Abstract
BackgroundImproving nursing home quality of care relies partly on reducing or stopping ineffective or harmful practices, a process known as de-implementation. We know little about de-implementation in this setting. Relatively recent policy changes reclassified resident position-change (bed and chair) alarms, which monitor resident movement, as restraints. This created an optimal environment in which to study impressions of an alarm de-implementation and sustainment intervention.MethodsThis cross-sectional interview study focused on understanding participants’ experience of a quality improvement program in the Department of Veterans Affairs Community Living Centers (nursing homes). The program’s goal was to improve resident outcomes and staff communication and teamwork through, among other foci, eliminating resident position-change alarms. The Community Living Centers were located in geographically dispersed areas of the continental United States. Interview participants were leadership and staff members from seven Community Living Centers. We conducted in-depth, semi-structured qualitative interviews using a convenience sample and used a thematic analytic approach.ResultsWe conducted seventeen interviews. We identified five main themes: Initiating De-implementation (compelling participants with evidence, engaging local leadership, and site-level education and training), Changing Expectations (educating staff and family members), Using Contrasting Approaches (gradual or abrupt elimination of alarms), Witnessing Positive Effects of De-implementation (reduction in resident falls, improved resident sleep, reduction in distressing behaviors, and increased resident engagement), and Staying the Course (sustainment of the initiative).ConclusionsFindings highlight how participants overcame barriers and successfully eliminated resident position-change alarms and sustained the de-implementation through using convincing evidence for the initiative, local leadership involvement and support, and staff and family member education and engagement. These findings and the resulting three-phase process to support nursing homes' de-implementation efforts expand the de-implementation science knowledge base and provide a promising framework for other nursing home-based de-implementation initiatives.
Highlights
Improving nursing home quality of care relies partly on reducing or stopping ineffective or harmful practices, a process known as de-implementation
Program overview Leaders from Veterans Affairs (VA)’s national facility-based care team in Washington, D.C. selected eight Community Living Center (CLC) to take part in a quality improvement learning intensive aimed at improving resident outcomes on Centers for Medicare and Medicaid Services quality measures and staff communication and teamwork processes through a structured, evidence-based curriculum that built on the outcomes of a series of research studies and quality improvement projects [15,16,17]
Fourteen interviews were with local leadership team members from seven CLCs
Summary
Improving nursing home quality of care relies partly on reducing or stopping ineffective or harmful practices, a process known as de-implementation. Recent policy changes reclassified resident position-change (bed and chair) alarms, which monitor resident movement, as restraints. This created an optimal environment in which to study impressions of an alarm de-implementation and sustainment intervention. Improving healthcare sometimes involves stopping or reducing services or practices known to be ineffective or harmful. This process, known as de-implementation, has potential public health benefits as well as implications for healthcare waste reduction [1]. Evidence about how best to approach de-implementation in nursing homes is sparse [6,7,8]
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