A State-Sponsored Approach to Quality Improvement in Nursing Homes: Insights From Providers

In 2006, the Minnesota Performance-based Incentive Payment Program (PIPP) was launched to fund provider-initiated quality improvement (QI) projects addressing a wide range of persistent quality issues in nursing homes (eg, falls, pain, mobility, psychotropic medication reduction, care transitions). In this article, the authors describe the perceptions of nursing home providers who participated in a PIPP-funded QI project and completed a survey addressing a variety of QI-related concerns. Respondents noted the importance of support from top leadership, reported being challenged by resource constraints, and generally thought that their project positively impacted quality within their facility. These findings highlight the importance of investing in QI initiatives at both the state and nursing home level to create sustainable QIs

Does Self-efficacy Influence the Application of Evidence-Based Practice?

Background: Implementation of Evidence-Based Practice (EBP) is complex and consequently, even within organizations that have made efforts to promote EBP use, EBP is often underutilized by individual clinicians. Purpose: The aim of our study was to better understand the relationship between self-efficacy and EBP implementation in clinical environments that have undergone efforts to increase EBP utilization. We suggest that EBP is a set of behaviors that result from individuals acquiring, applying, and sharing new knowledge with others in the organization. We hypothesize, based upon a social cognitive theoretical approach, that these behaviors are influenced by clinician perception of self-efficacy. Methods: We analyzed data provided by a 2011 survey of clinicians working within a national sample of hospitals that were actively participating in the Clinical Practice Model Resource Center (CPMRC), a collaborative consortium of health care organizations working to guide the implementation of EBP into the work worlds of clinicians. Structural equation modeling was used to examine the relationships between the acquisition, application, and sharing of evidence, and self-efficacy. Results: Self-efficacy increased the acquisition of evidence and application of evidence. Self-efficacy did not exert a significant influence on sharing evidence. Acquisition of evidence increased both application of evidence and sharing of evidence. Application of evidence then increased sharing of evidence among sampled clinicians. Conclusions: Efforts to promote self-efficacy in clinicians are powerful in that they directly promote the acquisition and application of evidence, and indirectly encourage communication between clinicians in an effort to justify and reinforce new knowledge. Efforts to boost self-efficacy would benefit from a focus on helping clinicians become more comfortable with actions related to acquiring evidence and generating new knowledge

Comorbid Chronic Pain and Depression: Patient Perspectives on Empathy

Clinician empathy is a well-documented component of effective patient/provider communication. Evidence surrounding the association between patient perspectives on clinician empathy and perception of pain management is currently limited, particularly among patients with chronic pain and depression. The aim of this study was to analyze patients’ perspectives on the emergent theme of empathy and describe how patients construct their experiences and expectations surrounding empathic interactions. A secondary analysis of focus group data was designed using grounded theory methodology. Veterans Affairs (VA) and University Primary Care Clinics. Respondents with chronic pain and comorbid depression (N = 18) were 27 to 84 years old (mean 54.8 years), 61% women, 22% black, and 74% white. Study participants highly valued empathy and two types of empathic interactions: empathic listening and empathic action. Patients who provided examples of empathic interactions claimed that others understood, valued, and cared for them. In contrast, patients who perceived a lack of empathy and empathic interactions felt frustrated and uncared for by others (including their physicians) physically and emotionally. Patients with chronic pain and depression claimed that empathy helped them feel understood, believed, taken seriously, and that their needs were met. In demonstrating empathy and engaging in empathic interactions with patients, providers relate better to patients, better understand their life experience, and provide patient-centered care that is meaningful for patients, providers, and the health care systems within which they interact. Future research is needed to purposefully study the effects of empathic interactions on outcomes for patients with chronic pain and comorbid depression

Communication and effectiveness in a US nursing home quality-improvement collaborative

In this study, we explored the relationship between changes in resident health outcomes, practitioner communication patterns, and practitioner perceptions of group effectiveness within a quality-improvement collaborative of nursing home clinicians. Survey and interview data were collected from nursing home clinicians participating in a quality-improvement collaborative. Quality-improvement outcomes were evaluated using US Federal and State minimum dataset measures. Models were specified evaluating the relationships between resident outcomes, staff perceptions of communication patterns, and staff perceptions of collaborative effectiveness. Interview data provided deeper understanding of the quantitative findings. Reductions in fall rates were highest in facilities where respondents experienced the highest levels of communication with collaborative members outside of scheduled meetings, and where respondents perceived that the collaborative kept them informed and provided new ideas. Clinicians observed that participation in a quality-improvement collaborative positively influenced the ability to share innovative ideas and expand the quality-improvement program within their nursing home. For practitioners, a high level of communication, both inside and outside of meetings, was key to making measurable gains in resident health outcomes

State Uses Financial Incentives To Fund Nursing Home–Initiated Quality Improvement Projects Through Competitive Bidding Process, Leading to Better Care

