Omissions of Care in Nursing Home Settings: A Narrative Review.

OBJECTIVES: This review aims to (1) examine existing definitions of omissions of care in the healthcare environment and associated characteristics and (2) outline adverse events that may be attributable to omissions of care among nursing home populations. DESIGN: Nonsystematic review. A literature search for published articles on care omissions in nursing home settings and related adverse events was performed using the databases PubMed, Web of Science, EBSCO Academic Search Premier, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) until January 2019. Articles were excluded if they were published in a language other than English or included samples that were not relevant to nursing home settings. SETTINGS AND PARTICIPANTS: Adult samples in nursing home settings or settings likely to include nursing homes as part of the continuum of care. MEASURES: Articles must provide a definition of missed or omitted care relevant to nursing home settings or include adverse events that can be attributed to care omissions. RESULTS: From a total of 2155 articles retrieved, 34 were retained for thematic synthesis. Key themes included broad agreement that any delay or failure of care is an omission; diverse views on including consideration of risks or occurrence of adverse events within the definition; diverse approaches to including components of care delivery systems in the definition; recognition that care in nursing homes includes both clinical and psychosocial care; and awareness that insufficient or inadequate resources to meet care demands can cause omissions. For research on adverse events attributable to omissions, 327 of 8385 articles were included for review. Nineteen adverse events were identified and omissions contributing to their incidence are highlighted. CONCLUSIONS/IMPLICATIONS: Definitions of omissions of care for nursing homes vary in scope and level of detail. Substantial evidence connects omissions of care with an array of adverse events in nursing home populations.

Omissions of Care in Nursing Homes: A Uniform Definition for Research and Quality Improvement.

Omission of care in US nursing homes can lead to increased risk for harm or adverse outcomes, decreased quality of life for residents, and increased healthcare expenditures. However, scholars and policymakers in long-term care have taken varying approaches to defining omissions of care, which makes efforts to prevent them challenging. Subject matter experts and a broad range of nursing home stakeholders participated in iterative rounds of engagement to identify key concepts and aspects of omissions of care and develop a consensus-based definition that is clear, meaningful, and actionable for nursing homes. The resulting definition is "Omissions of care in nursing homes encompass situations when care-either clinical or nonclinical-is not provided for a resident and results in additional monitoring or intervention or increases the risk of an undesirable or adverse physical, emotional, or psychosocial outcome for the resident." This concise definition is grounded in goal-concordant, resident-centered care, and can be used for a variety quality improvement purposes and for research.

Use of Internal Performance Measurement to Guide Improvement Within Medical Groups.

BACKGROUND: Public reporting of provider performance currently encompasses a range of measures of quality, cost, and patient experience of care. However, little is known about how medical groups use measures for performance improvement. This information could help medical groups undertake internal measurement while helping payers, policy makers, and measurement experts develop more useful publicly reported measures and quality improvement strategies. METHODS: An exploratory, qualitative study was conducted of ambulatory care medical groups across the United States that currently gather their own performance data. RESULTS: Eighty-three interviews were conducted with 91 individuals representing 37 medical groups. Findings were distilled into three major themes: (1) measures used internally, (2) strategies for using internal measurement for performance improvement, and (3) other uses of internal measurement. Medical groups used both clinical and business process measures, including measures from external measure sets and internally derived measures. Strategies for using internal measurement for quality improvement included taking a gradual, iterative approach and setting clear goals with high priority, finding workable approaches to data sharing, and fostering engagement by focusing on actionable measures. Measurement was also used to check accuracy of external performance reports, clarify and manage conflicting external measurement requirements, and prepare for anticipated external measurement requirements. Respondents in most groups did not report a need to assess costs of internal measurement or the capacity to do so. CONCLUSION: Despite challenges and barriers, respondents found great value in conducting internal measurement. Their experiences may provide valuable lessons and knowledge for medical group leaders in earlier stages of establishing internal measurement programs.

Scalability of an IT Intervention to Prevent Pressure Ulcers in Nursing Homes.

BACKGROUND: Pressure ulcers pose an important quality-of-care challenge in nursing homes, with serious consequences for residents' health. We assessed the scalability of the On-Time Pressure Ulcer Prevention (On-Time) intervention strategy, developed by the Agency for Healthcare Research & Quality, in nursing homes nationwide. INTERVENTION: On-Time uses electronic health record reports to identify changes in resident pressure ulcer risk and facilitate multidisciplinary input into clinical decision making. OBJECTIVE: To assess the scalability and impact of On-Time on pressure ulcer incidence in nursing homes. DESIGN: We used quasi-experimental methods, employing a difference-in-differences design, to compare the pre-post trends in pressure ulcer incidence in the treatment and comparison homes. SETTING AND PARTICIPANTS: The study population included long-stay residents at high risk for developing pressure ulcers in 47 nursing homes and matched comparison homes in 17 states. MEASURES: Stage 2 to 4 pressure ulcer incidence among long-stay residents who met the criteria for high risk, identified using an algorithm adapted from the Minimum Data Set 3.0 Percent of High-Risk Residents with Pressure Ulcers (Long Stay) measure. RESULTS: The overall decline in pressure ulcer rates for treatment relative to matched comparison homes was statistically insignificant (P > .05). A subgroup of heterogeneous homes experienced a statistically significant decline of 3.24 percentage points (61.0% relative decrease) in pressure ulcer rates relative to matched comparison homes, but no uniting characteristic common across homes readily explained their success. CONCLUSIONS/IMPLICATIONS: Scalability of future health information technology-based quality improvement interventions in nursing home settings requires nuanced implementation support, particularly around electronic health record report accessibility and accuracy.

The relationship between housing and health: children at risk.

In November 2002, the National Center for Healthy Housing convened a 2-day workshop to review the state of knowledge in the field of healthy housing. The workshop, supported with funds from the U.S. Centers for Disease Control and Prevention's National Center for Injury Prevention and Control and National Center for Environmental Health, was unique in that it focused solely on the effect of housing on children's health and the translation of research findings into practical activities in home construction, rehabilitation, and maintenance. Participants included experts and practitioners representing the health, housing, and environmental arenas. Presentations by subject-matter experts covered four key areas: asthma, neurotoxicants, injury, and translational research. Panel discussions followed the presentations, which generated robust dialogue on potential future research opportunities and overall policy gaps. Lack of consensus on standard measurements, incomplete understanding about the interaction of home hazards, inadequate research on the effectiveness of interventions, and insufficient political support limit current efforts to achieve healthy housing. However, change is forthcoming and achievable. Key words: asthma, childhood exposure, environmental toxicants, healthy housing, lead poisoning.