***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: In a statewide Best Practice s Project , the involvement of nurse educators in the implementation process improved the overall success of participating long-term care facilities in improving the quality  of resident care .  Two  nurse educators  provided consultation and training to nursing facility staff on three best practice protocol s : prevention of decline in the activities of daily living of eating and dressing , pain , and depression . Facility staff were given protocol s to follow , together with documentation forms to assist in determining resident appropriateness for participation in the assigned best practice , assessing resident involvement in the protocol over time , and tracking staff progress with the implementation . The success of the 2-year first phase of the project in significantly improving measurable  resident quality of care in best practice protocol areas has result ed in a second phase involving additional facilities and protocol PURPOSE The purpose of the study was to determine if simply providing nursing facilities with comparative quality performance information and education about quality improvement would improve clinical practice s and subsequently improve resident outcomes , or if a stronger intervention , expert clinical consultation with nursing facility staff , is needed . DESIGN AND METHODS Nursing facilities ( n = 113 ) were r and omly assigned to one of three groups : workshop and feedback reports only , workshop and feedback reports with clinical consultation , and control . Minimum Data Set ( MDS ) Quality Indicator ( QI ) feedback reports were prepared and sent quarterly to each facility in intervention groups for a year . Clinical consultation by a gerontological clinical nurse specialist ( GCNS ) was offered to those in the second group . RESULTS With the exception of MDS QI 27 ( little or no activity ) , no significant differences in resident assessment measures were detected between the groups of facilities . However , outcomes of residents in nursing homes that actually took advantage of the clinical consultation of the GCNS demonstrated trends in improvements in QIs measuring falls , behavioral symptoms , little or no activity , and pressure ulcers ( overall and for low-risk residents ) . IMPLICATION S Simply providing comparative performance feedback is not enough to improve resident outcomes . It appears that only those nursing homes that sought the additional intensive support of the GCNS were able to effect enough change in clinical practice to improve resident outcomes significantly BACKGROUND Interventions to improve the fracture prevention in nursing homes are needed . METHODS Cluster-r and omized , single-blind , controlled trial of a multi-modal quality improvement intervention .  Nursing homes ( n=67 ) with > or = 10 residents with a diagnosis of osteoporosis or recent hip fracture ( n=606 ) were r and omized to receive an early or delayed intervention consisting of audit and feedback , educational modules , teleconferences , and academic detailing . Medical record abstract ion and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period . Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering . RESULTS No significant improvements were observed in any of the quality indicators . The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0 % in the intervention group and 0.6 % in the control group , but the difference was not statistically significant ( P=.72 ) . Participation in the intervention activities was low , but completion of the educational module ( odds ratio [ OR ] 4.8 , 95 % confidence interval [ CI ] , 1.9 - 12.0 ) and direct physician contact by an academic detailer ( OR 4.5 , 95 % CI , 1.1 - 18.2 ) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models . CONCLUSIONS Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting , although results may have been tempered by low participation in the intervention activities The Prospect i ve Payment System had significant impact on home healthcare agencies throughout the nation . Virtua Home Care , located in Southern New Jersey , realized the need for process improvement in order to remain viable . Six Sigma was introduced to the agency and the Define , Measure , Analyze , Improve , and Control processes were initiated to achieve sustainable results , and within 9 months , Virtua Home Care improved regulatory compliance , experienced a deficiency-free survey , and recognized a 1.2 million dollars financial gain CONTEXT Death is common in nursing homes , but access to palliative care is limited . OBJECTIVE To test whether a quality improvement ( QI ) intervention in nursing homes increases hospice , pain management , and advance care planning . DESIGN AND SETTING The QI intervention was tested in seven nursing homes using a prepost study design . Two additional nursing homes served as control sites . PARTICIPANTS Nine nursing homes serving 1169 residents . INTERVENTION The intervention included recruitment and training of Palliative Care Leadership Teams in each facility , followed by six technical assistance meetings for team members . Hospice providers delivered six educational sessions for all nursing home staff using a structured curriculum . Teams received feedback of performance data on hospice enrollment , pain management , and advance care planning at 0 , 3 , and 6 months . MAIN OUTCOME MEASURES Percentage of residents receiving hospice or palliative services , pain assessment , pain treatment among residents in pain , and documented advance care planning discussion s. RESULTS Intervention facilities increased hospice enrollment from 4.0 % of residents at baseline to 6.8 % postintervention ( p = .01 ) and increased pain assessment s from 18 % to 60 % ( p < .001 ) . Among resident in pain , orders for nonpharmacologic pain treatments increased from 15 % to 35 % ( p < .001 ) , but pain medication use did not change . Residents with in-depth discussion s about end-of-life care increased from 4 % to 17 % ( p < .001 ) . There were no significant changes in control sites . CONCLUSIONS A quality improvement intervention was effective in increasing hospice enrollment , pain assessment , nonpharmacologic pain