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A Phased Cluster-randomized Trial of Rural Hospitals Testing a Quality Collaborative to Improve Heart Failure Care

Organizational Context Matters

Newhouse, Robin P., PhD*; Dennison Himmelfarb, Cheryl, PhD; Morlock, Laura, PhD; Frick, Kevin D., PhD; Pronovost, Peter, MD, PhD§; Liang, Yulan, PhD

doi: 10.1097/MLR.0b013e318286e32e
Original Articles

Background: Use of evidence-based practices for heart failure (HF) patients has the potential to improve outcomes and reduce variations in care delivery.

Objectives: To evaluate the effect of a rural hospital quality collaborative and organizational context (nurse staffing and practice environment) on 4 HF core measures.

Research Design: Phased cluster-randomized trial with delayed intervention control group. The intervention included a HF toolkit, 2 onsite meetings, and a monthly phone call.

Subjects: Twenty-three rural eastern US hospitals, registered nurses who care for HF patients (N=591).

Measures: Seven quarters of 4 HF core measures, nurse staffing (nursing skill mix, registered nurse hours per patient day, nurse-turnover), and a survey of practice environment.

Results: Using regression models with generalized estimating equation autoregressive methods, no statistically significant changes were found during the intervention period on all 4 core measures for either group. Higher nurse-turnover was related to all 4 core measures: lower compliance with discharge instructions [β=−1.042; 95% confidence interval (CI): −1.777, −0.307], smoking cessation (β=−1.148; 95% CI: −2.180, −0.117), left ventricular ejection fraction (β=−0.893; 95% CI: −1.784, −0.002), and prescribing angiotensin converting enzyme inhibitors on discharge (β=−1.044; 95% CI: −1.820, −0.269). Better practice environment was related to higher left ventricular ejection fraction (β=0.217; 95% CI: 0.054, 0.379).

Conclusions: Significant improvements in 4 core measures were realized in stable environments (less nurse-turnover). Assuring appropriate nurse staffing and stability is essential to increase organizational preparation for quality initiatives and adoption of best practices in HF care in rural hospitals.

*Organizational Systems and Adult Health

Department of Acute and Chronic Care, Johns Hopkins University School of Nursing

Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health

§The Armstrong Institute for Patient Safety and Quality, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine

Family and Community Health, University of Maryland School of Nursing, Baltimore, MD

The authors declare no conflict of interest.

Reprints: Robin P. Newhouse, PhD, Organizational Systems and Adult Health, University of Maryland School of Nursing, 655 West Lombard St., Baltimore, MD 21201. E-mail:

© 2013 Lippincott Williams & Wilkins, Inc.