Patient safety culture assessment in the nursing home.

OBJECTIVE: To assess patient safety culture (PSC) in the nursing home setting, to determine whether nursing home professionals differ in their PSC ratings, and to compare PSC scores of nursing homes with those of hospitals. METHODS: The Hospital Survey on Patient Safety Culture was modified for use in nursing homes (PSC-NH) and distributed to 151 professionals in four non-profit nursing homes. Mean scores on each PSC-NH dimension were compared across professions (doctors, pharmacists, advanced practitioners and nurses) and with published benchmark scores from 21 hospitals. RESULTS: Response rates were 68.9% overall and 52-100% for different professions. Most respondents (76%) were women and had worked in nursing homes for an average of 9.8 years, and at their current facility for 5.4 years. Professions agreed on 11 of 12 dimensions of the survey and differed significantly (p<0.05) only in ratings for one PSC dimension (attitudes about staffing issues), where nurses and pharmacists believed that they had enough employees to handle the workload. Nursing homes scored significantly lower (ie, worse) than hospitals (p<0.05) in five PSC dimensions (non-punitive response to error, teamwork within units, communication openness, feedback and communication about error, and organisational learning). CONCLUSIONS: Professionals in nursing homes generally agree about safety characteristics of their facilities, and the PSC in nursing homes is significantly lower than that in hospitals. PSC assessment may be helpful in fostering comparisons across nursing home settings and professions, and identifying targets for interventions to improve patient safety.

A culture of patient safety in nursing homes.

BACKGROUND: Few accounts of patient safety initiatives in nursing homes exist. OBJECTIVE: To (1) determine safety culture scores for nursing homes and (2) compare these results with existing data from hospitals. METHODS: Data were collected from a nationally representative sample of nursing homes (n = 2840 completed surveys and a response rate of 71%). From these nursing homes, administrators completed The Hospital Survey On Patient Safety Culture (HSOPSC) instrument. RESULTS: 11 of the 12 HSOPSC subscale scores from the nursing home sample were considerably lower than the benchmark hospital scores. In addition, almost all item scores from nursing homes were considerably lower than the benchmark hospital scores. These results indicate that a less well-developed safety culture exists in nursing homes. CONCLUSIONS: The results clearly show that the patient safety culture scores of nursing homes are considerably lower than those of hospitals. Residents of nursing homes may be at risk of harm as a result of patient safety errors.

Administrator turnover and quality of care in nursing homes.

PURPOSE OF THE STUDY: In this article, I examine the association between turnover of nursing home administrators and five important quality of care outcomes. DESIGN AND METHODS: The data came from a survey of 420 nursing facilities and the 1999 On-line Survey, Certification, and Reporting System. Using multivariate logistic regression analyses, I looked at the effects of turnover of administrators in nursing homes belonging to chain organizations and in nursing homes not belonging to chain organizations. RESULTS: I found the average annual turnover rate of administrators to be 43%. The multivariate logistic regression analyses show that in nursing homes belonging to chains, administrator turnover is associated with a higher than average proportion of residents who were catheterized, had pressure ulcers, and were given psychoactive drugs and with a higher than average number of quality-of-care deficiencies. In nursing homes not belonging to chains I found that turnover of administrators is associated with a higher than average proportion of residents who were restrained, were catheterized, had pressure ulcers, and were given psychoactive drugs. IMPLICATIONS: There is a need to improve understanding of how and why better outcomes are achieved in some nursing homes. This investigation serves to focus attention on nursing home administrators. I believe this study provides preliminary evidence that the turnover of administrators may have an important association with quality of care in nursing homes.

Relocation of the elderly.

In this article, the author reviews 78 studies addressing the relocation of the elderly. He begins by defining the four major forms of relocation and describing the trends in the current health care marketplace precipitating relocation events. Next, he reviews the major findings of studies assessing the potential negative and positive outcomes of relocation. These outcomes include changes in mortality rates, morbidity, and psychological or social changes. In addition, factors associated with successful relocation are presented. Finally, the primary contribution of this article is that the author assesses the strengths and limitations of this prior literature and combines the research he reviews in an analytic model. This model helps show some opportunities for future research in the relocation of the elderly.

Innovation in nursing homes: which facilities are the early adopters?

