Articles Posted in Quality of Care

On December 6, <a href="http://www.modernhealthcare.com/article/20111206/NEWS/312069976/leapfrog-recognizes-top-performing-hospitals# reported that Leapfrog Group>Modern Healthcare has recognized the 65 top hospitals of 2011. It is a great honor to receive Leapfrog Group’s “Top Hospital” award, as it is considered to be the most competitive hospital quality award in the country. The survey was based on three main areas: patient well-being, resources used to treat patients, and management practices to foster a safe and high-quality environment. Within each of these categories, staffing levels, hand hygiene, pneumonia care, patient experience, and use of computerized physician-order entry were just a few of the specific matters that were examined.

While the top 65 hospitals excelled in all of the above mentioned areas, the same cannot be said about most California nursing homes. This “Top Hospital” award, however, has definitely set a standard that must be met by all care facilities in the country. Concerning staffing levels, nursing homes often fail to meet the minimum of 3.2 nursing hours per patient per day. Even those that do meet this minimum requirement often do not meet the standard for quality of care, which is much more difficult to quantify. In order to provide high-quality care, nursing home management must train and often re-train their staff in order to keep them updated on the latest improvements in technology and scientific advancements.

Technology is an important variable in almost all industries today, including hospitals and nursing homes. This is made clear by the fact that the “Top Hospital” award was judged, in part, based on the use of computerized physician-order entry. It is important for you to ensure that your loved one’s care facility is updated with the latest technologies so that your loved one may enjoy the best possible quality of life.

While pneumonia care is an important area to observe, there are many other infections that nursing homes encounter on a daily basis, including pressure ulcers, the influenza, methicillin-resistant staphylococcus aureus (MRSA), scabies, clostridium difficile (C. difficile), and sepsis. The nursing home facility is also responsible for taking preventive measures against the spread of infection. Hand hygiene of nurses is an especially important preventive measure, and it was one of the focus areas that Leapfrog Group chose to study in its nationwide survey of hospitals.

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Weight loss is a very common issue among residents of nursing homes. Although it may seem to have a simple solution given the availability of food, malnutrition is actually a very serious, multifaceted problem because it is a direct cause of increased morbidity and mortality and poorer quality of life. A recent article, titled “Evidence-Based Practices for the Prevention of Weight Loss in Nursing Home Residents,” published in the 2011 volume of the Journal of Gerontological Nursing reports that 35-85% of elder adults living in nursing homes suffer from malnutrition.

Unintentional weight loss, which is a consequence of malnutrition, occurs in 27% of adults over the age of 65, and is defined as a loss of 10 pounds in 6 months, 5% per month, or 1% to 2% per week. The three main causes of weight loss are starvation or wasting, cachexia, and sarcopenia.

Starvation or wasting is the result of calorie deprivation. It is often seen in conjunction with a critical illness without adequate nutritional support, advanced AIDS, end-stage renal disease, end-stage liver disease, and marsmus. While starvation results in a loss of fat tissue, cachexia leads to a loss of muscle tissue. Cachexia is often a result of a critical illness with adequate nutritional support, congestive heart failure, liver disease, early renal failure, rheumatoid arthritis, HIV infection without opportunistic infection, and protein-calorie or protein-energy malnutrition.

Sarcophenia entails a decrease in muscle mass and strength that occurs during normal aging and results in physical frailty, increased risk of falling, and decreased ability to perform activities of daily living. Because it is possible to simultaneously have multiple types of weight loss or to progress from one to the next, it is essential to determine if your loved one suffers from unintentional weight loss, especially if he or she also suffers from any of the aforementioned illnesses.

Often, unintentional weight loss is a result of poor communication. Cognitive impairments prevent residents from feeding themselves. Consequently, nurses assist the residents in eating and often have difficulty interpreting the residents’ behavior and wishes. Even when residents are still able to feed themselves, they sometimes have trouble identifying their food and understanding the purpose of silverware.

Dental and oral health issues that are prevalent in elderly adults can also contribute to weight loss. Many residents of nursing homes need dentures but do not have them, while others who do have them are using defectives ones. These issues were discovered to be more common in adults who were dependent than those who were only semi-dependent, suggesting that many adults who are dependent are not receiving adequate care. A study has shown that a resident who received over three hours of care by a certified nursing assistant (CNA) per day had a 17% decreased probability of weight loss and those receiving over 4.1 hours got better feeding assistance. It is important to ensure that your loved one’s nursing home is not understaffed and that your loved one is receiving sufficient care from caregivers.

