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1.
JBI Database System Rev Implement Rep ; 18(1): 146-153, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31483341

RESUMEN

OBJECTIVE: This scoping review aims to provide an overview of the current evidence on huddles in healthcare settings involving frontline staff. INTRODUCTION: Team-based models are gaining prominence as the preferred method for delivering coordinated, cost-effective, high-quality health care. Huddles are a powerful method for building relationships among frontline staff members. Currently, no reviews have described huddles used among frontline staff in clinical settings. There is therefore a need to identify gaps in the literature on evidence informing this practice for a greater understanding of the resources available for frontline staff to implement huddles. INCLUSION CRITERIA: This scoping review will consider qualitative studies, experimental and quasi-experimental studies, analytic observational studies and descriptive cross-sectional studies that explore the use of frontline staff huddles to improve quality of care in a clinical setting. METHODS: An initial limited search of PubMed and CINAHL Plus with Full Text will be performed, followed by analysis of the title, abstract and MeSH used to describe the article. Second, searches of PubMed, EBSCOhost and ProQuest will be conducted, followed by searches in reference lists of all articles that meet the inclusion criteria. Studies published in English from inception to the present will be considered. Retrieved papers will be screened for inclusion by at least two reviewers. Data will be extracted and presented in tabular form and a narrative summary that align with the review's objective.

2.
Fed Pract ; 36(5): 228-231, 2019 May.
Artículo en Inglés | MEDLINE | ID: mdl-31138976

RESUMEN

Through implementation of the LOCK bundle of practices, VA Community Living Center staff develop, pilot, and spread new systems for communication, teamwork, and collaborative problem solving as well as for developing skills to participate effectively in these systems.

3.
J Am Med Dir Assoc ; 20(7): 810-815, 2019 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-30852172

RESUMEN

OBJECTIVES: Quality improvement (QI) may be a promising approach for staff to improve the quality of care in nursing homes. However, little is known about the challenges and facilitators to implementing QI interventions in nursing homes. This study examines staff perspectives on the implementation process. DESIGN: We conducted semistructured interviews with staff involved in implementing an evidence-based QI intervention ("LOCK") to improve interactions between residents and staff through targeted staff behavior change. The LOCK intervention consists of 4 practices: (1) Learn from the bright spots, (2) Observe, (3) Collaborate in huddles, and (4) Keep it bite sized. SETTING AND PARTICIPANTS: We interviewed staff members in 6 Veterans Health Administration nursing homes [ie, Community Living Centers (CLCs)] via opportunistic and snowball sampling. MEASURES: The semistructured interviews were grounded in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change and covered staff experience, challenges, facilitators, and lessons learned during the implementation process. The interviews were analyzed using thematic content analysis. RESULTS: Overall, staff accepted the intervention and appreciated the focus on the positives. Challenges fell largely within the categories of capability and opportunity and included difficulty finding time to complete intervention activities, inability to interpret data reports, need for ongoing training, and misunderstanding of study goals. Facilitators were largely within the motivation category, including incentives for participation, reinforcement of desired behavior, feasibility of intervention activities, and use of data to quantify improvements. CONCLUSIONS/IMPLICATIONS: As QI programs become more common in nursing homes, it is critical that interventions are tailored for this unique setting. We identified barriers and facilitators of our intervention's implementation and learned that no challenge was insurmountable or derailed the implementation of LOCK. This ability of frontline staff to overcome implementation challenges may be attributed to LOCK's inherently motivational features. Future nursing home QI interventions should consider including built-in motivational components.

4.
Ethn Dis ; 29(Suppl 1): 93-96, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30906155

RESUMEN

Ensuring equitable access to quality health care historically has focused on gaps in care, where patients fail to receive the high-value care that will benefit them, something termed underuse. But providing high-quality health care sometimes requires reducing low-value care that delivers no benefit or where known harms outweigh expected benefits. These situations represent health care overuse. The process involved in reducing low-value care is known as de-implementation. In this article, we argue that de-implementation is critical for advancing equity for several reasons. First, medical overuse is associated with patient race, ethnicity, and socioeconomic status. In some cases, the result is even double jeopardy, where racial and ethnic minorities are at higher risk of both overuse and underuse. In these cases, more traditional efforts focused exclusively on underuse ignore half of the problem. Second, overuse of preventive care and screening is often greater for more socioeconomically advantaged patients. Within insured populations, this means more socioeconomically disadvantaged patients subsidize overuse. Finally, racial and ethnic minorities may have different experiences of overuse than Whites in the United States. This may make efforts to de-implement overuse particularly fraught. We therefore provide several actions for closing current research gaps, including: adding subgroup analyses in studies of medical overuse; specifying and measuring potential mechanisms related to equity (eg, double jeopardy vs thermostat models of overuse); and testing de-implementation strategies that may mitigate bias.