Authorized in 2006 by the State legislature, Minnesota’s Performance-Based Incentive Program funds nursing home–initiated quality improvement projects for 1 to 3 years through increases of up to 5 percent in the operating per diem rate charged to Medicaid and private-pay residents. Funding decisions are made through a competitive bidding process administered annually by the Department of Human Services, with recommendations from a review committee. Program staff provide support to nursing homes during and after the application process. Nursing homes that do not achieve project-specific performance targets can lose up to 20 percent of the incentive payments. The program has engaged a high proportion of Minnesota nursing homes in quality improvement activities; meaningfully improved the quality of nursing home care; and had a positive impact on quality improvement processes, teamwork, and communication within nursing homes

State Policy Responses to COVID-19 in Nursing Homes

Context: COVID-19 has a high case fatality rate in high-risk populations and can cause severe morbidity and high healthcare resource use. Nursing home residents are a high-risk population; they live in congregate settings, often with shared rooms, and require hands-on care. Objectives: To assess state responses to the coronavirus pandemic related to nursing homes in the first half of 2020. Methods: An in-depth examination of 12 states’ responses to the COVID-19 pandemic in nursing homes through June 2020, using publicly reported information such as government decrees, health department guidance, and news reports. Findings: No state emerged as a model of care. All states faced difficulty with limited availability of testing and Personal Protective Equipment (PPE). State-level efforts to increase pay and benefits as a strategy to enable infected staff to quickly physically separate from residents were minimal, and other separation strategies depended on the ability to obtain test results rapidly and on state rules regarding accepting discharged COVID-19 patients into nursing homes. Visitor restrictions to reduce risk were ubiquitous, though based on a slim evidence-base. Limitations: The information used was limited to that which was publicly available. Implications: Overall, the results suggest that the states that handle the ongoing pandemic in nursing homes best will be those that find ways to make sure nursing homes have the resources to follow best practices for testing, PPE, separation, and staffing. Evidence is needed on visitor restrictions and transmission, as states and their citizens would benefit from finding safe ways to relax visitor restrictions

CEO succession and the CEO’s commitment to the status quo

Chief executive officer (CEO) commitment to the status quo (CSQ) is expected to play an important role in any firm’s strategic adaptation. CSQ is used often as an explanation for strategic change occurring after CEO succession: new CEOs are expected to reveal a lower CSQ than established CEOs. Although widely accepted in the literature, this relationship remains imputed but unobserved. We address this research gap and analyze whether new CEOs reveal lower CSQ than established CEOs. By analyzing the letters to the shareholders of German HDAX firms, we find empirical support for our hypothesis of a lower CSQ of newly appointed CEOs compared to established CEOs. However, our detailed analyses provide a differentiated picture. We find support for a lower CSQ of successors after a forced CEO turnover compared to successors after a voluntary turnover, which indicates an influence of the mandate for change on the CEO’s CSQ. However, against the widespread assumption, we do not find support for a lower CSQ of outside successors compared to inside successors, which calls for deeper analyses of the insiderness of new CEOs. Further, our supplementary analyses propose a revised tenure effect: the widely assumed relationship of an increase in CSQ when CEO tenure increases might be driven mainly by the event of CEO succession and may not universally and continuously increase over time, pointing to a “window of opportunity” to initiate strategic change shortly after the succession event. By analyzing the relationship between CEO succession and CEO CSQ, our results contribute to the CSQ literature and provide fruitful impulses for the CEO succession literature

Epidemiology of basal-like breast cancer

Risk factors for the newly identified “intrinsic” breast cancer subtypes (luminal A, luminal B, basal-like and human epidermal growth factor receptor 2-positive/estrogen receptor-negative) were determined in the Carolina Breast Cancer Study, a population-based, case–control study of African-American and white women. Immunohistochemical markers were used to subtype 1,424 cases of invasive and in situ breast cancer, and case subtypes were compared to 2,022 controls. Luminal A, the most common subtype, exhibited risk factors typically reported for breast cancer in previous studies, including inverse associations for increased parity and younger age at first full-term pregnancy. Basal-like cases exhibited several associations that were opposite to those observed for luminal A, including increased risk for parity and younger age at first term full-term pregnancy. Longer duration breastfeeding, increasing number of children breastfed, and increasing number of months breastfeeding per child were each associated with reduced risk of basal-like breast cancer, but not luminal A. Women with multiple live births who did not breastfeed and women who used medications to suppress lactation were at increased risk of basal-like, but not luminal A, breast cancer. Elevated waist-hip ratio was associated with increased risk of luminal A in postmenopausal women, and increased risk of basal-like breast cancer in pre- and postmenopausal women. The prevalence of basal-like breast cancer was highest among premenopausal African-American women, who also showed the highest prevalence of basal-like risk factors. Among younger African-American women, we estimate that up to 68% of basal-like breast cancer could be prevented by promoting breastfeeding and reducing abdominal adiposity