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Improving the overall quality and star rating at the sub-acute care center

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Improving the overall quality and star rating at the sub-acute care center

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Content Running head: IMPROVING THE STAR RATING OF A SUB ACUTE CARE CENTER 1

Improving the Overall Quality and Star Rating at the Sub-Acute Care Center

by

Olugbenga Agbelemose

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

August 2018

Copyright 2018 Olugbenga Agbelemose
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DEDICATION
First, I would like to give thanks to God Almighty for giving me the knowledge and
understanding to achieve my goals. To my wife, Valerie, who has been by my side through my
undergraduate years to now completing this doctorate degree. You are my rock and I will forever
love you. To my boys, Darryl and Timmi, know that the sky is the limit and you can achieve
whatever you set your minds to. Finally, to my brother, Shola, who inspires me and I look up to.
You have always been there for me and you are a source of my strength. We did it.

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ACKNOWLEDGMENTS
This dissertation represents the attainment of a long-awaited goal of mine, which is,
obtaining my doctorate degree. I did not obtain my medical doctorate as I had thought of when I
was a little boy, but this doctorate in education is just as significant, and I will cherish the degree
for the rest of my life. I would like to acknowledge and express my sincere appreciation to the
Rossier School of Education at the University of Southern California (USC) for accepting a
student like me into the program. I would also like to acknowledge and express my sincere
appreciation to all the professors in the Organizational Change and Leadership (OCL) program,
my dissertation chair, and committee members, especially Dr. Hirabayashi. Dr. “H”, as we all
called you, provided guidance and direction for completing my work. I would like to
acknowledge Dr. Rodrick Jenkins who was one of my first professor for Framing Educational
Leadership in a Global Context. You set the fear and motivation for me to succeed in the
program. I doubted myself when I took your class, but you encouraged me and gave me great
feedback on my writing. I also like to acknowledge Dr. Kathy Hanson who was my professor in
my Analyzing Organizational Change and its Effectiveness class. Everything I was learning in
the program "clicked" when I took your class.
I would like to acknowledge my cohort 4 members. During immersion 1, we all came
together as strangers, and now at graduation, I consider you my extended family. Most of all, I
am grateful to my wonderful wife, Valerie Rochelle Agbelemose, who constantly supported me
with words of encouragement as well as you showed patience with me in my quest to obtain my
doctorate degree.

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TABLE OF CONTENTS

DEDICATION ................................................................................................................................ 2
ACKNOWLEDGMENTS .............................................................................................................. 3
TABLE OF CONTENTS ................................................................................................................ 4
LIST OF TABLES AND FIGURES............................................................................................... 6
ABSTRACT .................................................................................................................................... 7
Introduction to Problem of Practice ................................................................................................ 9
Organizational Context and Mission .............................................................................................. 9
Importance of Addressing the Problem ........................................................................................ 11
Purpose of the Project and Questions ........................................................................................... 12
Organizational Performance Status ............................................................................................... 13
Organizational Performance Goal ................................................................................................. 13
Stakeholder Group of Focus and Stakeholder Goal ...................................................................... 14
Review of the Literature ............................................................................................................... 15
Historical Background about PAC............................................................................................ 15
The Star Rating System ................................................................................................................ 17
Assumed Knowledge, Motivation and Organizational Influences ............................................... 19
Knowledge Influences .............................................................................................................. 20
Motivation Influences ............................................................................................................... 22
Organizational Influences ......................................................................................................... 25
Data Collection ............................................................................................................................. 30
Data Collected by Document Review ....................................................................................... 31
Data Collected by Interviews .................................................................................................... 31
Data Analysis ................................................................................................................................ 33
Interviews .................................................................................................................................. 33
Document Analysis ................................................................................................................... 34
Findings......................................................................................................................................... 34
Recommendations and Solutions .................................................................................................. 49
Knowledge Recommendations ................................................................................................. 50
Motivation Recommendations .................................................................................................. 55
Organization Recommendation ................................................................................................ 59
Limitations .................................................................................................................................... 64
Recommendations for Future Research ........................................................................................ 65
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Conclusion – What is the Big Take-Away? .................................................................................. 66
Appendix A: Participating Stakeholders with Sampling Criteria ................................................. 67
Participating Stakeholders ............................................................................................................ 67
Criterion 1. Sampling Approach: .............................................................................................. 67
Criterion 2. Process for sampling participants and choice:....................................................... 67
Appendix B: Protocol ................................................................................................................... 68
Appendix C: Credibility and Trustworthiness .............................................................................. 69
Appendix D: Validity and Reliability ........................................................................................... 71
Appendix E: Ethics ....................................................................................................................... 72
Appendix F: Definitions and Types of PAC Facilities ................................................................. 74
References ..................................................................................................................................... 77

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LIST OF TABLES AND FIGURES

Table 1 – Organizational Mission, Global Goal, and Stakeholder Goals ..................................... 13
Table 2 - Different Sections for Knowledge, Motivation, and Organizational Culture ............... 27
Figure 1 - Interactive Conceptual Framework ............................................................................. 29
Table 3 - Deficiencies Identified at OLA in the past Three Years ............................................... 35
Table 4 - NCC MERP Harm Scale ............................................................................................... 36
Table 5 - Performance of OLA on Short Stay Measures ............................................................. 37
Table 6 - Performance of OLA on Long Stay Measures ............................................................. 38
Table 7 - Summary of Knowledge Influences and Recommendations ......................................... 54
Table 8 - Summary of Motivation Recommendations ................................................................. 58
Table 9 - Summary of Organizational Recommendations ........................................................... 63

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ABSTRACT
The purpose of this study is to use the knowledge, motivation, and organizational (KMO)
methodological approach in improving the problem of practice of improving the star and quality
rating of any post-acute care facility. Although there are several care models that are categorized
under the post-acute care umbrella, the emphasis of this dissertation will focus on long-term sub-
acute care. Sub-acute care was established on July 1, 1983, by the department of health care
services (DHS), and it is the level of care needed for patients who do not need acute
hospitalization any longer. These patients are considered medically fragile and require special
services on a long-term basis in other for them to return back to their normal state of health. In
healthcare, long-term care is defined as patients needing healthcare services for longer than 100
days.
As the cost of healthcare in the United States (U.S.) far exceeds that of any other country
in the world, healthcare advocates are requesting healthcare organizations to find ways of
improving the cost and care of healthcare services provided to their customers. Medicare is the
biggest payer of healthcare services in the U.S. Medicare is a government-sponsored insurance
program for individuals 65 years and older, as well as for some younger adults with a disability.
One of the current strategies being used to improve both care and quality is through the
evaluation and rating of healthcare facilities including nursing homes. The Department of Health
and Human Services (DHS) evaluates these acute and long-term facilities using an established
set of criteria, and the results are sent to the Center for Medicare and Medicaid Services (CMS).
It is from this inspection that a quality and star rating is provided to the nursing facility.
Reimbursement, as well as punishment of the facility, is now tied to the star rating of the facility
hence most long-term care facilities are looking at ways to improve their quality and star rating
especially since their reimbursement for care provided to patients are linked with their rating.
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The star rating ranges from one star to five stars, with the five-star rating being considered as a
facility providing the best quality care to its patients.
In this study, I will be analyzing empirical literature and journals and providing strategies
on how using the KMO model can improve the rating of a sub-acute care facility. Although there
are several articles that focus on post-acute care in general, there are currently no study that
focuses on sub-acute care environment that I am aware of.

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Introduction to Problem of Practice
The number of patients that will need post-acute care (PAC) in the United States (US) is
expected to increase to 3 million by 2030 (Harrington, Collier, & Schnelle, 2003), yet the quality
of care delivered at these facilities is not improving to meet the pace of the need. There are
several facilities that fall under post-acute care, and skilled nursing facility (SNF) is one of them.
Sub-acute care is a type of facility that falls under the category of SNF. According to the Centers
for Medicare and Medicaid Services (CMS), there are 1,120 post-acute care facilities in
California. PAC facilities are places where patients can continue their recovery process in a less
costly location. The CMS uses metrics to assess the quality of care provided at these facilities.
Through these metrics, a star rating system is awarded to the facility based on how the facility
performs on those metrics, therefore metrics are important for quality care measurement. The
CMS created the five-star rating system to help consumer differentiate between high and low
performing nursing homes so that the consumers can be more educated when selecting a facility
to receive care. The star rating ranges from one-star to five-stars, with a nursing home with five-
stars representing a facility that provides above average care, while the other extreme of one-star
reflects a facility that provides low quality of care. More details will be provided on what
constitutes the star rating.
Organizational Context and Mission
For this section, a pseudonym organization is used, and the name of the organization is
Our Lady of Apostles (OLA) Sub-Acute Care Center (SACC). OLA is part of a healthcare
organization that has a religious affiliation and is committed to providing for the needs of the
communities it serves, especially to those who cannot care for themselves and are considered
underrepresented. OLA SACC is part of a bigger health system which is highly ranked, and
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categorized among the top 25 not-for-profit health organization in the United States. The
system’s combined scope of services includes hospitals, physician clinics, senior services,
supportive housing, and other health and educational services across the Western part of the
United States. The health system includes more than 122,000 employees serving in a diverse
range of facilities from birth to end of life, including acute care, physician clinics, long-term and
assisted living, palliative and hospice care, home health, supportive housing, and education.
The mission of OLA is to show the Love of God in the way they care for those who do
not have the resources by how they care for them. This means that any OLA hospital will care
for any patient regardless of whether they can pay for the services or not. While these services
are being rendered, the staff will treat everyone with compassion. Their vision is to "make
healthcare simple for everyone," which means that as the healthcare industry continues to be
complicated, OLA will make sure that the services that are needed are provided at the right place
and time. Their promise is to respond to every person that comes through their doors, which
means they will "get acquainted with their patients" through the use of their sophisticated
computer system, "protect their patients" using the best technological system, and "simplify the
way" of the patient and family as being in a hospital can be a difficult time for the patient and
their family. The strategic outcome for OLA is to build fit groups of communities, together. This
means that creating a healthier community is not just the work of the community and the people
that live in that community. OLA will work with the community to provide free education
classes on healthy living and preventative care so that the people in the community can live a
healthy and productive life. In addition, OLA has published its core values as a way for its
customers to hold them accountable for their values. Their core values are reverence, solicitude,
honesty, superiority, and conservancy.
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Importance of Addressing the Problem
So, to begin, why is important to improve the quality rating at sub-acute care facilities,
and why is improving the overall quality of care at the sub-acute care center (SACC) the focus of
this dissertation? Data has shown that the population of the United States (US) is aging.
According to the United States Census Bureau, the 2017 population of the US is 325.7 million.
Out of this census numbers, it is estimated that there are 50 million citizens that are aged 65
years or older. This number is expected to increase to 55 million by the year 2020, and 70
million by 2030. With this increased numbers, there will be an increased amount of senior
utilizing a long term care facility. How do we know that we are taking our loved ones to a
facility that provides quality care, and the facility will keep them safe from harm? The quality of
care at sub-acute care facilities has been questioned, and American want to be reassured that
their loved ones will be safe if they are put in facilities similar to a sub-acute care facility to
receive care at any location in the US. The number of patients that will need post-acute care
(PAC) from this aging population in the United States (US) is expected to increase to 3 million
by 2030 (Harrington, Collier, & Schnelle, 2003), This is the main reason for this dissertation.
Data provided by CMS reflects that out of the 1,120 post-acute care facilities in the
United States (US), only 39% are rated as five stars, and another 36% have either a three star or
four stars (Centers for Medicare and Medicaid Services, 2013). Explored in this dissertation, are
literature and published articles on how to improve the SACC quality of care as measured by its
star rating using the knowledge, motivation, and organizational (KMO) culture framework for
this evaluation process. The stakeholders that will be evaluated for this work will be all the
employees that work at a SACC that is located in California. To protect the anonymity of the
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organization that will be evaluated, a pseudonym is used instead of the actual name of the
organization.
The pseudonym of the organization that will be evaluated is called Our Lady of Apostle
(OLA) Sub-Acute Care Center (SACC). The reasons for wanting to improve the overall quality
of the SACC will be addressed from three perspectives which are those of the patient or
consumers, hospital or organization, and regulatory or government. From the consumer
perspective, patients and family members want to know that their family members will be safe
and receive top quality healthcare when they choose to use a facility for their medical needs.
From the hospital perspective, reimbursement for care provided to patients are tied to the star
rating of the facility. In addition, since this data is publicly available to consumers, organizations
with higher rating tend to attract more patients to receive care at their facilities as compared to
facilities with a lower rating. Therefore, the rating of the facility can be seen as a recruitment
mechanism for patients to use that facility, as well as the sustainability of that organization to
attract more market share. From a government or regulatory perspective, organizations like
insurance organization may only want to send their consumers to higher rated facilities as this
reflects the higher quality of care provided at these facilities.
Purpose of the Project and Questions
The purpose of my dissertation is to conduct a focused modified gap analysis to examine
the knowledge, motivation, and organizational influences that have caused the SACC to be at its
current star rating. This analysis will begin by generating a list of possible or assumed interfering
influences that will be examined systematically to focus on actual or validated interfering
influences. The study will be available to all employees that are willing to participate in the study
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at one location of OLA SACC. The reason for surveying all employees at this center is because
everyone at the center contributes to the rating of the center in one form or the other.
As such, the questions that guide this study are the following:
1. To what extent is the organization meeting its goals?
2. What are the stakeholder's knowledge and motivation as related to the organizational /
stakeholders goal?
3. What are the interactions between organizational culture and context, and stakeholder
knowledge and motivation?
4. What are the recommendations for organizational practice in the area of knowledge,
motivation, and organizational resources?
Organizational Performance Status
As of current, the SACC has an overall rating of three stars. The rating is comprised of
three sections which have individual ratings. The ratings are; health inspection rating of two stars
which is categorized as below average, staffing rating of five stars which is categorized as much
above average, and quality of care rating of three stars which is categorized as average. These
individual rating for each category of assessment results in an overall rating of the SACC as
three stars.
Organizational Performance Goal
The SACC is inspected annually or within an 18-month time frame based on performance
on their previous year's inspection results. From documents reviewed, the last inspection date for
the SACC was July 2017. From the results of that inspection, 10 health citations were given to
the SACC with the average number of health citations in California at 9.5, and the total number
of health citations in the U.S. at 5.8 (Centers for Medicare and Medicaid Services, 2013).
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According to the executive leadership team at OLA, they have established a goal for the center
which is by the inspection of 2018, the SACC team will ensure compliance with all quality
measures and staffing level requirements to achieve a five-star rating. See Table 1 below which
provides OLA's organizational mission, organizational global goal, and the stakeholder's goal.
Table 1