5.
J Patient Saf ; 2019 Feb 09.
Artículo en Inglés | MEDLINE | ID: mdl-30747858

RESUMEN

OBJECTIVES: Improving nursing home safety is important to the quality of resident care. Increasing evidence points to the relationship between actual safety and a strong safety climate, i.e., staff agreement about safety norms. This national study focused on Veterans Health Administration nursing homes (Community Living Centers [CLCs]), assessing direct care staff and senior managers' agreement about safety norms. METHODS: We recruited all 134 CLCs to participate in the previously validated CLC Employee Survey of Attitudes about Resident Safety. To assess whether safety climate domains (7) differed by management level and by direct care staff occupation, we estimated multilevel linear regression models with random effects clustered by CLCs, medical center, Department of Veterans Affairs 2017 integrated service network (n = 20), and region. RESULTS: Of the 5288 individuals we e-mailed, 1397 (25.7%) completed surveys, with participation from 56 CLCs or 41.8% of 134 CLCs. In our analysis of 1316 nurses, nursing assistants, clinicians/specialists, and senior managers, senior managers rated co-worker interactions around safety (P < 0.0013) and overall safety in their CLC (P < 0.0001) more positively than did direct care staff. In contrast, on these same two domains, direct care groups had similar perceptions, though differing significantly in safety priorities, safety attitudes, and senior management commitment to safety. CONCLUSIONS: In this national sample of nursing homes in one of the largest integrated U.S. healthcare systems, direct care staff generally perceived weaker safety processes than did senior managers, pointing to future targets for interventions to strengthen safety climate.

6.
J Nurs Care Qual ; 34(3): 210-216, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30480614

RESUMEN

BACKGROUND: Blended facilitation, which leverages the complementary skills and expertise of external and internal facilitators, is a powerful strategy that nursing stakeholders and researchers may use to improve implementation of quality improvement (QI) innovations and research performed in nursing homes. PROBLEM: Nursing homes present myriad challenges (eg, time constraints, top-down flow of communication, high staff turnover) to QI implementation and research. APPROACH: This methods article describes the theory and practical application of blended facilitation and its components (external facilitation, internal facilitation, relationship building, and skill building), using examples from a mixed QI and research intervention in Veterans Health Administration nursing homes. CONCLUSIONS: Blended facilitation invites nursing home stakeholders to be equal partners in QI and research processes. Its intentional use may overcome many existing barriers to QI and research performed in nursing homes and, by strengthening relationships between researchers and stakeholders, may accelerate implementation of innovative care practices.


Asunto(s)
Práctica Clínica Basada en la Evidencia/métodos , Casas de Salud/normas , Mejoramiento de la Calidad/tendencias , Práctica Clínica Basada en la Evidencia/normas , Humanos , Investigación Cualitativa , Calidad de la Atención de Salud/normas , Estados Unidos , United States Department of Veterans Affairs/organización & administración , United States Department of Veterans Affairs/estadística & datos numéricos , Veteranos/psicología , Veteranos/estadística & datos numéricos
7.
Geriatr Nurs ; 40(2): 129-137, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30122402

RESUMEN

Maximizing nursing home (NH) resident autonomy is a person-centered care (PCC) best practice. The purpose of this study was to identify and describe specific autonomy-supportive techniques used by nursing assistants (NAs) in three NH neighborhoods at one Veterans Affairs medical center. Thirteen interviews and approximately 80 h of behavioral observation of NAs were conducted across the three NH neighborhoods. Data were analyzed using thematic analysis. Ten autonomy-supportive tactics were identified: assisting, monitoring, encouraging, bargaining, informing, providing instructions, persuading, asking, providing options, and redirecting. Although all tactics honored some degree of resident autonomy, some were more restrictive than others. Results from the study elucidate specific actions NAs can take to promote resident autonomy, even when cognitive or physical limitations are present or there is potential concern for safety, and thereby support PCC best practice.


