Quality of care deficiencies can be devastating in any nursing home: devastating to the resident, who can suffer a decline in health status or even death that may have been avoided with better care; and devastating to the facility in terms of financial penalties, litigation, and loss of reputation and good will. In the aftermath of such an event, administrative and interdisciplinary team members often lament, “We did everything we could to keep this from happening. We followed our process to the letter.” There is a message there: Perhaps the resident care process itself was deficient.
The tradition in nursing homes seems to be that resident care systems—the processes that instruct the staff on care to be provided, such as the pressure ulcer prevention and treatment program, or the incontinence management program—are implemented based on a director of nursing's preference or on customary practice. It is not unusual that with a new director of nursing come new resident care systems. That in itself is not necessarily a problem, particularly if the new processes are an improvement over the old. However, with any resident care system, a fundamental question must be answered first: When implemented as written, does the system actually do what it is intended to do? And, in fact, how does the facility know if it does or not?
Over the years, research on what works and what doesn't work when it comes to nursing and related care, especially about geriatric patients and particularly in nursing homes, was difficult to find. In recent years, though, the body of such research has been growing, and it can be used to develop systematic, sound resident care systems that can significantly improve the quality of care and quality of life for nursing home residents.
As an example of how research can inform practice, a study found that newly admitted patients who were at risk for developing pressure ulcers had a lower incidence of ulcers when they used a specially designed foam mattress compared with a foam overlay and a standard mattress. Other studies have demonstrated that the traditional intervention of turning residents every two hours to prevent pressure ulcers is inadequate for a significant proportion of the population—only individualized assessment can determine the optimal interval for each resident. These findings can be translated into components of an evidence-based clinical protocol for pressure ulcer prevention.
The prospect of incorporating research into clinical practice to lift the facility's level of quality to a higher level can be exciting. But realistically, directors of nursing don't have a lot of time to spend in front of the computer scouring the Internet for the latest research and revamping systems accordingly. They do, however, have access to evidence-based clinical protocols that bridge the gap between research and practice.
The University of Iowa Gerontological Nursing Interventions Research Center has developed evidenced-based protocols for most of the major risk areas for nursing home residents. Also, the American Medical Directors Association Clinical Practice Guidelines provide guidance for physicians and address the interface with nursing and other disciplines. These protocols are great tools to introduce to medical directors, who can assist with implementation. They also can be important tools for development of effective nursing, nutrition, social services, and other clinical protocols within the facility. Other examples of evidence-based protocols come from Agency for Healthcare Research and Quality (AHRQ), which also provides a National Guideline Clearinghouse. Federal regulations require facilities to operate and provide services in compliance with accepted professional standards and principles that apply to professionals providing services in such a facility [F492 §483.75(b)]. Implementation of evidence-based protocols can help with compliance with this requirement.
A director of nursing should not attempt to make the department's switch to evidence-based practice alone. The kind of change that this represents will require an organized and systematic effort and a commitment from the very top of the organization and all clinical disciplines. Also, this is process improvement at its best, and the facility's Quality Assessment and Assurance Committee (QAAC) should play an active role. To begin, a permanent clinical practice committee should be impaneled as a subcommittee of the QAAC with an initial purpose of identifying the process and setting the timeline for making the transition to evidence-based practice. The rollout should be slow and systematic, incorporating plenty of time for each phase of the project.
This committee should be comprised of at least two registered nurses and at least one LVN/LPN and a certified nursing assistant. Other disciplines should be included as indicated, depending on the focus of the protocols. Input from staff members of all disciplines who deliver the care is crucial, since they are key to successful adaptation of the protocols to the residents' and the facility's needs and to the integration of the protocols into the care delivery. The committee will need to develop its mission and goals based on the vision set by the facility's administrative team, but in general, its task should also include review of available evidence-based protocols and selection of protocols best suited to their facility that provide the basis for individualized, resident-directed, interdisciplinary care. The committee also should designate a process for training all staff on the new philosophy as well as on the new protocols.
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