title: A phased cluster-randomized trial of rural hospitals testing a quality collaborative to improve heart failure care: organizational context matters.
abstract: BACKGROUND
  Use of evidence-based practices for heart failure (HF) patients has the potential to improve outcomes and reduce variations in care delivery.
  
  
  OBJECTIVE
  To evaluate the effect of a rural hospital quality collaborative and organizational context (nurse staffing and practice environment) on 4 HF core measures.
  
  
  METHODS
  Phased cluster-randomized trial with delayed intervention control group. The intervention included a HF toolkit, 2 onsite meetings, and a monthly phone call.
  
  
  METHODS
  Twenty-three rural eastern US hospitals, registered nurses who care for HF patients (N=591).
  
  
  METHODS
  Seven quarters of 4 HF core measures, nurse staffing (nursing skill mix, registered nurse hours per patient day, nurse-turnover), and a survey of practice environment.
  
  
  RESULTS
  : Using regression models with generalized estimating equation autoregressive methods, no statistically significant changes were found during the intervention period on all 4 core measures for either group. Higher nurse-turnover was related to all 4 core measures: lower compliance with discharge instructions [β=-1.042; 95% confidence interval (CI): -1.777, -0.307], smoking cessation (β=-1.148; 95% CI: -2.180, -0.117), left ventricular ejection fraction (β=-0.893; 95% CI: -1.784, -0.002), and prescribing angiotensin converting enzyme inhibitors on discharge (β=-1.044; 95% CI: -1.820, -0.269). Better practice environment was related to higher left ventricular ejection fraction (β=0.217; 95% CI: 0.054, 0.379).
  
  
  CONCLUSIONS
  Significant improvements in 4 core measures were realized in stable environments (less nurse-turnover). Assuring appropriate nurse staffing and stability is essential to increase organizational preparation for quality initiatives and adoption of best practices in HF care in rural hospitals.
authors.affiliation: Organizational Systems and Adult Health, Johns Hopkins University School of Nursing, Baltimore, MD 21201, USA. newhouse@son.umaryland.edu
authors.forename: Robin P
authors.initials: RP
authors.lastname: Newhouse
authors.forename: Cheryl
authors.initials: C
authors.lastname: Dennison Himmelfarb
authors.forename: Laura
authors.initials: L
authors.lastname: Morlock
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Frick
authors.forename: Peter
authors.initials: P
authors.lastname: Pronovost
authors.forename: Yulan
authors.initials: Y
authors.lastname: Liang
mesh_terms: D019317:Evidence-Based Medicine; D006302:Health Services Research; D006333:Heart Failure / Q000628:therapy*; D006780:Hospitals, Rural / Q000592:standards*; D006801:Humans; D009741:Nursing Staff, Hospital / Q000592:standards*; D010043:Outcome and Process Assessment, Health Care; D010561:Personnel Staffing and Scheduling; D058996:Quality Improvement; D012044:Regression Analysis; D014481:United States