The Institute of Medicine (2001)
in its recently published report Improving the Quality of Long Term Care
, identified QI as one method by which nursing homes could improve care. However, the report also acknowledged the lack of evidence regarding the effectiveness of QI in nursing homes and the difficulty in implementing QI in a setting characterized by limited trained staff and organizational capacity. We performed a comprehensive evaluation of QI implementation in nursing homes maintained by the Department of Veterans Affairs to examine its association with organizational culture and its effects on care.
It is important to recognize that VA nursing homes differ from community nursing homes in two important ways. First, unlike many community nursing homes, VA nursing homes are part of a larger integrated health system that has made a significant investment in QI. Thus, VA nursing homes have access to information and staff resources that may not be available to independent nursing homes. However, a growing number of community nursing homes are becoming part of large chains and health systems and thus, in the future, may be more similar to VA nursing homes in terms of information systems and specialized staff. Second, nursing aides within the VA have less turnover than their counterparts in community nursing homes and, thus, may be more experienced. For example, 71 percent of the aides reported more than 10 years experience in health care with most of the experience obtained within the VA. These nursing aides may be more accepting of QI practices or better able to adopt these practices. Nevertheless, issues faced currently by VA nursing homes in implementing QI, such as how to focus on consumer needs, implement guidelines, and improve processes of care, are likely to be similar to the issues faced by other nursing homes. The VA may just be further along in implementing recommendations from the Institute of Medicine report in terms of organizational capacity and staff development.
In testing H1
, we found significant differences among VA nursing homes in their implementation of QI practices. Mean scores on the 5-point implementation scale at individual nursing homes ranged from less than 3 to greater than 4. This finding is consistent with those of Zinn et al. (1998)
in noting that there are differences among nursing homes in their level of interest in and commitment to QI practices. Our results indicate that some VA nursing homes have been more successful in responding to the system-wide initiative promoting QI. Success is not dependent on size, teaching status, or urban location. We cannot be certain why nursing homes located in the West had greater QI implementation.
Moreover, our results suggest that QI implementation is related to an underlying organizational culture. Consistent with our hypothesis (H2
), those nursing homes with a stronger group/developmental culture appeared to be further along in implementing QI practices. Our results are similar to those reported by Shortell et al. (1995)
in their study of hospitals. In our study, the mean group/developmental score of nursing homes was 45 (of 100) versus 46 in their study; a 10-point increase in the organizational culture score was associated with a 0.17 point increase in QI implementation in our study versus 0.18 in their study. Our results indicate that QI cannot just be implemented in any nursing home. Rather, the nursing home must be suitably predisposed to QI by having a culture that rewards innovation and teamwork. Efforts to implement QI in nursing homes without such a culture are less likely to be successful.
Our results highlight some of the benefits of QI implementation. Employees at nursing homes that had adopted more QI practices were significantly more satisfied with their jobs. Moreover, the magnitude of this effect appeared considerable. QI implementation may enhance satisfaction by empowering employees to be more active in daily care decisions. These results are consistent with those from hospitals reported by Shortell et al. (1995)
. They noted an association between QI implementation and human resource development as described by a scale that captures factors such as ability to recruit and retain clinical staff, nursing staff satisfaction, and employee turnover. Because of this prior work, we were especially interested in the association between QI implementation and satisfaction. However, it is possible that this effect is mediated by other factors that jointly influence QI implementation and employee satisfaction.
We also found that staff at nursing homes with a greater degree of QI implementation believed that they were doing a better job, as represented by their statement of having adopted best practices contained in the pressure ulcer guideline. Zinn et al. (1997)
also noted that administrators of nursing homes that had adopted QI perceived a positive impact of QI on quality of care and resident satisfaction. Yet we were unable to show that pressure ulcer preventive practices, as documented in the medical record, were actually better at nursing homes with more QI practices. We cannot be certain whether this truly indicates no differences in practices or simply the difficulty in detecting key practices, such as turning patients every two hours, in the medical record. Given how little is known about how guidelines are implemented in nursing homes (Berlowitz, Young, Hickey et al. 2001
), further evaluation of the association between QI implementation and the process of care is needed.
Ultimately, it is the effect of QI on patient outcomes that is of critical importance. Recent articles have highlighted the limited literature in this area as well as the uncertain effects of QI on care (Shortell, Bennett, and Byck 1998
; Shortell et al. 2000
). There are few clinical trials of QI implementation specific to nursing homes (Institute of Medicine 2001
). One study directed at improving the management of urinary incontinence found initial improvements that were not sustained (Schnelle et al. 1998). Other randomized clinical trials of QI and pressure ulcer care have either reported negative results (McKenna, Moyers, and Feurberg 1998
) or are still underway (Gifford 1999
). Concerns have been raised, though, as to whether QI can be assessed using randomized clinical trials. Thus, some studies, including ours, have considered an alternative approach that uses observational data from many nursing homes to measure the extent of QI implementation and determine its association with outcomes. Notably, Zinn et al. (1997)
found no association between QI adoption and the facility percentage of residents with urinary catheters, physical restraints, pressure ulcers, or contractures. In comparison to Zinn et al., the strengths of our study included the ability to study the incidence of pressure ulcer development rather than prevalence, the ability to consider patient-level factors in modeling, and the availability of an extensively validated risk-adjustment model for our outcome of interest.
Despite these strengths, we were unable to demonstrate a significant association between QI implementation and the risk-adjusted rate of pressure ulcer development. We did observe, however, a relationship that was in the expected direction whereby residents of nursing homes with a higher degree of QI implementation had a lower pressure ulcer rate. Furthermore, the effect size was clinically meaningful with a 1-point increase in the facility QI implementation score (approximately the difference between the nursing homes with the highest and lowest scores) being associated with an observed pressure ulcer rate 1.7 percent lower than the expected rate. If we had had a larger sample of nursing homes, and thus more statistical power, this effect might have been significant. Interestingly, neither staff-reported guideline adoption nor pressure ulcer preventive practices, as documented in the medical record, were associated with the rate of pressure ulcer development. The absence of such associations could also be due to inaccuracies in the data on pressure ulcer development. Although studies evaluating the PAF have been limited, good agreement among nurse-reviewers has been reported (Rudman, Bross, and Mattson 1994
). These results highlight the difficulties in trying to link process and outcome measures.
It is increasingly important to understand not only which nursing homes are doing well, but also how some nursing homes are achieving better outcomes (Brannon 1992
). We have now examined one method nursing homes may employ to improve the quality of their care. We have found that there are differences among nursing homes in their implementation of QI practices, and that QI appears to be associated with employee satisfaction and the perception of providing better care. However, our results were inconclusive in terms of demonstrating an effect of QI on quality of care. Thus, our results emphasize the need for continued study before QI is widely promoted as a means for improving nursing home quality. Our results do seem to support the importance of developing an organizational culture and capacity for implementing QI. Quality improvement, as well as other interventions to improve care, is unlikely to be successfully implemented in nursing homes that are not suitably predisposed to making the necessary changes in how care is delivered.