Is the Quality Promotion Model valid?

Abstract

This dissertation evaluates an innovative organizational model of change, the Quality Promotion Model (QPM). The model merges resource dependency and organizational innovation perspectives to explain how and why government promotion of standing orders programs (SOPs) for influenza vaccination of nursing facility (NF) residents is effective. The QPM posits that NFs that exhibit greater dependency on government for resources and abundance of general resources will have greater motivation to adopt and implement a quality improvement innovation in response to government intervention. The study utilizes evaluation data from a 1999--2001 Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) project in twelve states. Quality Improvement Organizations (QIOs), state-based private contractors of CMS, collected pre- and post-intervention survey data in all states and promoted SOP implementation to all Medicaid- and Medicare-licensed NFs in seven. The survey collected information about NF programs and staff perceptions of barriers to SOPs. The intervention consisted of QIO programs, which varied in intensity and relaxation of CMS rules prohibiting SOP policies in NFs. Structural characteristics of NFs from CMS administrative data measured abundance of general resources and resource dependency on CMS. Logistic regression models support the effectiveness of government intervention and QIO programs to increase SOP uptake. External policy disincentives, including legal authority of staff to vaccinate by standing orders, were important barriers to implementation, but less important in states that received high-intensity QIO programs. Study limitations impeded full QPM validity testing; however, evidence to support resource dependency and diffusion of innovation perspectives is present in the study population of NFs. Policy implications include the need for government to remove policy barriers to innovations early; increase intensity of QIO programs relative to implementation barriers; focus on states and NFs that accept the innovation; and conduct theory-based quality promotion research. Resources for government innovation promotion may be titrated most efficiently if barriers and program intensity data are collected and analyzed routinely. Alternative policies, e.g. stronger regulation, public reporting, and pay-for-performance incentives, should supplement quality promotion to achieve national public health goals.