JAMDA 15 (2014) 615e619

JAMDA

journal homepage: www.jamda.com

Editorial

Next Steps for Achieving Person-Centered Care in Nursing Homes

Sandra F. Simmons PhD a,b,*, Anna N. Rahman PhD c

aVanderbilt University, School of Medicine, Division of General Internal Medicine and Public Health, Center for Quality Aging, Nashville, TNbGeriatric Research, Education and Clinical Center, VA Medical Center, Nashville, TNcGerontological Research Consultant, Santa Monica, CA

To what extent are nursing home residents’ preferences for dailycare and recreational activities being met? In their article in this issueof the Journal, Van Haitsma and colleagues report on the develop-ment and pilot evaluation of an Excel-based toolkit designed to helpnursing homes address this question.1 It is an important question fornursing homes to both ask and answer, especially in light of recentemphasis on person-centered care (PCC) and culture change in long-term care settings.

PCC is considered by many to be the “true north” in health carequality as described by Berwick.2 Not only is such care consistentwith promoting quality of life, it also is considered critical toachieving quality of care and improved clinical outcomes.2,3 For thisreason, “the experiences of patients” are, as Berwick observed in anoften-cited essay, “the fundamental source of the definition of qual-ity.”2 This dictum seems especially applicable to nursing homes,which, as the term implies, serve not just as nursing facilities but alsoas home for the many older adults who reside there in what is oftentheir final years of life.

Only recently has the nursing home industry embraced PCC, both inpolicy and practice, generally operationalizing this multifacetedconcept by emphasizing the fundamental importance of individualchoice, particularly as it relates to daily care and recreational activities.Federal regulatory guidelines implemented in 2009, for instance, nowidentify choice over daily schedules as a resident right and explicitlyinstruct surveyors to ask and observe whether residents are offeredchoices about daily life activities, such as bedtimes and dining.4 Simi-larly, the Centers for Medicare and Medicaid Services have directedfederally funded Quality Improvement Organizations to work withnursing homes in all states to enhance PCC.5 Among providers, a cul-ture change movement to de-institutionalize and transform nursinghomes intomore home-like environmentswith residents at the centerhas spread rapidly with broad support from multiple long-term carestakeholder groups.6 In 2007, one-third of nursinghomes reported thatthey had implemented some aspects of culture change and anotherone-third reported they were planning to follow suit.7 To promotefaster uptake, the national collaborative Advancing Excellence

DOI of original article: http://dx.doi.org/10.1016/j.jamda.2014.02.004The authors declare no conflicts of interest.

* Address correspondence to Sandra F. Simmons, PhD, Vanderbilt University,School of Medicine, Division of General Internal Medicine and Public Health, Centerfor Quality Aging, 2525 West End, Suite 350, Nashville, TN 37203.

E-mail address: sandra.simmons@vanderbilt.edu (S.F. Simmons).

1525-8610/$ - see front matter � 2014 AMDA – The Society for Post-Acute and Long-Tehttp://dx.doi.org/10.1016/j.jamda.2014.06.008

in America’s Nursing Homes has advocated for culture change innursing homes through various initiatives and dissemination efforts,including involvement in the Van Haitsma et al1 study in this issue.In addition, a few states have launched pay-for-performance programsthat provide financial incentives for nursing homes to deliver andmonitor PCC,8 while the Veteran’s Administration currently uses newperformance measures to incentivize culture change in its nursinghomes, also referred to as “community living centers.”

Given this rush of incentives and initiatives, the PCC Toolkitdeveloped by Haitsma et al for the Advancing Excellence collabora-tive could not be more timely. The toolkit aims to help nursing homesmeasure “the quality of PCC delivery in a way that is concrete,feasible, and provides immediate, actionable, and up-to-date infor-mation about quality.”1 In our view, there is a lot to like about thetoolkit as a means for nursing home providers to measure theirprogress toward this goal.

