title: Inside the Green House "Black Box": Opportunities for High-Quality Clinical Decision Making.
abstract: OBJECTIVE
  To develop a conceptual model that explained common and divergent care processes in Green House (GH) nursing homes with high and low hospital transfer rates.
  Eighty-four face-to-face, semistructured interviews were conducted with direct care, professional, and administrative staff with knowledge of care processes in six GH organizations in six states.
  
  
  METHODS
  The qualitative grounded theory method was used for data collection and analysis. Data were analyzed using open, axial, and selective coding. Data collection and analysis occurred iteratively.
  
  
  RESULTS
  Elements of the GH model created significant opportunities to identify, communicate, and respond to early changes in resident condition. Staff in GH homes with lower hospital transfer rates employed care processes that maximized these opportunities. Staff in GH homes with higher transfer rates failed to maximize, or actively undermined, these opportunities.
  
  
  CONCLUSIONS
  Variations in how the GH model was implemented across GH homes suggest possible explanations for inconsistencies found in past research on the care outcomes, including hospital transfer rates, in culture change models. The findings further suggest that the details of culture change implementation are important considerations in model replication and policies that create incentives for care improvements.
authors.affiliation: School of Nursing, University of Wisconsin-Madison, Madison, WI.
authors.forename: Barbara
authors.initials: B
authors.lastname: Bowers
authors.affiliation: School of Nursing, University of Wisconsin-Madison, Madison, WI.
authors.forename: Tonya
authors.initials: T
authors.lastname: Roberts
authors.affiliation: School of Nursing, University of Wisconsin-Madison, Madison, WI.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Nolet
authors.affiliation: Center for Health Systems Research and Analysis, University of Wisconsin-Madison, Madison, WI.
authors.forename: Brenda
authors.initials: B
authors.lastname: Ryther
mesh_terms: D000066491:Clinical Decision-Making / Q000379:methods*; D066296:Grounded Theory; D006801:Humans; D009735:Nursing Homes / Q000458:organization & administration*; D009740:Nursing Staff / Q000458:organization & administration; D009936:Organizational Innovation; D010359:Patient Readmission; D010360:Patient Transfer / Q000706:statistics & numerical data; D036301:Qualitative Research
keywords: Medical decision making; culture change; long-term care; nursing; nursing homes; qualitative research