Quality Improvement Program in a Nursing Home

Introduction

The process of designing and implementing a quality improvement (QI) program in a nursing home requires significant effort from all involved specialists. Apart from financial needs that follow every QI initiative, members that want to enact change in an organization have to consider the theoretical framework behind their program’s design as well as the outcomes of their activities. Furthermore, the results of the intervention mustn’t disappear after the project’s end, requiring professionals to think about such aspects as continuity and sustainability. In this case, the setting for the QI program is a nursing home “Live with Care” that usually cares for approximately 100 permanent residents. The nursing home also employs registered nurses (RNs), licensed practical nurses (LPNs), physical therapists (PTs), and other medical and administrative workers.

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The analysis of the facility identified several weaknesses and strengths that the nursing home possesses. Notably, the recent efforts of the organization’s management led to the nursing home’s staff having high levels of interpersonal collaboration with nurses having advanced communication skills. However, the investigation also revealed that most nurses do not have time to work with patients and pay attention to learning, which significantly affects the quality of care. Thus, further QI initiatives are required to enhance residents’ experiences in the nursing home. To develop the quality program, the LOCK model was chosen as a supporting theoretical framework. Its elements are flexible, although they were designed with the specific characteristics of nursing homes in mind. The main aspects of the evidence-based programs include staff numbers’ increase, leadership training, and the participation of nurses in the innovation processes for the nursing home. It is expected that the use of the LOCK model will lead to nurses becoming more involved in the facility’s processes and help them allocate enough time to address each resident’s needs.

Theory to Support the Implementation

To design the program for this nursing home, one has to review the main aspects of the chosen theoretical framework. The LOCK model, introduced by Mills et al. (2018), is a relatively new approach to developing QI initiatives. The authors of this framework state that nursing homes encounter many problems when trying to innovate or improve their care provision (Mills et al., 2018). The need for collaboration and planning is recognized by most organizations, but the implementation process is often not based on evidence and real-life experiences. Hence, the LOCK model introduces five main principles that may help nursing homes to successfully implement a QI program. These concepts include “strengths-based learning, observation, relationship-based teams, efficiency, and organizational learning” (Mills et al., 2018, p. 598). These aspects are interconnected, producing a foundation for a variety of interventions.

Based on these principles, the scholars built five steps that one can take to complete a QI project. The first action is to “look for the bright spots” – identify the existing strengths of the organization or individuals as well as instances that could promote change (Mills et al., 2018, p. 598). During this step, the participants are encouraged to focus on the positive side of interventions. The second tenet is to observe all processes that happen inside the organization (Mills et al., 2018). Here, professionals gain an opportunity to break from their routine and see which aspects of their or others’ performance are influential or detrimental to the quality of care. Moreover, it allows people to understand which of their duties, habits, attitudes, and values can contribute to organizational growth.

The third idea is to share the collected information and previous experiences with one’s colleagues. Mills et al. (2018) invite professionals (NPs, LPNs, and other workers) to participate in meetings where they may talk about the insight that they have gained during the previous steps. This activity encourages communication and discussion of various practices and allows all professionals to contribute to the intervention in a meaningful way. The next element of the model proposes to keep all information “bite-sized” (Mills et al., 2018, p. 598). The researchers argue that nurses do not have significant time to study new frameworks or data without feeling overburdened or distracted from their duties. Thus, limiting the amount of new knowledge and maintaining nurses’ ability to provide timely care. The final tenet of the LOCK framework is facilitation – a simplification of all project activities that are based on the previous steps (Mills et al., 2018). By focusing on positive events and collaborating with others, nurses should not feel as though the QI program is too complicated to be successful.

The discussed model’s effectiveness is supported by scholarly research. First of all, the study by Mills et al. (2018) presents a case of a LOCK-based program that was implemented in Victory Nursing Home. The success of this QI initiative demonstrates the steps that can simplify the process of using this framework in similar conditions. Moreover, the principles of the suggested models align with the findings of previous research related to nurses’ performance in nursing homes. For instance, the LOCK model prioritizes communication among nurses and other employees. Mills et al. (2018) also suggest appointing champions in units that are responsible for disseminating information to other specialists and collecting their feedback, thus creating channels for quick and useful information transfer. According to the research by Woo, Milworm, and Dowding (2017), this practice is highly effective in the setting of a nursing home because it provides nurses with enough time to both perform their usual responsibilities and contribute to the QI program’s implementation. The LOCK framework may increase collaboration and interprofessional communication in the nursing home.

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Another aspect of the model that contributes to its usefulness in this particular case is its reliance on quick and simple activities. In the current situation, the nursing home “Live with Care” has a limited number of available nurses. Thus, they are likely to be busy at most times, caring for patients or performing some other duties. While the proposed intervention considers additional staffing as one of the solutions, their training will place additional stress on both new and existing nurses. According to Dellefield, Castle, McGilton, and Spilsbury (2015), nurses’ time with patients directly affect the quality of care. The use of the LOCK model implies that the focus on time allocation will be preserved. Professionals engaged in the QI program will not be stressed about needing to spend hours training or sharing new information (Zúñiga et al., 2015). This environment can contribute to the change initiative’s successful outcomes. Overall, the LOCK model allows one to apply the strengths of the facility (such as highly developed communicative skills) and apply them to combat the current issues.