For starters, the PCC Toolkit’s16 resident assessment items, whichaddress such daily care and recreational activities as choosing one’sown bedtime and doing favorite activities, align directly with the careand preference items used in the latest version of the Minimum DataSet (MDS) assessment instrument (version 3.0), which virtually allnursing homes are required to complete for all residents as part ofroutine assessments.9 Here it should be noted that completion of thisparticular section of the MDS (section F) is required only uponadmission and annually thereafter, or whenever a resident’s clinicalcondition changes significantly, which may not be sufficientlyfrequent to adequately assess residents’ daily care preferences.Nonetheless, this dovetailing with a well-known, required assess-ment instrument makes the PCC Toolkit more feasible for nursinghome staff to use as part of routine care practices, in particular careplanning conferences, which should occur at least quarterly. Pilot-testresults seemed to confirm the feasibility of the toolkit, for nursinghome staff members needed just 30 minutes of instruction to learnhow to conduct the recommended resident interviews (there are 2 ofthem: the first assesses the importance of each of the 16 care/activityitems; the second, follow-up interview assesses residents’ satisfactionwith the fulfillment of preferences rated as “important,” which thedevelopers deemed “preference congruence”).1 On average, theseresident interviews took approximately 15 minutes to complete perperson, with multiple types of staff being able to assist with the in-terviews. It should be noted, however, that most of the interviewedresidents had only mild to no cognitive impairment in this study.1

Once completed, a staff member at each test site entered resident

rm Care Medicine.

Editorial / JAMDA 15 (2014) 615e619616

responses into the Excel spreadsheet component of the toolkit. Moststaff members who tested this software tool reported that it was easyto use and produced analyses that helped enhance PCC. The instructionmanual that accompanies the toolkit, now available online from theAdvancing Excellence website (https://www.nhqualitycampaign.org/files/tools/AE_PersonCenteredCareInstructions_4-30-13.pdf), is just16 pages long and includes lots of helpful graphics and is easy to readand understand.

With its numerous strengths, we believe that the PCC Toolkit canhelp support nursing home efforts to achieve PCC. At the same time,however, we doubt that use of the toolkit alone is sufficient to achievethis outcome. Previous research strongly suggests that the toolkitmust be paired with additional change strategies if nursing homeproviders are to truly engage in and sustain quality improvement (QI)efforts. The unfortunate reality is that many improvement initiativesare unsuccessful, in part because these efforts focus solely or mostlyon forces outside organizations to spur change (eg, new initiatives orregulations) while failing to address forces within organizations thatconstrain change.10 In nursing homes, the latter have proved to beespecially powerful deterrents to QI efforts.11 In this editorial, weidentify common barriers to delivering PCC in nursing homes andsuggest strategies to counteract these barriers so that the care im-provements intended and facilitated by the PCC Toolkit are morelikely to be achieved and sustained.

How Do You Assess PCC?

Resident Interviews Alone Are Insufficient

One challenge to implementing PCC is the multifaceted nature ofthis construct, which can encompass a broad range of environmental(eg, home-like setting), staffing (eg, consistent resident assignment,special in-service training sessions), and care practice components(eg, expansion of dining options, adjustments to daily schedules). Thiscomplexity can make it difficult for a facility to determine when andto what degree it has actually implemented PCC. At its core, however,PCC is about offering residents choices about their daily care andrecreational activities.12 This makes “choice” a reasonable focal pointfor improvement efforts. Resident interviews, such as those advo-cated in the PCC Toolkit, as well as staff reports help shed light onwhether staff members are offering residents choices in their dailycare activities. But these retrospective reports may be biased orflawed by recall error and so should not be the sole sources of thiscritical information.

Supervisory Observations Are Needed

The true measure of whether PCC is being provided is most reli-ably assessed by directly observing staff-resident interactions. Arestaff members, in fact, offering residents choices during daily careprovision? One can reasonably contend that most, if not all, residentsshould be offered choices about their daily care activities to enhanceautonomy, wellbeing, and overall quality of life. At a minimum, staffmembers should routinely offer choices to residents who have re-ported in assessment interviews (eg, an MDS assessment or PCCToolkit interview) that choice is important to them for certain aspectsof care (eg, choosing one’s own bedtime or selecting what clothes towear each day).