Organizational Mission, Global Goal, and Stakeholder Goals

Organizational Mission
At Our Lady of Apostle (OLA) we show the Love of God in the way we care for those who do
not have resources by how we care for them.

Organizational Global Goal
By December 2018, Our Lady of Apostle (OLA) Sub-Acute Care Center (SACC) will improve
its overall star rating from three stars to five stars.

Stakeholder Goal
By the inspection of 2018, the SACC team will ensure compliance with all quality measures
and staffing levels required which are two of three components to achieve a 5-star rating.

Note. The table above shows OLA's mission, global goal, as well as the stakeholders goal.

Stakeholder Group of Focus and Stakeholder Goal
There are several stakeholder groups that directly contribute to, and benefit from the
achievements of the organization's global goal. It is well known that any organizations,
regardless of the product or service provided, strive to compete in a global economy, and the
company's success depends on several factors including both knowledge and motivation of its
workforce (Aguinis & Kraiger, 2009). For this study, all the employees that work at one
particular organization will be eligible to participate in this study. This is because they all
contribute to the rating of the SACC in one shape or another. For this problem of practice, the
stakeholder goal, as referenced in Table 1, is by the inspection of 2018, the SACC team will
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ensure compliance with all quality measures and staffing levels required which are two of the
three components to achieve a five-star rating.
Review of the Literature
This section will provide a general orientation for my readers regarding the topic of
improving the overall quality and rating at a sub-acute care center (SACC). Before explaining
how this section will be categorized, a description of "star" rating has been provided under
Appendix F of this dissertation. The first part will include some historical background and
developmental information about PAC. In addition, it will include how long the healthcare
community has been interested in PAC, what are the landmark changes and studies that have
impacted PAC, how has the need for PAC changed over time, and the legislative impact that has
increased the need of PAC facilities. The second part will focus on the "star" rating itself. This
will include what actions have led to the need to rate PAC facilities, why and how often are PAC
facilities inspected, what are the categories that comprise and make up the star rating system, and
activities contribute to the calculation of the star rating in the PAC environment. The third part
will discuss assumed knowledge, motivation, and organizational influences that may be affecting
OLA from attaining its goals. The last part will reference the Clark and Estes Gap Analytic
Conceptual Framework as the worked examples demonstrate.
Historical Background about PAC
Post-Acute Care (PAC) refers to a variety of medical care services that assist a person's
continued recovery from illness or management of a chronic illness or disability (Mechanic,
2014). Post-acute care facilities have been in existence since the mid-1960's (see Appendix F for
types of PAC facilities). These facilities were treated as individual entities and were not
identified as an extension of acute care facilities or a continuum for patient care recovery back to
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their previous state of health (Feder & Scanlon, 1980). In the mid-1980's, there were several
court decisions that expanded the coverage of PAC facilities by Medicare, which caused
increased growth and payment to PAC facilities. With the advancement in technology between
1984 and 1997, the regulations at that time permitted the movement of patients from inpatient
and outpatient facilities to PAC facilities (Buntin, Colla, & Escarce, 2009). This movement
created added revenue for hospitals and PAC facilities as there was no distinction in the way
Medicare paid for services between acute and PAC facilities, although it was cheaper to provide
care at PAC facilities. Between 1990 and 1995, it was estimated that the expenditure for PAC
rose from $2.5 billion to $11.7 billion during this period. A legislative decision and the passing
of the Balanced Budget Act of 1997 changed the way Medicare paid PAC facilities, and it
changed the focus on improving care at PAC facilities (Cotterill & Gage, 2002).
There is a common assumption in health care that facilities with a high rating must have a
higher quality of care. According to Krumholz, Rathore, Chen, Wang, and Radford (2002),
increasing interest in the quality of healthcare has led to the development of "report cards" to
grade and compare the quality of care and outcome of hospitals, physicians, and managed care
plans. Zusman (2012) cited a direct correlation between higher quality scores, patient
satisfaction, and increased reimbursement from the government. The research article from
Krumholz et al (2002) suggests that patient satisfaction scores will have a direct impact on the
bottom line of healthcare facilities. The study described that starting in October 2012, CMS will
reduce by 1% the base operating diagnosis-related group (DRG) payments to hospitals to create
an incentive fund, estimated at $850 million. This money will be distributed to hospitals based
on their performance on several “quality” measures, 30% of which will be based on how patients
rate their hospital experience on the Hospital Consumer Assessment of Healthcare Providers and
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Systems (HCAHPS) patient satisfaction survey. In a 2011 article, Rau stated that tying patient
opinions to payments will result in better care. But many hospital officials are wary, arguing the
scores do not necessarily reflect the quality of the care and are influenced by factors beyond their
control. Hospital staff will have to be vigilant and respond to the needs of the patient, otherwise
ignoring patient requests for assistance will affect the bottom-line of the medical center
(Mukamel et al., 2007).
The Star Rating System
The SACC is inspected annually or within an 18-month time frame based on performance
on their previous year's inspection results. The information about the star rating system is
synthesized from the nursing home compare website (https://www.medicare.gov/sign-up-
change-plans/decide-how-to-get-medicare/whats-medicare/what-is-medicare.html). The star
rating system was launched in 1998 as a way to empower consumers with information about a
facility prior to patients and family members deciding to use the facility. There are three scored
areas which are hospital inspections, staffing, and quality measures.
Hospital inspections refer to the number, scope, and severity of deficiencies identified at
the facility, as well as substantiated complaint findings during the most recent three years that
was conducted by trained inspectors. This also takes into consideration how many times the
facility was revisited to rectify an identified deficiency during an inspection. Staffing refers to
the number of hours of care provided by the nursing personnel of the organization. This number
is adjusted to reflect the acuity level of the patients at the facility, as well as the patient census at
the facility during a month. The quality measures reflect how well an organization has cared for
its patients by using both physical and clinical measures. There are 24 quality measures that the
facility is assessed on, and this information is derived from the minimum data set (see Appendix
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F for definition) which is an assessment that is done periodically by the nursing staff and is used
to develop the plan of care for the patient. Each area is awarded points, and the points are used to
calculate the star rating for that section. To calculate the overall star rating of the center, the star
rating of the health inspection is used as the starting point of the overall rating. Stars are added or
subtracted based on how the facility performs at the other two areas that are assessed. The
overall star rating cannot be more than five stars, or below one star.
The development of HCAHPS and its associated protocol has initiated increasing
research that focuses on PACs. HCAHPS is a survey instrument and data collection methodology
for measuring patients' perceptions of their hospital experiences. These surveys are being
administered by external agencies that are now being used by the Federal government as a way
to reimburse facilities. According to a research report performed by Lilford, Mohammed,
Spiegelhalter, and Thomson (2004), external agencies have been monitoring outcome measures
of facilities for quite some time. As a result of this monitoring, medical facilities are being
awarded star rating which does not directly reflect the work and quality of care performed at
these facilities. The report published by Lilford et al. (2004) was also supported by another
research performed by Lilford, Brown, and Nicholl (2007) who stated that it was acceptable to
use survey tools as a way to judge the quality of the medical institution. Further, the report
posited that institutions like the Health Care Commission in England and Medicare in the United
States use these tools as a way to impose penalties on medical centers. There are opposing views
that suggest that surveying hospitals help to improve the quality of care performed at these
facilities. One such article published by Giordano, Elliott, Goldstein, Lehrman, and Spencer
(2010) suggest that the benefits of such information improved consumer decision-making, and
increased the healthcare facility’s incentive to deliver high-quality care. With several articles
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reflecting on the pros and cons of surveying, there seems to be a predominant opinion that the
practice is beneficial as it makes facilities improve the care provided to the patient. Since the
survey results are now being tied to reimbursement, facilities will need to change and adapt to
these new requirements.
Assumed Knowledge, Motivation and Organizational Influences
Organizations, regardless of the product or service provided, strive to compete in a
global economy, and the company's success depends on several factors including both
knowledge and motivation of its workforce (Aguinis & Kraiger, 2009). Addressed in this section
are both knowledge, motivation, as well as organizational influences that affect Our Lady of
Apostle (OLA) Sub-Acute Care Center (SACC). This section has been divided into three main
parts. The first part will address knowledge and skill, and a definition of knowledge is provided,
as well as influences that affect knowledge. The next section addresses motivation, and a
definition of motivation is provided. The concept of how motivation works as it applies to OLA
is provided. The last section will address organizational culture, and what influences the
organization has on OLA achieving its goal. The sections will conclude with an influencer table
that depicts the organizational mission, global goal, stakeholder goal, as well as the different
knowledge, motivation, and organizational influences for OLA.
Mayer (2011) defines knowledge as skills, facts, and information that is acquired through
experience or education. When organizations do not meet their stated goals due to lack of
knowledge, it becomes necessary for organizations to perform a gap analysis to determine
whether the workforce members know how to close the gap and achieve their performance goals
(Clark & Estes, 2008). With OLA's organizational goal to improve its overall quality and star
rating from three-star to five-star, several gaps have been identified through research but the
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scope of this section will only focus on the identified knowledge gaps that are declarative and
metacognitive. This knowledge gap will be evaluated to ensure that all stakeholders in the
organization can ensure compliance with all quality measures and staffing level requirements
needed to achieve a five-star rating by the inspection date of 2018.
Knowledge Influences
Several researchers have done extensive work on the acquirement of knowledge and a
conclusion that knowledge cuts across several subject matter lines have been made. They
continue that knowledge dimensions contain four main categories which are factual, conceptual,
procedural and metacognitive (Krathwohl, 2002). Although all these knowledge types influence
OLA, I will only be examining the literature on three knowledge types relevant to the team as
they all play a role in making sure that OLA complies with all the quality measure and staffing
level requirements to achieve their desired five-star rating. The knowledge types that will be
evaluated are declarative (factual and conceptual), and metacognitive knowledge. These
knowledge types will explain reasons for the current lower star rating.
The relationship between patients served and the impact on quality. Rueda (2011)
defines conceptual knowledge as the knowledge of categories, classifications, and principles
pertinent to a particular area. A conceptual knowledge at OLA is that the whole healthcare team
needs to know what the quality report is comprised of so that they can know the relationship
between the types of patients the organization serves, and the impacts those patients have on the
organization's quality measures. For some organizations, the goal to achieve benchmarks, and
receive the highest quality rating with maximum reimbursement take precedence which makes
them very selective to the kind of patients they care for (Konetzka, Grabowski, Perraillon, &
Werner, 2015). OLA's mission is to provide care to those who do not have resources to provide
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care for themselves. Abiding by its mission means that OLA accepts and care for patients that
other medical facilities may not want. For this reason, when OLA is assessed to its peers, and
due to the higher patient acuity at the center, they receive a lower score. It is relevant for the
whole healthcare team to know what the quality report that the center is being evaluated to so
that they can assist the organization in meeting its goals when they are caring for patients at the
center. In addition, since the facility accept higher acuity patients, the executive team has to be
aware of this since realistic decisions have to be made which includes either continuing to abide
by its mission statement and accept these types of patients, or turn their backs on these
vulnerable patients for the sake of having a higher quality and star rating for the center.
Knowledge of what the star rating is. Another declarative knowledge that is vital for
the entire staff members to know what the star rating is. This is a factual knowledge which
Rueda (2011) defines as the knowledge of specific disciplines, contexts or domain. Knowing
what the star rating is, and how it is calculated will be a great benefit for the healthcare team that
works at the SACC. When it comes to the overall calculation of the star rating of an
organization, the team needs to be aware of how this overall rating is derived. They need to be
aware that there are three separate categories that are each awarded their own individual rating.
The rating is awarded based on how the organization performs to the standard that is measured.
The maximum star rating that can be awarded per category is five, and the least amount that can
be awarded is one star. Ultimately, if the employees know and understand what a star rating is
and how it is derived, they can contribute to the organization overall improvement in their rating.
The healthcare team needs to know what it will take for the organization to be at a
five-star rating. A metacognitive knowledge, which is knowledge of when and why we do
things (Rueda, 2011) for the healthcare team is understanding what it will take for the
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organization to be at a five-star rating. Since there are different types of healthcare teams that
work at the center, each discipline needs to know how their work contributes to the
organization's success and what that success looks like from a global perspective. Researchers
have shown that the way we think about practices as well as how we interact with one another
dramatically shapes our efforts on how to improve our outcomes (Best & Holmes, 2010). In the
case of OLA, the improved outcome will be attaining an overall five-star rating after the next
inspection of the center by regulatory bodies.
Motivation Influences
For this section, motivational goals and values as it relates to OLA, as well as the four
components of motivation, will be addressed. In addition, the conceptions of how motivation
works will be addressed, including expectancy theory, and the perceived value one gets from
performing a task. The last part will address two assumed motivational influences as it relates to
OLA.
There has been extensive research done on motivation and how motivation leads to
organizational change. Motivation and cognitive abilities represent two basic determinants of
learning and work performance (Kanfer & Ackerman, 1989). To begin, the Latin root of the
word "motivation" means "to move"; hence, in this basic sense, the study of motivation is the
study of action (Wigfield & Eccles, 2000). Clark and Estes (2008) define motivation in general
terms as the internal, psychological process that gets us going, keeps us moving, and helps us get
the job done. Rueda (2011) defines motivation as an internal state that initiates and maintains
goal-directed behaviors. Motivation has four components - motivation is personal, activating,
energizing, and directed (Mayer, 2011). According to cognitive theories of motivation, the most
IMPROVING STAR RATING 23

