The role of a nursing home administrator's education in influencing quality of care in US nursing homes

Nursing home literature links poor management practices to poor quality of care and resident outcomes. Since Nursing Home Administrators (NHAs) require an array of skills to perform their role, it is important to explore what makes a NHA effective. This research fills a gap in the literature and provides a possible option to improve the quality of care in nursing homes. Purpose of the study. The study examines whether NHAs with advanced education (defined as a Masters degree or more) are associated with better quality of care in licensed nursing homes (NHs). Design and Methods. Data was derived from the CDC’s 2004 National Nursing Home Survey, which is a representative sample of NHs across the US. A Donabedian- inspired structure-process-outcomes study model was created to explain how education relates to quality of care. Quality of care was defined as onsite oral care, employee influenza vaccination rates and staff recognition programs. Statistical analyses included multivariate logistic regression; covariates included facility-level variables used in similar peer-reviewed research but also included select measures from the Area Resource File to control for county-level factors. Results. Descriptive and analytical analyses confirm that NHAs with a Bachelor’s degree, Associate degree or high school diploma perform less well than NHAs with a Masters degree or more. NHAs with advanced education are more likely to have onsite dental care and recognition programs for staff than NHAs with a Bachelor’s degree (or less). Also NHAs with less than graduate education are more likely to provide off-site dental care. Employee vaccination rates are not impacted by education. Adding certification, tenure or years of experience to a NHA with advanced education gives them an advantage. In fact, certification and experience alone do not have a positive relationship to care indicators; however adding these to advanced education produces a significant result. Implications. This research provides preliminary evidence that advanced education for the NHA is associated with better quality of care. If future research can confirm these findings, there is merit in revisiting the qualifications. Education can be a legitimate option to support quality improvement efforts in US nursing homes. ^

Costs and quality of medication reconciliation practice in primary care clinics

Medication reconciliation, with the aim to resolve medication discrepancy, is one of the Joint Commission patient safety goals. Medication errors and adverse drug events that could result from medication discrepancy affect a large population. At least 1.5 million adverse drug events and $3.5 billion of financial burden yearly associated with medication errors could be prevented by interventions such as medication reconciliation. This research was conducted to answer the following research questions: (1a) What are the frequency range and type of measures used to report outpatient medication discrepancy? (1b) Which effective and efficient strategies for medication reconciliation in the outpatient setting have been reported? (2) What are the costs associated with medication reconciliation practice in primary care clinics? (3) What is the quality of medication reconciliation practice in primary care clinics? (4) Is medication reconciliation practice in primary care clinics cost-effective from the clinic perspective? Study designs used to answer these questions included a systematic review, cost analysis, quality assessments, and cost-effectiveness analysis. Data sources were published articles in the medical literature and data from a prospective workflow study, which included 150 patients and 1,238 medications. The systematic review confirmed that the prevalence of medication discrepancy was high in ambulatory care and higher in primary care settings. Effective strategies for medication reconciliation included the use of pharmacists, letters, a standardized practice approach, and partnership between providers and patients. Our cost analysis showed that costs associated with medication reconciliation practice were not substantially different between primary care clinics using or not using electronic medical records (EMR) ($0.95 per patient per medication in EMR clinics vs. $0.96 per patient per medication in non-EMR clinics, p=0.78). Even though medication reconciliation was frequently practiced (97-98%), the quality of such practice was poor (0-33% of process completeness measured by concordance of medication numbers and 29-33% of accuracy measured by concordance of medication names) and negatively (though not significantly) associated with medication regimen complexity. The incremental cost-effectiveness ratios for concordance of medication number per patient per medication and concordance of medication names per patient per medication were both 0.08, favoring EMR. Future studies including potential cost-savings from medication features of the EMR and potential benefits to minimize severity of harm to patients from medication discrepancy are warranted. ^

Development of a standard sign-out procedure for clinicians in a pediatric intensive care unit