Based on this rationale, we developed and evaluated an observa-tional tool to reliably assess staff offers of choice for specific morningcare activities, including when to get out of bed, when to get dressedand what to wear, where to dine for breakfast, and the need for toi-leting assistance (www.VanderbiltCQA.org see Training Modules/Providing Resident-Directed Care).13e16 We focused on these care

activities because most nursing home residents require some levelof staff assistance for one or more of them. These activities also tendto co-occur daily, usually within a predictable timeframe. As a result, itis feasible for researchers, surveyors and nursing home supervisors toobserve whether staff members are offering residents choices in thesecare areas.13e16 Using this tool to conduct hundreds of observationsacross 12 weeks in multiple nursing homes, we found disappointingresults. Staff members infrequently offered residents choices in thetargeted care areas (only 8% of the time for breakfast dining locationand a high of 21% for when to get out of bed in the morning).14,16 Thisoccurred despite reports from the residents during interviews thatchoice was important to them. Equally surprising, however, was thatfew of these same residents reported being dissatisfied with the lackof choice offered. Other studies have found that nursing home resi-dents often report being “satisfied” with suboptimal care quality.17e19

These findings underscore the importance of augmenting residentand staff reports of PCC with intermittent observations of daily carepractices. These observations, conducted by nursing home supervi-sors or other designated personnel (eg, Quality Assurance or MDSnurses), may target those residents who have recently reported in anMDS assessment or PCC Toolkit interview that choice is important tothem or residents who are due for a care planning conference, assuggested by Van Haitsma and colleagues.1 Ultimately, however,these observations should include even those residents who havereported that having a choice is “not very” or “not at all” important tothem as well as residents who have reported being “satisfied” withcurrent care practices, for it is possible that these responses simplyreflect the residents’ reduced expectations for care.17e19 If these res-idents were routinely offered more choices by the staff, they mightchange the level of importance they attach to certain aspects of theirdaily lives. The key point is that PCC is observabledand should beobserveddin the form of daily, routine staff offers of choice to resi-dents across a range of daily care activities.

Who Is Responsible for PCC?

Staffing Constraints

A second common challenge to implementing PCC is related tostaffing: who will take responsibility for PCC assessments, bothresident interviews and staff observations? How much time do thesetasks require and how often do they need to be done? Numerousstudies have shown that staffing constraints often limit the ability ofnursing homes to implement and sustain improvement efforts.20e24

In Van Haitsma et al’s evaluation, participating nursing homes re-ported inadequate staff time (55%), staff resistance (44%), and staffturnover (11%) as challenges to implementing PCC. The majority ofthese sites were 4- or 5-star, highly staffed facilities. The real chal-lenge will be getting lower performing nursing homes to engage inquality improvement efforts. Van Haitsma and colleagues note that“nursing homes with a low (CMS quality) rating are more likely tofocus on basic quality of care than PCC improvement.”1 This might, atleast partially, explain why only 12 of 40 invited homes (30%) chose toparticipate in this pilot evaluation. Even among this select group ofhigh performing homes, participants were required to submit datafrom only a small number of resident interviews (ie, with 5 short-stayand 5 long-stay residents) at only 1 point in time. In addition, asmentioned earlier, residents selected for interview had only mild tono cognitive impairment, which may have influenced the amount oftime required to complete each interview (15 minutes, on average).Starting small with residents who are most likely to be responsive is areasonable approach for a pilot test, but likely underestimates thetime needed to complete interviews with a larger number of resi-dents with a wider range of cognitive functioning at multiple time

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points, all of which would be necessary to maintain this effort facility-wide over a longer period of time.

Staffing Innovations

The good news is that staffing constraints may be addressedthrough more creative staffing models. Van Haitsma and colleagues,for instance, note that various types of staff can be trained to assistwith PCC interviews, and these investigators appropriately recom-mend that different staff members interview residents about theirpreferences (eg, nurse aides, MDS nurse) vs their satisfaction withhow these preferences are being met (eg, social workers, recreationaltherapists, licensed nurses). Similarly, multiple types of supervisory-level staff can be trained to conduct standardized observations ofdaily care quality.