PURPOSE: This study examined organizational and market factors associated with nursing homes that are most likely to be early adopters of innovations. Early adopter institutions, defined as the first 20% of facilities to adopt an innovation, are important because they subsequently facilitate the diffusion of innovations to others in the industry. DESIGN AND METHODS: Two groups of innovations were examined, special care units and subacute care services. I used discrete-time logistic regression analysis and nationally representative data from 13,162 facilities at risk of being early adopters of innovations during twelve 6-month intervals from 1992 to 1997. RESULTS: Organizational factors that increase the likelihood of early innovation adoption are larger bed size, chain membership, and high levels of private-pay residents. Four market factors that increase the likelihood of early innovation adoption are: a retrospective Medicaid reimbursement methodology, a more competitive environment, higher average income in the county, and a higher number of hospital beds in the county. IMPLICATIONS: This analysis shows that organizational and market characteristics of nursing homes affect their propensity toward early adoption of innovations. Some of the results may be useful for nursing home administrators and policy makers attempting to promote innovation.

Citations and compliance with the Nursing Home Reform Act of 1987.

The purpose of this article is to show which Nursing Home Reform Act (NHRA) regulations nursing homes are, and are not, complying with. This is achieved by using deficiency citations that are issued by state and federal inspectors when a facility does not meet a NHRA standard. Structural and process characteristics of nursing homes associated with these deficiency citations are presented. The results of these analyses are discussed in terms of their policy issues.

Deficiency citations for mental health care in nursing homes.

The Centers for Medicare and Medicaid Services (CMS) certifies approximately 17,000 nursing homes per year. When a facility does not meet a standard, a deficiency citation is issued. Using 1998 citations, we examined the structure and process characteristics of nursing homes that were associated with mental health deficiencies. Our findings showed that (a) some nursing homes have a high number of deficiencies in the area of mental health care; (b) these deficiencies do not appear to be associated with specific processes used in nursing homes; and (c) some structural factors such as staffing, private-pay occupancy, and Medicare occupancy appear to have an important influence on the number of mental health care deficiencies.

Deficiency citations for physical restraint use in nursing homes.

OBJECTIVES: The average percentage of residents restrained in nursing homes is approximately 20%. Facilities that do not meet Health Care Financing Administration standards for restraint use may be issued a deficiency citation. This article investigates which structure and process factors of nursing homes are associated with a deficiency citation for restraint use. METHODS: Nationally representative data from the 1997 On-line Survey Certification of Automated Records are used, first, to provide descriptive analyses, and second, for logistic regression analyses of structure and process factors associated with a deficiency citation for restraint use. RESULTS: A total of 2,321 facilities were found to have at least one restraint deficiency citation, and 14,703 had none. After controlling for seven other key variables, five structural factors and six process factors are significant. The structural factors--larger bed size, for-profit ownership, and hospital based--were significantly associated with a higher likelihood of a deficiency citation for restraint use; whereas higher numbers of full-time equivalent specialists per resident and nurse aide training were significantly associated with a lower likelihood. The process factors--suctioning therapy, pain management, and bladder training--were significantly associated with a lower likelihood of a deficiency citation for restraint use; whereas intravenous therapy, higher use of catheters, and physical restraints were significantly associated with a higher likelihood of a deficiency citation. DISCUSSION: This analysis establishes linkages between structures and processes and the outcome of a deficiency citation for restraint use. The structural results may have some utility for regulators. They could be used to develop a specific program to target facilities most commonly found to have inappropriate restraint use. The process results may have some utility for providers who could use the information to target residents for review of inappropriate restraint use.

Differences in nursing homes with increasing and decreasing use of physical restraints.

OBJECTIVES: This article examines the organizational characteristics of nursing homes associated with increasing and decreasing use of physical restraints since the implementation of the Nursing Home Reform Act (NHRA) in 1991. METHODS: Nationally representative data from the 1992 and 1997 On-Line Survey Certification of Automated Records are used first to provide descriptive analyses and second for multinomial logistic regression analyses of organizational factors associated with an increase or decrease in physical restraint use. RESULTS: The results show that 2,331 nursing homes increased their use of restraints by >4% and 2,100 decreased their use of restraints by >3%. Ownership, Alzheimer's special care units, and average occupancy rates have bidirectional influence and are associated with both decreases and increases in restraint use, depending on their values. Chain membership and staffing levels of rehabilitation services are associated with increases in restraint use, whereas Medicaid census and private-pay census are associated with decreases in restraint use. Change factors were also important. An increase in Medicaid census and a change to chain membership since 1991 have an unsettling effect on care practices, increasing restraint use. CONCLUSIONS: Although the period used in this analysis represents a time frame in which the restraint reduction mandates of the NHRA were in effect, these results show that some nursing homes have increased their use of physical restraints. The organizational characteristics of these nursing homes differ from those that decreased their use of physical restraints.