If you are unsure about your loved one’s health, nutritional assessments exist to determine whether or not he or she is suffering from unintentional weight loss. The most common indicator of weight loss is body mass index (BMI), which is weight divided by the square of height. Specialists say that a BMI between twenty-four and twenty-seven is acceptable. A lower mortality rate and best functional ability have been observed in women with a BMI between twenty-two and thirty and men with a BMI between twenty-three and thirty. If your loved one has a BMI between nineteen and twenty-three, he or she may be at risk of malnutrition. Additional assessments include the Mini Nutritional Assessment (MNA), the Council on Nutrition Appetite Questionnaire (CNAQ), the Simplified Nutritional Appetite Questionnaire (SNAQ), and the Minimum Data Set (MDS) administered by the U.S. Department of Health and Human Services.

There are many simple solutions to weight loss. Supplement intake may help prevent weight loss, as long as residents are continuing to consume the additional calories needed to gain or maintain weight. Food fortification allows residents to consume more nutrients without increasing the volume of food eaten. Feeding assistance from volunteers or family members can provide a positive social environment during mealtimes that also increase nutritional intake. Positive social engagement also helps wandering residents who tend to wander from the table during mealtimes.

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If your loved one resides in a Skilled Nursing Facility (SNF) or nursing home in Southern California, you should be mindful of the risks of malnutrition and related health problems.

A study was conducted with nursing home residents in Germany, described in the article titled Prevalence of Malnutrition in Orally and Tube-Fed Elderly Nursing Home Residents in Germany and Its Relation to Health Complaints and Dietary Intake, published in the 2011 volume of Gastroenterology Research and Practice. According to this study, malnutrition is widespread among nursing home residents and is related to serious health problems, such as constipation, nausea, and vomiting. Among the residents in the study, 26.7% suffered from malnutrition and 52.9% were at risk of malnutrition. Health problems were more prevalent among malnourished residents. For example, approximately 40% of well-nourished residents and 40% of residents at risk of malnutrition suffered from constipation. However, 55% of malnourished residents had constipation.

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Improving the quality of care in California nursing homes is one of the most pressing issues facing our state today. Yes, it’s even more important than our budget problems or who we elect to lead us in the political arena. Regardless of our social backgrounds or political opinions, none of us can escape the fact that as we age, all of us may be faced with the need to seek 24 hour skilled nursing care. This is a difficult reality facing many Californians today, as they grapple with not only selecting an appropriate nursing home for themselves or their loved ones, but also with ensuring that once there, the proper care and supervision is provided.
More, therefore, must be done to ensure significant improvements in the quality of care provided in California nursing homes, and particularly in nursing homes in Torrance, Long Beach and Santa Ana, given the significant rate of deficiencies issued to nursing homes in those areas in the last several years by the California Department of Public Health.
A recent study published in the August 2011 volume of the Journal of the American Medical Directors Association entitled “Randomized Clinical Trial of a Quality Improvement Intervention in Nursing Homes” (available for purchase online,) sheds further light on the various options at the disposal of nursing home owners and operators to improve the quality of care they deliver to our elderly, should they choose to avail themselves of such options. The authors designed a study to determine which of the following two options is more effective in improving clinical practices and resident outcomes: comparative quality performance information and education programs about quality improvement, or a quality improvement intervention that blends expert clinical consultation with existing nursing staff.
The results revealed that although there are no significant differences between the two groups, the outcomes of residents in nursing homes who made use of the clinical consultation showed improvements in Quality Indicators measuring falls, behavioral symptoms, little or no activity, and pressure ulcers.
The results suggest that simply giving comparative quality performance feedback and education are not enough to improve resident outcomes. Instead, nursing homes should seek out active clinical consultation by a gerontological clinical nurse specialist (GCNS) to improve clinical practice and care.
The findings of the study are consistent with California law regulating skilled nursing facilities, which mandates not only sufficient staffing in terms of numbers, but also in terms of the quality of the staff provided. It is insufficient to simply fill the nursing staff with certified nursing assistants (CNA) who do not have the training, education and expertise of licensed and registered nurses. It is clear that nursing homes can actually make an effort in improving clinical practices by putting these essential findings into practice.

Therefore, nursing home owners and operators should dedicate more resources to hiring a GCNS to provide consultation to the regular nursing staff delivering care to residents. A gerontological clinical nurse specialist can help improve the outcomes of pressure ulcer development, incontinence and aggressive behavior. Further, nursing homes should also have a well-developed comparative quality improvement system to improve resident outcomes. Nursing homes must hire more professional staff with leadership skills to implement the quality improvement programs effectively so as to provide better services to residents. With both clinical expertise and a strong quality improvement system in place, residents can receive better care and treatment from the nursing staff.

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Although understaffing is a common denominator of most injuries sustained by residents of California nursing homes, the issue of staffing is equally one of quality as it is quantity. Labor costs naturally comprise the most significant portion of a nursing home’s expenses. But both sufficient and qualified staffing are the essential components of a safe nursing home environment that not only prevents injuries to its residents, but actually improves their quality of life.

Often times, nursing home owners and operators make the unfortunate decision to place profits over people by cutting staffing and not providing sufficient qualified staff in order to increase their bottom line. Although much has and can be written about that issue, a recent study suggests other significant interventions that can improve the quality of care without significantly increasing staffing or costs of care.