Both resident interviews and observations of care quality can becompleted for small groups of residents each week (eg, 5 interviewsor observation periods per week). To affect real change over time,however, both tasksdinterviews and observations–must occur on anongoing basis and include most residents, not just the most capableresidents. Fortunately, although these changes may sound daunting,they are feasible to implement. Nursing home staff often assume thatconducting care observations for QI purposes is impractical for 2reasons: (1) the amount of time required, and (2) the belief that staffmembers perform differently (ie, better than usual) when underobservation. We have found both assumptions to be erroneous. Inreality, 1 supervisory-level staff member can effectively conduct ob-servations of morning care activities for 3e6 residents per week in1e2 hours or less.13,14 Observations of other daily care activitiesrequire even less time. For example, supervisors can observe meal-time activities for 6e8 residents dining within one area in 1 hour perweek or less and in that time gain useful information about theavailability of entrée options, dining location, and feeding assistancequality.25 In terms of the influence of observations on staff behavior,we have conducted hundreds of such observations in nursing homesacross the country and, while we have observed staff care behaviorsin need of improvement, we have found little to no change in routinestaff behavior prompted by these observations alone.26

One caveat is worth mentioning here: consistent staff-resident as-signments and documented care plans do not preclude the importanceof offering residents choices on a daily basis. The reality is that mostnursinghomeshavehigh staff turnover rates, particularly amongnurseaides, who are responsible formost aspects of residents’ daily care.27 Inaddition, many facilities use temporary staff on a frequent basis. Thus,there are a sufficient number of different staff members providing careto individual residents each day that staff members should routinelyoffer residents choices at the point of care delivery. In practice, thismeans that residents should be offered choices daily, multiple times aday, and this staff behavior should be observable duringmost any staff-resident care interaction. Offering choices whenever possible com-municates respect for residents and has been cited as central to theenhancement of individual wellbeing, autonomy, and quality oflife.28e30 In addition, resident engagement in decisions about theirdaily activities can help combat apathy and depression, both of whichare common among nursing home residents and may contribute toresident reports that having a choice is not important to them.31,32

How Do You Change Staff Behavior to Be MorePerson-Centered?

Attention to Change Strategies May Be Short-Changed

Now let’s turn to possibly the most significant challenge to im-plementing PCC: what to do with assessment information after

collecting it. Once you know that choice is important to residents(based on interviews) and that staff members are not offering itroutinely (based on supervisory observations), what do you do toeffect change in staff care behaviors? This is where the PCC Toolkit, atleast as described by Van Haitsma et al, potentially falls short. Theresearchers found in their evaluation that care conference attendancerates were lowest for direct care staff (ie, nurse aides). This ispotentially a significant problem because, presumably, it is duringcare conferences that strategies to meet resident preferences areidentified and agreed upon by the resident, family members, andstaff. Within the online toolkit itself, the “optimized care planning”spreadsheet, where staff can record the strategies identified for ad-dressing resident preferences, is labeled an “optional worksheet,” anunfortunate designation for what some would argue is the mostimportant step in implementing PCC.

Changes needed to address residents’ preferences may occur atthe resident-level (eg, making nurse aides aware of individual resi-dent preferences) or may require system-level adjustments. In eithercase, change can be challenging to achieve. Consider an example VanHaitsma et al. use in their study: “If the data reveal low preferencecongruence for snacks between meals, the nursing home can adjustsnack service delivery as desired.”1 Sounds simple, but such a changecan be surprisingly challenging to implement. For instance, consistentdelivery of between-meal snacks multiple times per day, 7 days perweek requires careful coordination between dietary and nursingpersonnel. In addition, an adequate number of staff members must beavailable both to deliver snacks to residents and offer appropriateassistance so that residents can enjoy the snacks.24 These changestypically translate into the need for staff members other than nurseaides to help out at snack times. Federal regulations allow non-nursing personnel to assist with feeding tasks, but here again,system-level changes would be required to recruit, train, deploy, andsupervise new snack-time assistants. Other system-level strategiesthat might be needed include better coordination of services amongmultiple departments, such as encouraging social activities personnelto incorporate snacks into routine group activities. As this exampledemonstrates, care quality improvements can be complex changes tomake even when they appear to require only a simple adjustment tothe resident’s care plan.