Outcomes measurement and quality improvement in long-term care.

As healthcare providers proceed with redesigning patient care, forming centers of excellence, developing clinical pathways, focusing on best practices, and restructuring care services in their efforts to improve the structures and the processes of healthcare, outcomes research can help to determine the most effective patient care regimens. In a similar manner, outcomes are also assuming a higher priority for administrators of long-term care facilities. This article defines outcomes, discusses how they are being used in long-term care settings, presents commonly used outcomes, and describes how these outcomes can be measured and graphically displayed.

Facility characteristics associated with hospitalization of nursing home residents: results of a national study.

OBJECTIVES: To test the effect of facility characteristics on the probability of hospitalization of nursing home residents, controlling for resident characteristics and the competing risk of death. RESEARCH DESIGN: Study data were derived from the evaluation of the implementation of the Resident Assessment Instrument, the Minimum Data Set (MDS) in 1993. The data consisted of 2080 residents in 253 NHs as well as the annual On-Line Survey Certification of Automated Records (OSCAR). MEASURES: Multinomial logistic regression was used to determine the effects of selected resident and facility characteristics on hospitalization or death within 6 months of baseline, adjusting for the complex sampling design (using SUDAAN). RESULTS: By controlling for resident demographics, advance directives, diagnoses, selected clinical signs, and type of payer, we found that homes with special care units, more physicians (above the median 0.08 FTE physicians on staff or contract), and any physician extenders (nurse practitioners or physician assistants) were less likely to hospitalize their residents. Homes in which over 3.6% of the residents received respiratory treatment were more likely to hospitalize their residents. CONCLUSIONS: Findings suggest that Medicare HMOs should consider the capacity of nursing facilities, especially in terms of medical care capacity and clinical resources, to limit hospital admissions.

Hospice and nursing homes.

In this article a descriptive analysis of nursing homes with special care hospice units is provided. These are compared to nursing homes with other special care units and to nursing homes without any special care units. An analysis of the determinants of nursing homes with special care hospice units is also provided. Factors such as ownership, staffing levels, having other special care units, case-mix intensity, competitiveness of the nursing home market, and the state Medicaid reimbursement rate structure are examined. Finally, the influence of policies on hospice care in nursing homes is discussed.

Physical restraints in nursing homes: a review of the literature since the Nursing Home Reform Act of 1987.

The use of physical restraints is one of the most negative features of nursing home care. Their use significantly affects the quality of life of residents. In an attempt to limit the use of restraints, the Nursing Home Reform Act (NHRA) of 1987 contained provisions regulating their use. In this article, the authors review the literature on the use and consequences of physical restraints in nursing homes since the passage of the NHRA. First, they describe the history behind the use of restraints and define what is considered to be a physical restraint. Second, they examine the four most common justifications for restraint use. Third, they describe the incidence and prevalence of restraint use. Fourth, they address demographic and clinical characteristics of residents that have been found to be associated with restraint use. Fifth, they examine negative outcomes of restraining residents. Finally, they describe alternatives to using restraints.

Advance care planning in nursing homes: pre- and post-Patient Self-Determination Act.

