Modeling efficiency at the process level: an examination of the care planning process in nursing homes.

OBJECTIVE: To examine the efficiency of the care planning process in nursing homes. METHODS: We collected detailed primary data about the care planning process for a stratified random sample of 107 nursing homes from Kansas and Missouri. We used these data to calculate the average direct cost per care plan and used data on selected deficiencies from the Online Survey Certification and Reporting System to measure the quality of care planning. We then analyzed the efficiency of the assessment process using corrected ordinary least squares (COLS) and data envelopment analysis (DEA). RESULTS: Both approaches suggested that there was considerable inefficiency in the care planning process. The average COLS score was 0.43; the average DEA score was 0.48. The correlation between the two sets of scores was quite high, and there was no indication that lower costs resulted in lower quality. For-profit facilities were significantly more efficient than not-for-profit facilities. CONCLUSIONS: Multiple studies of nursing homes have found evidence of inefficiency, but virtually all have had measurement problems that raise questions about the results. This analysis, which focuses on a process with much simpler measurement issues, finds evidence of inefficiency that is largely consistent with earlier studies. Making nursing homes more efficient merits closer attention as a strategy for improving care. Increasing efficiency by adopting well-designed, reliable processes can simultaneously reduce costs and improve quality.

Strategies for translating the resident care plan into daily practice.

The Omnibus Budget Reconciliation Act of 1987 required nursing facilities to complete a standardized comprehensive assessment known as the Resident Assessment Instrument (RAI) and to formulate a plan of care from the RAI to guide nursing care. The purpose of this retrospective case study was to examine the issues around the translation of nursing facility resident care plans to documents that guide daily care. Data were obtained by auditing 96 resident care plans in 10 nursing facilities in two states. Despite the importance of the resident plan of care, the audit revealed the provider approaches to resident problems varied appreciably in nursing facilities. The results of this study support the need for further research to assist in the development and implementation of strategies in nursing facilities that focus on standardized practices. Consistent systems can be promoted that translate the resident care plan into daily practice.

Care planning integrity in nursing facilities.

BACKGROUND: Although there is some evidence of improved quality in nursing home care after the implementation of the 1987 Omnibus Budget Reconciliation Act regulations, the nursing processes that contribute to that improvement are not well understood. Assumptions that the mandated tools for resident assessment and care planning account for the change remain uninvestigated. OBJECTIVES: To generate an empirically supported conceptual model of care planning integrity, incorporating five subconstructs: coordination, integration, interdisciplinary team, restorative perspective, and quality. METHODS: A correlational, model generation-model selection design guided the study. Using a random sample of 107 facilities, the research team combined primary data collected from care planning team members (n = 508) via a telephone survey, with variables extracted from the Medicaid Cost Reports and the Centers for Medicaid and Medicare Services Online Survey, Certification, and Reporting System (OSCAR) database. Primary and alternative models of care planning integrity were examined for fit to the data using structural equation modeling procedures. RESULTS: Using preliminary analyses, 18 observed indicators to represent the five latent subconstructs were identified. Fit indices for the primary model were borderline (comparative fit index =.892; root mean square error of approximation = .048), but were excellent for the alternative model (comparative fit index = .972; root mean square error of approximation = .026). Care planning integrity is demonstrated within nursing facilities through direct relationships with coordination, integration, and quality, and indirect relationships through integration with interdisciplinary team and restorative perspective. DISCUSSION: Care planning integrity captures differences in the way nursing facilities implement the care planning process, using the mandated standardized tools, that may make a difference in resident outcomes. Subsequent research is indicated to address those dynamics.

Care planning efficiency for nursing facilities.

The project reported here is the first in a series of cost analyses regarding the care planning process among 107 facilities. Process-based costing strategies and data envelopment analyses identified nursing facilities with efficient and less-efficient care planning processes. Having more people and more time devoted to the care planning process did not assure quality or efficiency. Efficiency varied across the nursing facilities and was not related to number of beds, profit status, or location; however, Medicare-certified facilities were less likely to be efficient.

Issues in nursing: strategies for an Internet-based, computer-assisted telephone survey.

The study describes the design and implementation of an Internet-based, computed-assisted telephone survey about the care-planning process in 107 long-term care facilities in the Midwest. Two structured telephone surveys were developed to interview the care planning coordinators and their team members. Questionmark Perception Software Version 3 was used to develop the surveys in a wide range of formats. The responses were drawn into a database that was exported to a spreadsheet format and converted to a statistical format by the Information Technology team. Security of the database was protected. Training sessions were provided to project staff. The interviews were tape-recorded for the quality checks. The inter-rater reliabilities were above 95% to 100% agreement. Investigators should consider using Internet-based survey tools, especially for multisite studies that allow access to larger samples at less cost. Exploring multiple software systems for the best fit to the study requirements is essential.

Continent or incontinent? That is the question.