Asunto(s)
Cuidados a Largo Plazo , Asistentes de Enfermería/psicología , Autonomía Personal , Femenino , Hospitales de Veteranos , Humanos , Masculino , Casas de Salud , Atención Dirigida al Paciente/métodos
8.
PLoS One ; 13(9): e0203764, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-30231033

RESUMEN

Ensuring quality of care in nursing homes is a public health priority, yet how nursing home quality relates to cost is not well understood. This paper addresses this relationship for 132 VA community living centers (nursing homes), for fiscal years 2014 and 2015. We estimated cost models using the VA Decision Support System which tracks total direct costs and nursing direct costs for individual resident segments of care. We summed residents' total costs and nursing costs to the community living center level for each year. Annual facility costs then were regressed on quality of care measured with composite scores based on 13 distinct adverse events. Results indicated that higher quality was associated with higher predicted cost. However, we did not find evidence that higher costs were driven by high nurse staffing levels.


Asunto(s)
Costos de la Atención en Salud , Calidad de la Atención de Salud/economía , United States Department of Veterans Affairs , Sistemas de Apoyo a Decisiones Clínicas , Humanos , Estados Unidos
9.
J Am Geriatr Soc ; 66(8): 1648, 2018 08.
Artículo en Inglés | MEDLINE | ID: mdl-30095159

Asunto(s)
Ageísmo , Suicidio , Adulto , Anciano , Humanos
10.
Gerontologist ; 58(4): e291-e301, 2018 07 13.
Artículo en Inglés | MEDLINE | ID: mdl-29718195

RESUMEN

Background and Objectives: For nursing home residents, positive interactions with staff and engagement in daily life contribute meaningfully to quality of life. We sought to improve these aspects of person-centered care in an opportunistic snowball sample of six Veterans Health Administration nursing homes (e.g., Community Living Centers-CLCs) using an intervention that targeted staff behavior change, focusing on improving interactions between residents and staff and thereby ultimately aiming to improve resident engagement. Research Design and Methods: We grounded this mixed-methods study in the Capability, Opportunity, Motivation, Behavior (COM-B) model of behavior change. We implemented the intervention by (a) using a set of evidence-based practices for implementing quality improvement and (b) combining primarily CLC-based staff facilitation with some researcher-led facilitation. Validated resident and staff surveys and structured observations collected pre and post intervention, as well as semi-structured staff interviews conducted post intervention, helped assess intervention success. Results: Sixty-two CLC residents and 308 staff members responded to the surveys. Researchers conducted 1,490 discrete observations. Intervention implementation was associated with increased staff communication with residents during the provision of direct care and decreased negative staff interactions with residents. In the 66 interviews, staff consistently credited the intervention with helping them (a) develop awareness of the importance of identifying opportunities for engagement and (b) act to improve the quality of interactions between residents and staff. Discussion and Implications: The intervention proved feasible and influenced staff to make simple enhancements to their behaviors that improved resident-staff interactions and staff-assessed resident engagement.


Asunto(s)
Envejecimiento/psicología , Hogares para Ancianos/normas , Casas de Salud/normas , Participación del Paciente , Relaciones Profesional-Paciente , Calidad de Vida , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Motivación , Participación del Paciente/métodos , Participación del Paciente/psicología , Atención Dirigida al Paciente/normas , Mejoramiento de la Calidad , Compromiso Laboral
11.
J Eval Clin Pract ; 24(1): 198-205, 2018 02.
Artículo en Inglés | MEDLINE | ID: mdl-29314508

RESUMEN

RATIONALE AND OBJECTIVES: One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition. RESULTS: We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together. CONCLUSIONS: By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.


Asunto(s)
Toma de Decisiones Clínicas , Cognición , Formación de Concepto , Aprendizaje , Uso Excesivo de los Servicios de Salud/prevención & control , Médicos , Humanos , Modelos Psicológicos , Médicos/psicología , Médicos/normas , Pautas de la Práctica en Medicina , Práctica Profesional/normas , Mejoramiento de la Calidad
12.
Gerontologist ; 58(2): e15-e24, 2018 03 19.
Artículo en Inglés | MEDLINE | ID: mdl-28499032