popular conceptions of how motivation works are based on choice, persistence, and mental
efforts (Clark & Estes, 2008). One of this concept will be elaborated on below.
Expectancy-value theory. Fully engaging in a task requires a desire to want to perform
the task (Clark & Estes, 2008). Eccles (2009) explains that the perceived value of a task is
determined by four related constructs: (1) intrinsic values which are the enjoyment one feels
while doing the task and find personally meaningful; (2) attainment value which is the linkage
between the task and the individual's own identity and preference; (3) utility value which is how
well the task fits into the individual's goals, plans, or fulfill other basic psychological needs; and
(4) the perceived cost of engaging in the activity (Eccles, 2009). All these factors will be
explained in greater detail as it applies to OLA.
Value of linking task of caring to the team's individual preference. There are several
motivation influences that contribute to teams engaging and persisting in whatever tasks they
have to perform (Rueda, 2011). These influences or variables include self-efficacy, value,
interest, attributions, goals and goal orientation, and emotions, with both value and self-efficacy
being the most important influences. For this research study, I will be focusing my research on
value with an emphasis on attainment and utility values as a strategy to meet the organizational
goal.
Eccles (2009) found that the interest and value one puts into a task influences the
outcome of the task. Most individuals that work in the healthcare field know at a young age that
they want to care for people. They have attained the skills and interest in caring for people with
the end results of seeing the patients get better. This is the ultimate reason why individuals
become doctors and nurses. Rueda (2011) explains that value is the importance an individual
place on a task. Eccles (2009) suggests that attainment value refers to the link between the task
IMPROVING STAR RATING 24

that is being performed and the individuals own identity as preferences. This means that the
value one puts on a task influences the individual's persistence in achieving that goal.
Harackiewicz, Tibbetts, Canning, and Hyde (2014), as well as Eccles (2009) both, agree that
individual’s motivation to engage in the demands of any particular situation is influenced by the
extent to which the setting provides opportunities to experience autonomy, social relatedness,
and a sense of competence. Moody and Pesut (2006) emphasize that despite challenging
circumstances, most nurses transcend organizational problems and are motivated to serve and
care for patients.
In their research on work engagement, Christian, Garza, and Slaughter (2011) suggest
that when individuals are engaged in their work, they invest personal energy in that work and
they experience an emotional connection with that work. Rich, Lepine, and Crawford (2010)
explain that popular articles, as well as business consultants, have claimed that when employees
are engaged in their work, this provides a competitive advantage for that organization among its
peers in the industry it operates. When nurses are motivated, they perform their best job. Nurses
get into careers in the healthcare field because of their willingness to engage and devote their
time and expertise to their patients.
Awareness of how daily task fulfills e m p loyee ’s psychological needs. Another aspect
of motivation that has been extensively researched is how the task being worked on fits into the
individual's goals, plans, or fulfills other psychological needs of the person doing the task
(Eccles, 2009). This is otherwise referred to as the utility value of the task. From another
perspective, the utility value one shows in a task is affected by the interest one has in
accomplishing that task. Pintrich (2003) confirms that there is a direct correlation between the
interest one has in performing a task and the motivation to perform the task. The interest one has
IMPROVING STAR RATING 25

in a topic helps them persist in getting the work completed. Interest can be either intrinsic or
extrinsic when it involves accomplishing a task (Linnenbrink & Pintrich, 2002).
Mayer (2011) state that individuals will work harder if there is an interest in the topic that
is being taught. The same applies to any industry that workers are involved in. In a hospital
environment, the healthcare team will work harder if there is an interest in the task being
performed. Tzeng (2002) posit that there is a linkage between nursing staff interest in their job
and job satisfaction in performing their role. This satisfaction leads to better outcomes for
patients and decreases employee turnover in the healthcare team
Organizational Influences
Addressed in this part are the organizational influences that affect OLA SACC, and it is
divided into two main sections. The first section will address the cultural models of OLA where
one influences in attaining its five-star goal will be addressed. The second section will focus on
the cultural settings of OLA where two influences will also be addressed. The organizational
section will conclude with a table that shows the organization's mission, global goal, stakeholder
goal, assumed knowledge, motivation, and organizational influences, as well as the
organization's influence assessment as it pertains to OLA.
The culture of an organization sets the tone of how business is performed at that
organization with both its internal and external customers. For some companies, the
organizational culture can be felt through its mission statement, core values, and through
interactions with employees of the company. Barney (1986) defines organizational culture as a
complex set of values, beliefs, assumptions, and symbols that interpret the way in which a firm
conducts its business. OLA's mission is displayed in the kind of patients that are cared for at the
center. There are occasions when organizational gaps or barriers prevent the workforce members
IMPROVING STAR RATING 26

from achieving the organizational goals. These gaps are identified when internal customers do
not have the tools or resources to perform their functions adequately (Clark & Estes, 2008). With
OLA's global goal to improve its overall star rating from a three-star to five-star rating, two
cultural model influences, as well as cultural setting influences, have been identified that will be
addressed below.
Patient selection for admission. Patients that are accepted to the SACC are those that
have several co-morbidities which require advanced care at the center. Under the quality metric
measurement, one of the areas the center is assessed is the number of long-term, high-risk
patients with pressure ulcers (Centers for Medicare & Medicaid Services, 2014). Due to the
complexity of the patients at the SACC, some of them do not get out of bed and are bed-bound.
Although several interventions have been put in place to prevent pressure ulcers in these patients,
these patients still develop pressure ulcers. Another area that the center is evaluated on is the
percentage of long-stay patients that have a urinary tract infection (UTI). Since there are a
considerable number of patients that are bed-bound, most of them have catheters that go into
their bladder to limit the need for changing the patient when there is a need to urinate.
Unfortunately, due to unacceptable practices like poor hand hygiene, or having the catheter bags
fall on the floor, infections tend to happen. These infections can be prevented by the organization
through strict enforcement of policies.
Shortage of adequate staffing. Another cultural setting influence is the shortage of
adequate staffing levels which results in staff working long hours, and overtime. This contributes
to staff fatigue and errors in care (Waldman, Kelly, Aurora, & Smith, 2004). West et al. (2014)
conducted an observational study on the availability of nursing and medical team to patients in
IMPROVING STAR RATING 27

the intensive care unit. They concluded that higher numbers of nurses and medical personnel
available at the patient's bedside were associated with an increased survival rate of the patient,
and the opposite caused a decreased survival rate of the patient.
Ineffective communication of organizational goals. A cultural setting inadequacy at
OLA is the ineffective communication of the organizational goal to all the stakeholders that work
for the organization. Although this is communicated to all new employees during their
orientation process, the ineffectiveness is encountered when the employee has completed their
hospital orientation. The organizational goal is no longer communicated to the employees which
make it challenging for stakeholders to know what the ultimate goal the organization is working
on. Researchers have done extensive analysis on communication in the healthcare setting, and
one of their conclusions is that ineffective communication is one of the leading causes of
dissatisfaction and not meeting the organization's goals (Dingley, Daugherty, Derieg, & Persing,
2008)
The three assumed influences explained above are presented in Table 2 which is below.
Table 2 shows OLA's organizational mission, global goal, and stakeholder goal. The table also
includes the different sections for knowledge, motivation, and organizational culture.
Table 2
Organizational Mission

At Our Lady of Apostle (OLA), we show the love of God in the way we care for those who do
not have resources by how we care for them.
Organizational Global Goal

By December 2018, Our Lady of Apostle (OLA) Sub-Acute Care Center (SACC) will improve
its star rating from three stars to five stars
Stakeholder Goal

By the inspection of 2018, the SACC healthcare team will ensure compliance with all quality
measures and staffing level required to achieve a five-star rating
IMPROVING STAR RATING 28

Assumed Knowledge Influence Knowledge Influence Assessment
Declarative knowledge
The whole healthcare team needs to know
what the quality report is comprised of so that
they can know the relationship between the
types of patients the organization serves and
the impacts those patients have on the
organization's quality measures.
The healthcare team will be interviewed to
access their knowledge of what the quality
report comprises of so as to assess their
understanding of the report.
Declarative Conceptual knowledge
The whole healthcare team needs to know and
understand what the star rating is.
The healthcare team will be interviewed to
assess their understanding of what the star
rating is.
Metacognition
The whole healthcare team needs to be able to
reflect on what it will take for the
organization to be at a five-star rating
The healthcare team will be asked to reflect
on what they believe the organization needs
to do to be at a five-star rating.
Assumed Motivation Influences Motivational Influence Assessment
Attainment Value: The healthcare will need to
link the task of caring for the types of patients
seen at OLA to their own individual
preference of wanting to care for people.
Interview question: How does their work
contribute to the overall rating of the center.
Utility Value: The healthcare team needs to
be aware of how their daily tasks fulfill their
psychological needs, and how this contributes
to meeting the organizational goal.
Interview question: Why are organizations
routinely inspected by regulatory agencies?
Assumed Organizational Influences

Organization Influence Assessment
Cultural Model Influence 1:
The culture of caring.

There is a culture of caring for those who are
poor and vulnerable and acceptance of
patients who have higher than normal co-
morbidities that other facilities will not care
for regardless of their ability to pay.
Cultural Setting Influence 1:
Lack of communication

Interview with the healthcare team to inquire
about their understanding of the
organizational and stakeholders goal.
Cultural Setting Influence 2:
Shortage of adequate staffing
Document analysis of publicly reported
staffing levels for the facility to assess if there
is a problem in the organization with staffing
levels.

IMPROVING STAR RATING 29

Interactive Conceptual Framework

Figure 1: OLA's Interactive Conceptual Framework

Our Lady of Apostle (OLA) Sub Acute Care Center (SACC)

Stakeholder's
Healthcare Team
Knowledge Motivation

Declarative - Conceptual.

