Perceptions of staff quality improvement training needs among Veterans Affairs nursing home leadership

Abstract

Assuring the quality of care in any healthcare provider is a central concern and finding a robust way of measuring it remains an important challenge. On one hand, quality indicators are frequently used by commissioners of care for performance management and reimbursement and also increasingly as an aid to consumer choice. On the other hand, good measurement helps staff to achieve a virtuous circle of constant improvement. Most high income countries use some sort of composite quality indicators to assure what can be a large and complex system; however, the evidence suggests that indicators are only useful if staff are engaged and committed to collecting data reliably. This paper explores the perceptions held by senior clinical leaders about the attitudes to quality assurance of frontline staff and in particular their attitudes to a standardised assessment system used widely in the USA and internationally. The Resident Assessment Instrument is used to develop care plans and a minimum data set drawn from the assessment is used to monitor quality. Surveying 97 skilled nursing facilities in the USA, the authors found that the leaders believed their staff did not fully understand how the minimum data set is used to create the quality indicators. The clinical leaders’ own perceptions are as revealing as their interpretation of the attitudes of frontline staff. The leaders themselves appear to have placed relatively little emphasis on technical aspects of improvement including trend tools and root cause analysis. They ranked training staff in specific quality improvement techniques such as statistical process control charts as the least important improvement intervention, preferring instead more training of staff to use the indicators as a clinical assessment tool. Knowing that a change is an improvement can be difficult and traditional research statistics are inappropriate due to the lack of power in individual units or organisations. Improvement Science is a relatively new discipline that explores measuring for improvement rather than for judgement and where it is embedded in practice (such as Jonkoping Council Healthcare in Sweden, Intermountain Healthcare in Utah, USA and Salford Royal NHS