Design of the Evidence-Based Program

The previous assessment of the nursing home “Live with Care” identified several areas that required improvement and needed to be addressed in the QI program. The first problem is understaffing – the nursing home serves around 100 residents but employs no more than 20 nurses. This small number of professionals overseeing patients is a prominent problem in many nursing homes (Harrington, Schnelle, McGregor, & Simmons, 2016). RNs in such facilities work with assistants and LPNs, but they still may not have enough time to accommodate all residents (Backhaus, Beerens, Van Rossum, Verbeek, & Hamers, 2018). This issue can have a substantial effect on the quality of care, apart from increasing nurses’ turnover rates (Harrington et al., 2016). Thus, the first step in the QI plan is to increase the staff. According to Mueller, Bowers, Burger, and Cortes (2016), the nursing home should follow the practice of having at least one RN on a 24-hour basis. Thus, each of the RNs employed by the facility should have enough time to rest between such shifts, which implies that the nursing home has to hire more RNs to meet this requirement.

The first step of the QI program does not follow the LOCK framework directly since it deals with human resource activities rather than internal change. Nonetheless, all other elements adhere to the theoretical framework. The second and third identified issues are the inefficiency of professional training among all healthcare providers and their lack of autonomy, innovativeness, and leadership skills. Here, the proposed intervention focuses on education that incorporates both medical and nonmedical skills. According to the LOCK model, the employees and managers need to work together to implement the program successfully. It is vital to discuss the intervention with all employees to ensure that all participants are aware of the changes that will be introduced. Then, the QI team should be formed to include champions from each unit. Champions may be chosen based on specialists’ experience, communicative skills, and readiness to interact with others (Woo et al., 2017). Thus, these individuals will represent the qualities that will improve the overall performance of the nursing home after the QI project is finished.

Next, Mills et al. (2018) suggest choosing the type of observations that nurses will conduct during the intervention. The staff will analyze the interactions of other members with the patients and evaluate their performance. Moreover, the assessment of personal successes will be encouraged. It is vital to specify that these observations should be positive – nurses do not need to point out each other’s or personal mistakes, focusing on strengths and improvements instead. For instance, one may report that a certain employee allocates time in such a way that allows them to interact with residents in a more productive way. Alternatively, a champion may observe that several LPNs exercise leadership qualities by sharing ideas to make their performance more efficient. These observations do not need to happen at all times – all staff members will contribute five minutes of their time two to three times each week to document these occasions.

All observations will then be shared with other employees during short stand-up meetings. Mills et al. (2018) call them bright spot huddles; they will encourage members to discuss their new knowledge and point out how some practices contribute to the facility’s performance. These meetings provide an opportunity for open dialogue, and the staff should talk about the implication and potential of each recorded experience. These hurdles will be conducted every week, not to interrupt nurses’ usual activities.

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Once the staff’s analysis yields enough information about the nursing home’s bright spots, the champions can form the requirements for the training program. This initiative will involve practices that have proven to be the most effective in terms of performance. All educational meetings will be brief since the LOCK model suggests keeping learning activities under 15 minutes (Mills et al., 2018). During these short weekly sessions, professionals will collaborate and discuss leadership practices, strategies to save time and improve performance, and ways to interact with residents in a meaningful way. Overall, the QI program will focus on several measurable indicators, including patient outcomes (mortality rates, falls, ulcers, satisfaction) and staff’s experiences (job satisfaction, retention, and turnover) (Jones, 2016). The outcomes of residents will be measured using patient records and standard assessment scales used in the nursing homes, and the satisfaction of workers will be documented through simple surveys.

Expected Outcomes and Sustainability

It is expected that the implementation of this QI plan will lead to several changes. First of all, the increased number of available nurses should allow all professionals to have sufficient time to care for all residents adequately. This implies a lower rate of falls and ulcers as well as lower mortality levels, although the number of staff members is not the only defining factor in these measures (Griffiths et al., 2018; Low, et al., 2015). Moreover, if the quality of care improves, patients’ satisfaction levels may also rise. The change in staffing levels does not mean that all nurses will be equally successful in engaging with patients, but their ability to have more time can positively affect nurse-resident relationships (Kimmey & Stearns, 2015). Moreover, nurses’ advanced communication skills should result in productive huddles and information sharing that will also lead to higher levels of participation from all employees (Sprangers, Dijkstra & Romijn-Luijten,2015). Finally, the focus on positive events and professional achievements should lower staff turnover rates and improve their job satisfaction levels.

