The Department of Veterans Affairs (VA) has devoted considerable effort and resources to promoting the implementation of quality improvement (QI) practices within its facilities. Yet relatively little is known regarding the impact of QI practices on outcomes of care. This is particularly true for nursing homes, an important venue of care for VA, and one in which there are widespread concerns regarding the quality of care. We now have examined the impact of QI implementation on a broad range of nursing home outcomes.
We addressed the following two research questions: 1) Do nursing homes that have a greater degree of QI implementation demonstrate better performance on risk-adjusted outcome measures? We hypothesize that nursing homes that have implemented more QI practices will demonstrate better care. 2) Do nursing homes that have a greater degree of QI implementation demonstrate improved performance over time on risk-adjusted outcome measures? We specifically hypothesize that nursing homes that have implemented more QI practices will demonstrate greater improvements in care.
We examined care between 1998 and 2001 at 35 VA nursing homes located in all areas of the country. Five risk-adjusted outcomes were examined including functional decline, behavioral decline, pressure ulcer development, mortality, and preventable hospitalization. Data used in calculating these outcomes were obtained from existing VA database including the Patient Assessment File and the National Patient Care Database. Information on QI implementation and organizational culture was obtained from a previously completed survey of employees at these sites. Staffing levels were based on interviews with nursing home administrators. Analyses examined the correlation of QI implementation on individual measures and on a composite quality measure that examines changes in observed and expected rates of outcomes over time.
Considerable differences exist among nursing homes in their performance on these outcome measures and in their extent of QI implementation. No clear associations were evident, though, between QI implementation and either baseline performance or change in performance over time. Staffing levels did not impact on the implementation of QI practices.
These results highlight the need for continued work in two primary areas. First, there is a need for new approaches to assessing the quality of nursing home care and to validating existing measures. Second, we need to better understand how best to improve nursing home care and maximize health status and quality of life for elderly veterans residing there.
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