Effectiveness of Quality Assurance and Performance Improvement

Effectiveness of Quality Assurance and Performance Improvement Initiatives in Nursing Homes

Problem Statement

From computer programming to maintenance of automobiles, quality assurance and quality improvement is an indispensable component of any service profession and the health care sector is not exceptional. Over the past decades, the health care industry has witnessed a persistent increase in the level of demand for quality and safety. As a consequence of the decline in HCAHPS and the provision of meaningful statistics in healthcare clinics that are often linked to low reimbursements, it has become a crucial component of any healthcare institution to enhance quality assurance system(Farzadnia,2017). Quality assurance connotes to the act of upholding a higher level of quality in the provision of services through continuos assessment of the effectiveness of the institution engaged in the provision of the services. Indeed, primary to meeting clients’ needs, establishing changes engineered to promote their comfort, clinical results and the value addition in health care institutions is a strong level of quality assurance program. Among the advantages of maintaining a strong quality assurance system is the ability to discern issues that can limit patient safety or care and making quick changes. Similar to other domains in the healthcare sector, nursing homes are constantly putting into practice industrial quality control measures in the bid to enhance healthcare. The management principles employed in the arena stresses on a given enterprise –broad approach to improving and understanding underlying processes in the job setting. These principles are generally referred to as the quality improvement (QI) or quality management (QM) in nursing homes, though not extensively focused in available pieces of scholarly work.

The limited evidence points to more than three-quarters of nursing homes being actively engaged in quality assurance initiatives andperformance improvement activities and that doing so results from the impacts of market and institutional factors (Zinn, 1998). However, most of these findings were arrived at from assessment of nursing home administrators and may not be relied upon in determining the effectiveness of quality assurance and performance improvement initiatives in nursing homes within the industry. Besides, most systems across the health care industry encounter numerous pressing issues and nursing homes are not exceptional. Some of these issues include medical errors, patient discharge delays, clinical variations, infections acquired from health care institutions and improper management of hospital finances. All these challenges point to the growing need for persistent innovations within the healthcare systems yet some quality improvement initiatives have failed to provide a return on their investments (Wagner et al., 2001). It is of these notions that the present study sets out to assess the effectiveness of quality assurance and performance improvement initiatives in nursing homes.The specific problem is nursing homes render quality assurance and quality improvement initiatives a low priority for staff. (Mills et al., 2018).

Purpose of the Study

People often spend their youth ensuring that they save up for retirement so that they do not have to depend on other people for upkeep whenever they get old. However, at some point after retirement especially if the person is unable to care for him or herself, they are usually taken to a care home. The quality of care that they receive in the nursing home entirely depends on the management and the level of understanding that the staff has towards their clients. It is thus important that nursing homes have high levels of quality to ensure that those in their care are given the best quality of service as possible (Harris &Clauser, 2002). Thus, this study sets out to shed more light on the need to implement programs such as quality assurance and performance improvements that are effective in enhancing patient care with a clear focus in nursing homes setting.

Quality assurance measures are established in a bid to correct, prevent, and detect challenges in the quality of services offered to the population and individuals. The primary to the focus of quality assurance in a healthcare setting is to combine client expectations and requirements. Services designed to get the two variables on the same page includes the safety of patients, patient health literacy, evidence-based care provision, client engagement and patient-success support systems. Quality assurance initiatives are also key to healthcare activity coordination. This is vital in lowering care fragmentation by establishing efficient networks which in turn (for instance) results in effective referrals.On the other hand, quality improvement initiatives are established to address the process of mitigating the challenges identified to ensure the desired quality and outcome. Performance improvement is realized through a continuous study approach whereby necessary modifications are employed. The purpose of this quantitative study is to explore the effectiveness of quality assurance and quality improvement initiatives in an effort to improve overall efficacy in nursing home environments.

