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2023 HSR&D/QUERI National Conference Abstract

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4086 — Quality Improvement Efforts in VA Community Living Centers Following Public Reporting of Performance

Lead/Presenter: Valerie Clark,  Bedford VAMC
All Authors: Davila H (Center for Access & Delivery Research and Evaluation, University of Iowa Carver College of Medicine), Mills WL (Center for Innovation in Long-Term Services and Supports, Brown University School of Public Health) Clark V (Center for Healthcare Organization and Implementation Research) Hartmann CW (Center for Healthcare Organization and Implementation Research, University of Massachusetts Lowell) Sullivan JL (Center for Innovation in Long-Term Services and Supports, Brown University School of Public Health) Mohr DC (Center for Healthcare Organization and Implementation Research, Boston University School of Public Health) Baughman AW (Massachusetts General Hospital, Harvard Medical School) Berlowitz DR (University of Massachusetts Lowell) Pimentel CB (Center for Healthcare Organization and Implementation Research, University of Massachusetts Lowell)

Objectives:
For two decades, the U.S. government has publicly reported performance measures for private sector nursing homes, spurring some improvements in quality. Public reporting is more recent, however, for VA’s 134 nursing homes (Community Living Centers [CLCs]). Performance ratings, based on regulatory inspections, staffing, and clinical quality measures, are reported on the “CLC Compare” website. As CLCs operate within a large, integrated healthcare system with unique financial and market incentives, their responses to public reporting may differ from their private sector counterparts. Yet no research to date has explored how CLCs respond to public reporting. We therefore explored the influence of public reporting on CLC’s internal quality improvement processes.

Methods:
This was a cross-sectional qualitative study involving a comparative case study approach. Cases involved three purposively selected, geographically diverse CLCs with low, mid, and high performance based on two consecutive quarters of CLC Compare ratings. We conducted semi-structured telephone interviews with CLC leaders from August–November 2019. Participants (n = 12) were responsible for quality measurement and quality improvement (associate chief nurses, nurse managers, resident assessment coordinators, and medical directors). Interviews focused on participants’ opinion of CLC Compare, challenges and facilitators to performing well on CLC Compare, motivations for change, and actions taken to improve or maintain CLC Compare ratings.

Results:
Across CLCs, participants agreed public reporting of CLC quality was helpful, both for transparency and to provide CLC staff and leaders with an “outside perspective.” Strategies used to improve CLC Compare ratings fell into three broad categories: 1) data and information, 2) individual roles, and 3) communication. All three CLCs made changes in each of these categories, yet respondents in the higher performing CLCs described using more strategies and implementing them longer. Common data and information strategies included educating staff on relevant regulations, establishing internal data-monitoring processes, and responding to data trends. Role-focused strategies involved clarifying and aligning individual responsibilities related to data collection, reporting, and quality improvement processes, plus hiring new staff. In all three CLCs, staff had individual roles in implementing quality improvement projects focused on specific quality measures (e.g., falls, hospitalizations, pain, pressure injuries). Communication strategies included processes to increase communication between staff about residents’ care, data collection and reporting, and quality improvement activities, such as through new or expanded interdisciplinary team meetings. Respondents felt motivated to deliver good care to residents and achieve CLC Compare scores that reflected the quality of care they believed they provided. For two CLCs, this meant devoting extra attention to identify and address internal weaknesses that contributed to lower scores.

Implications:
Public reporting of clinical performance improved internal data collection and quality improvement activities in CLCs. Although CLCs used similar strategies to improve or maintain their public ratings, they varied in number of strategies used and length of time using them.

Impacts:
Longstanding efforts to reform nursing home care reveal multiple strategies are needed to improve nursing homes quality. This study affirms that public reporting—including in public nursing homes—should be one of those strategies.