Recently, the Journal of the American Medical Directors Association conducted a comprehensive, multi-level intervention in twenty nine Missouri nursing homes in need of improving quality of care and resident outcomes. The results of the two year study, published in August 2011, revealed that skilled nursing facilities can improve the quality of care they provide and enhance the health and safety of their residents without increasing staffing or costs of care. The study, entitled “Randomized Multilevel Intervention to Improve Outcomes of Nursing Homes in Need of Improvement”, is available for purchase online.

The 29 intervention facilities underwent a 2-year multilevel intervention with monthly on-site intervention from expert nurses with graduate education in gerontological nursing. Although shorter intervals are appropriate, a two year period was chosen to ensure that both the administrative and nursing staff could adopt and maintain the improved care-delivery practices implemented by the study. The theoretical model for the multilevel intervention was “getting the basics of care done”, with organizational changes such as consistent nursing leadership, consistent administrative leadership, and an active quality improvement program. The intervention targeted three levels of staff responsible for operating a nursing home: owners, administrative staff, and direct care staff.

The study found that resident outcomes improved through the interventions, particularly in the areas of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in ADL. One of the study’s findings was that staff retention improved in the intervention facilities (as opposed to the control facilities) as the leadership learned to involve staff in decision making and improvement programs. This was significant, given the consensus that direct care staff and administrator turnover is associated with a negative effect on quality of care. The results were encouraging, as the intervention did improve the quality of care in the areas of pressure ulcers and weight loss.

From a legal standpoint, implementing the findings of this study would serve the nursing home owners’ and operators’ best interests as well, as nursing homes are required to take all steps necessary to improve the quality of care by setting up an administrative system designed to improve quality of care. Specifically, Title 42 of the Code of Federal Regulations, Subpart B, section 483.75, entitled “Administration” mandates: “A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.”

Essentially, the study finds that developing a greater and consistent management team dedicated to involving direct care givers in decision making and improvement programs can lead to greater quality of care. This is consistent with the findings linking high staff turnover with low quality of care levels. Most nurses are by nature dedicated to providing the best care they can to their patients, but they must be equipped with the tools and resources necessary to do so.

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Over the past three decades, the importance of registered nurse (“RN”) job satisfaction has been significantly highlighted, as job dissatisfaction leads to higher turnover rates and a decrease of RN’s in the workforce. A shortage of RNs in California and particularly in San Diego nursing homes, have resulted in not only lower RN-to-resident ratios and thus unmanageable workloads, but also a decrease in the quality of nursing care. Resolving the RN shortage problem and facilitating RN job satisfaction is essential to maintaining the quality of care to which elderly residents of nursing homes are entitled.

A recent article published on August 4, 2011 by JiSun Choi, Linda Flynn and Linda H. Aiken entitled Nursing Practice Environment and Registered Nurses’ Job Satisfaction in Nursing Homes addresses the issue of nursing adequacy as an essential contributing factor to quality of nursing care. The article concludes that, to increase the quality of nursing care, an adequate nursing workforce should be guaranteed by enhancing and maintaining RN job satisfaction. The article identifies a variety of factors contributing to RN job satisfaction, such as work-related, demographic, and facility characteristics. The article concludes that best method to increasing RN job satisfaction is the construction of a supportive nursing practice environment in nursing homes.

The first factor to constructing a supportive nursing practice environment is enhancing RN’s participation in facility affairs, in which nurses are able to get involved in making decisions on clinical and facility-level matters. Therefore, in order to improve the RN’s job satisfaction, nursing home administrators are encouraged to implement a self-governance model for their nurses, such as enabling nurses to develop their own schedules and assignments, making hiring decisions, and contributing to enhancing nursing home policies.

The second factor the article addressed is empowering a supportive manager. Managers of nursing homes can play a significant role in promoting job satisfaction and are urged to facilitate a supportive environment for practicing nursing care, promoting RN teamwork and enhancing RN’s self-recognition.

The last factor associated with RN job satisfaction is providing adequate resources for RNs. RNs are more satisfied with their jobs when there’s adequate staff to accomplish their work with a high level of quality. Implementing this recommendation allows nursing homes to fall in line with federal requirements related to nursing services. In particular, Title 42 of the Code of Federal Regulations, Subpart B, section 483.30, entitled “Nursing Services” specifically mandates: “The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.”

In fact, the Code of Federal Regulations go even further in that respect by mandating a minimum number of hours that RN’s must be on duty per week. 42 CFR § 483.30(b), entitled “Registered Nurse” mandates: “(1) Except when waived under paragraph (c) or (d) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.”

The issue of RN’s job satisfaction is closely associated with the quality of care that RNs are willing and able to provide. Maintaining and enhancing job satisfaction for RNs can significantly decrease the possibility of instances of elder abuse in San Diego nursing homes and in nursing homes throughout California.

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