                                                Significance

Potential findings from this research might lead to positive social change by increasing nursing home leaders’ ability to develop strategies to change include improving the delivery of care, which benefits the community through increased efficiency and improved patient health. Health care industry encounters increasing stress originating from the high demands for healthcare services. Attempts to mitigate the situation have seen most institutions within the industry seeking solutions from approaches of quality assurance and performance improvements. While present technologies are effective in boosting the service quality of care institutions, their use in healthcare services is wroth with certain obstacles. Therefore, important considerations should be given to care aspects and proper precautionary measuresupheld to establish a more comprehensive healthcare service delivery.Current and future demands on nursing homes make it imperative for nursing home leaders to contribute to change processes that enable them to implement quality improvement programs for improving care delivery.The study will help determine the factors that would improve the quality of service that the elderly receive at the care homes.Furthermore, for Quality Assurance Performance Improvement (QAPI) to thrive, nursing homes need to create an environment that balances safety and accountability with fairness and openness (CMS, 2013). QAPI cannot be imposed from the top down; rather, all levels of staff in nursing homes must be involved in planning and improving systems and processes in order to get effective results (CMS, 2013). All staff must know they contribute as individuals to the big picture: the successful achievement of the resident’s goals for quality of life and quality of care (CMS, 2013).

Dellefield et al. (2013) report that characteristics of quality in nursing homes are very different from those observed in sensitive healthcare domains such as hospitals. These differences result from the attributes of patients within the nursing homes, the healthcare setting, their demands, projected results, the circumstances for the needs and the fact that nursing home facilities are often permanent homes for their occupants and note temporary habitations for treatment of medical issues. Thus, this study will help in establishing the importance of quality of care in an institutional setting that is essential in enhancing the long-term quality of patient lives thus contributing to enhancement of professional practices. Indeed, most nursing home residence demands quality health care that goes for a considerable duration as a result of their lengthy stay in the facilities. This will not only influence the adoption of quality assurance and performance improvement Initiatives in these living situations but will also exploit competency-based practices and conscientious performance of all the attributes of the treatment plan.In any healthcare setting, performance improvement defines the step by step approaches initiated to enhance the level of quality healthcare service delivery. The chain of actions pursued in this context is cyclic thus demanding a constant performance improvement to upgrade these institutions from the traditional concepts to the more comprehensive technological instruments that exemplify the quality of performance. Continues adoption of improved practices and proven efficiency in undertaking patient care is effective in enhancing efficiency in undertaking healthcare procedures, streamlining the processes and making them simpler. Indeed, improved way of handling patients often notice processes issues before their occurrences and provides solutions that are effective in barring such occurrences. Such is the present interest in this paper that seeks to assess the effectiveness of quality assurance and performance improvement initiatives in nursing homes.

Background

A direct link exists between quality assurance and performance improvements and service delivery initiatives, patient care output, and client’s satisfaction level. A comprehensive program in the healthcare institutions demands the involvement of quality and performance improvement and nursing homes is not different. The Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87) enacted sweeping changes intended to improve quality of care in nursing homes. But since its implementation, there have been, at best, mixed findings regarding improvement across a range of indicators (Castle and Ferguson, 2010). The Affordable Care Act (ACA) contains the first significant legislation focused on improving quality of care in Centers for Medicare and Medicaid Services (CMS)-certified nursing homes since OBRA ‘87. As part of the Affordable Care Act (ACA) mandate, CMS-certified nursing homes will be required to implement quality assurance and performance improvement (QAPI) programs (Castle & Ferguson, 2010).

Selected articles relating to quality assurance and performance improvement initiatives are described here. The keywords search were quality assurance performance improvements in nursing homes, performance improvement projects in nursing homes, and nursing home quality measurement in databases CINAHL Plus,ProQuest Health and Medical Collection, as well as Thoreau Multi-Database Search.