Declarative - Procedural

Metacognition

Attainment Value

Utility Value

Cultural
Models
Mission
Cultural
Settings
Communication
Quality Care Staffing
Stakeholder's Goal
By the inspection of 2018, the SACC
administrative team will ensure compliance
with all quality measures and staffing level
requirement to achieve five-star rating
Organizational Global Goal
5-Star Overall Rating
IMPROVING STAR RATING 30

Data Collection

For this section, I will be providing information on how I collected the data for my
research. The strategy I used to select my participants will also be provided, in addition to the
protocols used during the interview session with the participants of my study. This protocol is
referenced in Appendix B.
Fink defines surveys as a data collection method used to collect information from and
about people (Fink, 2012). Data can be collected from participants through several common
methods. These methods include testing, filling out questionnaires, performing interviews, focus
group, and observations (Johnson & Christensen, 2008). Although performing observations, as
well as data mining from document and artifacts (Merriam & Tisdell, 2015) are strategies that
can be implemented for qualitative studies, for this study, I used a combination of participant
interviews and document analysis as my main data collection strategy for my research. The
documents reviewed were from federal public websites available to all consumers needing to
review the information for personal or professional use.
Prior to conducting the research, I as the primary investigator (PI), had to apply for
Collaborative Institutional Training Initiative (CITI) certification. After the certification was
received, the primary researcher had to apply to the University of Southern California (USC)
Institutional Review Board (IRB) for approval to conduct the research. In the application
document, there was a secondary investigator (SI) included in the application, whose
responsibility was to be the data collector for the research. After approval was received at USC
IRB, the PI had to apply for IRB approval at the organization that the research was conducted.
Prior to approval of the study at the host organization, the protocol application, completed
IMPROVING STAR RATING 31

protocol for the study, research information sheet, and interview questionnaire had to be
submitted for approval. Approval was received on December 4, 2017.
Data Collected by Document Review
Document analysis about OLA was retrieved from the government website
medicare.gov/nursinghomecompare. This government website is available to any organization or
individual looking for information about any nursing home in the US. From this website, the
definition of star rating, information about OLA's three previous inspections, as well as how the
technical information on how the star rating is calculated is provided. I was able to review the
last three inspection report for OLA to find out if there was a consistent theme that was identified
at every inspection. This information was triangulated with the interview transcripts so that
evidence-based recommendations can be provided to the organization in the recommendations
section.
Data Collected by Interviews
For this section, there were questions asked to assess the knowledge, motivation, and
organizational factors that have resulted in OLA being at its current rating from the stakeholders
that participated in the interview process. The interview period was supposed to be from January
1, 2018, to January 15, 2018, but there was one interview that was conducted outside of this time
frame which was two weeks after the posted deadline for interviewing participants. This
information will be presented in the "Findings" section of this dissertation.
At the time of selecting participant to be involved in the research, the PI worked at the
facilities that the research was conducted as an administrator. The participants of the study were
from one facility of OLA, and the IRB at the host organization was very informative as to how
the participants in this study had to be recruited. This was because of the position of the PI at the
IMPROVING STAR RATING 32

organization which the IRB at OLA did not want the information received during the interview
process to be biased. To protect the anonymity of the participants, an invitation or recruitment
flyer was developed. These flyers were placed in a centralized location of the facility where all
interested participants willing to participate in the study would call a telephone number that had
been provided to participate in the interview. It is important to include that about 300 employees
work at the SACC which includes both nursing, non-nursing, and ancillary staff members that
work at the center. For this reason, the exact occupation of the stakeholders that participated in
the organization is unknown to the investigators. By using this strategy for recruitment, eight
participants were involved in the interview process that was facilitated by the secondary
investigator (SI) on behalf of the PI. The SI was not an employee of OLA but was CITI certified
in addition to being knowledgeable in the KMO methodology that the research is grounded on.
When the interested participant in the research called the SI's number, the caller only
informed the SI that they were calling to participate in the study. All interviews were performed
over the phone. The SI conducted the telephone interview using the questionnaire in Appendix B
and the interview lasted between 45 minutes to 1 hour. The participants were labeled Participant
A, Participant B, etc., and that is how they were identified in the findings of the study. During
the interview process, there was no identifiable information collected from the participants which
maintain that anonymity of the participants. Participation in the study was strictly voluntary and
the participants could withdraw from or decline to answer any questions during the interview
process. There were 8 questions that were asked of the stakeholders (see Appendix B), and these
questions had additional probing questions for additional insight into the topic that were being
asked. These questions had a foundation that was knowledge, motivation, and organizationally
based so as to identify where gaps may exist in the organization which has resulted in the current
IMPROVING STAR RATING 33

rating of the center. During the phone interview, the conversation was recorded after consent was
given by the participants. After the responses were received, the information was labeled and
transcribed. An online transcription company called Rev Recorder transcribed the recording and
the transcriptions of the interview were coded to arrive at a common theme that was identified
during the interview process of all participants.
Data Analysis
Interviews
Three cycles of the coding process were utilized for the interview transcriptions.
Microsoft Excel for Windows was used to assign codes to the transcript, as well as Microsoft
Word that was used to create a codebook to write words that were repetitive and appeared more
than once in the transcript. The transcript was reviewed for the second time and any identifier
that could be linked to the participants of the interview was removed. Open coding was done so
as to put words identified into categories. According to researchers, investigators identify codes
as a way to categorize similar data chunks so that the researcher can easily identify words that
relate to a particular research question (Miles, Huberman, & Saldana, 2014). This coding helped
to symbolize or translate the data to provide meaning as well as detect patterns to form
prepositions as well as formulate a theory.
The other cycle used in the coding was to identify single words to full paragraphs in the
transcripts in addition to a refinement of the first level coding. Researchers have described the
coding process as a critical link between the data collection process to their interpretation of
meaning for the data (Saldaña, 2015). One thing I am cognizant of is the lens of the secondary
investigator that administered the research questions on my behalf. My secondary investigator is
IMPROVING STAR RATING 34

in the education profession and not medical inclined, therefore it may be easy for her to overlook
responses that may be of great relevance to my research question.
Document Analysis
The data retrieved from the document review was analyzed by comparing the
organizations three previous inspections to see if there was a consistent theme that was identified
at every inspection. The responses received from the interview transcript were all evaluated and
categorized by the corresponding question. Each response was categorized under the question
that was asked by the secondary investigator. All eight responses were then evaluated to find a
commonality in the responses that all the participants gave. From there, similar responses or
themes were identified which was used to synthesize a general response that the participant gave
as under the category of knowledge, motivation, or organizational gap in the findings section.
This information was also use to arrive at an assertion about what to recommend for OLA to
achieve its stakeholder goal set by the executive team which is "By the inspection of 2018, the
SACC team will ensure compliance with all quality measures and staffing levels required which
are two of the three components to achieve a five-star rating.
Findings
From the review of the document information as well as interview transcripts of those
that participated in the study, there are some assertions that I have derived from both data
collection strategy. These assertions are:
• There is a knowledge gap in the organization which relates to what the quality report of
the organization is, as well as the meaning of "star" rating to the stakeholders'
interviewed.
IMPROVING STAR RATING 35

• The organization was in transition due to an organizational restructuring that was
underway at the institution which may cause bias findings in the data.
• Clinical staff and patient ratios need to be re-evaluated so that quality care can be
provided to the patients at the center.
Data from Information Review. From the data reviewed, there were no consistent
deficiencies that were identified at every inspection. This is to note that OLA is a 125-bed
facility which is the largest facility in the State of California. During all three inspections, the
patient census at the facility was over 100 patients. The summary of the deficiencies is
provided in table 3 below
Table 3 - Deficiencies identified at OLA in the past three years

Deficiency Category
Inspection
Date:
07/27/2017
Compliant
Reporting
Period:
3/1/2017 -
2/28/2018
Inspection
Date:
05/24/2016
Compliant
Reporting
Period:
3/1/2016 -
2/28/2017
Inspection
Date:
02/03/2015
Compliant
Reporting
Period:
3/1/2015 -
2/29/2016
Freedom from Abuse, Neglect, and
Exploitation Deficiencies
1 1 0
Quality of Life and Care Deficiencies 2 3 4
Resident Assessment and Care Planning
Deficiencies
0 0 2
Nursing and Physician Services Deficiencies 0 0 0
Resident Rights Deficiencies 3 0 0
Nutrition and Dietary Deficiencies 0 1 1
Pharmacy Service Deficiencies 2 0 1
Environmental Deficiencies 1 1 3
Administration Deficiencies 1 0 0

IMPROVING STAR RATING 36

From the medicare.gov/nursinghomecompare website, there was no average number of
health deficiencies that are benchmarked in California, as well as the US, therefore the total
deficiencies received at OLA could not be benchmarked against other organizations. From the
document reviewed, OLA had 11 health deficiencies in 2015, 6 health deficiencies in 2016, and
10 health deficiencies in 2017. The report also provided different levels of deficiency tags which
identified the severity of the deficiency. The definition of this severity was reviewed for meaning
according to the National Coordinating Council for Medication Error Reporting and Prevention
(NCC MERP) website. The "harm scale" as it is referenced to is provided in table 4
Table 4: NCC MERP harm scale
Definition Level
Harm occurred that prolonged the Skilled
Nursing Facility (SNF) stay, or led to a transfer
to a different SNF or another post-acute
facility, and /or hospitalization (i.e., admission
to a hospital observation unit, emergency
department, or inpatient care)
F
Harm occurred that contributed to or resulted
in permanent resident harm
G
Harm occurred that required intervention to
sustain the resident's life
H
Harm occurred that may have contributed to or
resulted in resident's death
I

All the deficiencies identified at OLA from the three years reviewed showed that the level of
deficiency was classified as an F Level deficiency.
For the 2017 health inspection results, OLA received 10 health deficiencies. Although the
level of deficiency received was classified as an "F" level deficiency, this resulted in the health
inspection rating to be categorized as two-star which is below average.
For the staffing component of the report, a recent rating of the staffing is currently at
five-stars. Although the staffing level reported to the government seems to be much above
IMPROVING STAR RATING 37

average, staff/patient ratios were a concern that was validated during the interview process as
one that needs to be addressed at the center. During the interview process, the response received
when the participant was asked the question “what do we need to do to have a five-star rating”,
five of the eight gave a response that referenced staffing. One of the participants stated, “In order
to have a five-star rating, we have to have full staff every day, which is very challenging when
some people get sick and don’t have the full staff that we want.”
For the quality of resident care data for OLA, this is currently rated at three-stars which
are considered an average rating. This three-star rating is based on OLA's performance measure
on two groups of residents at the facility. The first group is considered short stay patients who
reside at the facility for 100 days or less, and the other group of patients is considered long-stay
patients who reside at the facility for 101 days or more. The performance measures, as well as
OLA's scores, are referenced in table 5 and 6 below.
Table 5 - Performance of OLA on short-stay performance measures according to the CMS

Short-Stay residents
Our Lady of
Apostle Sub-
Acute Care
Center
California
Average
National
Average
Percentage of short-stay residents who
improved their ability to move around on their
own. Daily activity includes task such as
bathing, grooming, dressing, eating, toileting,
bed mobility, and moving from bed to chair
Higher percentages are better.

80.5%

67.5%

67.5%
Percentage of short-stay residents who were
re-hospitalized after a nursing home
admission.
Lower percentages are better.

NOT
AVAILABLE

21.1%

21.1%
Percentage of short-stay residents who have
had an outpatient emergency department visit.
Lower percentages are better.

NOT
AVAILABLE

11.0%

11.9%
Percentage of short-stay residents who were
successfully discharged to the community.
Higher percentages are better.

NOT
AVAILABLE

56.0%

57.0%
IMPROVING STAR RATING 38

Percentage of short-stay residents who report
moderate to severe pain.
Lower percentages are better.

1.8%

8.1%

13.7%
Percentage of short-stay residents with
pressure ulcers that are new or worsened.
Pressure ulcers are areas of damaged skin
caused by staying in one position for too long
Lower percentages are better.

2.6%

0.6%

0.9%
Percentage of short-stay residents who needed
and got a flu shot for the current flu season.
Higher percentages are better.

76.9%

85.1%

81.0%
Percentage of short-stay residents who needed
and got a vaccine to prevent pneumonia.
Higher percentages are better.

86.8%

87.4%

83.1%
Percentage of short-stay residents who got
antipsychotic medication for the first time
during this nursing home admission
Lower percentages are better.

8.5%

1.5%

2.0%

Note: The numbers in green represent that OLA is above both the CA and National Bench,
yellow represent being above one benchmark, and red represent being below both benchmark
data.
Table 6 - Performance of OLA on long-stay performance measures according to the CMS

Long-Stay residents
Our Lady of
Apostle Sub-
Acute Care
Center
California
Average
National
Average
Percentage of long-stay residents experiencing
one or more falls with major injury.
Lower percentages are better.

0.0%

1.8%

3.4%
Percentage of long-stay residents with a
urinary tract infection.
Lower percentages are better.

2.6%

2.4%

3.7%
Percentage of long-stay residents who report
moderate to severe pain.
Lower percentages are better.

0.0%

2.9%

5.6%
Percentage of long-stay high-risk residents
with pressure ulcers. Pressure ulcers are areas
of damaged skin caused by staying in one
position for too long. High-risk residents have
at least one of the following conditions:

20.5%

5.6%

5.6%
IMPROVING STAR RATING 39

impaired mobility, difficulty staying
nourished, or they are in a coma
Lower percentages are better.
Percentage of long-stay low-risk residents
who lose control of their bowels or bladder.
Lower percentages are better.