For this QI program to have a sustained effect on the nursing home, the proposed steps should be integrated into the staff’s daily routine. It is crucial to highlight the effects of this intervention, such as higher quality of care, lower mortality rates, and nurses’ job satisfaction levels when discussing the achievement with nurses, managers, and other employees (Barsanti, Walker, Seghieri, Rosa, & Wodchis, 2017; Braithwaite et al., 2017). According to Mills et al. (2018), the reinforcement of strong points and the avoidance of punitive measures should create an encouraging environment and inspire the staff to continue change-related efforts. The sustainability of this program depends on the staff’s preparedness to participate in future interventions and their low resistance to change.

Conclusion

The present QI initiative for the nursing home “Live with Care” is based on the LOCK framework. This theory-based model poses five tenets, highlighting the importance of positive events, observation, communication, brevity, and facilitation. The identified areas for improvement in the facility are the inadequate staffing levels, nurses’ lack of education, and undeveloped leadership qualities. The LOCK model encourages nursing homes to invite staff members to tackle these issues through interprofessional collaboration. Employees will observe their setting for five minutes two or three times a week, document “bright spots,” and share them every week to find the most effective strategies. As a result, it is expected that all staff members will become more confident in their abilities, and the increased staff numbers will provide nurses with enough time to care for each patient. To make the intervention sustainable, the program should continue, inspiring nurses to introduce new ideas and educate each other.

References

  1. Backhaus, R., Beerens, H. C., Van Rossum, E., Verbeek, H., & Hamers, J. P. H. (2018). Rethinking the staff-quality relationship in nursing homes. The Journal of Nutrition, Health & Aging, 22(6), 634-638.
  2. Barsanti, S., Walker, K., Seghieri, C., Rosa, A., & Wodchis, W. P. (2017). Consistency of priorities for quality improvement for nursing homes in Italy and Canada: A comparison of optimization models of resident satisfaction. Health Policy, 121(8), 862-869.
  3. Braithwaite, J., Testa, L., Lamprell, G., Herkes, J., Ludlow, K., McPherson, E.,… Holt, J. (2017). Built to last? The sustainability of health system improvements, interventions and change strategies: a study protocol for a systematic review. BMJ Open, 7(11).
  4. Dellefield, M. E., Castle, N. G., McGilton, K. S., & Spilsbury, K. (2015). The relationship between registered nurses and nursing home quality: An integrative review (2008-2014). Nursing Economic$, 33(2), 95-108.
  5. Griffiths, P., Maruotti, A., Recio Saucedo, A., Redfern, O. C., Ball, J. E., Briggs, J., … Smith, G. B. (2018). Nurse staffing, nursing assistants and hospital mortality: Retrospective longitudinal cohort study. BMJ Quality & Safety.
  6. Harrington, C., Schnelle, J. F., McGregor, M., & Simmons, S. F. (2016). Article commentary: The need for higher minimum staffing standards in US nursing homes. Health Services Insights, 9, 13-19.
  7. Jones, T. (2016). Outcome measurement in nursing: Imperatives, ideals, history, and challenges. The Online Journal of Issues in Nursing, 21(2).
  8. Kimmey, L. D., & Stearns, S. C. (2015). Improving nursing home resident outcomes: Time to focus on more than staffing. Journal of Nursing Home Research, 1, 89-95.
  9. Low, L. F., Fletcher, J., Goodenough, B., Jeon, Y. H., Etherton-Beer, C., MacAndrew, M., & Beattie, E. (2015). A systematic review of interventions to change staff care practices in order to improve resident outcomes in nursing homes. PloS One, 10(11), e0140711.
  10. Mills, W. L., Pimentel, C. B., Palmer, J. A., Snow, A. L., Wewiorski, N. J., Allen, R. S., & Hartmann, C. W. (2018). Applying a theory-driven framework to guide quality improvement efforts in nursing homes: The LOCK model. The Gerontologist, 58(3), 598-605.
  11. Mueller, C., Bowers, B., Burger, S. G., & Cortes, T. A. (2016). Policy brief: Registered nurse staffing requirements in nursing homes. Nursing Outlook, 64(5), 507-509.
  12. Sprangers, S., Dijkstra, K., & Romijn-Luijten, A. (2015). Communication skills training in a nursing home: Effects of a brief intervention on residents and nursing aides. Clinical Interventions in Aging, 10, 311-319.
  13. Woo, K., Milworm, G., & Dowding, D. (2017). Characteristics of quality improvement champions in nursing homes: A systematic review with implications for evidence-based practice. Worldviews on Evidence‐Based Nursing, 14(6), 440-446.
  14. Zúñiga, F., Ausserhofer, D., Hamers, J. P., Engberg, S., Simon, M., & Schwendimann, R. (2015). Are staffing, work environment, work stressors, and rationing of care related to care Workers’ perception of quality of care? A cross-sectional study. Journal of the American Medical Directors Association, 16(10), 860-866.
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