A qualitative, emergent, case study design guided the description of care provided to nursing home residents with urinary incontinence in three Midwestern nursing facilities. Participants included 17 residents and 16 family members or friends of the respective residents. Staff and managers involved in the planning and delivery of care to the participating residents also were included. The three facilities represented variation in size, location, ownership, and Medicare certification. Data were collected via observation, resident record audit, and semi-structured interview. Definitions of incontinence varied among staff. A collectively held expectation that residents would be toileted every 2 hours was not met. Maintaining skin integrity was the primary motivation for keeping residents clean and dry. Medical directors viewed incontinence as a nursing problem. Staff described situations in which incontinence was improved for specific residents, but there was little evidence of formal programs to maintain continence or improve incontinence.

The context for nursing home resident care: the role of leaders in developing strategies.

Data obtained from three Midwestern nursing homes were used to identify and describe contextual factors that influenced resident care. A qualitative, emergent, case study design guided the study. In addition to 17 residents and 16 family members or friends of the respective residents, participants included 66 staff members and 9 managers involved in the planning and delivery of care to the participating residents. Data were collected via observation, semi-structured interview, and resident record audit. Contextual factors seemed to integrate or fragment care planning and delivery. Important integrators were shared values, the role of the Minimum Data Set coordinator, the role of other leaders, and family influence. Two fragmenting factors, competing demands for the staff members' time and a task orientation to care, appeared to be ubiquitous. External accountability also fragmented care to a discernible degree.

Care planning for nursing home residents: incorporating the Minimum Data Set requirements into practice.

This study was designed to describe the care-planning process used in nursing homes and identify links among care planning, care provided, and the Resident Assessment Instrument and Minimum Data Set (MDS). Study participants in three Midwestern nursing homes included residents and family members, MDS coordinators, direct care staff, administrators, directors of nursing, and medical directors. Data were collected via semi-structured interview, observation, and resident record audit. The care-planning process differed among the three facilities despite the common MDS system structure. Care planning and the MDS system were linked to the care provided to residents through documentation in residents' records, translation of the MDS care plan to the documents used for daily care, and ongoing communication through end-of-shift report and other venues.

The NDNQI-Adapted Index of work satisfaction.

The valid measurement of nurses' job satisfaction is critical because job satisfaction is important for the retention of qualified nurses to provide patient care in hospitals. Two studies were conducted to adapt the Stamps Index of Work Satisfaction (1997b) to measure work satisfaction at the patient care unit level for use by the National Database of Nursing Quality Indicators (NDNQI). In Study 1 (n = 918 RNs) exploratory factor analysis of data obtained using the NDNQI-Adapted Index replicated the conceptual dimensions of the Stamps measure. Associations with scores on Job Enjoyment were evidence that the Index measured the intended construct. Using theta, the reliability of the composite subscales was .91. The adapted Work Satisfaction subscale scores explained 46% of the variance in Job Enjoyment, with each subscale contributing uniquely (p < .001). In Study 2 (n = 2277 RNs) confirmatory factor analysis using structural equation modeling supported the 7-subscale structure for the Adapted Index (CFI [719] = .88; RMR = .05). Replication of associations between scores on the Index subscales and Job Enjoyment provided further evidence regarding validity of the data, since the Work Satisfaction subscales explained 56% of the variance in Job Enjoyment. The feasibility of using an on-line version of the Adapted-Index for data collection was demonstrated. The findings from the two studies indicate that the adapted Index of Work Satisfaction has a structure similar to the original instrument and is a reliable and valid measure of work satisfaction at the patient care unit level.

Process-based costing.

Understanding how quality improvement affects costs is important. Unfortunately, low-cost, reliable ways of measuring direct costs are scarce. This article builds on the principles of process improvement to develop a costing strategy that meets both criteria. Process-based costing has 4 steps: developing a flowchart, estimating resource use, valuing resources, and calculating direct costs. To illustrate the technique, this article uses it to cost the care planning process in 3 long-term care facilities. We conclude that process-based costing is easy to implement; generates reliable, valid data; and allows nursing managers to assess the costs of new or modified processes.

Nurse anesthesia research: a follow-up study.

We describe a follow-up study comparing nurse anesthesia research in the 1990s with findings of a previous study. Research reported in the AANA journal in 1995 and 1996 (n = 38 studies) was compared with the earlier description of research from 1985-1986 (n = 18) and 1975-1976 (n = 14) periods. The amount of research published in the Journal has increased steadily, with a stable focus on clinical practice. In addition, there has been an increase in educational and safety-related research reported. In an attempt to locate research published in other nursing and medical journals, we found and reviewed additional articles (n = 28) authored or coauthored by CRNAs during the 1995-1996 period. By the 1990s, all studies demonstrated at least 1 indicator of theoretical orientation. Convenience samples of hospitalized patients were the most common type of sample. As in the earlier study, there was minimal reporting on reliability and validity of data and the psychometric evaluation of instruments. Recommendations include increased emphasis on methodological studies, multisite studies, programs of research, and collaboration among CRNAs, nurses in other specialties, and people in other disciplines.