Quality Improvement Strategies

To succeed, QI changes demand thoughtful planning, im-plementation, and ongoing monitoring. With respect to monitoring,our research has shown that standardized observations of daily carepractices are needed to evaluate whether new interventions aremeeting their goals.14,25 Returning to snack provision as an example,we have found that nursing home efforts to improve this processoften have resulted in snacks being offered immediately prior to, oreven during, scheduled mealtimes, which defeats their purpose.Then, too, nursing homes often offer few snack options for residentsto choose among and/or inadequate staff assistance to promoteconsumption. The best and probably most efficient way to identifysuch process problems is by systematically observing new carepractices as they are implemented.

The next step, aimed at rectifying problems so as to improveprocesses, is to provide feedback from the care observations to allrelevant staff members. In several studies, we trained nursing homesupervisors to do just this, to conduct standardized observations of adaily care activity, such as snack delivery between meals, and then toconduct structured, brief (<15 minutes), weekly feedback sessionswith staff to facilitate improvement. The observations combined withweekly feedback allowed staff members to discuss barriers, problem-solve, and track improvement over time.14,25,33 In this way, all staff

Editorial / JAMDA 15 (2014) 615e619618

members were held accountable as a team. Even modest improve-ments from week-to-week were acknowledged and praised as suc-cessful, incremental steps toward a defined goal. This approach isconsistent with the widely advocated health-care quality improve-ment strategy known as Quality Assessment and PerformanceImprovement, which combines performance improvement with datamonitoring and features a feedback system that actively elicits inputfrom staff and residents.34 Numerous studies across a range of fieldshave shown that this QI approach is associated with measurableimprovements in outcomes.35,36

Recommendations for Other Change Agents

Although we believe that PCC in nursing homes is achieva-bledand facilitated by such tools as the PCC Toolkitdwe also believethat supporting efforts from other changes agents are needed toensure lasting improvements take root in nursing homes. Below wepresent change recommendations for policymakers, advocacy orga-nizations, and researchers to consider.

Policymakers

We strongly advocate policy changes that eliminate the stigmathat often results when nursing homes identify care areas in need ofimprovement. Our well-intentioned federal regulations, surveyorguidelines, and publicly-reported quality measures have inadver-tently created a system that often is more punitive than constructivefor nursing homes, particularly those with fewer resources. StateQuality Improvement Organizations help mitigate the negative, un-intended consequences of regulatory mandates by providing educa-tion, information and, in some states, financial incentives to supportnursing home QI efforts, but more support is needed. Going forward,less emphasis should be placed on nursing home clinical outcomes(ie, quality indicators) and more on day-to-day care processes. Ulti-mately, nursing homes should receive recognition for attemptinggenuine QI efforts. Based on years of conducting research in nursinghomes, we have found that facilities that proactively identify areas inneed of improvement tend to do better at assessingdand ad-dressingdunmet resident needs than those that purport to have fewproblematic areas. In 2 separate studies, for instance, we found thatnursing homes reporting high prevalence estimates for pain anddepression performed significantly better on care process measuresrelated to assessment and treatment for these two conditions thannursing homes with low prevalence estimates for these clinical out-comes. Moreover, when we independently assessed pain anddepression among residents in both groups of homes, the actualprevalence rates for these conditions were comparable.37,38 In otherwords, the “low prevalence” facilities simply failed to identify painand depression among a substantial proportion of residents. Thesefindings contradict the underlying assumption of publicly reportednursing home quality measures for pain and depression, whosepremise is that higher rates indicate poorer care quality. We shouldkeep these findings in mind when we ask nursing homes to report ontheir QI efforts in other areas, including PCC. Nursing homes that haveproactively identified problems to address through QI initiatives arelikely off to an excellent start and should be commended for theirefforts.

