Journal of Gerontological Nursing

Quality Improvement in Nursing Facilities: A NURSING LEADERSHIP PERSPECTIVE

Linda Adams-Wendling, PhD, MSN, RN; Robert Lee, PhD



The purposes of this study were to characterize the state of quality improvement (Ql) in nursing facilities and to identify barriers to improvement from nursing leaders' perspectives. The study employed a non-experimental descriptive design, using closedand open-ended survey questions in a sample of 51 nursing facilities in a midwestern state. Only two of these facilities had active Ql programs. Furthermore, turnover and limited training among these nursing leaders represented major barriers to rapid implementation of such programs. This study is consistent with earlier findings that Ql programs are limited in nursing homes.



The purposes of this study were to characterize the state of quality improvement (Ql) in nursing facilities and to identify barriers to improvement from nursing leaders' perspectives. The study employed a non-experimental descriptive design, using closedand open-ended survey questions in a sample of 51 nursing facilities in a midwestern state. Only two of these facilities had active Ql programs. Furthermore, turnover and limited training among these nursing leaders represented major barriers to rapid implementation of such programs. This study is consistent with earlier findings that Ql programs are limited in nursing homes.

Concerns about nursing home quality continue to exist Although the landmark Institute of Medicine study (1986) underpins much of the current regulatory structure, public efforts to improve the quality of care in nursing homes date approximately to the 1960s (Committee on Labor and Public Welfare, 1966). Nonetheless, significant quality problems persist The General Accounting Office reports that one-fifth of nursing homes still have serious quality problems, even though the quality of care appears to have improved in numerous domains during the past decade (Berlowitz, Bezerra, & Brandeis, 2000; Casde, 2000; Casde & Mor, 1999; U.S. General Accounting Office, 1999).

The Nursing Home Quality Initiative, which the Centers for Medicare and Medicaid Services launched in Fall 2002, represents one response to these ongoing problems. As part of a broader federal effort to improve health care quality, the Initiative expanded public access to quality of care data. It also directed Medicare Quality Improvement Organizations to provide technical support for nursing homes' quality improvement (QI) efforts (U.S. Department of Health & Human Services, 2002).

The Nursing Home Quality Initiative's emphasis on QI (also known as Total Quality Management or Continuous Quality Improvement) highlights the apparent slow diffusion of robust QI programs in nursing homes. The conventional wisdom is that most nursing homes adhere to a quality assurance model emphasizing compliance with regulatory standards (American Health Quality Association, 2003; Institute of Medicine, 2001). In addition, many studies (Casde, Zinn, Brannon, & Mor, 1997; Dimant, 1991; McLaughlin & Kaluzny, 1990; Sheridan, Fairchild, Haddock, & Jones, 1995; Zinn & Brannon, 1995; Zinn, Weech, & Brannon, 1998) have reported that QI has spread relatively slowly in nursing homes.

Although the authors' experience suggests that QI has not been widely adopted in nursing homes, it is not entirely clear that this is true. Two systematic analyses of nursing homes have found widespread QI adoption. Zinn, Brannon, and Weech (1997) found that 76.4% of a 1995 sample of Pennsylvania nursing homes used QI techniques. They also learned that 27.4% met their criteria for having implemented a comprehensive QI program. Rondeau and Wagner (2002) found that 73.9% of a 1997 sample of Canadian nursing homes had implemented a formal QI program.

It should be noted that Zinn et al. (1 997) were concerned that respondents may have given socially acceptable answers (i.e., exaggerating use of QI). In addition, this article's companion study (Lee & Adams-Wendling, 2004) showed that some survey formats led nursing home leaders to overstate the role of QI in their facilities.

This study reports on the current state of QI in a random sample of Kansas nursing facilities. Obtaining accurate information about the actual use of QI is important; therefore, the authors used a variety of techniques in the data collection process to minimize the reporting of socially acceptable answers. Because nurses often play a vital role in QI efforts, this study focuses on the responses of nursing leaders with significant QI responsibilities. Because the slow diffusion of QI in nursing homes is unlikely to be an accident, the authors also examine whether the training, experience, and tenure of nursing leaders provides them with the proper tools to develop and direct QI programs.


