Objective. To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care. Data Sources/Study Settings. Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database. Study Design. A cross-sectional analysis of the association among the different measures was performed. Data Collection/Extraction Methods. Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database. Principal Findings. Nursing homes differed significantly ( po.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, po.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, po.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development. Conclusions. Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.

BackgroundMeta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness.MethodsThe study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months.ResultsInterviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003).ConclusionsDepression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed.Trial RegistrationClinicalTrials.gov: NCT00105820

Caregivers of patients with dementia and diabetes face extraordinary challenges managing both conditions and the accompanying BPSD. Their identified need for a greater response from the healthcare system should be tested in quality improvement programs for this overlooked yet rapidly growing population.

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Background: Although many health care organizations require routine pain screening (eg, "5th vital sign") with the 0 to 10 numeric rating scale (NRS), its accuracy has been questioned; here we evaluated its accuracy and potential causes for error.Methods: We randomly surveyed veterans and reviewed their charts after outpatient encounters at 2 hospitals and 6 affiliated community sites. Using correlation and receiver operating characteristic analysis, we compared the routinely measured "5th vital sign" (nurse-recorded NRS) with a research-administered NRS (research-recorded NRS) and the Brief Pain Inventory (BPI).Results: During 528 encounters, nurse-recorded NRS and research-recorded NRS correlated moderately (r ‫؍‬ 0.627), as did nurse-recorded NRS and BPI severity scales (r ‫؍‬ 0.613 for pain during the last 24 hours and r ‫؍‬ 0.588 for pain during the past week). Correlation with BPI interference was lower (r ‫؍‬ 0.409). However, the research-recorded NRS correlated substantially with the BPI severity during the past 24 hours (r ‫؍‬ 0.870) and BPI severity during the last week (r ‫؍‬ 0.840). Receiver operating characteristic analysis showed similar results. Of the 98% of cases where a numeric score was recorded, 51% of patients reported their pain was rated qualitatively, rather than with a 0 to 10 scale, a practice associated with pain underestimation ( 2 ‫؍‬ 64.04, P < .001). Conclusion

Automated drug interaction alerts have the potential to dramatically increase clinicians' recognition of selected drug interactions. However, perceived poor specificity of drug alerts may be an important obstacle to efficient utilization of information and may impede the ability of such alerts to improve patient safety.

We wished to develop a cost-effective, rapid strategy to detect and identify Bartonella species in the clinical laboratory and to determine the prevalence of Bartonella infection in the Houston veteran population. Bartonella colonies were identified by colony morphology, Gram stain, RapID ANA, repetitive extragenic palindromic-PCR (REP-PCR) and whole-cell fatty acid (CFA) analysis, and these methods were compared for their usefulness. A new test order for ''Rochalimaea culture'' (the genus Bartonella was previously known as the genus Rochalimaea) was instituted, and in addition, all blood specimens submitted for fungal culture (obtained in an isolator tube) were processed for Bartonella culture. Over a 16-month period we isolated Bartonella henselae from only 0.4% (2 of 533) of total cultures but from 1% (2 of 204) of human immunodeficiency virus-positive patients. After sufficient growth, identification of the Bartonella isolates to the species level could be obtained in 2 days. The REP-PCR allowed discrimination of all known species, whereas CFA analysis distinguished all except B. henselae and Bartonella quintana. The RapID ANA results failed to differentiate between B. henselae and B. quintana, and results for other species differed by only one or two tests. Blood obtained from a kitten which had been introduced into the household of one patient 2 months before the onset of fever yielded a Bartonella strain which was shown to be different from the strain from the patient and distinct from other Bartonella species by a combination of REP-PCR, CFA, and growth characteristics. Subsequent analysis of the citrate synthase gene sequence showed only an 86% similarity with any of the other known Bartonella species, suggesting that this isolate represents a distinct, previously uncharacterized species of Bartonella.

NHs' overall adherence to PU prevention guidelines is relatively low and is characterized by large variations between homes in adherence to many recommendations. The low level of adherence and high level of variation to many best-care practices for PU prevention indicate a continued need for quality improvement, particularly for some guidelines.