63.9%

43.9%

47.7%
Percentage of long-stay residents who have or
had a catheter inserted and left in their
bladder. A catheter is a tube placed in the
body to drain and collect urine from the
bladder
Lower percentages are better.

8.8%

1.9%

1.9%
Percentage of long-stay residents who were
physically restrained.
Lower percentages are better.

8.2%

0.7%

0.4%
Percentage of long-stay residents whose
ability to move independently worsened.
Lower percentages are better.

9.4%

15.1%

18.2%
Percentage of long-stay residents whose need
for help with daily activities has increased.
Daily activity includes task such as bathing,
grooming, dressing, eating, toileting, bed
mobility, and moving from bed to chair
Lower percentages are better.

7.4%

10.5%

15.0%
Percentage of long-stay residents who lose too
much weight.
Lower percentages are better.

3.1%

5.8%

7.1%
Percentage of long-stay residents who have
symptoms of depression.
Lower percentages are better.

0.0%

0.8%

4.9%
Percentage of long-stay residents who got an
anti-anxiety or hypnotic medication. Anti-
anxiety and hypnotic medication can be used
to treat certain mental health conditions
Lower percentages are better.

20.5%

18.8%

22.7%
Percentage of long-stay residents who needed
and got a flu shot for the current flu season.
Higher percentages are better.

88.9%

95.6%

94.9%
Percentage of long-stay residents who needed
and got a vaccine to prevent pneumonia.
Higher percentages are better.

97.6%

96.5%

94.1%
Percentage of long-stay residents who got an
antipsychotic medication. Anti-psychotic
medications can be used to treat certain
mental health conditions.
Lower percentages are better.

2.6%

11.6%

15.7%
IMPROVING STAR RATING 40

Note: The number green represents that OLA is above both the CA and National Bench, yellow
represent being above one benchmark, and red represent being below both benchmark data.
The information from the artifact reviewed was validated by some of the knowledge
finding from the interview process. These findings are categorized as knowledge, motivation, or
organizational findings.
Knowledge findings. There were several knowledge gaps that were identified during my
research. These knowledge gaps will be evaluated and categorized as factual, conceptual, and
metacognition.
Factual knowledge findings. An assertion that I made was that there were factual
knowledge gaps in the organization which relates to lack of knowledge of the information in the
quality report, as well as the meaning of star rating to the stakeholders interviewed. These two
gaps were both validated through the review and analysis of the interview transcripts. During the
interview, the participants were asked the question "What do you think contributes to our three-
star rating?" The two main categories of responses received were the type of patients seen at the
center, as well as staffing. From the artifact reviewed, OLA scored poorly in both their short and
long-term residents that developed new or worsening pressure ulcers. Since one of the strategies
to prevent pressure ulcers is to frequently turn the patient so that patients are not laying in one
spot for a long period of time, this higher percentages can be an indication of staffing problems
that need to be addressed at the center.
When asked, "From your perspective, why are organizations routinely inspected by
regulatory agencies" all the participants could provide some reason why organizations are
routinely inspected. There was a 100% response which was applicable to the reasons why
IMPROVING STAR RATING 41

facilities are routinely inspected. Their reasons included this was a regulatory requirement by the
government. When asked a follow-up question of "Can you explain to me the different parts of
the quality report", the appropriate response should have been quality of care, staffing, and the
center performance in the last two previous health inspections. None of the participants provided
the correct response. Some mentioned elements that were contained in the quality report such as
pressure ulcers and fall, Participant A responded, “I am not familiar with that the report is”. This
identified gap needs to be improved for the stakeholder to be able to achieve the organizational
goal.
Conceptual knowledge findings. When asked the question of "What do we need to do to
have a five-star rating", there were some similarities in responses but not one person could
account what the facility needed in order to have a five-star rating. Participant A responded,
"better follow-up on patients after they have left the facility", Participant B stated that "we need
to improve our pressure ulcers". Participant B’s response implied that there was a high
occurrence of patients that had pressure ulcers at the facilities which were also validated in the
artifact data review. Pressure ulcers are areas of damaged skin caused by patients laying or
staying in one position for too long at a time. This information was also identified in the data
artifact review of the facility. Participant C and D responded by saying "having the right staffing
ratios". Although the staffing at the center is above average, according to the information
provided to the State, evidence from the artifact reviewed indicated otherwise. An example is the
higher percentage of long-term patients that were physically restrained. No having enough staff
can be a reason for the increased use of restrains instead of having a staff member physically
monitor the patients. Participant E stated, "we can continue to reduce our infection rates",
participant F responded, "to improve on the facilities quality measures", while participants G and
IMPROVING STAR RATING 42

H responded, "we needed to have adequate staffing at the facility". When an additional probing
question was asked "Does a budget or adequate staffing help achieve a 5-star rating", participant
A responded that the facility was adequately staffed, participant B said yes, but could not expand
on this idea. Participants C, D, G, and H reiterated that staffing ratios needed to be re-evaluated.
From this response, one participant stated that staffing was adequate which was also validated in
the document artifact review as the facility is rated 5-stars for staffing. There was a consensus (4
out of the 8 participants) that the patient/caregiver ratios needed to be reevaluated. From the data
artifact review, there was a high percentage of long-stay residents who were physically
restrained. Using physical restrains is an indication that the patient may unknowingly injure
themselves. To prevent injury, the patient needs to be closely monitored by an employee more on
a one-on-one basis. The staff that is usually assigned to monitor these patients are the CNA's. At
OLA, the CNA's have a patient ratio of 1 CNA to 8 patients. A patient that has a high incident of
injuring themselves cannot be monitored by the CNA as there are seven additional patients that
have to be cared for by the CNA. This lack of available CNA to monitor these patients may have
led to the use of physically restraining patients. Therefore, the best way for the patients to be
supervised is by physically restrain the patient from harming themselves,
Metacognition findings. When the participants were asked to reflect on "What do we
need to do to have a five-star rating," the responses varied from needing knowledge of what the
five-star rating is based on, decreasing the number of patients with decubitus ulcers, reassessing
staff/patient ratios, and education. From the transcript, participant A responded to the question,
I think for the hospital to get a five-star rating, all employees need to know exactly what the five-
star rating is based on. Maybe the company needs to do road shows that provide examples of
IMPROVING STAR RATING 43

those topics that are related to the five-star rating so that employees can be sure that their roles
are performing near those types of outcomes that they would want.
Participant B responded, “we need to improve on decreasing the patients with pressure ulcers”,
which participant C responded, “they (referring to the organization) need to reassess the patient
ratios so that all aspects of care are being attended to by staff”. Participant D stated that
“There are several factors needed to have a five-star rating. I would say the staffing ratios
need to be addressed, following Title XXII which is the regulatory code that is used to
govern long-term facilities, making sure that we are providing the patient a safe
environment while creating a home-like environment, and decreasing our number of
patients having pressure sores”
Participant E stated, “We need to continue to reduce our infection rate, and continue to be
vigilant with moving patients thereby preventing bed sores”, participant G responded, “We have
to have full staff every day which is very challenging when some people get sick and you don’t
have the full staff that is required”. Participant H responded with an identifier, which is
summarized to provide additional staffing so that quality care can be provided to all patients at
the facility.
Motivation finding. Motivational influences like self-efficacy, interest, goals,
attributions, goal orientation, and emotions all play a part in accomplishing or achieving a task.
The influence that will be discussed in this motivations section is value. Values are the
importance that stakeholders place on performing or doing a task or achieving a performance
goal. The values that were assessed are attainment, and utility value.
Attainment value. Rueda (2011) defines attainment value as the importance stakeholders
place on doing well at a task. From the interview transcript, when the participants were asked
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"How do you think your work contributes to the overall rating of the center", 7 out of 8
responded appropriately while one responder did not know how to respond to the question. The
one response that was deemed not appropriate was from participants A. Participant A responded
"Well, I don't know! We all work as a team, but I am not sure how my work individually would
do anything related to the overall rating of the center". Participant H responded "The way I
contribute is that I believe in teamwork. We work as a family and the teamwork I mentioned is
that I always want to see every patient happy. I want to see that smile on their face, so we are
connected". All the other participants could articulate how their work contributed to the overall
rating of the center. Some of the information provided by the participants in the study as to how
their work contributed to the overall rating of the center had identifiers that could be linked to a
particular person, therefore the direct quotes are not used in this section to show evidence of how
their work was important in the organization.
Utility value. Rueda (2011) defines utility value as how useful one believes a task or
activity is for achieving some future goal. When the participants were asked “How important do
you think your work is to the star rating of the center,” everyone including Participant A agreed
that they think their work was important to the star rating of the center. Even though Participant
A agreed that they think their work was important, they continued by saying “But I really don’t
have an answer for that” when asked to provide additional details to the comment provided. The
other participants provided additional information as to why they think their work was important
to the star rating of the center but the information contained identifiers that could be linked to a
person, therefore the other direct quotes are not used in this section to protect the anonymity of
the participants.
IMPROVING STAR RATING 45

Organizational findings. For this section, the organizational finding from the interview
transcript will be described under the heading of the culture of caring, lack of communication,
and a shortage of adequate staffing. Although organizational influences can be categorized as
cultural models and cultural settings, these two categories play an important role in the
organization meeting its set goals.
Cultural Model: Culture of caring. During the data analysis of the interview transcript, it
was clear that the mission of OLA to care for a population that cannot care for themselves was
vividly acknowledged by the participants of the study. During the interview process, the
participants were asked to respond to the question, "How would you describe the culture of your
organization"? Participant A responded that "The culture of the organization is very good".
When asked to elaborate on that comment, participant A continued "I like the fact that we are a
[religious]-based facility, and that anybody can be here, regardless of your faith. I like the fact
that they treat you from medical needs to spiritual needs". In response to the same question,
participant E stated,
I think that the group of patients that we care for are rather unique. This is not a hospital;
it is a sub-acute care center that we are at. Because of the uniqueness of the patients, the
fact that they are long-term patients, there is more of a closeness to the patients, I think
than in an acute hospital. I think the staff is closer to each other simply because again
these patients are there for a long, long time. They almost become friends and families in
many ways. The culture otherwise is one of cooperation and trying to help the patients
and doing the best that we can for these unfortunate patients.
When participant F was asked the same question, the response received was "It's a nonprofit and
we do lots of things to help the low-income patients, the poor and vulnerable, like our mission".
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As a faith-based organization, OLA accepts patients that have higher co-morbidities that other
organizations would not accept. Since OLA is abiding by its mission to show the Love of God in
the way they care for those who do not have the resources by how they care for them, this
finding was considered an asset for the organization.
Cultural setting influence: Shortage of adequate staffing. A cultural setting influence
that was identified was not the lack of adequate staffing to care for all the patients at the center,
but the staffing ratios that was assigned to the healthcare team. Although staffing is one of the
components that is assessed by the CMS to arrive at the overall star rating of the center, the
organization is currently being rated at five-stars which means that staffing was not an issue for
the organization according to the Center for Medicare and Medicaid Services (CMS) that awards
the rating to all long-term care facility. From the CMS perspective, the information that is
requested in the total staffing that works at the facility in a twenty-hour period. The total staffing
does not address the ratios that each healthcare worker is assigned during their shift. To better
evaluate the staffing levels that work at a particular facility, the correct question that should be
asked by the CMS is the ratios of staff to patients. This will provide a better reflection of if the
facility has adequate staffing or not.
The participants that took part in this study stated on several occasions that although it
might appear as if the center is adequately staffed, the nurse-patient ratio was a concern. The
front-line staff work twelve-hour shift three days per week. They stated that on average, a
registered nurse (RN) is assigned to 32 patients at the center. Although the RN has a licensed
vocational nurse (LVN) that is also assigned to care for the patient, the LVN has a patient ratio
of eight to nine patients. There is also a CNA that is assigned to the care of these patients with a
similar ratio as the LVN. As referenced in the transcript, words used by the participant to
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describe the patients at the center include “lots of care needed”, “very heavy care”, and “patients
needing total care”. Since most of these patients need total care, the team assigned to care for the
patient reflected that the work was too much for one licensed staff to care for eight patients.
During the interview session, a probing question was asked which was "What recommendations
would you suggest improving your organization", participant B responded, "More staff, more
room for the employees and the patients". When asked to elaborate on that comment, participant
B continued "I know there's been an issue with staffing for the nurses". In response to the same
question, participant C stated,
We have one RN to 32 patients right now, and aside from taking care of our patients, we
have other responsibilities to do. We are in charge of the whole unit. We troubleshoot any
issues from family members, to checking patient’s diapers. Our CNAs are loaded. They
always want us to have exceptional quality patient care, but what is provided is not
helping us at all
This information appears to be validated by some of the data from the artifact reviewed.
The center seems to have a high incidence of patients with pressure ulcers which means that
patients are not turned frequently. In addition, the center has a high percentage of patients that
lose control of their bowels or bladder which means that the patients are not assisted to the
bathroom in a timely fashion, therefore the center utilizes diapers for their patients. These high
percentages may be due to several factors which may be attributed to include staffing.
Another question that was asked of the participants was "In your opinion, what barriers
do you feel prevent any organization from achieving its goals?" All the participants in the study
made some form of reference to one of the following which included finances, staffing, lack of
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education, workloads causing staff burnout, and communication. Although not directly
identified, these barriers align more with organizational factors. Participant B responded,
For me, I think what prevents any organization from achieving its goals are either not
enough staff or lack of education on how to prevent pressure ulcers in our patients. We
need more staff to know how to handle these patients because that's a big part of our job.
Participant C responded "I think number one is budget. If they think a million times about
the budget, they don't provide us with enough staffing, and not including a ratio. I think that's the
main one I believe". Participant D responded in a similar fashion,
Personal issues between staffs which are very common. In addition, early identification
of the staff that's getting burnt out with the workload. 'Cause there's a lot of barriers that
affect patient care or affects the star rating of the facility. Most commonly is really being
burn out. Which if the staffs are burned out, it's very easy for them to commit mistakes.
So I think, number one is communication, culture, and early identification of staff being
burnt out with the workload.
The theme regarding the workload at the center, as well as staffing ratios continued with other
participants in reference to this question.
Cultural setting: Lack of communication. A gap identified after the interview
transcript was reviewed was the ineffective communication of the goals to all stakeholders in the
organization. The transcript revealed that not all the participants of the study knew what the
organization’s goal was. When the participants were asked a probing question of "What role do
you think the leaders in this organization play in helping to achieve the organization's goal", 6
out of the 8 participants initially asked what the organizational goals were before responding to
the question which meant that they did not have knowledge of what the organizational goals
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were. When asked the question, participant E responded, “We didn’t really define the
organizational goals, did we?” They continued to respond to the question, but it was obvious that
they did not have knowledge of what the organization's goals were. The organizational goals
were not the only thing that the participants were lacking. Some of the participants wanted some
communication about the change they were experiencing during the data collection. In reference
to the question above, participant C stated "The leaders should ask the consensual [sig] of
everybody because what they want to do is based on the management level and for the company.
Although the ordinary workers are for the company and for the patients. What works best for us
they should consider that instead of just starting changes and all this kind of stuff, which
bothered everybody".
Recommendations and Solutions

