Quality improvement implementation in the nursing home.
OBJECTIVE
To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care.


METHODS
Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database.


METHODS
A cross-sectional analysis of the association among the different measures was performed.


METHODS
Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database.


RESULTS
Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development.


CONCLUSIONS
Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.
Berlowitz
Dan R
DR
CHQOER, Bedford VA Hospital, MA 01730, USA.
Young
Gary J
GJ
Hickey
Elaine C
EC
Saliba
Debra
D
Mittman
Brian S
BS
Czarnowski
Elaine
E
Simon
Barbara
B
Anderson
Jennifer J
JJ
Ash
Arlene S
AS
Rubenstein
Lisa V
LV
Moskowitz
Mark A
MA
D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005260:Female; D006707:Homes for the Aged / Q000592:standards*; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009735:Nursing Homes / Q000592:standards*; D015279:Organizational Culture; D009936:Organizational Innovation; D017063:Outcome Assessment, Health Care; D003668:Pressure Ulcer / Q000453:epidemiology / Q000628:therapy*; D011785:Quality Assurance, Health Care / Q000379:methods / Q000458:organization & administration*; D017749:Total Quality Management / Q000379:methods / Q000458:organization & administration*; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000706:statistics & numerical data; D014768:Virginia / Q000453:epidemiology