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Gerontologist. 2018 May 8;58(3):598-605. doi: 10.1093/geront/gnx023.

Applying a Theory-Driven Framework to Guide Quality Improvement Efforts in Nursing Homes: The LOCK Model.

Author information

Center for Innovation in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas.
Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas.
Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester.
Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, Massachusetts.
Alabama Research Institute on Aging, University of Alabama, Tuscaloosa.
Department of Psychology, University of Alabama, Tuscaloosa.
Tuscaloosa Veterans Affairs Medical Center, Alabama.
Department of Health Law, Policy and Management, School of Public Health, Boston University, Massachusetts.


Purpose of the Study:

Implementing quality improvement (QI) programs in nursing homes continues to encounter significant challenges, despite recognized need. QI approaches provide nursing home staff with opportunities to collaborate on developing and testing strategies for improving care delivery. We present a theory-driven and user-friendly adaptable framework and facilitation package to overcome existing challenges and guide QI efforts in nursing homes.

Design and development:

The framework is grounded in the foundational concepts of strengths-based learning, observation, relationship-based teams, efficiency, and organizational learning. We adapted these concepts to QI in the nursing home setting, creating the "LOCK" framework. The LOCK framework is currently being disseminated across the Veterans Health Administration.


The LOCK framework has five tenets: (a) Look for the bright spots, (b) Observe, (c) Collaborate in huddles, (d) Keep it bite-sized, and (e) facilitation. Each tenet is described. We also present a case study documenting how a fictional nursing home can implement the LOCK framework as part of a QI effort to improve engagement between staff and residents. The case study describes sample observations, processes, and outcomes. We also discuss practical applications for nursing home staff, the adaptability of LOCK for different QI projects, the specific role of facilitation, and lessons learned.


The proposed framework complements national efforts to improve quality of care and quality of life for nursing home residents and may be valuable across long-term care settings and QI project types.

[Available on 2019-05-08]

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