RESUMEN

Purpose of Study: To develop a structured observational tool, the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE), to measure 2 critical, multi-faceted, organizational-level aspects of person-centered care (PCC) in nursing homes: (a) resident engagement and (b) the quality and frequency of staff-resident interactions. Design and Methods: In this multi-method psychometric development study, we conducted (a) 120 hr of ethnographic observations in one nursing home and (b) a targeted literature review to enable construct development. Two constructs for which no current structured observation measures existed emerged from this phase: nursing home resident-staff engagement and interaction. We developed the preliminary RAISE to measure these constructs and used the tool in 8 nursing homes at an average of 16 times. We conducted 8 iterative psychometric testing and refinement cycles with multi-disciplinary research team members. Each cycle consisted of observations using the draft tool, results review, and tool modification. Results: The final RAISE included a set of coding rules and procedures enabling simultaneously efficient, non-reactive, and representative quantitative measurement of the interaction and engagement components of nursing home life for staff and residents. It comprised 8 observational variables, each represented by extensive numeric codes. Raters achieved adequate to high reliability with all variables. There is preliminary evidence of face and construct validity via expert panel review. Implications: The RAISE represents a valuable step forward in the measurement of PCC, providing objective, reliable data based on systematic observation.


Asunto(s)
Envejecimiento/psicología , Actitud del Personal de Salud , Técnicas de Observación Conductual/métodos , Hogares para Ancianos , Casas de Salud , Participación del Paciente , Calidad de Vida , Anciano , Anciano de 80 o más Años , Femenino , Evaluación Geriátrica/métodos , Humanos , Masculino , Participación del Paciente/métodos , Participación del Paciente/psicología , Relaciones Profesional-Paciente , Psicometría/métodos , Reproducibilidad de los Resultados
13.
Gerontologist ; 58(3): 598-605, 2018 05 08.
Artículo en Inglés | MEDLINE | ID: mdl-28651351

RESUMEN

Purpose of the Study: Implementing quality improvement (QI) programs in nursing homes continues to encounter significant challenges, despite recognized need. QI approaches provide nursing home staff with opportunities to collaborate on developing and testing strategies for improving care delivery. We present a theory-driven and user-friendly adaptable framework and facilitation package to overcome existing challenges and guide QI efforts in nursing homes. Design and development: The framework is grounded in the foundational concepts of strengths-based learning, observation, relationship-based teams, efficiency, and organizational learning. We adapted these concepts to QI in the nursing home setting, creating the "LOCK" framework. The LOCK framework is currently being disseminated across the Veterans Health Administration. Results: The LOCK framework has five tenets: (a) Look for the bright spots, (b) Observe, (c) Collaborate in huddles, (d) Keep it bite-sized, and (e) facilitation. Each tenet is described. We also present a case study documenting how a fictional nursing home can implement the LOCK framework as part of a QI effort to improve engagement between staff and residents. The case study describes sample observations, processes, and outcomes. We also discuss practical applications for nursing home staff, the adaptability of LOCK for different QI projects, the specific role of facilitation, and lessons learned. Implications: The proposed framework complements national efforts to improve quality of care and quality of life for nursing home residents and may be valuable across long-term care settings and QI project types.


Asunto(s)
Ciencia de la Implementación , Casas de Salud , Mejoramiento de la Calidad , Conducta Cooperativa , Humanos , Modelos Teóricos , Observación , Estudios de Casos Organizacionales , Calidad de la Atención de Salud , Calidad de Vida
14.
Geriatr Nurs ; 39(3): 271-278, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-29129450

RESUMEN

A central component of person-centered care, resident choice in daily life, has received little research attention in the U.S. CONTEXT: This study investigated nursing home staff experiences in realizing resident choice. Twenty-six qualitative staff interviews were conducted in an opportunistic sample from two Veterans Health Administration (VHA) Community Living Centers (CLCs, i.e., nursing homes) implementing the Green House Model. Thematic content analysis surfaced several key tensions at the intra-personal, inter-personal, and organizational levels. Most salient were staff mental models within the intra-personal level. Staff conveyed a lack of clarity on how to realize resident choice when faced with varying tensions, especially the competing goal of resident medical and safety needs. Staff-employed resolutions to resident choice-related tensions also emerged (e.g., preventive practices, staff reinforcement, and staff deliberation). This study offers specific and concrete insights on how resident choice in daily life, and thus resident quality of life, can be advanced.