Background: Poor communication among health care providers is cited as the most common cause of sentinel events involving patients. Sign-out of patient data at the change of clinician shifts is a component of communication that is especially vulnerable to errors. Sign-outs are particularly extensive and complex in intensive care units (ICUs). There is a paucity of validated tools to assess ICU sign-outs. ^ Objective: To design a valid and reliable survey tool to assess the perceptions of Pediatric ICU (PICU) clinicians about sign-out. ^ Design: Cross-sectional, web-based survey ^ Setting: Academic hospital, 31-bed PICU ^ Subjects: Attending faculty, fellows, nurse practitioners and physician assistants. ^ Interventions: A survey was designed with input from a focus group and administered to PICU clinicians. Test-retest reliability, internal consistency and validity of the survey tool were assessed. ^ Measurements and Main Results: Forty-eight PICU clinicians agreed to participate. We had 42(88%) and 40(83%) responses in the test and retest phases. The mean scores for the ten survey items ranged from 2.79 to 3.67 on a five point Likert scale with no significant test-retest difference and a Pearson correlation between pre and post answers of 0.65. The survey item scores showed internal consistency with a Cronbach's Alpha of 0.85. Exploratory factor analysis revealed three constructs: efficacy of sign-out process, recipient satisfaction and content applicability. Seventy eight % clinicians affirmed the need for improvement of the sign-out process and 83% confirmed the need for face- to-face verbal sign-out. A system-based sign-out format was favored by fellows and advanced level practitioners while attendings preferred a problem-based format (p=0.003). ^ Conclusions: We developed a valid and reliable survey to assess clinician perceptions about the ICU sign-out process. These results can be used to design a verbal template to improve and standardize the sign-out process.^

Let their voices be heard: Understanding the barriers to seeking early prenatal care for low-income non-Hispanic Black women

Background: Receipt of early prenatal care, care during the first three months of pregnancy, is the standard in the United States. Sixty percent of non-Hispanic Black women who had a live birth in the Sunnyside community of Houston did not obtain early prenatal care in 2009. ^ This study's aims were to: 1) Describe the barriers to obtaining early prenatal care in non-Hispanic Black women who live in the Sunnyside community of Houston; and, 2) Describe the actions that could encourage non-Hispanic Black women who live in the Sunnyside Community to obtain early prenatal care. The goal was to provide information to organizations that promote early prenatal care use in non-Hispanic Black women in Harris County that may aid in developing interventions. ^ Methods: The Participatory Learning for Action rapid assessment qualitative method was used in a group setting to answer the research questions on behalf of women in the community. Women who participated in the group sessions also participated in an in-depth interview. Key informants who work in the community with pregnant women, or promote the use of prenatal care services, were also interviewed. An inductive analysis of the data was conducted to identify common themes that address the study's aims. ^ Results: Aim 1: Group participants identified fear of the reaction from family and/or the baby's daddy and shame, not having insurance or money, and lack of knowledge of the pregnancy and resources as the top three barriers to early prenatal care for women in the community. Aim 2: Group participants stated that to help women to overcome these barriers, communication, awareness and support; help, resources and services; and information and early education are needed. Participant in-depth interviewees echoed the themes of fear of the reaction from family and/or the baby's daddy and not knowing of the pregnancy. Key informants mentioned these themes as well, though not at the same priority level. Participants and key informants also mentioned similar themes for helping women to overcome barriers to early prenatal care. ^ Conclusion: A comprehensive approach is needed to improve early prenatal care use in the Sunnyside community. Education efforts must include all members of the community, young and old, to promote support for pregnant women. Community members must be a part of the process for developing education campaigns. Engaging the community builds a relationship with organizations that serve the community, which may promote use of the organizations' services, and build trust with the community. All efforts must be ongoing so that women and men of all ages in the community understand the importance of prenatal care and support women obtaining care early in the pregnancy.^

Use of empowerment evaluation to determine a sustainability plan for a community-based preconception care program

