Dr. Debra BakerjianDr. Debra Bakerjian is Senior Director for Nurse Practitioner and Physician Assistant Clinical Education and Practice as well as an Assistant Adjunct Professor at the Betty Irene Moore School of Nursing at UC Davis. Previously, Bakerjian was a Betty Irene Moore School of Nursing postdoctoral scholar with a specialty in Health Policy and System Change.

ElderBranch interviewed Dr. Bakerjian to discuss her paper, Applying the Advancing Excellence in America’s Nursing Homes Circle of Success to improving and sustaining quality, which she wrote along with Dr. Anna Zisberg, also of the Betty Irene Moore School of Nursing at UC Davis.

Why did you decide to explore the quality improvement process in nursing homes? Why is this topic important?

As a long-time clinical provider in nursing homes, I was able to directly observe many of the problems that were occurring and then reoccurring over and over in the nursing homes. Despite dedicated, hard-working and caring nursing staff and administrators, poor resident outcomes were common. I realized that the reason the problems kept popping up is that staff would correct an individual resident issue but often did not address the “root cause” of the problem and change the system so that future problems could be prevented.  The nursing home industry really needed to rethink how they were managing poor outcomes and make sure that there was a systematic approach to making changes in the system of care and not just blaming a particular individual.

Quality improvement is based on examining the systems of care. When done right, it encompasses a strong culture of patient safety in which problems are assumed to be a systems issue first and then those root causes become identified. Interventions are focused on changes in the system such as changing a policy and procedures, improving the knowledge and skill base of the stakeholders, or making changes in the environment. Only by fully embracing quality improvement and the culture of safety can we really make long-lasting and sustainable improvements.

What is the Quality Assurance Performance Improvement program? How will it change the standard of care in nursing homes?

In the past, nursing homes were required to have a quality assurance program.  Quality assurance involves a retrospective look back to what has been done and a determination if the performance meets a set of minimum standards. As long as the minimum standards are met, everyone was okay. This system does NOT address any improvement processes or try to achieve a high degree of success in implementing best practices. Quality or performance improvement (QI or PI) is a process where a specified improvement goal is established and a specific process change is made and then progress is measured regularly to determine if the improvement happens. We use a Plan-Do-Study-Act (PDSA) cycle to identify a problem, conduct an investigation to identify the cause of the problem, plan a change intervention, and determine how we will measure the change, implement and measure the change process, study the process and then determine what next actions should be taken. This cyclical process is repeated over and over until the goals are achieved and sustained.

The new CMS legislation that goes into effect in 2014 will require both the QA and the PI (QI) in nursing homes. This will be an important improvement.

What is the Advancing Excellence Circle of Success framework and how can nursing homes apply it in order to improve their quality of care?

The Advancing Excellence Campaign (AEC) is a public-private, all volunteer partnership between all of the stakeholders in nursing homes including professional and provider organizations, consumers, and the federal and state governments. The entire purpose of this organization is to provide a high level and central focus on quality in nursing homes. The Circle of Success is a model that the campaign has adopted that will help nursing homes understand and implement quality improvement. In addition to the PDSA cycle itself, it takes into account some of the contextual issues that are important contributors to the success of PI/QI, such as the leadership of the nursing home.

What role can nurses play in quality improvement efforts in nursing homes?

Nurses are integral to the success of QI in nursing homes. They plan, conduct, and monitor the care provided to all residents. They are the only group of clinicians who are actually there interacting with patients 24 hours per day, 365 days per year.  Administrators and other nursing home staff are there for a much shorter period of time, typically during day shift and early evening shift. Physicians, nurse practitioners, physician assistants, and other clinical consultants are only there periodically in most nursing homes. Nurses play many different roles in QI but QI is best accomplished when it is a representative, interdisciplinary team.

What do you anticipate will be the biggest challenge for nursing homes as they implement the Quality Assurance Performance Improvement program?

I think there are multiple challenges but the two biggest challenges are ensuring that all of the stakeholders, particularly the leaders (Directors of Nursing and Nursing Home Administrators) are educated and competent in how to conduct QAPI and also that they understand how (and are compelled) to create a culture (environment) in which QI can succeed. It must be a priority and not an afterthought. 

The biggest reason that QI is not sustainable is because complete system change does not occur, facilities stop projects as soon as they achieve the first goal or they achieve a goal in a particular area but don’t take the next step, or they partially achieve a goal but then don’t figure out to make it fully successful. Staff turnover is also a major impediment because someone who is working on, leading or championing a project leaves and then the project peters out.

The fact that it will now be part of the survey process should help because, unfortunately, most nursing homes are very focused on survey readiness alone. 


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