treatment , and advance care planning discussion BACKGROUND Pain constitutes a constant challenge facing staff and residents of skilled nursing facilities ( SNF ) and nursing homes ( NH ) . Many SNF and NH have not adopted a uniform plan to assess and treat pain for their residents despite published literature that demonstrates that the implementation of scales improves detection and treatment of pain . The objective of this study was to analyze the baseline pain level in the institutionalized elderly , and then implement a st and ard pain scale for its assessment and evaluation , while simultaneously identifying challenges in adopting this st and ardized method . METHODS As part of a Quality Improvement Project ( QI ) , a total of 40 patients were chosen at r and om in 2 of the major skilled care and dementia units at a Columbia area nursing home , 20 patients from each . A chart review was conducted to document the presence or absence of pain syndromes , pain medications used , and use of st and ardized tools for the evaluation of pain . Documentation regarding diagnosis of depression and behavioral problems were also noted as potential markers for the manifestation of pain . Verbal and nonverbal pain scales were introduced and approved by the medical and nursing staff . Training sessions for the administration of such tools were implemented . A baseline evaluation of pain level was obtained applying these newly adopted tools . One cycle using the PDSA ( Plan-Do- Study and Act ) model for QI was followed . RESULTS Our evaluation showed that 84.2 % ( 32/38 ) of our study population were females , and the mean age was 91.4 years . Fifty percent ( 19/38 ) of patients had mild to moderate pain .  Because of nonst and ardized approaches to analgesia , some regimens rendered clear potential for toxicity : ie , receiving more than 3 grams per day of acetaminophen . Most patients with cognitive deficits had lower levels of moderate pain ( 9.5 % [ 2/21 ] ) but higher levels of mild pain ( 33.3 % [ 7/21 ] ) when compared with patients with normal cognition or mild cognitive deficits ( 35.3 % [ 6/17 ] and 17.6 % [ 3/17 ] , respectively ) . Nursing staff adopted successfully the chosen pain tools and gave positive feedback after the trial period , indicating that they were helpful tools to identify pain and treat it promptly . Active participation of nursing staff through the process of decision making , tailoring of the pain assessment scales , and feedback during the period of implementation of pain assessment tools was perceived to facilitate better results . New cycles of pain evaluation and improvement were scheduled . CONCLUSIONS Pain evaluation and management is of paramount importance because of its high prevalence and demonstrated deleterious effects on both quality of life and long-term survival . Tools for verbal and nonverbal evaluation of pain are necessary in both NH and SCF . Also , regular cognitive and behavioral assessment may help evaluate pain by providing additional information to physicians , nurses , and other caregivers when treatment becomes more challenging and complex . The use of st and ard st and ing orders can easily help decrease the potential of toxicity related to the use of analgesics OBJECTIVES To evaluate effects on  patient outcomes  of Outcome -Based Quality Improvement ( OBQI ) , a continuous quality improvement methodology for home health care ( HHC ) . DESIGN A quasi-experimental design with prospect i ve pre/post and study /control components within two multiyear demonstration trials ( occurring from 1995 to 2000 ) in which 73 home health agencies implemented OBQI  , receiving several annual cycles of outcome reports to evaluate and enhance patient outcomes . SETTING New York and 27 other states . PARTICIPANTS The study involved 157,548 predominantly older adult patients admitted over 3 years to 54 OBQI agencies from 27 states in the National Demonstration Trial , 105,917 patients admitted over 4 years to 19 OBQI agencies in the New York State Trial , and 248,621 patients admitted over 3 years to non-OBQI control agencies in the 27 demonstration states . INTERVENTION As a clinical management and administrative intervention , OBQI involves collecting , encoding , and transmitting patient-level health status data to a central source that provides each OBQI agency with a risk-adjusted outcome report comparing the agency 's patient outcomes with those from a reference population and with its own outcomes from the prior period . Target outcomes are selected and focused plans of action implemented to change care behaviors . Outcome changes are evaluated through the next report cycle . MEASUREMENTS Outcome measures include hospitalization rates and improvement and stabilization outcome rates in functional , physiological , emotional/behavioral , and cognitive health . RESULTS For the National and New York State Demonstration Trials , the risk-adjusted relative rates of decline in hospitalization of 22 % and 26 % , respectively , for OBQI patients over the 3-year and 4-year demonstration periods were significant ( P < .001 ) and unparalleled by considerably smaller rates of decline for the non-OBQI patients in the 27 states . The risk-adjusted rates of improvement in OBQI target outcome measures of health status averaged 5 % to 7 % per year in both demonstration trials and were significantly greater ( P < .05 ) than analogous improvement rates for nontarget comparison outcomes , which averaged about 1 % per year . CONCLUSION It is feasible to integrate the programmatic , data collection , data transmission , and outcome enhancement components of OBQI into the day-to-day operations of home health agencies . The aggregate findings and the agency-level evidence available from site-specific communications suggest that OBQI had a pervasive effect on outcome improvement for home health patients .  OBQI appears to warrant expansion and refinement in HHC and experimentation in other healthcare setting 
    Output:
    
CONCLUSIONS / IMPLICATION S The most frequently cited issues contributing to unsuccessful quality improvement interventions were lack of staff , high staff turnover , and limited time available to train staff in ways that would improve client care .