Advocacy Organizations

Organizations such as the Advancing Excellence collaborative thatdisseminate toolkits, best-practice guidelines, and other QI materialsshould recognize that education in these forms is necessary butinsufficient to affect real change in nursing homes.11,22 Often missing

from such materials are specific strategies related to who completesassessments, how often assessments are completed, and, mostimportantly, what to do with the information once collected. Well-intentioned nursing homes may add another assessment tool totheir “to do” lists but lack the necessary knowledge for translating theassessment information into actions (eg, staff behavior change) thatlead to measurable improvements, which we believe is the mostimportant step in the QI process. In our experience, many nursinghomes tend to view QI as a serial process, whereby a problem isaddressed, resolved, then forgotten as the next problem is addressed.To sustain improvements, however, QI must, instead, be a continuousprocess.35,36

Researchers

Researchers who test clinical or educational interventions innursing homes or conduct program evaluations should avoid relyingsolely on nursing home staff reports or even medical record docu-mentation of outcomes, for both data sources are often inaccurateand biased in the direction of over-estimating care quality.17,39 Ideally,researchers should directly observe daily care routines or staffbehavior to determine whether desirable practices are occurring asintended. Equally important, such observations also shed light on thepotential barriers from which we can learn for future efforts.

Conclusions

In our view, the PCC Toolkit is a welcome resource that can helpnursing homes achieve PCC, but users should recognize that thetoolkit guides them through just one step toward a much larger goal.PCC is not evidenced by completed toolkit worksheets; rather, itshould be demonstrated by observable changes in daily care practice.

References

1. Van Haitsma K, Crespy S, Humes S, et al. New toolkit to measure quality ofperson-centered care: Development and pilot evaluation with nursing homecommunities. J Am Med Dir Assoc 2014;15:671e680.

2. Berwick D. A user’s manual for the IOM’s ‘Quality Chasm’ report. Health Affairs2002;21:80e90.

3. Shier V, Khodyakov D, Cohen LW, et al. What does the evidence really say aboutculture change in nursing homes? Gerontologist 2014;54:S6eS16.

4. Centers for Medicare and Medicaid Services. 2009. Nursing HomeseIssuance ofRevisions to Interpretive Guidance at Several Tags, as Part of Appendix PP, StateOperations Manual (SOM), and Training Materials. Letter to State SurveyAgency Directors. Available at: http://www.cms.gov/SurveyCertificationGenInfo/downloads/SCletter09_31.pdf. Accessed May 24, 2014.

5. Centers for Medicare and Medicaid Services. 2014a. Future development ofthe QIO program: Getting your feedback. Special Open Door Forum byCenters for Medicare & Medicaid Services Center for Clinical Standardsand Quality. January 24, 2014. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs/Downloads/QIOSODF01-24-13.pdf. Accessed May 5, 2014.

6. Rahman A, Schnelle J. The nursing home culture change movement: Recentpast, present, and recommendations for future research. Gerontologist 2008;48:142e148.

7. Koren M. Person-centered care for nursing home residents: The culture-changemovement. Health Affairs 2010;29:312e317.

8. Miller SC, Cohen N, Lima JC, Mor V. Medicaid capital reimbursement policy andenvironmental artifacts of nursing home culture change. Gerontologist 2014;54:S76eS86.

9. Centers for Medicare and Medicaid Services. 2014b. MDS 3.0 RAIManual. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.Accessed May 24, 2014.

10. Senge P, Kleiner A, Roberts C, et al. The Dance of Change: The Challenges toSustaining Momentum in Learning Organizations. New York: Doubleday; 1999.

11. Rahman A, Applebaum R, Schnelle JF, Simmons S. Translating research intopractice in nursing homes: Can we close the gap? Gerontologist 2012;52:597e606.

12. Bishop CE, Stone R. Implications for policy: The nursing home as leastrestrictive setting. Gerontologist 2014;54:S98eS103.

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13. Schnelle JF, Bertrand R, Hurd D, et al. Resident choice and the survey process:The need for standardized observation and transparency. Gerontologist 2009;49:517e524.

14. Schnelle JF, Rahman A, Durkin DW, et al. A controlled trial of an intervention toincrease resident choice in long-term care. J Am Med Dir Assoc 2013;14:345e351.

15. Simmons SF, Durkin DW, Rahman A, et al. Resident characteristics related tothe lack of morning care provision in long term care. Gerontologist 2013;53:151e161.

16. Simmons SF, Rahman A, Beuscher L, et al. Resident-directed long term care:Staff provision of choice during morning care. Gerontologist 2011;51:867e875.

