Perception gap in quality-of-life ratings: an empirical investigation of nursing home residents and caregivers.

PURPOSE: Several studies have previously documented the existence of a perception gap-the extent to which quality-of-life ratings provided by nursing home residents and caregivers diverge. In this study we use Helson's adaptation-level theory to investigate three types of antecedents: (a) focal factors, (b) background factors, and (c) residual factors. DESIGN AND METHODS: We calculated the perception gap for 11 quality-of-life domains. Caregivers rated both job satisfaction and their perception of quality of life of residents in the unit where they provided service. Concurrently, residents from these units completed quality-of-life interviews. We computed the perception gap by subtracting the residents' ratings from the caregivers' ratings for each quality-of-life domain. We conducted a hierarchical linear model using 3,850 observations to predict the perception gap. RESULTS: Caregivers perceive quality of life to be lower than residents do across all domains fairly consistently. Caregiver demographics do not directly predict the perception gap. However, satisfaction with work, pay, and promotion were significant predictors (p <.05), and satisfaction with supervisor was a marginally significant predictor (p <.10), of the perception gap. As satisfaction with these job dimensions increased, the perception gap decreased. Additional models show that several caregiver demographics directly influence job-satisfaction dimensions, though they did not influence the perception gap. IMPLICATIONS: Job-satisfaction dimensions, rather than caregiver characteristics, are the appropriate predictors of the perception gap. However, caregiver demographics exert their influence indirectly by means of job satisfaction. A key finding is that higher job satisfaction leads to a smaller perception gap. Helson's adaptation-level theory appears to be a useful approach for understanding the antecedents of the perception gap.

Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home.

OBJECTIVE: Quality improvement (QI) processes in nursing homes are highly variable and often ineffective. This study evaluated an innovative QI process to reduce pressure ulcers (PUs) in a nursing home with a high rate of PUs. DESIGN: This was a 48-week, longitudinal study comparing the incidence of PUs during 12-week baseline and intervention and post-intervention periods. SETTING: Not-for-profit, 136-bed nursing home in urban Western Pennsylvania. PATIENTS OR OTHER PARTICIPANTS: All residents and all staff at the nursing home participated in this study. INTERVENTIONS: The intervention consisted of 3 components: Ability enhancement, incentivization, and management feedback. To enhance ability, all staff members completed a computer-based interactive video education program on PU prevention and were mandated to use penlights to promote early detection. Incentivization included $75 for each staff member if the desired reduction in PU incidence was achieved. Management feedback provided real-time information of staff"s adherence to the mandated training. MAIN OUTCOME MEASURES: Outcome measures consisted of staff's adherence to mandated training and the incidence of new PUs during the baseline period compared to the intervention and post-intervention periods. RESULTS: Management responded to noncompliance with training with both rewards and stepped discipline. Adherence to protocol, as measured by training compliance, was 100%. There was a significant reduction (P < .05) in the incidence of stage 2 or worse PUs during the intervention period. During the post-intervention periods, the effect was lost. CONCLUSION: An innovative QI initiative resulted in a significant decrease in PUs in 1 facility. This intervention was not sustainable when the 3 components of the QI intervention were no longer actively maintained.

Organizational change and quality improvement in nursing homes: approaching success.

Nursing home residents' quality of life (QoL) is directly related to the quality improvement (QI) processes mandated by federal law. This article describes a 3-year longitudinal study of QI process innovations in two nursing homes and highlights details of a successful 6-month initiative. The initial QI initiatives were based on the principles of staff empowerment, enhanced ability through training, and financial incentives. After 18 months without measurable success, the QI process was modified to include real-time feedback. Two not-for-profit nursing homes participated in this study to explore the effect of organizational change in nursing homes on residents' quality of care and QoL and staff members' job satisfaction. At 6-month intervals, residents and staff participated in structured assessments of residents' QoL and quality of care and staff members' job satisfaction. When the QI process was modified to include real-time feedback, there was a significant reduction in the rate of new pressure ulcers, stage 2 or greater (p < .05), in one of the facilities that had struggled with this problem for more than 18 months. By examining QI processes in nursing homes, the researchers were able to identify some of the obstacles to improving quality of care and QoL. Only when the element of real-time feedback was introduced, in combination with enhanced staff abilities and financial incentives, were substantial improvements seen in key clinical outcomes.