The literature on quality improvement strategies includes several potential design frameworks or paradigms for use in designing an effective quality improvement program.8 While differing in detail, all include a series of logical steps to (1) assess or identify the nursing facility quality problem at hand; (2) evaluate or analyze the issue in order to determine the best approach to resolving it; (3) create a plan for implementing the program design or activity intended to improve the problem; (4) define the interaction between TA staff and the survey agency; and (5) evaluate whether the intervention as designed and implemented actually resulted in quality improvement.
In an effort to categorize the quality improvement programs in the study states, we looked at the extent to which each program had been developed with this general sequence of steps in mind. We found only two states (Texas and Missouri) that had followed such a strategy in full, with rigorous program designs that included an evaluation component. Other state programs were developed through an essentially ad hoc process.9
The Plan, Do, Study, Act cycle of improvement (also referred to as Shewart's Cycle for Learning and Improvement) is one that is commonly cited by organizations, such as CMS's Quality Improvement Organizations, that conduct continuous quality improvement activities. Another (see Massoud, 2001) specifies a different set of steps: identify, analyze, develop, and test/implement. Yet another uses the standard steps of the nursing process: assessment planning, implementation, reassessment, and evaluation.
Maine did create what it called a "vision" for what quality improvement programs should look like, though this was developed too recently to be relevant for the Maine programs included in this study.