17. Simmons SF, Schnelle JF. Strategies to measure nursing home residents’satisfaction and preference related to incontinence and mobility care: Im-plications for evaluating intervention effects. Gerontologist 1999;39:345e355.

18. Simmons SF, Ouslander JG. Resident and family satisfaction with incontinenceand mobility care: Sensitivity to intervention effects? Gerontologist 2005;45:318e326.

19. Simmons SF, Levy-Storms L. The effect of staff care practices on nursing homeresidents’ preferences: Implications for individualizing care. J Nutr HealthAging 2006;10:216e221.

20. Harrington C, Kovner C, Mezey M, et al. Experts recommend minimum nursestaffing standards for nursing facilities in the United States. Gerontologist2000;40:5e16.

21. Rahman A, Simmons S, Applebaum R, et al. The coach is in: Improving nutri-tional care in nursing homes. Gerontologist 2012;52:571e580.

22. Schnelle JF, Alessi CA, Simmons SF, et al. Translating clinical research intopractice: A randomized controlled trial of exercise and incontinence care withnursing home residents. J Am Geriatr Soc 2002;50:1476e1483.

23. Schnelle JF, Simmons SF, Harrington C, et al. Relationship of nursing homestaffing to quality of care. Health Serv Res 2004;39:225e250.

24. Simmons SF, Schnelle JF. Individualized feeding assistance care for nursinghome residents: Staffing requirements to implement two interventions.J Gerontol 2004;59:966e973.

25. Simmons SF, Schnelle JF. A continuous quality improvement pilot study:Impact on nutritional care quality. J Am Med Dir Assoc 2006;7:480e485.

26. Schnelle JF, Ouslander JG, Simmons SF. Direct observations of nursing homecare quality: Does care change when observed? J Am Med Dir Assoc 2006;7:541e544.

27. Donoghue C. Nursing home staff turnover and retention: An analysis of na-tional level data. J Appl Gerontol 2010;29:89e106.

28. Kane RA, Caplan AL, Urv-Wong EK, et al. Everyday matters in the lives ofnursing home residents: Wish for and perception of choice and control. J AmGeriatr Soc 1997;45:1086e1093.

29. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsicmotivation, social development, and well-being. Am Psychol 2000;55:68e78.

30. Zimmerman S, Sloane PD, Williams CS, et al. Dementia care and quality of lifein assisted living and nursing homes. Gerontologist 2005;45:133e146.

31. Cassie KM, Cassie WE. Organizational and individual conditions associatedwith depressive symptoms among nursing home residents over time. Geron-tologist 2012;52:812e821.

32. Meeks S, Looney SW. Depressed nursing home residents’ activity participationand affect as a function of staff engagement. Behav Ther 2011;42:22e29.

33. Simmons SF, Durkin DW, Shotwell M, et al. A staff training and managementintervention in VA long-term care: Impact on feeding assistance care quality.Transl Behav Med 2013;3:189e199.

34. Centers for Medicare and Medicaid Services. 2014c. QAPI description andbackground. Available at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/qapidefinition.html. Accessed May 24, 2014.

35. Deming WE. Out of the Crisis. Cambridge, Massachusetts: MassachusettsInstitute of Technology, Center for Advanced Engineering Study; 1986.

36. Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor’s ChecklistCan Help Us Change Health Care from the Inside Out. New York: Hudson StreetPress; 2010.

37. Cadogan MP, Schnelle JF, Yamamoto-Mitani N, et al. A Minimum Data Setprevalence of pain quality indicator: Is it accurate and does it reflect differencesin care processes? J Gerontol A Biol Sci Med Sci 2004;59:281e285.

38. Simmons SF, Cadogan MP, Carbonera GR, et al. The Minimum Data Setdepression quality indicator: Does it reflect differences in care processes?Gerontologist 2004;44:554e564.

39. Schnelle JF, Bates-Jensen BM, Chu L, Simmons SF. Accuracy of nursing homemedical record information about care process delivery: Implications for staffmanagement and improvement. J Am Geriatr Soc 2004;52:1378e1383.