1. Abrahamson, K; Davila, H; Hountz, D. (2018).The article presents author’s views on the Quality Assurance and Performance Improvement program and Affordable Care Act. Topics discussed include staff engagement in quality improvement (QI) and nursing assistants (NAs); knowledge of NAs in sharing project and covering quality gaps; and improved care.
2. Boltz, M., Lee, K. H., Shuluk, J., &Secic, M. (2018) focused on developing and piloting tests, which was a sound tool psychometric that staff in long-term care settings could involve in examining the care surrounding as well as an improvement activity guide performance.
3. Smith, K. M., Castle, N. G., &Hyer, K. (2015) provided information on nursing homes’ readiness to implement a quality assurance and performance improvement program as required by Section 6102 of the Affordable Care Act.
4. Woo, K., Milworm, G., & Dowding, D. (2017) focused on role determination, preparation, and use of champions in nursing home settings as a form of informing upcoming strategies of quality improvement in nursing settings.

1. Chadborn, N.H, Devi, R., Hinslif –Smith, K., Banerjee, J.,& Gordon., A.L.,(2020)reviewed the effective strategies employed in care homes in European geriatric medicine. The scholarly work was engineered to assess the effectiveness of enhancing quality for a longer period in a healthcare setting.
2. Wagner, C.Van der Wal,G., Groenewegen, P.p.,& De Bakker, D.H(2001) assessed the effectiveness of quality systems in nursing homes through a review of BMJ Quality & Safety.
3. Farzadnia, E., Hosseini, Z.,&Riahi, A.(2017)conducted a study on nursing home quality management and the rate of improvement in these patient residences. The article was primarily focused on humanitarian insights.

Framework

In respect to their applicative nature, theoretical frameworks are of importance due to their ability to shed more light on nature, purpose and issues linked to a phenomenon so that the audience may employ the knowledge in understanding investigations. To link an investigative phenomenon to existing knowledge and to articulate the questions that the study seeks to find answers to, a framework is vital. Guided by the framework, a researcher can establish the grounds for the research methods and the hypothesis of the study. Besides, frameworks are effective in ascertaining the limits to the study generalizations at it helps in specifying the variables with greater impact on the phenomenon of interest. The theoretical framework for this study will be the LOCK framework. The framework is based on the concepts of strengths-based learning, efficiency, organizational learning, observation, and team-based strategy. The LOCK framework is executed using five tenets, which include looking for bright spots, observation, collaboration in groups, keeping it bite-sized, and lastly, facilitation (Mills et al., 2018). The improvement of identified problems in the nursing home service delivery is made easy utilizing the above approach that helps solve the problem amicably. The executors of the framework use methods such as observation, processing the identified issues, and applying the outcomes as seen. The framework is essential in problem identification, improving the quality of care and life for the residents under nursing home care. Therefore, the approach is necessary for and of significant value in the long term in a home nursing care setting. The LOCK framework has proved significantly how effective the process is resulting in scrutiny by paying attention to the minute aspects to ensure all components are advocated for.

Research Question(s) and Hypotheses

Developing research question is an essential aspect of the research project for various reasons. An appropriate and relevant research question and its critical appraisal is vital to the application of the findings of the research to a clinical practice. Research questions usually arise out of the perceived knowledge of a gap in literature within the subject area. In-depth knowledge about the subject may lead to a number of questions, and it is therefore necessary to know if the particular study can answer the questions of not. A good research hypothesis is based on a good research question. A good research question is original and of interest to both the researcher and the outside world, and its hypotheses can be formulated and be tested(Wyatt, 2012).  The following research questions and hypothesis will be investigated in the study.

RQ      To what extent does Quality Assurance and Performance Improvement initiatives provide nursing home staff with opportunities to collaborate on developing and testingstrategies for improving care delivery?

H₀    There is a significant relationship between Quality Assurance and Performance Improvement initiatives and providing staff with opportunities to develop and test strategies for improving care delivery in nursing homes.

H_a There is a no significant relationship between Quality Assurance and Performance Improvement initiatives and providing staff with opportunities to develop and test strategies for improving care delivery in nursing homes.

