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Archived Service Delivery Profile:

Nursing Home Learning Collaborative Improves Quality of Care, Reduces Staff Turnover


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Snapshot

Summary

In an approach to improving nursing home care known as the "Wellspring Program," nursing homes join an alliance that allows participants to exchange performance experience and conduct interdepartmental group training for both frontline staff and leadership on quality improvement and culture change processes. The goals of this program are to enhance the quality of resident care and life and to improve the nursing home work environment. A comparison study found that the program reduced deficiency rates significantly and improved staff retention compared with peer institutions.

Evidence Rating (What is this?)

Moderate: The key evidence consists of two comparisons of retention rates (before and after the program was implemented at participating nursing homes versus nonparticipating nursing homes), as well as a before and after comparison of the number of deficiencies uncovered during annual inspections at participating nursing homes.
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Developing Organizations

Wellspring Innovative Solutions for Integrated Health Care
Green Bay, WI
The Wellspring Program is now administered by the Beacon Institute, Columbia, MD.end do

Use By Other Organizations

  • Wellspring Innovative Solutions is currently working with nursing home alliances in several states. These alliances were either self-funded or a result of outside funding (e.g., civil monetary penalties, Duke Endowment grant). In 2009, a new program to introduce nursing homes to culture change (for those nursing homes beginning on the journey) was implemented. In addition to the alliance model, Wellspring now offers educational programs and consultative services to individual nursing homes that may not be able to participate in an alliance due to the availability of other interested nursing homes, budget constraints, or other factors. These options are detailed on the Web site.

Problem Addressed

Nursing homes can be a high risk and unsatisfying environment for residents and an unattractive place to work.
  • Quality problems: The U.S. Government Accountability Office (previously known as the General Accounting Office) has found that one-fourth of the country's 16,000 nursing homes have serious deficiencies that cause actual harm to residents or place their health and safety at risk.1
  • High turnover: In 2001, annual turnover among nursing home nurses aides was 40 to 75 percent nationally and exceeded 100 percent in certain nursing homes. Research has found that staff shortages, insufficient training, and disenfranchised workers are at the root of the quality problem.1 A 2005 study of 354 nursing homes in four states found that 1-year turnover rates were 98.6 percent, 66.8 percent, and 55.4 percent for nurse assistants, licensed practical nurses, and registered nurses, respectively.2

What They Did

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Description of the Innovative Activity

In an approach to improving nursing home care known as the "Wellspring Program," nursing homes come together in a learning collaborative called an alliance to exchange performance data and conduct group training for both management and frontline staff on quality improvement processes. The goals of the program are to enhance the quality of resident care and improve the nursing home work environment. Key elements include the following:

  • Educational modules: Educational programs on best practices related to major clinical issues (e.g., dementia, malnutrition, incontinence, and topics related to culture change concepts and practices) are provided throughout the year to nursing home staff who represent various departments and levels of employees. On completion of the programs, participants form implementation teams (a concept developed by Barbara Bowers, RN, PhD, of the University of Wisconsin School of Nursing) that include both leaders and frontline staff.
  • Leadership training: The Wellspring Program has introduced a management curriculum and self-assessment tool to encourage culture change among nursing home leaders. This leadership module consists of:
    • One-day training/orientation session: Leadership staff learn about the Wellspring Program and how to encourage culture change. The leadership staff use a "Culture Change Staging Tool" to benchmark their performance in a number of areas, including leadership, education, staff development, and communication. This exercise allows nursing homes to identify the areas most in need of improvement.
    • Educational session for formal and informal leaders: Nursing home leaders attend a session in which they learn techniques to help support the work of the frontline teams. Participants form implementation teams that include both leadership and frontline staff. This training module is critical to getting staff to overcome hierarchy-driven barriers and to educate leaders about the resources that frontline staff need to be successful.
    • Frontline staff leadership session: Nursing assistants, dietary aides, housekeepers, and other frontline staff attend a session in which they learn about basic leadership, communication, time management, guest relations, and self-care skills.
  • Wellspring coordinators: Each participating nursing home designates a registered nurse, typically the nursing home's nurse educator or assistant director of nursing, to serve as the "Wellspring Coordinator." This individual attends all training modules, recruits the care resource teams (see below), facilitates the work of the care resource teams within the nursing home, and collects and reports data to the collaborative.
  • Networking meetings: Member nursing homes' Wellspring coordinators and administrators attend quarterly meetings during which participants have an opportunity to meet with and learn from peers. The group networks between these meetings via telephone conferences and e-mail communications.
  • Data collection, analysis, and reporting: Each month, all collaborative participants collect and share clinical data, including incontinent episode prevalence, number of falls, the prevalence of weight loss, staff turnover and retention, and other nursing home performance indicators. A centralized database aggregates the information and generates analytical reports that are distributed at the quarterly meetings. Reports allow nursing home representatives to compare their performance with that of other collaborative participants as well as national benchmarks. Data from the reports are used to plan educational programs and special emphasis from the nurse consultants.
  • Care resource teams: Each participating nursing home designates a nonhierarchical, multidisciplinary team of frontline workers and managers who are responsible for attending collaborative educational programs, training their peers, spearheading the implementation of concepts and practices learned during training, and serving as a general resource to staff.
  • Nurse consultants: A geriatric nurse consultant travels to each participating nursing home four or more times a year to support implementation of concepts and practices learned during training and to help identify and overcome any implementation barriers. The nurse consultant also facilitates the meetings of the Wellspring coordinators and is available to all collaborative members for as-needed consultations by telephone or e-mail.
  • E-communications: A monthly Wellspring e-newsletter, sent to all participating nursing homes, shares news from all the alliances, available resources, and relevant research. E-blasts are sent as new information arises.