Women With IMPACT (WWI) is a community-based preconception care educational intervention. WWI is being implemented by the Impacting Maternal and Prenatal Care Together (IMPACT) Collaborative and targets zip codes in Harris County, Texas at high risk for infant mortality, low birthweight, and preterm birth. WWI started March 2012 and continues through August 2013. Three workshop series are planned. This study was conducted with participants and facilitators from the first workshop series. This study aimed to 1) evaluate the WWI program using empowerment evaluation, 2) engage all WWI stakeholders in an empowerment evaluation so the method could be adopted as a participatory evaluation process for future IMPACT activities, and 3) develop recommendations for sustainability of the WWI intervention, based on empowerment evaluation findings and results from the pre/post program evaluation completed by WWI participants. Study participants included WWI participants and facilitators and IMPACT Collaborative Steering Committee members. WWI participants were female, 18-35 year-old, non-pregnant residents of zip codes at high risk of adverse birth outcomes. All other study participants were 18 years or older. A two-phased empowerment evaluation (EE) was utilized in this study. Sessions 1-4 were conducted independently of one another – 3 with participants at different sites and one with the facilitators. The fifth session included WWI participant and facilitator representatives, and IMPACT Steering Committee members. Session 5 built upon the work of the other sessions. Observation notes were recorded during each session. Thematic content analysis was conducted on all EE tables and observation notes. Mission statements drafted by each group focused on improvement of physical and mental health through behavior change and empowerment of all participants. The top 5 overall program components were: physical activity, nutrition, self-worth, in-class communication, and stress. Goals for program improvement were set by EE participants for each of these components. Through thematic content analysis of the tables and observation notes, social support emerged as an important theme of the program among all participant groups. Change to a healthy lifestyle emerged as an important theme in terms of program improvement. Two-phased EE provided an opportunity for all program stakeholders to provide feedback regarding important program components and provide suggestions for program improvement. EE, thematic content analysis, pre/post evaluation results, and inherent program knowledge were triangulated to make recommendations to sustain the program once the initial funding ends. ^

Improving disclosure of medical errors: Including patients and family members in the disclosure process

Over the last decade, adverse events and medical errors have become a main focus of interest for the standards of quality and safety in the U.S. healthcare system (Weinstein & Henderson, 2009). Particularly when a medical error occurs, the disclosure of medical errors and its practices have become a focal point of the healthcare process. Patients and family members who have experienced a medical error might be able to provide knowledge and insight on how to improve the disclose process. However, patient and family member are not typically involved in the disclosure process, thus their experiences go unnoticed. ^ The purpose of this research was to explore how best to include patients and family members in the disclosure process regarding a medical error. The research consisted of 28 qualitative interviews from three stakeholder groups: Hospital Administrators, Clinical Service Providers, and Patients and Family Members. They were asked for their ideas and suggestions on how best to include patients and family members in the disclosure process. Framework Analysis was used to analyze this data and find prevalent themes based on the primary research question. A secondary aim was to index categories created based on the interviews that were collected. Data was used from the Texas Disclosure and Compensation Study with Dr. Eric Thomas as the Principal Investigator. Full acknowledgement of access to this data is given to Dr. Thomas. ^ The themes from the research revealed that each stakeholder group was interested and open to including patients and family members in the disclosure process and that the disclosure process should not be a "one-way" avenue. The themes gave many suggestions regarding how to best include patients and family members in the disclosure process of a medical error. Secondary aims revealed several ways to assess the ideas and suggestion given by the stakeholders. Overall, acceptability of getting the perspective of patients and family members was the most common theme. Comparison of each stakeholder group revealed that including patients and family members would be beneficial to improving hospital disclosure practices. ^ Conclusions included a list of recommendations and measureable appropriate strategies that could provide hospital with key stakeholders insights on how to improve their disclosure process. Sharing patients and family members experience with healthcare providers can encourage a shift in culture where patients are valued and active in participating in hospital practices. To my knowledge, this research is the very first of its kind and moves the disclosure process conversation forward in a patient-family member inclusion direction that will assist in improving disclosure practices. Future research should implement and evaluate the success of the various inclusion strategies.^