Marcia Flesner

Clinical information systems in nursing homes: an evaluation of initial implementation strategies.

This article presents qualitative results collected 6 months after implementation of a clinical information system in four nursing homes in the Midwestern USA. Researchers explored initial implementation strategies, discussed employee experiences and analyzed employee satisfaction. Transcript-based analysis and axial coding were completed to illustrate recurring phenomena. Common attributes were identified by two gerontological nurse experts and a researcher with human factors expertise. Common themes emerging from 22 focus groups and direct observation of more than 120 nursing home staff were perception and cognition, change, workable systems, competence, and connectedness. Implementation strategies associated with lower satisfaction were availability of equipment, training resources, and the presence of information technology professionals. Initial clinical information system implementation strategies and employee satisfaction could be enhanced by the inclusion of a system life cycle charter plan, emphasizing change management procedures, improving start-up projections, hiring adequately trained information technology staff, and providing a system support plan. Findings will be useful to administrators and policy makers who are contemplating implementation of a clinical information system.

Randomized Multilevel Intervention to Improve Outcomes of Residents in Nursing Homes in Need of Improvement

OBJECTIVES A comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement. DESIGN/SETTING/PARTICIPANTS Intervention facilities (N = 29) received a 2-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (N = 29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders. INTERVENTION The authors conducted a randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living. It was hypothesized that following the intervention, experimental facilities would have higher quality of care, better resident outcomes, more organizational attributes of improved working conditions than control facilities, higher staff retention, similar staffing and staff mix, and lower total and direct care costs. RESULTS The intervention did improve quality of care (P = .02); there were improvements in pressure ulcers (P = .05) and weight loss (P = .05). Organizational working conditions, staff retention, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups. CONCLUSION AND IMPLICATIONS Some facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed. Medical directors in collaborative practice with advanced practice nurses are ideally positioned to implement this low-cost, effective intervention nationwide.

Getting the Basics Right: Care Delivery in Nursing Homes

In this study, the key exemplar processes of care in facilities with good resident outcomes were described. It follows that with description of these processes, it is feasible to teach facilities about the basics of care and the ways to systematically approach care so they can adopt these care processes and improve resident outcomes. However, for this to happen key organizational commitments must be in place for staff to consistently provide the basics of care. Nursing leadership must have a consistent presence over time, they must be champions of using team and group processes involving staff throughout the facility, and they must actively guide quality improvement processes. Administrative leadership must be present and express the expectation that high quality care is expected for residents, and that workers are expected to contribute to the quality improvement effort. If facilities are struggling with achieving average or poor resident outcomes, they must first make an effort to find nursing and administrative leaders who are willing to stay with the organization. These leaders must be skilled with team and group processes for decision-making and how to implement and use a quality improvement program to improve care. These leaders must be skilled at building employee relations and at retention strategies so residents are cared for by consistent staff who know them. The results of this study illustrate the simplicity of the basics of care that residents in nursing facilities need. The results also illustrate the complexity of the care processes and the organizational systems that must be in place to achieve good outcomes. Achieving these outcomes is the challenge facing those currently working in and leading nursing facilities.

Field testing, refinement, and psychometric evaluation of a new measure of nursing home care quality.

The primary aim of this NINR-NIH–funded field test in 407 nursing homes in 3 states was to complete the development of and conduct psychometric testing for the Observable Indicators of Nursing Home Care Quality Instrument (Observable Indicators, OIQ). The development of the OIQ was based on extensive qualitative and iterative quantitative work that described nursing home care quality and did initial validity and reliability field testing of the instrument in 123 nursing homes in 1 state. The scale is meant for researchers, consumers, and regulators interested in directly observing and quickly evaluating (within 30 minutes of observation) the multiple dimensions of care quality in nursing homes. After extensive testing in this study, the Observable Indicators instrument has been reduced to 30 reliable and discriminating items that have a conceptually coherent hierarchical factor structure that describes nursing home care quality. Seven first-order factors group together into two second-order factors of Structure (includes Environment: Basics and Odors) and Process (includes Care Delivery, Grooming, Interpersonal Communication, Environment: Access, and Environment: Homelike) that are classic constructs of Quality, which was the third-order factor. Internal consistency reliability for the 7 first-order factors ranged from .77 to .93. Construct validity analyses revealed an association between survey citations and every subscale as well as the total score of the OIQ instrument. Known groups analysis revealed expected trends in the OIQ scores. The Observable Indicators instrument as a whole shows acceptable interrater and test-retest reliabilities, and strong internal consistency. Scale subscales show acceptable reliability as well. Generalizability Theory analyses revealed that dependability of scores can be improved by including a second site observer, or by revisiting a site. There is a small additional benefit from increasing observers or visits beyond two.

