Jennifer A. Palmer

The Medicare Policy of Payment Adjustment for Health Care-Associated Infections Perspectives on Potential Unintended Consequences

In 2008, the Centers for Medicare & Medicaid Services introduced a new policy to adjust payment to hospitals for health care-associated infections (HAIs) not present on admission. Interviews with 36 hospital infection preventionists across the United States explored the perspectives of these key stakeholders on the potential unintended consequences of the current policy. Responses were analyzed using an iterative coding process where themes were developed from the data. Participants’ descriptions of unintended impacts of the policy centered around three themes. Results suggest the policy has focused more attention on targeted HAIs and has affected hospital staff; relatively fewer systems changes have ensued. Some consequences of the policy, such as infection preventionists having less time to devote to HAIs other than those in the policy or having less time to implement prevention activities, may have undesirable effects on HAI rates if hospitals do not recognize and react to potential time and resource gaps.

A bibliometric review of cost-effectiveness analyses in the economic and medical literature: 1976-2006.

Background. Cost-effectiveness analysis (CEA) presenting a cost per quality-adjusted life year (QALY) ratio is frequently used to determine ‘‘value for money’’ in health care. Despite the proliferation of CEA research, there has been no detailed study focusing on the bibliometric properties of this literature. Objectives. To describe and analyze trends in publications and coauthorship in the CEA literature from 1976 to 2006 and to identify the most prolific authors and research groups conducting CEAs. Methods. The authors used the Tufts Medical Center Registry of original CEAs published through 2006 (www.cearegistry.org). For each article, they recorded the year of publication, the journal title, and the number of contributing authors and their names. Authors were assigned credit based on their weighted contribution to the study (1 credit point for the first and last authors, ½ point for the second author, and 1=n credit points for all other authors, where n reflects the number of coauthors). Results. Approximately 1400 CEAs presenting a cost/QALY ratio were published in 420 journals through 2006. The mean number of contributing authors was 4.7 ± 2.4. Medical journals were characterized by a higher number of coauthors, as compared with the economic and health policy journals: 4.8 ± 2.4 v. 4.2 ± 2.0, P < 0.001. The lowest average number of coauthors was in Medical Decision Making (3.6) and the highest in the Journal of the American College of Cardiology (8.2). The most prolific authors were affiliated with Harvard and Tufts Universities and their affiliated hospitals. The authors identified 4 major research groups that contributed substantially to the field of cost-effectiveness analysis but did not find any substantial academic relationships across these groups. Conclusions. The CEA literature continues to proliferate. Coauthorship trends appear to follow the rapid increase in the mean number of authors found in other publication types.

Longitudinal Pressure Ulcer Rates After Adoption of Culture Change in Veterans Health Administration Nursing Homes

To examine facility‐level pressure ulcer (PrU) development rates and variations in these rates after a system‐wide adoption of culture change in Veterans Health Administration (VHA) nursing homes.

Validation of a Novel Safety Climate Instrument in VHA Nursing Homes

Improvements in nursing home safety climate could lead to enhanced resident safety. Yet safety climate has been little studied in the nursing home setting, and existing safety climate instruments have significant limitations. To investigate safety climate in Veterans Health Affairs nursing homes (Community Living Centers [CLCs]), this study had two objectives: (a) to develop a resident safety climate instrument for use in CLCs and (b) to assess this instrument’s psychometric properties by administering it in a sample of CLCs. Using a standard conceptual framework, the CLC Employee Survey of Attitudes about Resident Safety was developed with the aid of an expert panel and multiple rounds of cognitive interviews. It was subsequently pilot tested in a sample of CLC employees. After refinement based on the pilot results, it was administered in a sample of five CLCs, where it was found to have adequate reliability and validity.

Adaptation of a nursing home culture change research instrument for frontline staff quality improvement use.

Enhanced interpersonal relationships and meaningful resident engagement in daily life are central to nursing home cultural transformation, yet these critical components of person-centered care may be difficult for frontline staff to measure using traditional research instruments. To address the need for easy-to-use instruments to help nursing home staff members evaluate and improve person-centered care, the psychometric method of cognitive-based interviewing was used to adapt a structured observation instrument originally developed for researchers and nursing home surveyors. Twenty-eight staff members from 2 Veterans Health Administration (VHA) nursing homes participated in 1 of 3 rounds of cognitive-based interviews, using the instrument in real-life situations. Modifications to the original instrument were guided by a cognitive processing model of instrument refinement. Following 2 rounds of cognitive interviews, pretesting of the revised instrument, and another round of cognitive interviews, the resulting set of 3 short instruments mirrored the concepts of the original longer instrument but were significantly easier for frontline staff to understand and use. Final results indicated frontline staff found the revised instruments feasible to use and clinically relevant in measuring and improving the lived experience of a changing culture. This article provides a framework for developing or adapting other measurement tools for frontline culture change efforts in nursing homes, in addition to reporting on a practical set of instruments to measure aspects of person-centered care.

Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship

Purpose of Study To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions. Design and Methods In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification. Results The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review. Implications The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.

