NHs have been characterized as “total institutions” since they control most of the services and many environmental inputs. Therefore, care provided in NHs is thought to influence residents' outcomes more directly than care provided in other settings. Identifying care and work environment attributes associated with better resident outcomes is a necessary first step in moving towards quality improvement.
In this study, we focused on NH management practices such as teams, consistent assignment, and staff cohesion, and their association with risk-adjusted resident outcomes for pressure ulcers and incontinence. In healthcare, the role of teams in improving care quality has been widely heralded, and almost all healthcare organizations are known to report some form of team practice (Shortell, Marsteller, Lin, & et al., 2004
). A handful of studies have suggested that in NHs self-managed work teams have a modest positive impact on empowerment and performance among the CNAs (Yeatts & Cready, 2007
; Yeatts, et al., 2004
). Furthermore, penetration of self-managed teams has been shown to be associated with fewer NH quality of care deficiencies (Temkin-Greener, et al., 2010
To the best of our knowledge ours is the first study to empirically demonstrate that higher penetration of self-managed team practice is significantly associated with better resident risk-adjusted outcome in NHs. However, we find this association only for pressure ulcers, not for incontinence, and only with regard to self-managed teams, not those formally organized by the management; even though both types of teams report similar multidisciplinary structures (Temkin-Greener, Cai, Katz, & Mukamel, 2009
). Team approach to care has been viewed as the norm in risk assessment, prevention, and treatment of residents at high risk for pressure ulcers (AHRQ, 2008
), although typically such teams are quite specialized and are formally organized. It is possible that in absence of formal PU teams, self-managed teams may also positively influence this outcome. While formally organized teams may be structured and tasked to perform specific functions (in this case not PU-specific), more organically structured self-managed teams may be more apt to quickly respond to resident care needs as they arise. Such teams may be less hierarchical and more spontaneous in the way members communicate, coordinate care, and problem-solve, and thus may be more effective in situations needing quick response as is often the case with pressure ulcers. Our prior work may provide an alternative explanation. We found that prevalence of formal teams was associated with cost savings, while prevalence of self-managed teams was not (Mukamel, Cai, & Temkin-Greener, 2009
). If formally organized teams are structured by the management to achieve cost savings, it may not be surprising that we find no association between their prevalence and outcome measures. Similarly, in our prior work we found no associated between formally organized teams and deficiency citations, but found such an association for self-managed teams (Temkin-Greener, et al., 2010
We found no relationship between team presence, either self-managed or formally organized, and the incontinence outcome. Team approach to care in nursing homes may be successful for improving specific outcomes, but is not likely to be a panacea for all outcomes. At the same time, it may be possible that for certain outcomes teams cannot be effective in improving quality before they reach a minimum penetration threshold. In our sample, only 16% of staff in an average facility reported practicing in either self-managed or formal teams. At this level of penetration team impact on some measures of quality may be too marginal to be detectable.
Consistent assignment of nursing staff to residents has been viewed as another means for improving NH work environment. Nationally over 70% of nursing home directors reported consistent assignment of CNAs to residents (Doty, Kane, & Strula, 2008
). In our study sample, almost 40% of staff (SD=16.41%) in average facility said they had consistent assignment. Although consistent assignment is relatively widespread across the study facilities, our findings do not provide support for its association with resident outcomes. Similarly, in our prior work we did not find an association between consistent assignment and deficiency citations (Temkin-Greener, et al., 2010
). Although conceptually, consistent assignment provides an opportunity for staff to develop closer relationships with residents and families, it is not by any means a guarantee that such relationships will be positive and effectively lead to better outcomes. Just as creating teams without further investment in ensuring that they are “well functioning teams” is not likely to ensure good outcomes, consistent assignment without sufficient support or means for problem resolution may create as many poor as good relationships, thus failing to bring about the hoped for results.
Staff cohesion appears to be the only one of the three attributes that consistently showed a statistically significant association with both pressure ulcers and incontinence measures. In an average facility, one standard deviation (0.23) increase in the staff cohesion score was associated with 4.3% lower odds of PUs and 7.6% lower odds of incontinence. Thus, a less than ¼ point improvement in a facility's staff cohesion score may be associated with rather substantial improvements in health outcomes of interest. Prior literature identified several factors as being important predictors of staff cohesion in healthcare organizations (Shortell, Marsteller, Lin & et al.,2004
; Temkin-Greener, et al.,2004) including leadership, communication and coordination, and conflict management. In our prior work we also demonstrated these factors to be important predictors of staff cohesion in nursing homes (Temkin-Greener, et al.,2009). Based on a 5-point Likert scale, we found that a one point increase in communication/coordination score resulted in a 0.36 increase in staff cohesion, while the effects of leadership and conflict management resulted in substantially lower impacts on staff cohesion, at 0.14 and 0.19 respectively. Since not all of these dimensions appear equally important predictors of staff cohesion, managers wishing to foster better staff cohesion may be well advised to focus first and foremost on interpersonal communication and coordination of care among their staff.
Controlling for all facility-level characteristics, residents in facilities located downstate were at a significantly higher risk of pressure ulcers, but not of incontinence, compared to residents in upstate facilities. The lack of association with both outcome measures is not surprising as the literature on outcomes typically demonstrates little if any correlation between different quality measures. Facilities that provide good PU care need not also provide good incontinence care. However, it is not immediately clear what explains the observed differential with regard to PU outcome by location, and this issue deserves further examination.
Two study limitations should be noted. First, although this study is based on NHs from the largest state in the US, NYS, generalizations to facilities elsewhere should be made with caution. Second, participation in the survey was voluntary and the possibility of a response bias should be considered. In comparing all eligible NHs to those that participated in the survey, with regard to the outcome measures, we found no statistically significant differences (). Furthermore, there were no significant correlations between facility response rates and the independent or dependent variables, except for a correlation between lower prevalence of PUs in facilities with higher response rates. Although statistically significant, this correlation is very small (r= −0.230, p=0.004) suggesting that response bias, if present, was minimal.
In summary, our findings demonstrate that residents in NHs with poorer staff cohesion experience worse resident risk-adjusted outcomes for pressure ulcers and incontinence. Our findings for other work environment attributes, such as team presence, were less consistent. These findings, which were echoed in our prior work on deficiency citations (Temkin-Greener, et al., 2010
) emphasize the importance of good NH management practices in contributing to good resident outcomes.