2017 HSR&D/QUERI National Conference

4060 — Formative Evaluation of a New Theory-Driven Framework to Guide Quality Improvement in Community Living Centers

Lead/Presenter: Whitney Mills, COIN - Houston
All Authors: Mills WL (HSR&D Center of Innovation in Quality, Effectiveness and Safety, Houston, TX) Pimentel CB (University of Massachusetts) Palmer JA (Center for Healthcare Organization and Implementation Research (CHOIR), Bedford/Boston, MA) Snow AL (Tuscaloosa VAMC) Wewiorski NJ (HSR&D CHOIR) Allen RS (University of Alabama) Hartmann CW (HSR&D CHOIR)

Despite recognized need to improve quality of care and quality of life in nursing homes, staff continue to encounter significant challenges. Quality improvement (QI) methods offer promising opportunities for nursing home staff to work together to develop, test, and implement innovations for improving care. Specific guidance on how to implement QI strategies is scarce. We developed and evaluated a framework and facilitation package to help Community Living Center (CLC; i.e., VA nursing home) staff conduct QI initiatives.

The evidence-based concepts of strengths-based learning, observation, relationship-based teams, efficiency, and facilitation were adapted for CLCs to create the four LOCK framework tenets to guide CLC QI work: 1) Look for the bright spots, 2) Observe, 3) Collaborate in huddles, and 4) Keep it bite-sized. We conducted a formative evaluation of LOCK's implementation in 12 units at 6 CLCs. Qualitative data were collected from research team field notes and semi-structured staff interviews. We conducted content analysis to identify practical applications of LOCK, its adaptability, usefulness of blended facilitation (i.e., internal and external facilitation) as an implementation strategy, and lessons learned.

Staff valued opportunities to focus on desired behaviors (i.e., bright spots) rather than deficits. Through observing peers and sharing bright spots in brief huddles, staff reported increased collegiality, teamwork, and morale. CLCs were creative in developing opportunities to share observed bright spots (e.g., electronic picture frames). Blended facilitation played a critical role in cultivating staff buy-in and ongoing unit-specific adaptations. Lessons learned related to improving implementation methods, including timing and location of observations, simplifying feedback reports, maintaining focus on positives, and importance of engaging all CLC staff in QI efforts, including non-nursing staff.

LOCK is a theory-driven, user-friendly, and adaptable framework and facilitation package that is applicable to varied settings. Frontline staff felt LOCK was feasible for use in the CLC, useful for a variety of QI efforts, and fostered positivity and teamwork.

Engaging CLC staff in QI efforts accelerates innovation and implementation of promising new practices in care delivery. LOCK can serve as a practicable guide for staff who may be new to this work and have applicability outside the CLC setting.