Asunto(s)
Conducta de Elección , Disentimientos y Disputas , Casas de Salud/tendencias , Personal de Enfermería/psicología , Humanos , Entrevistas como Asunto , Calidad de Vida
15.
Psychol Serv ; 14(3): 337-346, 2017 08.
Artículo en Inglés | MEDLINE | ID: mdl-28805418

RESUMEN

Enhanced interpersonal relationships and meaningful resident engagement in daily life are central to nursing home cultural transformation, yet these critical components of person-centered care may be difficult for frontline staff to measure using traditional research instruments. To address the need for easy-to-use instruments to help nursing home staff members evaluate and improve person-centered care, the psychometric method of cognitive-based interviewing was used to adapt a structured observation instrument originally developed for researchers and nursing home surveyors. Twenty-eight staff members from 2 Veterans Health Administration (VHA) nursing homes participated in 1 of 3 rounds of cognitive-based interviews, using the instrument in real-life situations. Modifications to the original instrument were guided by a cognitive processing model of instrument refinement. Following 2 rounds of cognitive interviews, pretesting of the revised instrument, and another round of cognitive interviews, the resulting set of 3 short instruments mirrored the concepts of the original longer instrument but were significantly easier for frontline staff to understand and use. Final results indicated frontline staff found the revised instruments feasible to use and clinically relevant in measuring and improving the lived experience of a changing culture. This article provides a framework for developing or adapting other measurement tools for frontline culture change efforts in nursing homes, in addition to reporting on a practical set of instruments to measure aspects of person-centered care. (PsycINFO Database Record


Asunto(s)
Casas de Salud/organización & administración , Cultura Organizacional , Innovación Organizacional , Mejoramiento de la Calidad , Humanos , Estados Unidos , United States Department of Veterans Affairs , Salud de los Veteranos
16.
Res Gerontol Nurs ; 10(3): 129-138, 2017 05 01.
Artículo en Inglés | MEDLINE | ID: mdl-28541589

RESUMEN

Quality of care in nursing homes has begun to address the importance of resident choice in daily life, yet there are no published tools to teach nursing home staff how to offer such choice. In the current study, a formative assessment tool was developed that can provide staff with detailed and concrete feedback on how to realize resident choice. The tool was created and refined through 22 hours of ethnographic observation in two Veterans Health Administration Community Living Centers (CLCs), 22 hours of developmental testing in two CLCs, review by a modified Delphi panel, and use of an algorithm to assess its logical structure. The resulting Supporting Choice Observational Tool (SCOT) documents how choice is or is not offered and is or is not enabled within a singular staff-resident interaction. SCOT findings could be used in clinical teaching, quality improvement, or research efforts intent on enhancing nursing home resident quality of life. [Res Gerontol Nurs. 2017; 10(3):129-138.].


Asunto(s)
Hogares para Ancianos/organización & administración , Relaciones Enfermero-Paciente , Casas de Salud/organización & administración , Satisfacción del Paciente , Encuestas y Cuestionarios/normas , Actividades Cotidianas , Anciano , Anciano de 80 o más Años , Femenino , Evaluación Geriátrica/métodos , Humanos , Masculino , Participación del Paciente
17.
Adv Skin Wound Care ; 29(5): 226-38; quiz E1, 2016 May.
Artículo en Inglés | MEDLINE | ID: mdl-27089151

RESUMEN

PURPOSE: To present findings of a study of institutional factors related to pressure ulcer (PrU) prevention in Veterans Health Administration nursing homes. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Identify the study's design, process, and purpose.2. List the factors pertaining to sites with improving performance. OBJECTIVES: Important gaps exist in the knowledge of how to achieve successful, sustained prevention of pressure ulcers (PrUs) in nursing homes. This study aimed to address those gaps by comparing nursing leadership and indirect care staff members' impressions about the context of PrU prevention in facilities with improving and declining PrU rates. SETTING: The study was conducted in a sample of 6 Veterans Health Administration nursing homes (known as community living centers) purposively selected to represent a range of PrU care performance. DESIGN AND PARTICIPANTS: One-time 30-minute semistructured interviews with 23 community living center staff were conducted. Qualitative interview data were analyzed using an analytic framework containing (a) a priori analytic constructs based on the study's conceptual framework and (b) sections for emerging constructs. MAIN RESULTS: Analysis revealed 6 key concepts differentiating sites with improving and declining PrU care performance. These concepts were (1) structures through which the change effort is initiated; (2) organizational prioritization, alignment, and support; (3) improvement culture; (4) clarity of roles and responsibilities; (5) communication strategies; and (6) staffing and clinical practices. Results also pointed to potential contextual facilitators of and barriers to successful PrU prevention. CONCLUSIONS: Leadership's visible prioritization of and support for PrU prevention and the initiation of PrU prevention activities through formal structures were the most striking components represented at sites with improving performance, but not at ones where performance declined. Sites with improving performance were more likely to align frontline staff and leadership goals for PrU prevention.