Sample, Design, and Procedures

After receiving approval of the study protocol by the Institutional Review Board at a midwestern university, the authors drew a random sample of 174 Kansas nursing facilities and called each facility's administrator to request informed consent for participation in the survey. If the administrator agreed to participate, the team scheduled a telephone interview with a facility representative, indicated by the facility's administrator to be a reliable source, during Fall 2001 and Spring 2002. The interview was then conducted using the survey instrument and a semi-structured telephone interview approach. Team members completed telephone interviews with 106 facilities (61% of the sample). Comparisons of the number of beds, ownership, system membership, and Medicare participation identified no statistically significant differences between participants and non-participants.

With a focus on QI from nursing leadership's perspective, this study is an examination of 51 facilities where the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) was the respondent The number of beds, ownership, system membership, and Medicare participation of the subsample was compared with the same data for other participants and non-participants, resulting in no significant differences. This was performed to ensure the subsample was similar or representative of the original sample of Kansas nursing facilities.

Few of the participating facilities were large. The mean number of beds was 80.9 (the 25th percentile was 55 beds, the median was 60 beds, and the 75th percentile was 92 beds). Seventyfive percent of the respondents participated in Medicare and 57% were members of a system. For-profit organizations owned 59% of the facilities, not-for-profit organizations owned 31%, and governments owned 10%.

Instrument and Data Collection

The research team used a telephone survey to obtain information about the QI activities from the random sample. The questionnaire used was developed by the principal investigator, and included both open- and closed-ended questions. It was based on a survey tool fielded byZinnetal. (1997). The research team piloted the original mail survey version of the instrument in Fall 2000 and found that this version encouraged socially acceptable answers, thus leading to an overestimate of the presence of QI in nursing facilities. Modifications to the questionnaire were made, including the addition of more open-ended questions focusing on the details of each facility's quality management system and the identification of the facility's most important QI project in the past year. Three DONs favorably evaluated the face and content validity of the revised questionnaire.


After the investigators completed data collection, the results of the telephone interviews were entered in the Statistical Package for the Social Sciences software, version 10 (SPSS Inc., Chicago, IL) for frequency and distribution analysis. All data collected were non-parametric and coded into categories prior to frequency and descriptive analysis.


Three of the respondents were ADONs. The remaining 48 respondents were DONs. Two (3.8%) of the respondents had a master's degree, 15.4% had a bachelor's degree, 73.1% had an associate's degree, 5.8% had a nursing diploma, and 1.9% had a high school diploma. These findings are consistent with state and national results that report the majority of nursing leaders in nursing homes have less than a bachelor's degree (Decker, Gruhn, Dollard, Tucker, & Bizette, 2002; Kansas Association of Homes and Services for the Aging [KAHSA], 2002).

Twenty-eight (54.9%) of the respondents held their current position for a year or less, and 45.1% had been in their current position for 2 years or less. These findings are also consistent with reported state (52.3%) and national (49.7%) turnover rates for nursing leaders in nursing homes (Decker et al, 2002; KAHSA, 2002).

When asked how long individuals had held their position during the past 5 years, 31.4% said 3 years or more, 25.5% did not know or gave no answer, 23.5% said 2 years, and 19.6% said they had been in the position the entire time. All but one who did not know or gave no answer had held their position for a year or less.

As mandated by federal regulations, all of the Quality Assurance Committees met at least quarterly. Two (3.9%) of the Committees met weekly, and 56.9% met monthly. None of the ADONs were the Quality Assurance Committee chair, but 13 of the DONs had this tide. Thirty-eight (74.5%) of the Quality Assurance Committees reviewed the quarterly Quality Indicator Reports that the state produced. The Committees also reviewed incident reports (75%), facility-generated data (29.4%), and complaints (29.4%).

Twelve of the facilities had not designated a Quality Improvement Coordinator (or a similar tide). Among the other facilities, the DON was the Quality Improvement Coordinator in 16 (41%). In the remaining facilities, a wide range of other personnel had been designated the Quality Improvement Coordinator. The Quality Improvement Coordinators averaged 15.4 hours per week.