The findings section presented the results from data collected through both artifact
document review and interview of participants that volunteered to be part of this research to
assess the knowledge, motivation, and organizational gaps that may exist and causing Our Lady
of Apostles (OLA) from achieving its organizational goal of “by December 2018, OLA Sub-
Acute Care Center (SACC) will improve its overall star rating from three stars to five stars.
There were eight initials gaps that were identified, but upon the review of the literature as well as
an interview of participants, one of the influences identified as a gap was considered an asset to
the organization.
The solutions and recommendations are based on the findings that were identified during
the research process. These findings will be categorized under the heading of knowledge,
motivation, and organizational recommendations.
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Knowledge Recommendations
Declarative knowledge. There are several declarative gaps that were identified during
my research. The two most important ones identified that I will be addressing here are as
follows; Conceptual knowledge which means that the healthcare team at Our Lady of Apostle
(OLA) need to know what the quality report is comprised of so that they can know the
relationship between the types of patients the organization serves and the impacts those patients
have on the organization's quality measures. In addition, the whole healthcare team needs to have
factual knowledge which is knowledge of what the star rating is. These two were selected
because for the organization to be able to improve its overall star rating, all employees of the
organization need to know both influences to be able to contribute to improving this goal from its
current levels.
To improve the identified gap, research has shown that both training and education are
the strategies to improve knowledge gaps. Clarke and Estes (2008) define training as any
situation where people can acquire “how to” knowledge, and education is defined as any
situation where people can acquire the knowledge and skills to handle future challenges and
problems (Clark & Estes, 2008). In the medical field, education is very complex, technical, and
researched based as to why things happen and what causes things to happen. Krathwohl (2002)
provided definitions for the knowledge types identified as gaps at OLA. He defines factual
knowledge as basic elements practitioners must know to be acquainted with the discipline. This
includes knowledge of terminology which in this case, the terminology is the star rating used to
assess the center by the regulatory organization. In addition, Krathwohl (2002) also provided a
definition for conceptual knowledge as the interrelationship among basic elements within a
larger structure. At OLA, this was an identified gap as to the connection between the patients
cared for at the center and how those patients contributed to the overall rating of the center.
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McCrudden, Schraw, and Hartley (2006), as well as Schraw and McCrudden (2006),
found that when individuals learn information that can be related to information they have
learned in the past, it is very easy to learn that information and commit that information into
memory. These leaners can utilize an aid to help them remember the information that is been
provided (Krathwohl, 2002). This would suggest that providing learners with integrated prints
and visual information about the topic will support their learning (McCrudden, Schraw, &
Hartley, 2006). The recommendations would be that the education team at OLA might provide
an integrated handout of what the quality report is comprised of, and provide meaning for why
the star rating is important for the organization. The overall goal is for the team to be able to
comprehend the information presented, therefore providing the integrated prints is a start towards
building on the information provided.
Kirschner et al. (2009), and Aisami (2015) both suggest that the retention of information
starts at the organization stage in which significant information needs to be organized and
visualized in order to be moved from short-term memory to long-term memory where it can be
stored (Aisami, 2015). This information has to be meaningful and meaningful learning is
reflected in the ability of the practitioners to apply what is taught to a new situation (Mayer &
Moreno, 2003). The use of visual aids has been shown to create this retention of information that
the team at OLA needs to be able to recollect what the star rating is, as well as the different parts
of the quality report (Mayer, 2011). Kirschner et al. (2009) continue that since most individual
function with working memory which is only limited to about seven new information at a time,
aids must be provided so that a connection can be made and the information committed to long-
term memory, otherwise the information will be lost (Kirschner, Paas, & Kirschner, 2009).
Mayer and Moreno (2003) suggest that training that uses visual design can help reinforce
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learning. With the case of informing the healthcare team at OLA what the quality report is
comprised of, as well as what star rating means, the education team can provide the training that
includes the use of job aide and diagrams that the team can reference when there is a need.
Metacognitive. A metacognitive influence that was identified during the research is that
the participants of the study at OLA could provide some reflection on what it would take for the
organization to be at a five-star rating. During the interview transcript review, participant gave
information that was centered around one theme what was an organizational improvement. For
the organization to be able to improve its overall star rating, all employees of the organization
need to be able to reflect on what it will take for OLA to have a five-star rating. Baker (2006)
found that when individuals understand oneself as a learner, as well as strategies they can use to
facilitate learning, they can better grasp what is being learned. This would suggest that at OLA,
the healthcare team needs to be aware of what they know of the hospital rating and how the
organization can improve its current rating to its goal of five-stars. The recommendation would
be that the education team at OLA might provide opportunities for the team during huddle or
staff meetings to provide examples and references so that they can address if the team can
connect the information learned to prior knowledge.
Deschenes and Goudreau (2017) describe that for nurses to be able to comprehend the
information they have received; the learner needs to process and connect this learning to prior
knowledge. Being able to connect the information to prior knowledge requires that the nurses
understand themselves as a learner, as well as how they learn. These researchers refer to this as
mental scripting which nurses need to have to be able to solve complex clinical problems and is
vital for nursing education. “Mental scripting” as defined by Deschenes and Goudreau (2017) is
the organized knowledge that the nurses have developed during their career to be able to address
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complex nursing situations. For the educators at OLA to be effective, they can engage the
healthcare team during meeting and huddles and provide scripts to the team. The scripts can
assist the healthcare team to identify tasks that need to be completed to accomplish the specific
goal. In this instant, the goal of the organization is to be at a five-star rating. The education team
can assist the healthcare team with coming up with scripts that include tasks that have to be
learned and completed accurately in order to achieve the desired rating.
Abrami et al., (2015) evaluated empirical evidence on the impact of instruction on the
development and enhancement of critical thinking skills. The review included 341 quasi or true
experimental studies that used standardized measures of critical thinking as outcome variables.
They concluded that two best way to develop critical thinking skills included strategies where the
educator posed questions in a discussion group and the group participated in responding, as well
as exposing the students to authentic or situated problems where they role played in their
responses (Abrami et al., 2015). Critical thinking skills by the healthcare team occur when they
can think critically about a problem, and provide solutions because of their deep thinking. This
critical thinking process helps to develop the metacognitive skill of the team or individual. To
support the Abrami et al., (2015) analysis, Magno (2009) posits that critical thinking happens
when individuals or teams use their cognitive skills to increase the probability of an outcome
(Magno, 2010). As such, the recommendations being made from the OLA is that the healthcare
team may benefit from role-playing to solve problems, as well as educator lead discussions
where the team can dialogue and come up with resolutions to the situations.
The Table 7 below provides a summary of the knowledge influences and recommendations.

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Table 7
Summary of Knowledge Influences and Recommendations
Knowledge Type and
Influence:

Validated
Yes, or
No
Principle and Citation Context-Specific
Recommendation
Declarative (Conceptual)

The whole healthcare team
needs to know what the
quality report is comprised
of so that they can know
how the relationship
between the types of
patients the organization
serves and the impacts
those patients have on the
organization's quality
measures.
Validated

How individuals organize
knowledge influences how
they learn and apply what
they know (Schraw &
McCrudden, 2006).
Integrating auditory and
visual information
maximizes working memory
capacity (Mayer, 2011).
Information learned
meaningfully and connected
with prior knowledge is
stored more quickly and
remembered more accurately
because it is elaborated with
prior learning (Schraw &
McCrudden, 2006)
Provide
organization goals
to all employees
in the form of
handout, flyers,
education sessions
provided by the
center's educator
Declarative (Factual)

The whole healthcare team
needs to know what the star
rating is. The lack of
knowledge was evident
during the interview process
as not all the respondents
were able to speak to the
star rating of the
organization.
Validated

Information learned
meaningfully and connected
with prior knowledge is
stored more quickly and
remembered more accurately
because it is elaborated with
prior learning (Schraw &
McCrudden, 2006)

Learning is enhanced when
the learner’s working
memory capacity is not
overloaded (Kirschner et al.,
2009).

How individuals organize
knowledge influences how
they learn and apply what

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they know (Schraw &
McCrudden, 2006).

Metacognition

The whole healthcare team
needs to be able to reflect
on what it will take for the
organization to be at a five-
star rating.

Validated

The use of metacognitive
strategies facilitates learning
(Baker, 2006).

Ask learners to think aloud:
have them talks about what
they are doing as they solve
a problem or read a text
(Baker, 2006)

Assess whether
the connection to
prior knowledge
has been made by
having the
healthcare staff
provide examples
and references

Attempt to
understand how
the learner
organizes their
knowledge.