OBJECTIVES: (1) To identify resident and organizational factors associated with the use of advance care plans pre- and post-implementation of the Patient Self-Determination Act (PSDA), and (2) to identify changes (pre- and post-implementation of the PSDA) in the relationship between these factors and the use of advance care plans. DESIGN: Complex, multistage cluster sampling. SETTING: Ten states were selected for variation in geographic location, Medicaid reimbursement rate, and average staffing patterns. Participants were 4,215 nursing home residents in 268 facilities. PRINCIPAL FINDINGS: Seventeen resident and organizational factors were associated with the use of do-not-resuscitate (DNR) orders in 1990, and 12 resident and organizational factors were associated with their use in 1993. Five factors showed a significant change from 1990 to 1993: activities of daily living (ADL) scores, race, cognitive performance scale (CPS) scores, full-time equivalent (FTE) nurse aides per resident, and bed size. Ten resident and organizational factors were associated with use of do-not-hospitalize (DNH) orders in 1990 and six resident and organizational factors were associated with DNH orders in 1993. Four factors showed a significant change from 1990 to 1993: legal guardian, FTE LPNs per resident, Medicaid census, and forprofit ownership. Five resident and organizational factors were associated with the use of living wills in 1990 and seven resident and organizational factors were associated with the use of living wills in 1993. Four factors showed a significant change from 1990 to 1993: ADL scores, race, length of stay, and for-profit ownership. CONCLUSION: The results indicate that the PSDA may have been successful in increasing the use of advance care plans and in changing the types of residents who use advance care plans. However, they also show that the use of advance care plans is associated with organizational characteristics, indicating that some types of facilities may be more willing and able to address the PSDA mandates.

Characteristics of nursing homes that are restraint free.

Using nationally representative data from the On-line Survey and Certification of Automated Records (OSCAR) and the Area Resource File (ARF), comprising 15,074 nursing homes, the differences between restraint free and non-restraint free nursing homes were examined. Restraint free nursing homes were found more likely to have residents with less ADL deficiencies and lower average numbers of residents who were bowel or bladder incontinent. They were more likely to be not-for-profit, smaller, low occupancy facilities that did not belong to nursing home chains, and were located in urban and more competitive areas. With regard to staffing factors, restraint free facilities had a richer mix of nursing staff, although the total number of staff per resident did not differ. Restraint free facilities were likely to utilize more full-time equivalent (FTE) registered nurses (RNs) per resident, but less FTE nurse aides and licensed practical nurses (LPNs) per resident. Psychoactive drug use rates did not differ between the types of homes.

The use of physical restraints in nursing homes: pre- and post-Nursing Home Reform Act.

The purposes of this paper are: (1) to determine resident risk factors for the use of physical restraints since the implementation of the Nursing Home Reform Act (NHRA) of 1987, (2) compare these results with resident risk factors for the use of physical restraints prior to the implementation of the NHRA, and (3) to identify facility characteristics associated with the use of physical restraints. The data used are from 4,215 nursing home residents in 268 facilities who were evaluated using the Minimum Data Set (MDS) in six month periods in both 1990 and 1993. Results indicate that the NHRA may have been successful in reducing the use of physical restraints; however, it would appear to have had less impact on the types of residents who are restrained. It is also shown that the use of physical restraints is associated with facility characteristics.

Variation in psychotropic drug use in nursing homes.

Numerous studies of health service use reveal considerable variation in the degree of services provided. In this article the variation in psychotropic drug use in nursing homes is examined. First, a descriptive analysis of nursing homes with and without high levels of psychotropic drug use is provided. Second, an analysis of the determinants of high levels of psychotropic drug use in nursing homes is provided. Factors such as ownership, staffing levels, having special care units, case-mix intensity, competitiveness of the nursing home market, and the state Medicaid reimbursement rate structure are examined. The results of these analyses are discussed in terms of their policy issues.

Top management team characteristics and innovation in nursing homes.

This study examines how the demographic characteristics of the top management team in 236 nursing homes can affect the adoption of innovations. The computerization of the Minimum Data Set (MDS) is the innovation we examine, and tenure, education, and involvement in a professional society are the demographic characteristics investigated. Controlling for 10 organizational and environmental factors, the results are generally significant for each of these demographic factors. However, the results for top managers of nonchain nursing homes show a greater association between these demographic factors and innovation than the results for top managers of nursing homes belonging to a chain. We discuss these results in terms of their significance for innovation research, nursing homes, and top management.

Mental health services and the mortality of nursing home residents.

This article examines the impact of mental health services on the mortality rate for mentally ill nursing home residents. Previous research has documented the unmet need for mental health services among nursing home residents. Some research using small data sets has indicated patient benefits from treatment. This article examines the issue using data from the nationally representative National Nursing Home Survey. In a series of multivariate logistic regressions, treatment for mental illness provided by either general practice physicians or by mental health specialists appears to have few impacts on mortality. A statistically significant treatment effect is found only for residents with schizophrenia, other psychoses, or anxiety disorders when treated by mental health specialists. The results are discussed with reference to ongoing reforms for mental health care in nursing homes.