Contextual Facilitators of and Barriers to Nursing Home Pressure Ulcer Prevention.

PURPOSE: To present findings of a study of institutional factors related to pressure ulcer (PrU) prevention in Veterans Health Administration nursing homes. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Identify the study’s design, process, and purpose. 2. List the factors pertaining to sites with improving performance. ABSTRACT OBJECTIVE: Important gaps exist in the knowledge of how to achieve successful, sustained prevention of pressure ulcers (PrUs) in nursing homes. This study aimed to address those gaps by comparing nursing leadership and indirect care staff members’ impressions about the context of PrU prevention in facilities with improving and declining PrU rates. SETTING: The study was conducted in a sample of 6 Veterans Health Administration nursing homes (known as community living centers) purposively selected to represent a range of PrU care performance. DESIGN AND PARTICIPANTS: One-time 30-minute semistructured interviews with 23 community living center staff were conducted. Qualitative interview data were analyzed using an analytic framework containing (a) a priori analytic constructs based on the study’s conceptual framework and (b) sections for emerging constructs. MAIN RESULTS: Analysis revealed 6 key concepts differentiating sites with improving and declining PrU care performance. These concepts were (1) structures through which the change effort is initiated; (2) organizational prioritization, alignment, and support; (3) improvement culture; (4) clarity of roles and responsibilities; (5) communication strategies; and (6) staffing and clinical practices. Results also pointed to potential contextual facilitators of and barriers to successful PrU prevention. CONCLUSIONS: Leadership’s visible prioritization of and support for PrU prevention and the initiation of PrU prevention activities through formal structures were the most striking components represented at sites with improving performance, but not at ones where performance declined. Sites with improving performance were more likely to align frontline staff and leadership goals for PrU prevention.

Developing the Supporting Choice Observational Tool (SCOT): A Formative Assessment Tool to Assist Nursing Home Staff in Realizing Resident Choice

Quality of care in nursing homes has begun to address the importance of resident choice in daily life, yet there are no published tools to teach nursing home staff how to offer such choice. In the current study, a formative assessment tool was developed that can provide staff with detailed and concrete feedback on how to realize resident choice. The tool was created and refined through 22 hours of ethnographic observation in two Veterans Health Administration Community Living Centers (CLCs), 22 hours of developmental testing in two CLCs, review by a modified Delphi panel, and use of an algorithm to assess its logical structure. The resulting Supporting Choice Observational Tool (SCOT) documents how choice is or is not offered and is or is not enabled within a singular staff-resident interaction. SCOT findings could be used in clinical teaching, quality improvement, or research efforts intent on enhancing nursing home resident quality of life. [Res Gerontol Nurs. 2017; 10(3):129-138.].

Resident Choice: A Nursing Home Staff Perspective on Tensions and Resolutions

ABSTRACT A central component of person‐centered care, resident choice in daily life, has received little research attention in the U.S. context. This study investigated nursing home staff experiences in realizing resident choice. Twenty‐six qualitative staff interviews were conducted in an opportunistic sample from two Veterans Health Administration (VHA) Community Living Centers (CLCs, i.e., nursing homes) implementing the Green House Model. Thematic content analysis surfaced several key tensions at the intra‐personal, inter‐personal, and organizational levels. Most salient were staff mental models within the intra‐personal level. Staff conveyed a lack of clarity on how to realize resident choice when faced with varying tensions, especially the competing goal of resident medical and safety needs. Staff‐employed resolutions to resident choice‐related tensions also emerged (e.g., preventive practices, staff reinforcement, and staff deliberation). This study offers specific and concrete insights on how resident choice in daily life, and thus resident quality of life, can be advanced.

Impact of Intervention to Improve Nursing Home Resident–Staff Interactions and Engagement

Background and Objectives For nursing home residents, positive interactions with staff and engagement in daily life contribute meaningfully to quality of life. We sought to improve these aspects of person-centered care in an opportunistic snowball sample of six Veterans Health Administration nursing homes (e.g., Community Living Centers-CLCs) using an intervention that targeted staff behavior change, focusing on improving interactions between residents and staff and thereby ultimately aiming to improve resident engagement. Research Design and Methods We grounded this mixed-methods study in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change. We implemented the intervention by (a) using a set of evidence-based practices for implementing quality improvement and (b) combining primarily CLC-based staff facilitation with some researcher-led facilitation. Validated resident and staff surveys and structured observations collected pre and post intervention, as well as semi-structured staff interviews conducted post intervention, helped assess intervention success. Results Sixty-two CLC residents and 308 staff members responded to the surveys. Researchers conducted 1,490 discrete observations. Intervention implementation was associated with increased staff communication with residents during the provision of direct care and decreased negative staff interactions with residents. In the 66 interviews, staff consistently credited the intervention with helping them (a) develop awareness of the importance of identifying opportunities for engagement and (b) act to improve the quality of interactions between residents and staff. Discussion and Implications The intervention proved feasible and influenced staff to make simple enhancements to their behaviors that improved resident-staff interactions and staff-assessed resident engagement.