The respondents were asked about the previous year's most important QI project. Falls (26%) was the most common response, and "do not know" (10%) was the next most common. The remaining responses varied. Several respondents mentioned skin care, hydration, urinary tract infections, and weight discrepancies.

Thirteen respondents (25.5%) said their most important project was prompted by a quarterly Quality Indicator Report, 17.6% responded to a regulatory action, 16.7% responded to an impression, and the remaining respondents said a variety of motives prompted them. Five (9.8%) of the facilities used a flowchart in this project, 11.8% used a run or control chart, and 2% used a histogram or Pareto chart Twenty-nine facilities (56.9%) involved staff not on the Quality Assurance Committee in the project Registered nurses were the most apt to be involved (35.3%), with both LPNs and CNAs likely to play a role (29.4%). Other staff (17.6%) were the least likely to be involved in the project

Thirty respondents (58.8%) indicated that staff had been trained in QI principles. Ten (19.8%) reported having used a flowchart, and 11.8% reported having used a run or control chart. (A flowchart describes a process in detail. Run and control charts track performance over time.)

Every facility had some mechanism to identify opportunities for improvement Some used measures that could be tracked over time, such as quarterly (13.7%) or annual (29.4%) resident and family satisfaction surveys. Most facilities used somewhat less systematic methods, including complaints (45.1%), Resident Councils (35.3%), Family Councils (29.4%), family participation in care planning (17.6%), and informal interactions (17.6%).


Six principles were used to assess whether nursing facilities had adopted QI (Berwick, 1989; Berwick, Godfrey, & Roessner, 2001; Castle et al., 1997; Institute of Medicine, 2001; Joint Commission on Accreditation of Health Care Organization [JCAHO], 1993). They are:

(1) Quality is the organization's central priority.

(2) The leaders are knowledgeable about, committed to, and involved in QI.

(3) The facility focuses on strengthening functions and processes.

(4) The facility uses reliable statistical methods to measure processes and outcomes.

(5) The employees participate and cooperate in QI through teamwork.

(6) The facility focuses on customer needs.

Principle 1

Based on this criterion, most facilities appear not to have adopted QI. Assessing whether quality represents a central priority for a facility is difficult. The authors used two indicators that stressed tangible actions - whether the facility had allocated resources to QI and whether the facility had a leadership structure consistent with a commitment to quality. Nearly three-fifths of the facilities reported offering QI training to employees who were not on the Quality Assurance Committee, and nearly three-quarters reported having identified a QI coordinator. However, QI coordinators averaged only 15 hours per week, and two-fifths of the QI coordinators were already-overloaded DONs. Because the content of this training and the duties of these QI coordinators are unknown, this is not compelling evidence that quality is a key goal. The turnover among nursing leadership as reported by the facilities was not consistent with a fundamental commitment to quality.

Turnover of leaders has been discussed as a major obstacle to QI implementation. QI requires time and consistency of effort, and leadership changes make this problematic (Castle et al., 1997; Gustafson, Sainfort, Van Konigsveld, & Zimmerman, 1990). Constant turnover does not allow for continuity or follow-through related to care improvement processes, and it drains the organization of financial resources. An outcome of continual nurse leadership turnover results in a cyclical effect where the facility is in a constant state of transition. As nurse leaders learn their roles, time and resources are not available to mobilize the QI process and to provide education to increase the staff knowledge related to QI.

More than half of the respondents in this study had been in their current position for only a year or less. More than half of these respondents reported that their positions had been held by two or more other nurses during the past 5 years. This suggests that facilities did not use resources to make these positions desirable. With this reported nurse leadership turnover, the fundamental commitment to quality cannot be attained.

Principle 2

Evidence was mixed in relation to the respondents' knowledge about, commitment to, and involvement in QI. If respondents were knowledgeable, it was not a result of formal training or experience in their current positions. More than 80% had fewer than 2 years of post-high-school training, and more than 70% had been in their current roles for fewer than 2 years. In addition, less than one of eight reported using standard QI tools on the past year's most important project, suggesting they were unfamiliar with these tools.