Person-centered care and organizational culture in long-term care.

FOR those who have been in healthcare for any period of time, “buzzwords” about the latest new terminology bring to life an old idea. Every few years, experts and consultants bring to long-term care (LTC) providers the latest example of a new design to solve the quality of life and quality of care p

The use of bedside electronic medical record to improve quality of care in nursing facilities: a qualitative analysis

It appears that the implementation and use of a bedside electronic medical record in nursing homes can be a strategy to improve quality of care. Staff like using the bedside electronic medical record and believe it is beneficial. Information gleaned from this qualitative evaluation of four nursing homes that implemented complete electronic medical records and participated in a larger evaluation of the use of an electronic medical record will be useful to other nursing homes as they consider implementing bedside computing technology. Nursing home owners and administrators must be prepared to undertake a major change requiring many months of planning to successfully implement. Direct care staff will need support as they learn to use the equipment, especially for thefirst 6 to 12 months after implementation. There should be a careful plan for continuing education opportunities so that staff learn to properly use the software and can benefit from the technology. After 12 to 24 months, almost no one wants to return to the era of paper charting.

Initiative to test a multidisciplinary model with advanced practice nurses to reduce avoidable hospitalizations among nursing facility residents.

Author Affiliations: Sinclair School of Nursing (Drs Rantz, Alexander, Vogelsmeier, Popejoy, Flesner, and Crecelius and Ms Lueckenotte), School of Social Work, College of Human and Environmental Sciences (Dr Galambos), and Curtis W. and Ann H. Long Department of Family and Community Medicine (Dr Koopman), University of Missouri, Columbia; and College of Nursing and Health Sciences, University of Wisconsin–Eau Claire (Dr Zwygart-Stauffacher).

Preparing Nursing Homes for the Future of Health Information Exchange

OBJECTIVE Our purpose was to describe how we prepared 16 nursing homes (NHs) for health information exchange (HIE) implementation. BACKGROUND NH HIE connecting internal and external stakeholders are in their infancy. U.S. initiatives are demonstrating HIE use to increase access and securely exchange personal health information to improve patient outcomes. METHOD To achieve our objectives we conducted readiness assessments, performed 32 hours of clinical observation and developed 6 use cases, and conducted semi-structured interviews with 230 participants during 68 site visits to validate use cases and explore HIE. RESULTS All 16 NHs had technology available to support resident care. Resident care technologies were integrated much more with internal than external stakeholders. A wide range of technologies were accessible only during administrative office hours. Six non-emergent use cases most commonly communicated by NH staff were: 1) scheduling appointments, 2) Laboratory specimen drawing, 3) pharmacy orders and reconciliation, 4) social work discharge planning, 5) admissions and pre-admissions, and 6) pharmacy-medication reconciliation. Emerging themes from semi-structured interviews about use cases included: availability of information technology in clinical settings, accessibility of HIE at the point of care, and policies/procedures for sending/receiving secure personal health information. CONCLUSION We learned that every facility needed additional technological and human resources to build an HIE network. Also, use cases help clinical staff apply theoretical problems of HIE implementation and helps them think through the implications of using HIE to communicate about clinical care.

Advances in measuring quality of care in nursing homes: a new tool for providers, consumers, regulators, and researchers.

The purpose of this column is to discuss innovations and quality improvement efforts in a variety of long-term care settings. These issues are of importance to healthcare professionals as our nation faces the burgeoning growth of the aging population, creating increased demand for improved and innovative long-term care services. This column is coordinated by Marilyn J. Rantz, PhD, RN, FAAN, NHA, e-mail: rantzm@missouri.edu.

Better Care, Better Quality: Reducing Avoidable Hospitalizations of Nursing Home Residents.

DOI: 10.1097/NCQ.0000000000000145 33% more per stay than for other Medicare hospitalizations.1 In 2012, the US Department of Health and Human Services provided funding opportunities for organizations to test a series of evidence-based clinical interventions to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions.2 In response to this opportunity, the Sinclair School of Nursing of the University of Missouri developed the Missouri Quality Initiative (MOQI) intervention and received funding under the Patient Protection and Affordable Care Act (Pub L No. 111-148) to implement this intervention.3 The MOQI intervention is a 4year demonstration of a care coordination effort using advanced practice registered nurses (APRNs) in 16 nursing homes in a region of Missouri where the transfer rates were one of the nation’s highest for Medicare readmissions within 30 days of discharge (rates of 16.7%-18.9% for medical discharges).4 The MOQI Intervention Model3 illustrates the key components of the intervention. An APRN guides the intervention delivering care