Context of the Innovation

Wellspring Innovative Solutions for Integrated Health Care began in 1994 as a proactive response to challenges posed by the health care environment, such as falling managed care reimbursement and limited labor resources. The Wellspring model was initially implemented in 11 independent, not-for-profit nursing homes in northeastern Wisconsin; these nursing homes ranged in size from 63 to 415 beds and were located in both rural and urban areas. In 2009, administration of Wellspring was transferred to The Beacon Institute, the educational arm of the Maryland Lifespan Network, and the name was changed to the Wellspring Program. The Wellspring Program is based on the idea that education and training can enable and encourage all nursing home staff to participate in resident-oriented care decisions and in quality improvement efforts.

Did It Work?

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Results

A nonrandomized comparison of collaborative participants to other Wisconsin nursing homes and a pre/post-implementation analysis of collaborative participants1,3 found that the Wellspring model reduced care deficiency rates while simultaneously improving staff retention at no additional net cost to participating nursing homes. Results are as follows:
  • Improved staff retention: The retention rate for Wellspring nursing staff increased over the 4-year study period, from 70 to 76 percent. During that same time, the retention rate among non-Wellspring nursing homes in Wisconsin fell from 74 to 68 percent.
  • Decline in care deficiencies: In nursing homes participating in the learning collaborative, the number of deficiencies uncovered during annual inspections declined significantly during the study period, from an average of 1.9 deficiencies before implementation to 0.8 after. Severe deficiencies were effectively eliminated. Before implementation, 22.2 percent of all deficiencies were classified as severe; after the implementation, this dropped to 0 percent.
  • Improved quality of life: Findings from observation and interviews indicate that Wellspring residents enjoyed a better quality of life and benefited from improved interaction with the staff.
  • No change in outcomes: Clear evidence of improvements in resident outcomes could not be documented.
  • No change in net costs: Collaborative participation did not increase overall costs for the participating nursing homes. Although each of the participating nursing homes pays a monthly fee to participate in the collaborative (see "How They Did It"), nursing homes have experienced savings as a result of quality improvements that are reportedly equal to or greater than the ongoing costs of participation. For example, the costs of laundry and continence supplies dropped owing to better-scheduled toileting. In fact, the collaborative participants generally had lower costs than did other nursing homes.
  • More proactive staff: Anecdotal evidence suggests that Wellspring staff members are more vigilant in assessing problems in quality and take a more proactive approach to resident care.

Evidence Rating (What is this?)

Moderate: The key evidence consists of two comparisons of retention rates (before and after the program was implemented at participating nursing homes versus nonparticipating nursing homes), as well as a before and after comparison of the number of deficiencies uncovered during annual inspections at participating nursing homes.

How They Did It

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Planning and Development Process

Selected steps in the planning and development process include the following:
  • Board creation: Wellspring created a board to oversee all aspects of the model; the board makes all decisions about the structure of the program, including the nature and scope of training.
  • Hiring the traveling nurse consultant: Wellspring hired a geriatric nurse practitioner to serve as the traveling nurse consultant.
  • Training on best practices: A team of clinical consultants developed the training modules and materials and reviews best practices on an ongoing basis to determine necessary updates.

