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In hospitals, good care is paramount. But in nursing homes, good care is only half the picture: equally important is providing a good place to live. In traditionally run nursing homes, consideration of quality of life is often neglected at the expense of efficiently delivered clinical services.
The Picker/Commonwealth Program on Quality of Care for Frail Elders focuses on improving quality in nursing homes by working to change the prevailing culture in facilities from one that is institutionally centered to one that is resident-centered. The Fund does this by making strategic grants to organizations or supporting projects that can influence the industry to become more resident-centered, or that provide a platform to disseminate practices or models that embody that conviction.
Wellspring is one model of resident-centered care. Nursing homes that join together in a Wellspring "alliance" (26) become part of an ongoing quality improvement collaborative that has been shown to improve nursing home performance without increasing costs. (27)One of the vital questions nursing home leaders must ask themselves before joining a Wellspring alliance is, What does our current culture look like? To help answer this question, Leslie Grant of the University of Minnesota's Carlson School of Management developed a "culture/climate" survey, which enables nursing homes to perform a self-assessment before beginning the Wellspring process (28) and to monitor their progress during the journey. The survey asks, for example, whether the facility is committed to supporting resident-directed care; whether leadership staff encourages all employees to participate in resident-directed care; and whether staff have the opportunity to participate in decision-making. Coupled with a leadership module that Grant and culture change expert LaVrene Norton of Action Pact developed jointly, this tool has provided critical information for nursing homes in new alliances, and could be useful to institutions outside Wellspring. In addition, the Fund supported several projects to improve specific elements of the original model. One of these elements is Wellspring's system for sharing data to improve quality—a key strength of the program. Work undertaken by David Zimmerman of the University of Wisconsin enhanced Wellspring's data system, which now allows member nursing homes not only to calculate clinical outcome prevalence rates but to help identify those residents who are at high risk for a problem, such as pressure ulcers, before it develops.
The Wellspring model also addresses a shortcoming common to many programs that seek to educate staff: that giving people better, or more, information may be insufficient to change practice. Recognizing that the clinical care teams were having difficulty implementing what they had been taught, Barbara Bowers, a professor at the University of Wisconsin-Madison School of Nursing, developed with Fund support an implementation package for "just-in-time learning" that is intended for nursing assistants and other frontline staff. Individual sections of the package are distributed to staff to complement particular training sessions.
Over the past year, the Fund also supported work to ready the infrastructure of Wellspring Innovative Solutions (WIS), the entity formed to disseminate the model, for active marketing and outreach efforts. In 2004, a new nursing home alliance in Maryland was inaugurated and an alliance of homes in North and South Carolina should be ready to start in early 2005. Groups of nursing homes in California and elsewhere have contacted Wellspring for information about forming alliances, indicating that many nursing homes are eager for tested ways to achieve better performance.
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