RQ     To what extent does effective quality assurance and performance improvement initiatives provide healthcare organizations with a framework for evaluating system efficacy?

H₀    There is a significant relationship between Quality Assurance and Performance Improvement initiatives and a healthcare organization’s framework for evaluating system efficacy.

H_a There is no significant relationship between Quality Assurance and Performance Improvement initiatives and a healthcare organization’s framework for evaluating system efficacy.

RQ      To what extent does the organizational culture of the nursing home influence the outcome of the quality improvement initiatives?

H₀    There is a significant relationship between the organizational culture of the nursing home and the outcome of the Quality Assurance and Performance Improvement initiatives.

H_a There is no significant relationship between the organizational culture of the nursing home and the outcome of the Quality Assurance and Performance Improvement initiatives

The research hypotheses designed above is supported by the mentioned research questions, and this will have an influence on the type of the research design to be considered in the study.

Nature of the Study

Qualitative, quantitative, and mixed methods are the methodologies that researchers employ. Quantitative researchers quantify the problem between variables by generating numerical data.Mixed methods researchers explore both qualitative and quantitative methods to answer research problems. Qualitative researchers explore to comprehend underlying reasons, motivations, and opinions in order to perform a conclusive study. Furthermore, qualitative researchers probe meanings, and the relations and activities of social life. I selected the quantitative method as it is the most germane to address the purpose of the study, which is to explore effectiveness of quality assurance and performance improvement initiatives aimed at overcoming existing challenges and evaluate system efficacy in nursing homes.

One of the methods of data collection in the quantitative study that the research will use is employee survey. In this method, employees from the targeted nursing homes will be chosen from a list of the staff to consist of all the attending physicians, nurse managers, and nurse practitioners. A random sampling of the remaining staff will be done to get representative sample from the registered nurses, nursing aides, physical therapists, licensed practice nurses, dieticians, and other staff. Observation method will be used to assess the outcome of the quality assurance and performance improvement initiatives. Other methods in the quantitative research strategies will also be employed for collecting data.

Secondary Data Types and Sources of Information

The federal database will be searched to determine the records of an index of quality care in nursing homes.  The nursing residency health records will be evaluated for the changing prominence of resident care and subsequent influence on the quality of care in nursing homes. Secondary data will also be obtained from researches that have been done on the topic before. This may include books written by experts in the field, researches done by qualified researches and even interviews held by owners and management of several nursing homes on the practices that they have adopted to improve the quality of care that they give to their residents.The search for articles of research done previously will be constructed using the following PICO question: (P) healthcare workers in nursing homes, (I) quality assurance and performance improvement initiatives, (C) no comparison, (O) overcoming existing challenges and evaluate system efficacy. Various electronic databases will be used to conduct the search for the article, including PubMed, ProQuest, Ovid Medline, and other Non-indexed Citations published between 2015 and 2020. The search will be restricted to only the articles published in English, and especially those studies using the quality assurance and performance improvement initiatives in a nursing home or other healthcare setting. The search will not be extended to nonhealthcare databases (Woo et al., 2017).

Limitations, Challenges, and/or Barriers

A limitation of the study may be that quality care is relative from one institution to another.  Another limitation may be fear expressed by the management of the nursing homes that may prevent them from giving truthful information as majority of nursing homes face criticism for the quality of care provided to residents.Consequently, the study may have integral prejudice, which may be beyond the control of the investigator. With regards to the primary data sources such as surveys and open-ended questionnaires, the investigator may be barred from collecting the data directly from the respondents to address the research topic.

The use of secondary sources of information will be limited to healthcare settings, hence studies that have used rigorous methods in other nonhealthcare settings to evaluate quality improvement initiatives will be disregarded. An additional limitation will be the focus on only healthcare workers specifically, which will exclude other staff members, as well as other studies which used other professions in the role. However, the nature of the nursing home has healthcare workers as the key staff in the daily care of the residents, hence the likelihood of ignoring some studies will be diminished.