TESTING THE QUALITY HEALTH OUTCOME MODEL FOR INFECTION PREVENTION IN HOSPITALS
Definition of Theory: The QHOM is a conceptual model of nursing that contains four major constructs: system or context, intervention, client, and outcomes and is an extension of the time honored structure-process-outcome framework described by Donabedian for quality assessment. The QHOM is a unique systems model for it challenges the traditional view that interventions directly produce expected outcomes, as adjusted for client characteristics. In this secondary analysis study, measures to represent the QHOM concepts were selected from the Prevention of Nosocomial Infection and Cost-effectiveness – Refined dataset. Instruments that measured adherence to central line-associated bloodstream infection (CLABSI) prevention interventions, and the organizational context variables of organizational climate and the work environment were selected, along with CLABSI outcomes from participating intensive care units.
Internal Consistency: The QHOM for Infection Prevention in Hospitals was tested and confirmed using data from 614 hospitals. One-half of the dataset was used for exploration of the concepts, the second half for confirmation of the model. The latent variable for adherence to CLABSI interventions was confirmed as a single factor model (x2 (9) = 50.64, p <.0000; CFI = .99; RMSEA = .12), while the organizational context variable was confirmed as a second order model represented by organizational climate and work environment items (x2 (980) = 1,680.75 p <.0000; CFI = .94; RMSEA = .05). Ultimately, SEM indicated support for the proposed middle-range theoretical model, for the model fit the data well (x2 (1,315) = 1,986.30, p <.0000; CFI = .97; RMSEA = .04). The relationship between adherence to CLABSI interventions and organizational context was confirmed (β = .22, p <.01). The relationship between organizational context and CLABSI outcomes was not statistically significant (β = -.06, p = .37).
Concept to Practice: The prevention of HAIs is a complex topic of research. Organizational context is believed to be a key factor in the success or failure of HAI initiatives. This study confirmed a middle-range theoretical model that identifies and explains the relationships between the concepts of adherence to CLABSI interventions, organizational context, and CLABSI outcomes. Though we have not completely answered the question of why some HAI programs are successful and others are not, we are able to offer that the context of an organization has a direct effect on adherence to CLABSI interventions.
Conclusion: This study is the first to empirically test the relationships between interventions, organizational context, and outcomes, using infection prevention concepts. Our findings support the current recommendation that organizational context be measured in HAI prevention studies to determine the role of context in the success or failure of patient safety programs. Ongoing use of this theory will inform the planning and interpretation of HAI research projects and will aid in the explanation of variations in HAI project outcomes.