Motivation Recommendations
There are several motivation influences that contribute to teams engaging and persisting
in whatever tasks they have to perform (Rueda, 2011). The two motivation influences that were
evaluated in this research were utility and attainment values, therefore the recommendations
provided are based on these two validated values.
From the review and analysis of the interview transcript, it became obvious the healthcare
team that participated in the study could not articulate how their work contributes to the overall
rating of the organization. Eccles (2009) found that the interest and value one puts into a task
influences the outcome of the task (Eccles, 2009). Most individuals that work in the healthcare
field know at a young age that they want to care for people. They have attained the skills and
interest in caring for people with the end results of seeing the patients get better. This is the
ultimate reason why individuals become doctors and nurses. These individuals also need to be
able to link their own personal duty to the organization's goal to be able to effect change. The
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recommendation then is for the education team to dialogue with all the healthcare team in a
meeting or during huddle rounds to help connect the healthcare team's tasks to the organization's
goal.
Attainment value. Rueda (2011) defines attainment value as the importance stakeholders
place on doing well at a task. Eccles (2009) suggests that attainment value refers to the link
between the task that is being performed and the individuals own identity as preferences. This
means that the value one puts on a task influences the individual's persistence in achieving that
goal. Harackiewicz, Tibbetts, Canning, and Hyde (2014), as well as Eccles (2009) both, agree
that individual’s motivation to engage in the demands of any situation is influenced by the extent
to which the setting provides opportunities to experience autonomy, social relatedness, and a
sense of competence. Moody and Pesut (2006) emphasize that despite challenging
circumstances, most nurses transcend organizational problems and are motivated to serve and
care for patients (Moody & Pesut, 2006). Since the majority of the participants responded
appropriately, the motivation of other staff members has to be validated as well to make sure that
they can verbalize how their work contributes to the overall rating of the center. Therefore, from
a theoretical perspective, informing the healthcare team the value why they chose to work in the
healthcare field and connecting that value to the organization's goal can lead to better
organizational performance.
In their research on work engagement, Christian, Garza, and Slaughter (2011) suggest
that when individuals are engaged in their work, they invest personal energy in that work and
they experience an emotional connection with that work (Christian, Garza, & Slaughter, 2011).
Rich, Lepine, and Crawford (2010) explain that popular articles, as well as business consultants,
have claimed that when employees are engaged in their work, this provides a competitive
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advantage for that organization among its peers in the industry it operates (Rich, Lepine, &
Crawford, 2010). When nurses are motivated, they perform their best job. Nurses get into careers
in the healthcare field because of their willingness to engage and devote their time and expertise
to their patients. Rich, Lepine, and Crawford (2010) conducted a study involving 245 full-time
firefighters in which participants rated several factors that affected their work including job
engagement on a five-point Likert scale that ranged from strongly disagree to strongly agree.
They concluded that engagement in the work was directly proportional to the outcome of the task
performed, suggesting that the healthcare team can be more engaged in their tasks, the outcome
of their performance is greatly improved.
Utility value. Another aspect of motivation that has been extensively researched is how
the task being worked on fits into the individual's goals, plans, or fulfills other psychological
needs of the person doing the task (Eccles, 2009). This is otherwise referred to as the utility
value of the task. From another perspective, the utility value one shows in a task is affected by
the interest one has in accomplishing that task. Pintrich (2003) confirms that there is a direct
correlation between the interest one has in performing a task and the motivation to perform the
task (Pintrich, 2003). The interest one has in a topic helps them persist in getting the work
completed. Interest can be either intrinsic or extrinsic when it involves accomplishing a task
(Linnenbrink & Pintrich, 2002). Analysis of the interview transcript showed that all the
participants respond appropriately and gave descriptions of why their work was important to the
star rating of the center. This reflected that the participant had interest and valued the importance
of their work to the rating of the center.
Mayer (2011) state that individuals will work harder if there is an interest in the topic that
is being taught. In a hospital environment, the healthcare team will work harder if there is an
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interest in the task being performed. Tzeng (2002) posit that there is a linkage between nursing
staff interest in their job and job satisfaction in performing their role. This satisfaction leads to
better outcomes for patients and decreases employee turnover in the healthcare organization.
Nurses from three hospitals located in Taiwan participated in her study where questionnaires
were sent to these nurses and 648 completed surveys were received. Analysis of their data
revealed that nurses with an interest in their job were inclined to work harder for their patients
which improved the outcome of their patients. She also concluded that due to the interest of the
nurses, their role in caring for patient met their personal goals which also decrease the nursing
turnover at those institutions. Therefore, a recommendation will be that during staff or huddle
meeting, the educators at OLA can dialogue with the team on reasons why their work was
important to the star rating of the organization. The education team will also need to help the
team connect the value of their role in the organization to support the organizational goal.
The Table 8 below shows the motivational influences and recommendations for OLA.
Table 8
Summary of Motivational Recommendations
Motivational Type
and Influence:

Validated
Yes, or
No

Principle and Citation Context-Specific
Recommendation
Attainment Value

The healthcare team
needs to link the
task of caring for the
types of patients
seen at OLA to their
own individual
preference of
wanting to care for
people, and not just
Validated

Learning and motivation are
enhanced if the learner values
the task (Eccles, 2009).

Higher expectations for success
and perceptions of confidence
can positively influence learning
and motivation (Eccles, 2009)
Having the educator
list several tasks and
ask the health care
team which of those
tasks are most valuable
to them
The educator can
provide the risks
associated with not
connecting the task the
healthcare team
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seeing it as a job to
do.
performs to their
personal preference
Utility Value

The healthcare team
needs to be aware of
how their daily tasks
fulfill their
psychological needs
and how this
contributes to
meeting the
organizational goal.
Validated Rationales that include a
discussion of the importance and
utility value of the work or
learning can help learners
develop positive values (Eccles,
2009; Pintrich, 2003).
Learning and motivation are
enhanced when learners have
positive expectancies for success
(Pajares, 2006).
The educator can
provide reasons or
rationale why the
organization is
routinely inspected.
This reason can be put
on an information
board, or job aid that
can be given to the
healthcare team during
huddle meetings

Organization Recommendation
There are several organizational recommendations that will be provided because of the
transcript analysis. These recommendations have been categorized under cultural model and
cultural setting.
Cultural model: Culture of caring. The first validated organizational influence is an
asset to the organization. Access to adequate healthcare needs is not always available to those
who are low income or belong to an under-represented group. At OLA, an organizational asset
that was validated during the data analysis process was the organization living by its mission
which is to care for those that cannot care for themselves. During the interview process at the
organization, there were some organizational changes that had recently happened and some
leaders had been transitioned. There were some benefit changes as well which was what
participant C was referring to. As a result of the organization living by its mission, there is a
culture of caring for those who are poor and vulnerable. This means that OLA accepts and care
for patients that have a higher than normal comorbidities that other facilities will not care for.
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For some organizations, the quality of patient care has always conflicted with the bottom line of
the balance sheet (Kinzer, 1984).
Due to the culture of caring that exist at OLA, Knowles (1980) emphasize that adults are
more motivated to participate and learn when they see the relevance of the mission to their own
circumstance. It is the organization leadership role to assure that their own values and mission
are in sync with the organization's mission otherwise a conflict will exist. If there is a conflict
between the vision and mission of the leadership team and that of an organization, the leadership
team will have difficulty leading the team to believe and continue the mission of the organization
(Schein, 2010). As a result of this mission, the healthcare workers that care for these patients are
committed to caring, which is an asset to the organization as a whole. In addition, companies like
OLA tend to have a high level of commitment from its employees within the organization
(Campbell, 1992) which helps to decrease staff turnover in the organization. From this assertion,
it is recommended that OLA continue to abide by its mission statement and continue to care for
those that cannot care for themselves.
Cultural setting: Shortage of adequate staffing. An organizational setting influence
that has been validated during the interview transcript analysis was the lack of adequate staffing
to care for all patients at the center. Words used in the transcript include "patients are heavy
patients" which referred to the patients needing total care needs that has to be facilitated by the
care team, as well as “modify by decreasing the nurse-patient ratio from its current ratio of 32
patients to one nurse”. This request for modification also applies to both the licensed practical
nurse (LPN) and the certified nursing assistant (CNA) from 1 to 8 to 1 to 7. For this
organizational influence, there must be effective accountability systems to ensure that adequate
fiscal resources are in place to meet the organizational goals and to drive improvement.
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Documents analyzed from the center for Medicare and Medicaid Services (CMS) reflect
that the staffing at the organization is adequate, and it is currently rated at five-stars which shows
that the staffing is adequate at the facility. The limitations of this data could be that the overall
staffing for the organization is analyzed which is adequate. The data does not reflect the
individual workload that each healthcare giver is responsible for during their shift. In their
analysis of staffing shortage, Aiken, Clarke, Sloane, Sochalski, and Silber (2002) posit that
shortage of hospital staff may be linked to unrealistic workload for the healthcare workers which
leads to burnout, dissatisfaction, and increased mortality for the patients in their care (Aiken,
Clarke, Sloane, Sochalski, & Silber, 2002).
Organizational effectiveness increases when leaders ensure that employees have the
resources needed to achieve the organizational goals. In a study by Lapane and Hughes (2007),
1283 nurses and nursing assistants were surveyed in which they were asked what the sources of
their stress were while at work. A major source of stress that was provided by the nursing
assistants was not enough staffing to get everything done well during their shift. In a similar
response from the nurses, their major source of stress was also not having enough staffing to
perform their duties well. For this reason, the average 1-year turnover rate is high for nursing
assistants and licensed practical nurses at 85.8%, and registered nurses at 55.4% (Lapane &
Hughes, 2007). For this reason, the organization should consider re-evaluating their staffing
matrix to see how the ratios can be adjusted so that quality care can be provided to the patients,
as well as decrease staff turnover and dissatisfaction with their daily work.
Cultural setting: Ineffective communication of organizational goals to stakeholders. An
organizational gap that was identified and validated is the ineffective communication of the goals
of the organization to all stakeholders in the organization. During the review of the interview
IMPROVING STAR RATING 62

transcript, not all the participants were able to state what the goal(s) of the organization was from
a follow-up question of “What role the organization leaders play in achieving the organization
goals”. Although the sample size that participated in the study was quite small compared to the
total employees that work at the center, this information can be generalized that majority of the
employees at OLA SACC are not aware of the organization's goals. The reason for this may be
that the goals of the organization have not been clearly communicated to all stakeholders at
OLA. Evidence has shown that organizational effectiveness increases when leaders encourage
open lines of communication. In a field study performed by Pincus (1986) on communication
satisfaction, 327 hospital nurses were investigated to find the relationship between their
perceived satisfaction with organizational communication and job satisfaction. It was concluded
that among nursing staff, effective supervisor communication was strongly correlated with job
satisfaction and job performance (Pincus, 1986).
Effective leaders are aware of their influence on communication and its impact on the
change process within the organization. To be able to effect change in an organization, leaders
have to be able to communicate constantly and candidly to all their stakeholders about their plans
and progress for the organization (Clark & Estes, 2008). Klein (1996) suggested that using
different mediums to communicate information, helps with message retention to the audience
that the information is targeted to.
For this reason, the recommendation for OLA on how to effectively communicate its
organizational goal to all its stakeholders should include using already existing forms of
communication (email, posts, town hall meetings, etc.), as well as incorporating technology like
webcams, web posting, and using social media to reach all stakeholders. Since OLA SACC
operate on a 24/7 basis, the webcam communication can be recorded and the link sent to all its
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employees so that this can be viewed at times convenient for the employees. In addition, they
must use all these different forms regularly and judiciously. The table below (table 9) shows the
organizational influences and its recommendation.
Table 9
Summary of Organizational Recommendations
Organizational
Type and
Influence:

Validated
Yes, or No

Principle and Citation Context-Specific
Recommendation
Cultural Model

The culture of
caring.

There is a culture
of caring for those
who are poor and
vulnerable and
acceptance of
patients who have
higher than
normal co-
morbidities that
other facilities will
not care for
regardless of their
ability to pay.

Cultural Setting

Lack of adequate
staffing to care for
all patients.

Validated

Validated

Adults are more motivated to
participate (and learn) when
they see the relevance of
information, a request, or task
(the “why”) to
their own circumstances. They
are goal oriented (Knowles,
1980).

Leaders whose espoused
values are not in sync with the
organization’s culture will
have
difficulty leading (Schein,
2004).

Funding impact on nurses
creates dissatisfaction and
increases patient mortality
(Aiken, Clarke, Sloane et. al.,
2002).

Leaders should not focus on
culture change. Focus on the
business problem: what isn’t
working. The key to problem
identification is to become
very specific (Schein, 2004).
During the interview
process, a percentage
of the stakeholders
will be assessed to see
if they are aware of the
organization’s
mission and vision?

Regularly monitor the
use of resources to
ensure that all
members of your
workforce have access
to the tools they need
to do their jobs
effectively.

Meet with the frontline
staff and supervisors
monthly to evaluate
staffing ratios and
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adjust based on acuity
of patients
Cultural Setting

Ineffective
communication of
goals to all
stakeholders.

Validated

Among nursing staffs,
effective supervisor
communication was strongly
correlated with job
satisfaction and job
performance (Pincus, 2006).
Effective change efforts are
communicated regularly and
frequently to all key
stakeholders (Clark and Estes,
2008).
Use multiple
communication
strategies (writing,
listening, webcam) to
reach all stakeholders,
and use those
strategies judiciously.

Look for ways to work
your message into
already-existing forms
of communication, but
then also look for new
ways as people may
have gotten used to
(and now ignore) the
regular
communication
vehicles.