The authors cannot assess the respondents' commitment to QI, but virtually all were involved in quality-related activities. Respondents often chaired the Quality Assurance Committee, most were members of the Committee, some had been appointed the QI Coordinator (or similar title), and most participated in the previous year's most important quality initiative.

Principle 3

Strengthening functions and processes is the third hallmark of QI. To do so, facilities must be able to describe their processes, typically by creating a flowchart. Few met this criterion. Less than 20% of the respondents reported ever having used a flowchart, and only 10.4% used a flowchart on the past year's most important project. This represents clear evidence that a QI orientation was not the norm among these facilities.

Principle 4

The fourth principle of QI is use of reliable statistical methods to measure performance (JCAHO, 1993). The gold standard is a control chart, which tracks performance over time and distinguishes normal variations from those because of special causes. (A run chart is a similar, if less sophisticated, tool.) Only 11.8% of the respondents ever used a run or control chart, the same proportion who used a run or control chart in the past year's most important project. In short, few of these facilities used QI techniques to analyze data. As a result, most were unable to distinguish meaningful changes in performance from normal variations.

Principle 5

The fifth principle of QI is widespread participation of employees, but front-line staff did not routinely participate in QI efforts. Less than a third of the previous year's most important improvement efforts involved CNAs or LPNs. This suggests that most facilities used a traditional quality assurance approach to problems rather than a QI approach.

Principle 6

Focusing on customer needs requires facilities to systematically query residents and their families about how well those needs are being met (Institute of Medicine, 2001). Less than 40% of these facilities conducted any resident or family satisfaction surveys, and less than 14% surveyed residents or family often enough to be useful for a QI program. Every facility had some mechanism for identifying customer concerns, but most of these mechanisms were relatively unstructured in nature (e.g., complaints or informal interactions), and were unlikely to present a systematic picture of how well customers were being served.

To synthesize these results, the authors focused on a subset of their criteria. Any facility that has trained nonmanagement staff in the principles of QI, has ever developed a flowchart, or has ever developed a run or control chart will be defined as having a QI program. Only two facilities (3.9%) met this minimal definition.


The generalizability of these results may be limited because the sample was drawn from one state. In addition, the information for this study was gathered from a single respondent in each facility, although this individual was chosen by each facility's administrator and identified as a reliable source. The very limited number of active QI programs and the study's modest sample size effectively preclude linking the effects of QI to clinical and financial outcomes. All of these limitations are common in studies of this type, but the main argument for them is limited resources. Research is needed that examines QI nationally, provides a more detailed description of QI activities in nursing facilities, and examines the effects of QI on quality and cost.

Notwithstanding these limitations, these results reinforce the perception that relatively few nursing facilities have really adopted QI. Most continue to adhere to the quality assurance approach that the survey process reinforces. A quality assurance approach is led by (and often restricted to) managers, and emphasizes compliance with external standards.

These results also reinforce the perception that the implementation of QI faces major barriers in nursing facilities. These barriers include the absence of a clear business case for QI, the presence of disruptive leadership turnover, and limitations on resources (including QI expertise). These obstacles may largely arise from the uncertain financial rewards of QI for nursing facilities (Berlowitz et al., 2000, 2003; Leatherman, Berwick, & lies, 2003). The authors suspect that facilities lacking an effective QI program have been able to meet survey standards and fill their beds, even though their quality of care falls far short of what is possible.

In other sectors, QI has resulted in impressive increases in profitability, employee satisfaction, and customer satisfaction (Hendrick & Singhal, 2001). It has the potential to be at least as powerful in long-term care. However, QI is more likely to succeed when the regulatory environment rewards it, when the market environment rewards it, and when organizational leaders have made credible commitments to it (Shortell, Bennett, & Byck, 1998). The ongoing Nursing Home Quality Initiative may represent an important change in the regulatory environment, and the push toward publicizing nursing facility quality indicators may represent an important change in the market environment.

Nursing leaders who want to begin or improve their current process of QI can obtain materials tailored to nursing facilities by contacting Dr. Robert Lee at This information was developed by the University of Kansas Center on Aging (Lee, 2002), and is based on the principles of QI that underpin this study. The authors believe that education may be an important next step in the implementation of QI in nursing facilities.


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