5.9% during the baseline period to 0.8% during the intervention period. CONCLUSIONS: Targeted gown and glove use by healthcare personnel for high-risk care activities while caring for residents with wounds or medical devices, regardless of their S. aureus colonization status, is feasible and potentially decreases S. aureus acquisition and transmission in short-stay community-based nursing-home residents.

Quality evaluation questionnaires – nursing homes (QEQ-NH); validation of questionnaires for measuring quality of care in nursing homes from various perspectives.
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Triemstra M, Menting J, van den Berg B.
BMC health services research 2021 sep;21(1):961.
BACKGROUND: This study aims to describe the validation and optimization of a new instrument designed to comprehensively measure and evaluate the quality of care in nursing homes; the Quality Evaluation Questionnaires for Nursing Homes (QEQ-NH). This instrument comprises several questionnaires on the perceived quality of care for various perspectives (e.g. clients, family and professional caregivers) and covers eight themes of the national quality framework for nursing home care in the Netherlands. METHODS: Data were collected in six nursing homes between September 2017 and June 2018, among 359 residents, 48 family caregivers and 648 professional caregivers who completed a subgroup-specific questionnaire of the QEQ-NH. Construct and criterion validity of the three questionnaires were tested with item- and scale analyses. Content validity of the questionnaires was tested in cognitive interviews with 20 participants (7 residents, 5 family caregivers and 8 professional caregivers). RESULTS: Psychometric analyses confirmed the multidimensionality and reliability of the three questionnaires, and the cognitive interviews showed various possibilities for further optimization of the instrument. Construct, criterion and content validity of the three questionnaires ranged from acceptable to good. Cronbach’s alphas were > .70 for almost all scales. More than half of the items were candidate for optimization according to the cognitive interviews, mainly due to clarity or knowledge problems, and the questionnaires of the QEQ-NH were optimized accordingly. CONCLUSIONS: The Quality Evaluation Questionnaires for Nursing Homes (QEQ-NH) provide a solid basis to measure the quality of nursing home care, by covering the national quality themes and by integrating the various perspectives of all parties involved. With real-time feedback, the instrument provides the management and care teams with information to select possibilities or areas for improvement and to continuously monitor the effects of quality improvement in nursing homes.