Resources Used and Skills Needed

  • Staffing: No new staffing is required. The designated Wellspring coordinator at each nursing home spends between 1 and 3 days each week on collaborative activities. Each nursing home administrator spends roughly 1 day per month on the collaborative.
  • Training: Four 2-day training sessions are held each year; each nursing home sends the Wellspring coordinator and a team of six to eight individuals to each training session.
  • Costs: Each participating nursing home pays $1,000 per month to support the centralized infrastructure of the collaborative, including training, traveling alliance nurse, etc. Nursing homes also incur labor costs related to staff participation in training and other collaborative activities. In addition, each nursing home paid between $4,000 and $5,000 to purchase a bladder scanner.
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Funding Sources

Wellspring Innovative Solutions for Integrated Health Care; Commonwealth Fund; Weinberg Foundation
The Commonwealth Fund provided some initial grant money. Grants have also been obtained from the Weinberg Foundation.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Align philosophy and structure: To succeed, a collaborative must align the philosophy and structure of the umbrella organization with the administrative, operational, and management structures of participating nursing homes.
  • Facilitate culture change: Empowering frontline staff is challenging, and training alone is not enough to achieve this goal. Instead, culture change is necessary, including a willingness for staff nurses to work with nurse assistants to make them feel more empowered in their decisionmaking.
  • Develop mechanisms to translate learning into practice: Explicit mechanisms are needed at each nursing home to facilitate the implementation of what is learned in training into everyday practice.
  • Focus on training: Centralized, cross-disciplinary training appears to be an effective and efficient method of training for multiple nursing homes.
  • Consider testing on a small scale: The benefits of a learning collaborative tend to increase with the number of organizations involved (although these benefits likely run out once the collaborative gets too large). Thus, it is difficult to implement this approach on a small scale. That said, the approach could be tried first among a handful of nursing homes to test whether some benefits accrue.

Sustaining This Innovation

  • Use the superstructure to facilitate improvement: The organizing superstructure of the collaborative—the alliance—plays a critical role in facilitating quality improvement within and across nursing homes.
  • Use an expert nurse consultant: The traveling nurse consultant appears to be effective in helping individual nursing homes to overcome implementation barriers.
  • Consider setting up a separate collaborative if the concept grows too large: The benefits of a learning collaborative may diminish if the collaborative gets too large. Thus, once an alliance reaches a critical mass, it would likely be best to start over with a new collaborative rather than expand an existing one.

Use By Other Organizations

  • Wellspring Innovative Solutions is currently working with nursing home alliances in several states. These alliances were either self-funded or a result of outside funding (e.g., civil monetary penalties, Duke Endowment grant). In 2009, a new program to introduce nursing homes to culture change (for those nursing homes beginning on the journey) was implemented. In addition to the alliance model, Wellspring now offers educational programs and consultative services to individual nursing homes that may not be able to participate in an alliance due to the availability of other interested nursing homes, budget constraints, or other factors. These options are detailed on the Web site.

More Information

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References/Related Articles

Improving the quality of nursing home care: the Wellspring Model. The Commonwealth Fund. October 2005. Available at: http://www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=234694.

Nursing home innovation enhances quality and reduces staff turnover—recent health care developments. Health Care Financing Review. Fall 2002. Available at: http://findarticles.com/p/articles/mi_m0795/is_1_24/ai_96193737.

Stone RI, Reinhard SC, Bowers B, et al. Evaluation of the Wellspring Model for improving nursing home quality. The Commonwealth Fund. August 2002. Available at: http://www.commonwealthfund.org/usr_doc/stone_wellspringevaluation.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Footnotes

1 Improving the quality of nursing home care: the Wellspring Model. The Commonwealth Fund. October 2005. Available at: http://www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=234694.
2 Engberg J, Castle N. Staff turnover and quality of care in nursing homes. MedCare. 2005; 43(6):616-26. [PubMed]
3 Stone RI, Reinhard SC, Bowers B, et al. Evaluation of the Wellspring Model for improving nursing home quality. The Commonwealth Fund. August 2002. Available at: http://www.commonwealthfund.org/usr_doc/stone_wellspringevaluation.pdf.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 17, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 22, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.