Healthcare providers and public reporting of Community Living Center (CLC) quality: Investigating responses and opportunities for intervention through the PROACTIVE mixed-methods study

背景：2018年6月，VHA开始公开报告其135个社区生活中心 (CLCS)基于国家质量数据的五星级评级系统的综合质量 《中图法》中捕获的指标进行比较。鉴于私营部门在以下方面的积极经验 成绩单，这是刺激可衡量的质量改进的开创性时刻 CLCS。然而，《中图法》比较数据的公开报告带来了重大和直接的影响 对于CLC。例如，成绩单便于社区公民和社区之间的比较 疗养院的CLC通常情况更差。这可能会导致员工焦虑和潜在的 意想不到的后果(例如，选择性病人入院--“撇奶油”)。此外, 《中图法》比较旨在促进改进，但成绩单的激励方面 都是未知的。了解员工的态度和早期反应是建立 公开报道的能力，以提高质量。 具体目标：因此，我们建议调整现有的社区疗养院公共报告 调查揭示支持CLC质量改进努力的重要杠杆点。我们的 工作将以战略导向的概念框架为基础，并在 与退伍军人事务部老年医学和长期护理办公室(GEC)建立伙伴关系。我们有两个目标。 1.定性检验《中图法》工作人员对《中图法》比较的反应。 2.改编和扩展现有的社区养老院调查，以涵盖广泛的 回答的范围，然后在CLCS试行调整后的调查。 方法：目标1：我们将与3家CLC的工作人员进行访谈(1星级、1星级、3星级和 一个五星级)以确定(1)针对其《中图法》的公开数据采取的具体员工行动，(2) 员工对使用《中图法》的承诺/使用《中图法》的困难比较质量改进，以及(3)因素 激励员工提高《中图法》质量。目标2：我们将把这些发现与我们的 调整和扩展社区养老院调查的概念框架，以适应当前 CLC环境。我们将对1CLC的工作人员进行认知访谈，以完善调查 物品。然后，我们将在6个CLC(两个一星级、两个三星级和两个五星级)中试行调查以进行评估 调查的可行性、可接受性和初步的心理测量学特性。 预期结果和下一步：我们预计将制定一份简短的调查报告，供未来使用 国家行政管理部门(1)确定全系统对《中图法》比较的反应；(2)评估 CLC比较对退伍军人临床结局和满意度的影响；以及(3)开发、测试、 并传播干预措施，以支持有意义地使用《中图法》质量比较 进步。从这次试点和未来工作中获得的知识将有助于GEC改进 使用《中图法》比较，确保中图法工作人员理解并激励他们使用其质量 数据，落实提高临床质量的具体行动。这项试点的产品还将 促进研究公共报告在其他VHA临床关键领域的影响。 对退伍军人健康的意义和相关性：这项研究回应了高铁和高铁的长期 关爱优先领域和退伍军人更多选择的VHA优先。就像公开的一样 对VHA医院表现的报告导致了积极和不适应的反应 比较可能会对CLC工作人员和他们的4万名脆弱退伍军人产生类似的影响 发球。这项研究抓住了机会，确定了积极的、意外的和 潜在的适应不良，对CLC的早期反应有助于改善VHA的长期护理。

Background: In June, 2018, VHA began public reporting of its 135 Community Living Centers’ (CLCs’) overall quality using a five-star rating system based on data from the national quality measures captured in CLC Compare. In light of the private sector’s positive experience with report cards, this is a seminal moment for stimulating measurable quality improvements in CLCs. Yet public reporting of CLC Compare data raises substantial and immediate implications for CLCs. The report cards, for example, facilitate comparisons between CLCs and community nursing homes in which CLCs generally fare worse. This may lead to staff anxiety and potential unintended consequences (e.g., selective patient admissions—“cream skimming”). In addition, CLC Compare is designed to spur improvement, yet the motivating aspects of the report cards are unknown. Understanding staff attitudes and early responses is a critical first step in building the capacity for public reporting to spur quality. Specific Aims: We thus propose to adapt an existing community nursing home public reporting survey to reveal important leverage points to support CLCs’ quality improvement efforts. Our work will be grounded in a conceptual framework of strategic orientation and conducted in partnership with the VA Office of Geriatrics and Extended Care (GEC). We have 2 aims. 1. Qualitatively examine a sample of CLC staff reactions to CLC Compare. 2. Adapt and expand upon an extant community nursing home survey to capture a broad range of responses, then pilot the adapted survey in CLCs. Methods: Aim 1: We will conduct interviews with staff at 3 CLCs (one 1-star, one 3-star, and one 5-star) to identify (1) specific staff actions taken in response to their CLC’s public data, (2) staff commitment to/difficulties with using CLC Compare for quality improvement, and (3) factors that motivate staff to improve CLC quality. Aim 2: We will integrate these findings with our conceptual framework to adapt and expand a community nursing home survey to the current CLC environment. We will conduct cognitive interviews with staff in 1 CLC to refine survey items. We will then pilot the survey in 6 CLCs (two 1-star, two 3-star, and two 5-star) to assess survey feasibility, acceptability, and preliminary psychometric properties. Expected Results and Next Steps: We expect to develop a brief survey to be used in a future national administration to (1) identify system-wide responses to CLC Compare; (2) evaluate the impact of CLC Compare on Veterans’ clinical outcomes and satisfaction; and (3) develop, test, and disseminate interventions to support meaningful use of CLC Compare for quality improvement. Knowledge gained from this pilot and from future work will help GEC refine how CLC Compare is used, ensure that CLC staff understand and are motivated to use its quality data, and implement concrete actions to improve clinical quality. Products from this pilot will also facilitate studies of the effects of public reporting in other critical VHA clinical areas. Significance & Relevance to Veterans’ Health: This study responds to HSR&D’s Long-Term Care priority domain and the VHA priority of Greater Choice for Veterans. Just as public reporting of VHA hospital performance led to both positive and maladaptive responses, CLC Compare may have similar impacts on CLC staff and the 40,000 vulnerable Veterans they serve. This study seizes the opportunity to identify positive, as well as unintended and potentially maladaptive, early responses to CLC Compare to help improve VHA long-term care.