The Veterans Health Administration (VHA) is transforming its culture. It is moving from a medical-model culture to one that embraces a person-centered perspective. VHA Community Living Centers (CLCs - formerly known as nursing homes) are part of this transformation, which includes alterations in the physical environment of CLCs and in staff care and work practices. A strong person-centered culture relies in part on positive interactions between staff and residents living in CLCs and on creating an environment that engages these residents. "Bright spots" of positive interactions and engaging environments already exist in all CLCs. Much can be learned by (a) focusing on the bright spots, (b) understanding what helps them take place, and (c) spreading their motivation, information, and facilitators. But no current instrument measures these fundamental aspects of person-centeredness, and no specific tools exist to help staff improve.
Pilot work developed a standardized, observation-based, research tool to measure staff-resident interactions and resident engagement: the Resident-centered Assessment of Interactions with Staff and Engagement tool (RAISE). An action-oriented protocol to help busy frontline staff adopt person-centered care improvements was also developed in the pilot study: the Advancing Cultural Transformation in Our Neighborhoods! Plan (ACTION! Plan).
This study built on the pilot work and had the following objectives: (1) Collaborate with staff at two CLCs to develop a staff-friendly version of the RAISE instrument (the RAISE-sf) and a draft program implementation guide -- including all instruments, instructions, and a training video. (2) Evaluate two types of implementation strategies for the draft guide at 6 sites. (3) Finalize the program implementation guide to enable sustainable implementation of the RAISE-sf and ACTION! Plan in CLCs nationwide.
This 3-phase study used mixed-methods and a purposive sample of CLCs. In Phase I, the ACTION! Plan was initially refined using an advisory panel process. Staff from two CLCs then provided iterative feedback on draft RAISE-sf tools and the ACTION! Plan through phone and in-person interviews. Feedback from state nursing home inspectors was also gathered. The RAISE-sf was iteratively modified based on feedback. The ACTION! Plan was modified and renamed the LOCK framework (i.e., Look for the bright spots, Observations by everyone, Collaborate in huddles, and Keep it bite-size). At the end of Phase I, a training video and draft program implementation guide (including the RAISE-sf, which comprised 3 separate tools, and the LOCK framework) were created. In the Phase II, 6 sites implemented the guide, each over a 6-month period. Three of the sites received in on-site training for all participating staff and an in-person check-in visit as well as phone check in. The three others received on-site training for key staff in a train-the-trainer approach and received remote (i.e., phone) check-in only. Baseline and post-implementation data were collected on-site by researchers using validated instruments. Phase III was dedicated to finalizing the guide and its content based on data collected at the Phase II sites.
This study resulted in multiple findings. (1) To address the need for easy-to-use instruments to help nursing home staff members evaluate and improve person-centered care, the study identified and used a framework for developing or adapting measurement tools for frontline culture change efforts in nursing homes. The research-based RAISE instrument was modified through CLC staff input into a practical set of instruments to measure aspects of person-centered care (the RAISE-sf). (2) The study developed and implemented a theory-driven and user-friendly adaptable framework and facilitation package to overcome existing challenges and guide quality improvement efforts in nursing homes. 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 quality improvement in the nursing home setting, creating the LOCK framework. The LOCK 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 quality improvement project types. (3) The study examined blended facilitation as a powerful implementation strategy, leveraging the complementary expertise of implementation experts operating outside the study setting and CLC staff working as internal facilitators in the study setting. (4) Qualitative analyses of interviews conducted with participating CLC staff indicated noticeable, positive changes in CLC staff interactions with CLC residents and with CLC resident engagement. (5) Preliminary quantitative analyses support the intervention and analyses of these data are continuing thru December, 2017.
Given the study's promising results and products, VHA's Office of Geriatrics and Extended Care funded the national rollout of the intervention (i.e., the RAISE-sf tools and the LOCK implementation framework) in what is known as the CLC Bright Spots Program. The CLC Bright Spots Program was launched nationwide in fiscal year 2017. The evidence-based bundle of four practices comprising the quality improvement infrastructure of the Bright Spots Program as developed in this study has been demonstrated to lead to more effective resident care quality improvement efforts. It teaches CLC staff to use quality improvement huddles that strengthen communication lines between quality teams and frontline staff. The Bright Spots Program quality improvement huddle framework pulls frontline staff into quality improvement efforts in a bite-size, feasible way that becomes a regular quality improvement habit. This framework promotes a trial-and-error collaborative problem-solving mindset that motivates and supports staff to persist in quality improvement efforts. More information is available on the VA's Pulse site on the CLC Bright Spots Program page.
- Pimentel CB, Mills WL, Palmer JA, Dillon K, Sullivan JL, Wewiorski NJ, Snow AL, Allen RS, Hopkins SD, Hartmann CW. Blended Facilitation as an Effective Implementation Strategy for Quality Improvement and Research in Nursing Homes. Journal of nursing care quality. 2019 Jul 1; 34(3):210-216.
- Mills WL, Pimentel CB, Snow AL, Allen RS, Wewiorski NJ, Palmer JA, Clark V, Roland TM, McDannold SE, Hartmann CW. Nursing Home Staff Perceptions of Barriers and Facilitators to Implementing a Quality Improvement Intervention. Journal of The American Medical Directors Association. 2019 Jul 1; 20(7):810-815.
- Carey K, Zhao S, Snow AL, Hartmann CW. The relationship between nursing home quality and costs: Evidence from the VA. PLoS ONE. 2018 Sep 19; 13(9):e0203764.
- Hartmann CW, Mills WL, Pimentel CB, Palmer JA, Allen RS, Zhao S, Wewiorski NJ, Sullivan JL, Dillon K, Clark V, Berlowitz DR, Snow AL. Impact of Intervention to Improve Nursing Home Resident-Staff Interactions and Engagement. The Gerontologist. 2018 Jul 13; 58(4):e291-e301.
- Mills WL, Pimentel CB, Palmer JA, Snow AL, Wewiorski NJ, Allen RS, Hartmann CW. Applying a Theory-Driven Framework to Guide Quality Improvement Efforts in Nursing Homes: The LOCK Model. The Gerontologist. 2018 May 8; 58(3):598-605.
- Snow AL, Jacobs ML, Palmer JA, Parmelee PA, Allen RS, Wewiorski NJ, Hilgeman MM, Vinson LD, Berlowitz DR, Halli-Tierney AD, Hartmann CW. Development of a New Tool for Systematic Observation of Nursing Home Resident and Staff Engagement and Relationship. The Gerontologist. 2018 Mar 19; 58(2):e15-e24.
- Palmer JA, Parker VA, Berlowitz D, Snow AL, Hartmann CW. Resident Choice: A Nursing Home Staff Perspective on Tensions and Resolutions. Geriatric nursing (New York, N.Y.). 2018 May 1; 39(3):271-278.
- Hartmann CW, Palmer JA, Mills WL, Pimentel CB, Allen RS, Wewiorski NJ, Dillon KR, Snow AL. Adaptation of a nursing home culture change research instrument for frontline staff quality improvement use. Psychological Services. 2017 Aug 1; 14(3):337-346.
- Hartmann CW, Snow AL. We're All in This Together: Multiple Stakeholder Insights on Integrating Quality Improvement in a Large System. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2016 Aug 18; New Orleans, LA.
Aging, Older Veterans' Health and Care