Asunto(s)
Grupo de Enfermería/organización & administración , Úlcera por Presión/prevención & control , Prevención Primaria/organización & administración , Cicatrización de Heridas/fisiología , Anciano , Anciano de 80 o más Años , Femenino , Hogares para Ancianos/organización & administración , Humanos , Entrevistas como Asunto , Cuidados a Largo Plazo/organización & administración , Masculino , Casas de Salud/organización & administración , Úlcera por Presión/enfermería , Investigación Cualitativa , Mejoramiento de la Calidad , Medición de Riesgo , Cuidados de la Piel/normas
18.
J Am Geriatr Soc ; 64(1): 151-5, 2016 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-26782865

RESUMEN

OBJECTIVES: 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. DESIGN: Four-year retrospective longitudinal design. SETTING: VHA facilities (N=109) representing 132 nursing homes known as community living centers (CLCs). PARTICIPANTS: VHA nursing home residents. MEASUREMENTS: 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. CONCLUSION: 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.


Asunto(s)
Hogares para Ancianos , Casas de Salud , Úlcera por Presión , Anciano , Anciano de 80 o más Años , Femenino , Hogares para Ancianos/normas , Hogares para Ancianos/estadística & datos numéricos , Humanos , Cuidados a Largo Plazo/métodos , Cuidados a Largo Plazo/normas , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Casas de Salud/normas , Casas de Salud/estadística & datos numéricos , Cultura Organizacional , Úlcera por Presión/diagnóstico , Úlcera por Presión/epidemiología , Úlcera por Presión/etiología , Úlcera por Presión/prevención & control , Estudios Retrospectivos , Ajuste de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Estados Unidos/epidemiología , Veteranos
19.
Geriatr Nurs ; 34(5): 388-94, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-23850129

RESUMEN

This article describes the development and particulars of a new, comprehensive model of nursing home culture change, the Nursing Home Integrated Model for Producing and Assessing Cultural Transformation (Nursing Home IMPACT). This model is structured into four categories, "meta constructs," "care practices," "workplace practices," and "environment of care," with multiple domains under each. It includes detailed, triangulated assessment methods capturing various stakeholder perspectives for each of the model's domains. It is hoped that this model will serve two functions: first, to help practitioners guide improvements in resident care by identifying particular areas in which culture change is having positive effects, as well as areas that could benefit from modification; and second, to emphasize the importance in culture change of the innumerable perspectives of residents, family members, staff, management, and leadership.


Asunto(s)
Modelos Organizacionales , Casas de Salud/organización & administración , Cultura Organizacional , Innovación Organizacional , Humanos , Pacientes Internos/psicología , Admisión y Programación de Personal , Calidad de Vida , Administración de la Seguridad , Lugar de Trabajo
20.
Res Gerontol Nurs ; 6(3): 152-60, 2013 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-23777296

RESUMEN

This study examined nursing home staff members' comfort levels with specific culture change scenarios and observed whether there were differences by occupation. We conducted a cross-sectional survey of 218 staff members in all occupational categories at four Veterans Health Administration Community Living Centers (i.e., nursing homes). Staff indicated their comfort level using a 9-point scale (1 = not at all comfortable to 9 = extremely comfortable). The culture change scenarios were divided into three subscales: Resident Safety (5 items), Resident Experience (5 items), and Staff Experience (2 items). Overall, respondents were slightly uncomfortable with the scenarios (overall mean = 4.57). Staff reported least comfort with the Resident Safety subscale (mean = 3.63) and most comfort with the Resident Experience subscale (mean = 5.65), with significant differences within these two subscales by occupational category. Existent power differentials among staff may influence comfort levels with culture change. Assessing staff comfort with culture change may help guide implementation efforts in a strategic manner.


Asunto(s)
Empleo/psicología , Casas de Salud , Cultura Organizacional , Innovación Organizacional , Estudios Transversales , Humanos , Seguridad del Paciente , Recursos Humanos
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