Approaches to quality improvement in nursing homes: Lessons learned from the six-state pilot of CMS's Nursing Home Quality Initiative

BACKGROUND: In November 2002, the Centers for Medicare & Medicaid Services (CMS) launched a Nursing Home Quality Initiative that included publicly reporting a set of Quality Measures for all nursing homes in the country, and providing quality improvement assistance to nursing homes nationwide. A pilot of this initiative occurred in six states for six months prior to the launch. METHODS: Review and analysis of the lessons learned from the six Quality Improvement Organizations (QIOs) that led quality improvement efforts in nursing homes from the six pilot states. RESULTS: QIOs in the six pilot states found several key outcomes of the Nursing Home Quality Initiative that help to maximize the potential of public reporting to leverage effective improvement in nursing home quality of care. First, public reporting focuses the attention of all stakeholders in the nursing home industry on achieving good quality outcomes on a defined set of measures, and creates an incentive for partnership formation. Second, publicly reported quality measures motivate nursing home providers to improve in certain key clinical areas, and in particular to seek out new ways of changing processes of care, such as engaging physicians and the medical director more directly. Third, the lessons learned by QIOs in the pilot of this Initiative indicate that certain approaches to providing quality improvement assistance are key to guiding nursing home providers' desire and enthusiasm to improve towards a using a systematic approach to quality improvement. CONCLUSION: The Nursing Home Quality Initiative has already demonstrated the potential of public reporting to foster collaboration and coordination among nursing home stakeholders and to heighten interest of nursing homes in quality improvement techniques. The lessons learned from this pilot project have implications for any organizations or individuals planning quality improvement projects in the nursing home setting

In Situ Bioremediation through Mulching of Soil Polluted by a Copper–Nickel Smelter

Received for publication September 8, 2000. Bioremediation of a heavy metal–polluted soil was investigated in a 3-yr field experiment by adding mulch to a polluted forest floor. The mulch consisted of a mixture of compost and woodchips. The remediation treatment decreased the toxicity of the soil solution to bacteria as determined by the [3H]-thymidine incorporation technique, that is, by measuring the growth rate of soil bacteria extracted from unpolluted humus after exposing them to soil solution containing heavy metals from the experimental plots. Canonical correlation analysis was performed in order to identify the chemical and microbiological changes in the soil. The pH of the mulched organic layer increased by one unit. The concentration of complexed Cu increased and that of free Cu2+ decreased in the soil solution from the mulch treatment. According to basal respiration and litter decomposition, microbial activity increased during the 3 yr following the remediation treatment. The [3H]-thymidine incorporation technique was also used to study the growth rate and tolerance of bacteria to Cu. The bacterial growth rate increased and the Cu tolerance decreased on the treated plots. The structure of the microbial community, as determined by phospholipid fatty acid (PLFA) analysis, remained unchanged. The results indicate that remediation of the polluted soil had occurred, and that adding a mulch to the forest floor is a suitable method for remediating heavy metal–polluted soil

RNA-Seq Analysis to Identify Novel Roles of Scleraxis during Embryonic Mouse Heart Valve Remodeling

<div><p>Heart valve disease affects up to 30% of the population and has been shown to have origins during embryonic development. Valvulogenesis begins with formation of endocardial cushions in the atrioventricular canal and outflow tract regions. Subsequently, endocardial cushions remodel, elongate and progressively form mature valve structures composed of a highly organized connective tissue that provides the necessary biomechanical function throughout life. While endocardial cushion formation has been well studied, the processes required for valve remodeling are less well understood. The transcription factor Scleraxis (Scx) is detected in mouse valves from E15.5 during initial stages of remodeling, and expression remains high until birth when formation of the highly organized mature structure is complete. Heart valves from <i>Scx^-/-</i> mice are abnormally thick and develop fibrotic phenotypes similar to human disease by juvenile stages. These phenotypes begin around E15.5 and are associated with defects in connective tissue organization and valve interstitial cell differentiation. In order to understand the etiology of this phenotype, we analyzed the transcriptome of remodeling valves isolated from E15.5 <i>Scx^-/-</i> embryos using RNA-seq. From this, we have identified a profile of protein and non-protein mRNAs that are dependent on Scx function and using bioinformatics we can predict the molecular functions and biological processes affected by these genes. These include processes and functions associated with gene regulation (methyltransferase activity, DNA binding, Notch signaling), vitamin A metabolism (retinoic acid biosynthesis) and cellular development (cell morphology, cell assembly and organization). In addition, several mRNAs are affected by alternative splicing events in the absence of <i>Scx</i>, suggesting additional roles in post-transcriptional modification. In summary, our findings have identified transcriptome profiles from abnormal heart valves isolated from E15.5 <i>Scx^-/-</i> embryos that could be used in the future to understand mechanisms of heart valve disease in the human population.</p></div

Top 25 most differentially expressed protein-coding mRNAs (>1.5-fold change, p<0.05) in <i>Scx^-/-</i> atrioventricular canal samples compared to <i>Scx^+/+</i> controls.

<p>Top 25 most differentially expressed protein-coding mRNAs (>1.5-fold change, p<0.05) in <i>Scx^-/-</i> atrioventricular canal samples compared to <i>Scx^+/+</i> controls.</p

Exon-level splicing indices of mRNAs affected by alternative splicing events in <i>Scx^-/-</i> samples at E15.5.

<p>Splicing indices of the top 8 mRNAs affected by changes in exon abundance (at least 10 exons) in the absence of Scx. * indicate significant differences in exon abundance (p<0.05).</p

Bioinformatics pathway analysis to predict molecular functions and biological processes significantly affected by the loss of Scx in heart valves at E15.5.

<p>(GO, Gene Ontology).</p

Validation of RNA-seq analysis.

<p>(A) Fold changes in gene expression of <i>Actn4, Aldha1</i> and <i>Dot1L</i> based on RNA-seq analysis. Grey line indicates normalized gene expression levels in <i>Scx^+/+</i> controls (set at 1). (B) qPCR to show fold changes in <i>Scx, Actn4, Aldha1</i> and <i>Dot1L</i> expression in rat VICs infected with an adenovirus overexpressing Scx (AdV-Scx) compared to AdV-GFP infected controls. *, p<0.05, n = 3. Grey line indicates normalized gene expression levels in AdV-GFP treated rat VICs (set at 1). (C-H) Fluorescent immunohistochemistry to detect Type IV Collagen (Col4) (C, D at 10x magnification), Fibromodulin (Fmod) (E, F at 20x magnification) and Heparin sulfate proteoglycan 2 (Hspg2) (G, H at 20x magnification) in mitral valves (highlighted by white line) from E15.5 <i>Scx^+/+</i> controls (C, E, G) and <i>Scx^-/-</i> (D, F, H) embryos. Note reduced expression in tissue sections from <i>Scx^-/-</i> embryos. mv, mitral valve; IVS, interventricular septum.</p