title: Longitudinal Pressure Ulcer Rates After Adoption of Culture Change in Veterans Health Administration Nursing Homes.
abstract: OBJECTIVE
  To examine facility-level pressure ulcer (PrU) development rates and variations in these rates after a system-wide adoption of culture change in Veterans Health Administration (VHA) nursing homes.
  
  
  METHODS
  Four-year retrospective longitudinal design.
  
  
  METHODS
  VHA facilities (N=109) representing 132 nursing homes known as community living centers (CLCs).
  
  
  METHODS
  VHA nursing home residents.
  
  
  METHODS
  PrUs were identified using fiscal year (FY) 2008-11 Minimum Data Set (MDS) data. PrU development was defined as a Stage 2 or larger PrU on an MDS assessment with no PrU on the previous assessment. A risk adjustment model was developed using 105,274 MDS observations to predict the likelihood of PrUs (c-statistic=0.72). A Bayesian hierarchical model that adjusted for differences in the precision of PrU rates from different-size facilities was used to calculate smoothed risk-adjusted (SRA) rates for each facility. The statistical significance of the trend over the 4 years was determined by examining the 95% interval estimate for the slope.
  
  
  RESULTS
  Over the 4-year period, the beginning of which coincided with the VHA's system-wide adoption of culture change as a performance measure, median SRA facility PrU development rates were fairly consistent at approximately 4%. The range in SRA rates declined over the years, from a 14.8-percentage point spread to 10.1-percentage point spread. Some facilities had significantly improving SRA rates (e.g., declined steadily from 5.5% to 3.9%) and some had significantly worsening SRA rates (e.g., increased steadily from 5.1% to 7.9%). Seven sites had significantly improving rates (P<.001) that were below the median across all 4 years.
  
  
  CONCLUSIONS
  A system-wide culture change implementation did not affect CLC PrU development rates, but there was significant variation in facility rates, and some facilities had sustained high performance.
authors.affiliation: Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts.|Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts.
authors.forename: Christine W
authors.initials: CW
authors.lastname: Hartmann
authors.affiliation: Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.|School of Management, Boston University, Boston, Massachusetts.
authors.forename: Michael
authors.initials: M
authors.lastname: Shwartz
authors.affiliation: Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts.
authors.forename: Shibei
authors.initials: S
authors.lastname: Zhao
authors.affiliation: Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Palmer
authors.affiliation: Center for Healthcare Organization and Implementation Research, Bedford Veterans Affairs Medical Center, Bedford, Massachusetts.|Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts.
authors.forename: Dan R
authors.initials: DR
authors.lastname: Berlowitz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006707:Homes for the Aged / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D008134:Long-Term Care / Q000379:methods / Q000592:standards; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009735:Nursing Homes / Q000592:standards / Q000706:statistics & numerical data; D015279:Organizational Culture; D003668:Pressure Ulcer / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D012189:Retrospective Studies; D020379:Risk Adjustment; D012307:Risk Factors; D012720:Severity of Illness Index; D014481:United States / Q000453:epidemiology; D014728:Veterans
keywords: culture change; nursing homes; pressure ulcer; veterans health