Limitations
There were several identified limitations which were identified at the beginning of the
study. These limitations include:
• Not knowing the demographics of the participants of the study, or what area of the center
the participants worked to find out if the participant were a suitable candidate for the
research;
• There were only 8 participants in the study, which does not truly reflect the total number
of employees that work at the organization
• The trustworthiness of the participants as to their true intentions of participating in the
survey may have been different than the intended purpose of the participant.
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• The participants may have thought the study was administered by the organization and it
was their way to share their opinion with the management team at OLA;
• The secondary investigator was not a medical professional, therefore the areas of the
interview that could have benefitted for further probing may not have been adequately
emphasized
The was an organizational restructuring that was underway at the time of the data collection
which may have created some bias opinion from the participants. The stakeholder group that
participated in this study were all the employees that work at the OLA SACC. The information
to participate was placed in a centralized location where any employee that wanted to participate
in the study could. Since this was open to all employees at the center, there are different job
classifications that work at the center and they all have different education requirement. Some
employees are involved in direct patient care, while others are not involved in the direct care of
the patient.
Recommendations for Future Research
This study evaluated the knowledge, motivation, and organizational influences that may
prevent any sub-acute care center (SACC) from achieving its organizational goals. Since only
eight participants were interviewed for this study, future research is needed to identify the areas
the participants work in the organization, and if they are directly or indirectly involved with
patient care at the center. Future research should also involve interviews with leaders at the
center so that different perspectives can be obtained from a managerial perspective. This study
was conducted at one sub-acute facility which is one of the largest facility in the Western part of
the US. Expanding the scope of the research to other post-acute care facilities may confirm the
validity of identified influences, or validate additional influences. Incorporating other post-acute
IMPROVING STAR RATING 66

care facilities like inpatient rehabilitation facilities (IRF), and long-term care facilities (LTAC)
would also be beneficial in determining whether the validated influences are isolated only to one
organization such as OLA, or if it is generalizable to other PAC facilities as well.
Conclusion
The topic of improving the overall quality and star rating of a sub-acute care center
(SACC) sparked my interest because I was thrown into an environment that I had limited
knowledge of. After working primarily in the acute care environment for more than 20 years, I
fell in love with the vulnerability of the types of patients cared for the SACC. Most nursing
homes, as the SACC is under this category, has a reputation for low quality of care, high burnout
rates, high employee turnovers, and increased patient mortality. The information in this
dissertation did not explore all the possible solutions to improving the overall quality of care at a
sub-acute care unit, but it is a start for other researchers that are interested in the quality of care
and star rating of any long-term care facility. From a global perspective, CMS created the star
rating methodology for the consumers to be able to use the information to help select a place for
themselves or their loved ones. From this research, it is evident that it is difficult for a layperson
to fully understand the methodology of how this rating is derived. If this information is
consumer-centric, then it has to be provided in a format where consumers can understand the
information provided and what it really means to have a certain rating for a facility. It is with the
hope that the research will continue so that all patients are safe in any long-term care facility that
services are received.

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Appendix A: Participating Stakeholders with Sampling Criteria
for Interview, and Surveys

Participating Stakeholders
This has been addressed in the data collection and instrumentation section.
Criterion 1. Sampling Approach:
All the participants for this interview all work at one of the facilities of OLA located in
Southern California. For the recruitment of the participants for this study, a recruitment
information flyer was created which was approved by the host organization IRB. The flyer was
located in a centralized location of the organization where any individual that wanted to
participate in the study would call a number on the flyer and participate in the study. This
process made the participants anonymous to the researchers of the study. The goal was to have 6-
20 participants in the study.
Criterion 2. Process for sampling participants and choice:
For this research, the data collection strategy that will be utilized will be participants
interview. This is because this method of data collection allows the interviewer to probe and ask
follow-up questions on something already asked. This probing feature cannot be utilized if either
survey or observation is used to collect the data (Merriam & Tisdell, 2015b). In addition,
interviewing is a better data collection method for the questions being asked as it can provide the
desired data needed to answer the question (Creswell, 2013a).

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Appendix B: Protocol
The following are the questions used for my interview
1. How would you describe the culture of your organization? (Follow up question: What
role do you think the leaders in this organization play in helping to achieve the
organization's goal?)
2. What is it like to work at this organization? (Follow up: What recommendations would
you suggest improving your organization?)
3. What things do you think contribute to our three-star rating? (Follow-up: what about the
types of patients that you care for?)
4. From your perspective, why are organizations routinely inspected by regulatory
agencies? (Follow up question: Can you explain to me the different parts of the quality
report?)
5. What do we need to do in order to have a five-star rating? (Follow-up: Budget, Adequate
staffing?)
6. How do you think your work contributes to the overall rating of the center? (Follow up
question: How important do you think your work is to the star rating of the center?)
7. In your opinion, what barriers do you feel prevents any organization from achieving its
goals? Based on the response, please classify them into knowledge, motivation or
organizational deficits.
8. If you had to change one thing in the way your organization provides services to its
customers, what would it be? (Follow up question: Based on the response, please
elaborate why you answered the way you did).

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Appendix C: Credibility and Trustworthiness

Credibility and trustworthiness are not magical spells that can be cast on the results of my
findings to make my audience accept the work that has been put forth. For the results to credible
and trustworthy, there are certain elements that the results have to have. For this section,
definitions of both credibility and trustworthiness will be provided. Based on the reference
source, the term credibility can also be referred to as validity. The same applies to
trustworthiness where the terms consistency and interchangeability can be used to reference the
same concept.
Merriam and Tisdell (2015) explain that credibility of data requires the researcher to link
the study findings with the real-world situations so as to demonstrate the truth in the research
findings (Merriam & Tisdell, 2015a). In addition, for the results of a research study to be
credible, the same results have to be obtained by different researchers when the experiment or
research is carried out at different times or location, hence the results have to be validated. There
are behaviors that boost the credibility of data results, and one is using multiple sources of data
to cross-check the findings. With regards to the trustworthiness of data, this is tied directly to the
trustworthiness of those who collect and analyze the data. The credibility and trustworthiness of
my data will be explained below.
For my research, I will be working on evidence-based plans on how to improve the
quality and star rating of an organization that I worked for, whose pseudonym is Our Lady of
Apostles (OLA). To ensure credibility and trustworthiness of my research, it all begins with the
study design. I was an administrator at the location where the research was conducted, but I am
no longer employed with the organization. I did not own the organization; therefore, there were
no direct benefits that I received from improving the organization's star and quality rating. To
IMPROVING STAR RATING 70

arrive at the overall quality and star rating of the organization, there are three components that
are used to calculate the overall rating according to the Center for Medicare and Medicaid
Services. One of the components are the results of previous three inspections of the organization.
Since I was only in my role for one year, the constraints of my improvement are also based on
years I was not in charge of the area I am attempting to improve. From this research, the benefit
to the organization will be to improve the quality and star rating from three stars to five stars.
Accomplishing this goal would allow the organization to receive maximum reimbursement from
government payers, as well as being used as a marketing tool to attract patients to a facility that
provides high-quality care to its patients. High star and quality rating mean better outcomes on
care for our patients as compared to other long-term care facilities.
During the data analysis process, all the data and information provided from the
interviews were used to aggregate and identify themes that were relevant to the data, instead of
just aggregating the data that supports my own conclusion. In addition, evidence that supports as
well as do not support my research will be reported. It is through these behaviors that I can
ensure the credibility and trustworthiness of my research.

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Appendix D: Validity and Reliability
The validity and reliability of my study are critical to my dissertation. Before going into
details, I would like to provide definitions of both validity and reliability. Salkind (2016) defines
the validity of a survey tool as having properties of measuring what the tool is intended to
measure as defined by the researcher. Reliability is defined as knowing that the instrument used
provides consistent result every time it is used (Salkind, 2016).
The bias that I currently have is not having an adequate number of participants in the
study which may make the analysis a bit difficult. As of current, I am hoping for 6-20
participants in the survey. For this reason, I am willing to accept a minimum of 6 participants for
the study. This rate is sufficient to be able to provide adequate data for my research. To
conclude, I have decided to add document analysis to my research due to the availability of the
information on government-sponsored websites.

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Appendix E: Ethics
As a qualitative researcher, my goal is to conduct my research in an ethical manner in
which no harm is caused during the process of this research (Merriam & Tisdell, 2015a). Ethics
are the moral principles that influence a researcher's behavior, and the rules of how a researcher
conducts his or her research originated from medical and other intrusive research (Glesne, 2015).
For this reason, it is important for me to make ethical decisions during the course of this study as
my data collection strategy will be a telephone interview of my participants. Since human
subjects are involved in my research and to ensure their safety, details of my research will be
submitted to the University of Southern California Institutional Review Board (IRB) where I
pledge to follow their rules and regulations regarding the protection of the rights and welfare of
the participants in my study. My responsibilities during this research to my participants will
include showing respect to my interviewees, honor promises that I have agreed upon as long as
they are not in violation of any applicable laws and regulations, not pressuring my interviewee to
participate in my study or answer questions that they are reluctant to answer, as well as do no
harm to any individual or the environment (Rubin & Rubin, 2011). Participants that will be
recruited for my study will be given an informed consent at the beginning of the study which will
inform them of the study's risk and rewards, inform them that their participation is voluntary and
will be kept confidential to the greatest degree. They will also be made aware that they can quit
participating in the study at any time. In addition, I will solicit their approval to record our
conversation so as to prove that our dialogue will not be changed for the benefit of my research.
This idea has also been referenced by several researchers including (Krueger & Casey, 2009).
My dissertation in practice is on improving the overall quality and star rating of an
organization that I was previously employed by. To protect the confidentiality of the
IMPROVING STAR RATING 73

organization, a pseudonym name has been used called Our Lady of Apostles (OLA) Health and
Services. I was a hospital administrator at the organization where the study was conducted, and
my potential interest in this topic was to help the organization achieve an overall quality and star
rating of five stars when they are inspected by the DHS. The center where the research was
conducted is currently at three stars out of a five-star rating.

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Appendix F: Definitions and Types of PAC Facilities
Post-Acute Care (PAC): Skilled nursing care and therapy typically furnished after an
inpatient hospital stay (Centers for Medicare & Medicaid Services, 2014).
Skilled Nursing Facility (SNF): A facility that has the staff and equipment to provide
nursing and therapy services to individuals, on a 24-hour basis, who do not require high-intensity
services provided in the hospital setting (Centers for Medicare & Medicaid Services, 2014).
Inpatient Rehabilitation Facilities (IRF): A facility that provides intensive rehabilitation
services to patients after an injury, illness, or surgery. These programs are supervised by
rehabilitation physicians and include services such as physical and occupational therapy,
rehabilitation nursing, prosthetic and orthotic devices, and speech-language pathology (Centers
for Medicare & Medicaid Services, 2014).
Long-Term Care Hospitals (LTCH): A facility certified as acute care hospital, but focus
on patients who, on average, stay more than 25 days. Many of the patients in LTCHs are
transferred there from an intensive or critical care unit. LTCHs specialize in treating patients
who may have more than one serious condition, but who may improve with time and care, and
return home (Centers for Medicare & Medicaid Services, 2014).
Sub-Acute Care Centers (SACC): A facility that provides a specialized level of care to
medically fragile patients. Sub-acute patients are individuals who do not need acute care, but
who are too ill to be cared for by most skilled-nursing facilities. Frequently, these individuals are
ventilator-dependent or require frequent respiratory treatments. While sub-acute beds are
licensed as skilled nursing beds, they are reimbursed differently and are subject to additional
staffing and patient criteria requirements (Centers for Medicare & Medicaid Services, 2014).
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Home Health Agencies (HHA): A facility that provides a wide range of healthcare
services that can be administered in patients home for an illness or injury. Home health care is
usually less expensive, more convenient, and just as effective as care provided in a hospital or
SNF (Centers for Medicare & Medicaid Services, 2014).
Hospice: A facility that focuses on caring, and not restoring to health. In most cases, care
is provided in the patient's home. Hospice care also is provided in freestanding centers, hospitals,
and nursing homes and other long-term care facilities (Centers for Medicare & Medicaid
Services, 2014).
Rating: An assessment of healthcare facilities by the Center for Medicare and Medicaid
Services (CMS) based on performance on health inspection surveys, staffing levels, and a set of
quality measures (Centers for Medicare & Medicaid Services, 2014)
Star Rating: A range of one star to five stars with one star being defined as much below
average, three stars defined as average, and five stars defined as much above average (Centers
for Medicare & Medicaid Services, 2014).
Medi-Cal: A California medical assistance program for low-income individuals, while
Medicare insurance is for patients who are age 65 years and above, that have paid into the
Medicare system through their employer payroll system while they were younger (Centers for
Medicare & Medicaid Services, 2014).
Medicare: This is the national social insurance program that is available to citizens of the
United States which were implemented in 1966. This program is only available to citizens that
are 65 years or older, or younger adults with disabilities (https://www.medicare.gov/sign-up-
change-plans/decide-how-to-get-medicare/whats-medicare/what-is-medicare.html)
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Minimum Data Set (MDS): This is a federally mandated process for clinical assessment
of all patients in a Medi-Cal and Medicaid certified nursing home. This process provides a
comprehensive assessment of the patient's functional capabilities and helps the nursing team
identify the early problems the patient may have. (https://www.cms.gov/Research-Statistics-
Data-and-Systems/Computer-Data-and-Systems/Minimum-Data-Set-3-0-Public-
Reports/index.html)

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Asset Metadata

Creator Agbelemose, Olugbenga (author)

Core Title Improving the overall quality and star rating at the sub-acute care center

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 07/26/2018

Defense Date 05/23/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,quality of care,star rating,sub-acute care

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kimberly (committee chair), Foulk, Susanne (committee member), Krop, Cathy (committee member)

Creator Email agbelemo@usc.edu,gbengaag@yahoo.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-33291

Unique identifier UC11671909

Identifier etd-Agbelemose-6523.pdf (filename),usctheses-c89-33291 (legacy record id)

Legacy Identifier etd-Agbelemose-6523.pdf

Dmrecord 33291

Document Type Dissertation

Format application/pdf (imt)

Rights Agbelemose, Olugbenga

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA