Corinne Schalm

The Use of Data for Process and Quality Improvement in Long Term Care and Home Care: A Systematic Review of the Literature

BACKGROUND Standardized resident or client assessments, including the Resident Assessment Instrument (RAI), have been available in long term care and home care settings (continuing care sector) in many jurisdictions for a number of years. Although using these data can make quality improvement activities more efficient and less costly, there has not been a review of the literature reporting quality improvement interventions using standardized data. OBJECTIVES To address 2 questions: (1) How have RAI and other standardized data been used in process or quality improvement activities in the continuing care sector? and (2) Has the use of RAI and similar data resulted in improvements to resident or other outcomes? DATA SOURCES Searches using a combination of keyword and controlled vocabulary term searches were conducted in MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, the Cochrane Library, and PsychINFO. ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: English language publications from database inception to October 2008 were included. Eligibility criteria included the following: (1) set in continuing care (long-term care facility or home care), (2) involved some form of intervention designed to improve quality or process of care, and (3) used standardized data in the quality or process improvement intervention. STUDY APPRAISAL AND SYNTHESIS METHODS After reviewing the articles, we grouped the studies according to the type of intervention used to initiate process improvement. Four different intervention types were identified. We organized the results and discussion by these 4 intervention types. RESULTS Key word searches identified 713 articles, of which we excluded 639 on abstract review because they did not meet inclusion criteria. A further 50 articles were excluded on full-text review, leaving a total of 24 articles. Of the 24 studies, 10 used a defined process improvement model, 8 used a combination of interventions (multimodal), 5 implemented new guidelines or protocols, and 1 used an education intervention. CONCLUSIONS/IMPLICATIONS The most frequently cited issues contributing to unsuccessful quality improvement interventions were lack of staff, high staff turnover, and limited time available to train staff in ways that would improve client care. Innovative strategies and supporting research are required to determine how to intervene successfully to improve quality in these settings characterized by low staffing levels and predominantly nonprofessional staff. Research on how to effectively enable practitioners to use data to improve quality of care, and ultimately quality of life, needs to be a priority.

Innovative dementia care: functional status over time of persons with Alzheimer disease in a residential care centre compared to special care units.

Residential care centres (RCCs) for persons with Alzheimer disease are increasing worldwide, but there are few studies that compare the functional outcomes of RCC residents to residents of other types of continuing care settings. This study compared residents of the first Canadian RCC on physical, cognitive, behavioural and emotional functioning 6, 12 and 18 months after admission to residents of special care units (SCUs) operated by the same continuing care provider. SCU residents were initially functioning lower than RCC residents on most outcome measures and these differences persisted over time. Resident functioning declined over time regardless of care setting and, when the initial status was controlled for, the rates of decline were similar. However, RCC residents experienced greater independence/freedom of choice, fewer physical or psychotropic medication restraints and were more active, which may have enhanced their quality of life.

Mobility of Vulnerable Elders Study: Effect of the Sit-to-Stand Activity on Mobility, Function, and Quality of Life

OBJECTIVES The aim of this study is to assess the effect of the sit-to-stand activity on the mobility, function, and health-related quality of life of nursing home residents with dementia. DESIGN A longitudinal quasi-experimental intervention study with intervention and control groups. SETTING The study was conducted in 7 nursing homes (4 intervention; 3 control) in Edmonton, Canada. PARTICIPANTS Eligible residents had a diagnosis of dementia and were able to transfer independently, or with the assistance of 1 person. INTERVENTION Health care aides prompted residents to repeat the sit-to-stand activity daily during care routines on day and evening shifts. MEASUREMENTS Mobility was measured using the 30-second sit-to-stand test and the time to complete one sit-to-stand. Function (Functional Independence Measure), health status (Health Utilities Index Mark 2 & 3) and disease-specific quality of life (Quality of Life-Alzheimers Disease instrument) were also measured. Outcome measures were collected at baseline, and at 3 and 6 months. The covariates cognition, depression, and medical instability were derived from the Resident Assessment Instrument Minimum Data Set (Version 2.0), and the facility context covariate was measured using the Alberta Context Tool. RESULTS A total of 111 residents completed the 6-month trial (56 intervention; 55 control). Residents in the intervention facilities maintained mobility, as measured by the time to complete one sit-to-stand (P = .01), and experienced a slower functional decline, as measured by the Functional Independence Measure (P = .01), from baseline to 6 months compared with residents in the control facilities, after adjusting for age, sex, cognition, depression, medical instability, and context. CONCLUSIONS Maintaining the ability to transfer using the sit-to-stand activity is a promising means of optimizing the mobility and function for residents with dementia in nursing homes.

Alberta's Resident Classification System for Long Term Care Facilities. Part I: Conceptual and Methodological Development

In 1988 the Alberta government introduced a new resident classification system to measure the nursing care requirements of long-term care facility residents, and to provide case-mix information for a new funding system. This article describes the conceptual and methodological development of the system. Specific steps in the development process were to (1) define key care domains reflecting the major types of assistance required by long-term care residents; (2) identify indicators of care requirements within each care domain; (3) develop criteria for determining which items to include in the final version of the Resident Classification Form; (4) develop decision rules for combining scores on individual items in order to group residents into categories; and (5) test the psychometric properties of the classification system. The classification system has seven categories ordered from low to high in terms of nursing care requirements and a measure of nursing resource use.

Involving stakeholders in health services research: developing Alberta's resident classification system for long-term care facilities.

Little attention has been directed in Canada to identifying stakeholders at the administrative policy level to whom relevant health services research information can be targeted. This article describes a case study in which key stakeholders (long-term care facility owners, operators, and care providers) were explicitly defined not only as targets of original research information to inform administrative public policy but also as collaborators in the research process and dissemination of results. The research involved development of a classification system to measure resident care requirements in the provinces nursing homes and auxiliary hospitals. The classification system formed the basis of a new government administrative policy for allocating public funds to these facilities based on levels of care. The authors describe the rationale for involving stakeholders in the research process, the role of stakeholders as collaborators, and lessons learned from the Alberta experience. Examples are presented of how stakeholders can contribute to the health services research process and outcome: by providing experiential knowledge related to the research outcome, anticipating and overcoming potential problems with policy implementation, facilitating policy-oriented learning across stakeholder groups, assisting in the transfer of research information to wider stakeholder audiences, and promoting acceptance for policy change.

Data for improvement and clinical excellence: protocol for an audit with feedback intervention in long-term care

BackgroundThere is considerable evidence about the effectiveness of audit coupled with feedback, although few audit with feedback interventions have been conducted in long-term care (LTC) settings to date. In general, the effects have been found to be modest at best, although in settings where there has been little history of audit and feedback, the effects may be greater, at least initially. The primary purpose of the Data for Improvement and Clinical Excellence (DICE) Long-Term Care project is to assess the effects of an audit with feedback intervention delivered monthly over 13 months in four LTC facilities. The research questions we addressed are:1. What effects do feedback reports have on processes and outcomes over time?2. How do different provider groups in LTC and home care respond to feedback reports based on data targeted at improving quality of care?Methods/designThe research team conducting this study comprises researchers and decision makers in continuing care in the province of Alberta, Canada. The intervention consists of monthly feedback reports in nine LTC units in four facilities in Edmonton, Alberta. Data for the feedback reports comes from the Resident Assessment Instrument Minimum Data Set (RAI) version 2.0, a standardized instrument mandated for use in LTC facilities throughout Alberta. Feedback reports consist of one page, front and back, presenting both graphic and textual information. Reports are delivered to all staff working in the four LTC facilities. The primary evaluation uses a controlled interrupted time series design both adjusted and unadjusted for covariates. The concurrent process evaluation uses observation and self-report to assess uptake of the feedback reports. Following the project phase described in this protocol, a similar intervention will be conducted in home care settings in Alberta. Depending on project findings, if they are judged useful by decision makers participating in this research team, we plan dissemination and spread of the feedback report approach throughout Alberta.

Data for Improvement and Clinical Excellence: Protocol for an Audit with Feedback Intervention in Home Care and Supportive Living

BackgroundAlthough considerable evidence exists about the effectiveness of audit coupled with feedback, very few audit-with-feedback interventions have been done in either home care or supportive living settings to date. With little history of audit and feedback in home care or supportive living there is potential for greater effects, at least initially. This study extends the work of an earlier study designed to assess the effects of an audit-with-feedback intervention. It will be delivered quarterly over a one-year period in seven home care offices and 11 supportive living sites. The research questions are the same as in the first study but in a different environment. They are as follows:1. What effects do feedback reports have on processes and outcomes over time?2. How do different provider groups in home care and supportive living sites respond to feedback reports based on quality indicator data?MethodsThe research team conducting this study includes researchers and decision makers in continuing care in the province of Alberta, Canada. The intervention consists of quarterly feedback reports in 19 home care offices and supportive living sites across Alberta. Data for the feedback reports are based on the Resident Assessment Instrument Home Care tool, a standardized instrument mandated for use in home care and supportive living environments throughout Alberta. The feedback reports consist of one page, printed front and back, presenting both graphic and textual information. Reports are delivered to all employees working in each site. The primary evaluation uses a controlled interrupted time-series design, both adjusted and unadjusted for covariates. The concurrent process evaluation includes observation, focus groups, and self-reports to assess uptake of the feedback reports. The project described in this protocol follows a similar intervention conducted in our previous study, Data for Improvement and Clinical Excellence--Long-Term Care. We will offer dissemination strategies and spread of the feedback report approach in several ways suited to various audiences and stakeholders throughout Alberta.SignificanceThis study will generate knowledge about the effects of an audit with feedback intervention in home care and supportive living settings. Our dissemination activities will focus on supporting sites to continue to use the Resident Assessment Instrument data in their quality improvement activities.

Data for improvement and clinical excellence: report of an interrupted time series trial of feedback in long-term care

BackgroundThere is considerable evidence about the effectiveness of audit coupled with feedback for provider behavior change, although few feedback interventions have been conducted in long-term care settings. The primary purpose of the Data for Improvement and Clinical Excellence-Long-Term Care (DICE-LTC) project was to assess the effects of a feedback intervention delivered to all direct care providers on resident outcomes. Our objective in this report is to assess the effect of feedback reporting on rates of pain assessment, depression screening, and falls over time.MethodsThe intervention consisted of monthly feedback reports delivered to all direct care providers, facility and unit administrators, and support staff, delivered over 13 months in nine LTC units across four facilities. Data for feedback reports came from the Resident Assessment Instrument Minimum Data Set (RAI) version 2.0, a standardized instrument mandated in LTC facilities throughout Alberta. The primary evaluation used an interrupted time series design with a comparison group (units not included in the feedback intervention) and a comparison condition (pressure ulcers). We used segmented regression analysis to assess the effect of the feedback intervention.ResultsThe primary outcome of the study, falls, showed little change over the period of the intervention, except for a small increase in the rate of falls during the intervention period. The only outcome that improved during the intervention period was the proportion of residents with high pain scores, which decreased at the beginning of the intervention. The proportion of residents with high depression scores appeared to worsen during the intervention.ConclusionsMaintaining all nine units in the study for its 13-month duration was a positive outcome. The feedback reports, without any other intervention included, did not achieve the desired reduction in proportion of falls and elevated depression scores. The survey on intention to change pain assessment practice which was conducted shortly after most of the feedback distribution cycles may have acted as a co-intervention supporting a reduction in pain scores. The processing and delivery of feedback reports could be accomplished at relatively low cost because the data are mandated and could be added to other intervention approaches to support implementation of evidence-based practices.

Knowledge translation interventions to sustain direct care provider behaviour change in long‐term care: A process evaluation

RATIONALE, AIMS, AND OBJECTIVES Process evaluation can be used to understand the factors influencing the impact of knowledge translation (KT) interventions. The aim of this mixed methods process evaluation was to evaluate the processes and perceived outcomes of eight KT interventions that were used with healthcare aides (HCAs) to introduce a mobility innovation into their daily care practices. The study examined the perceived effectiveness of various KT interventions in sustaining daily performance of the sit-to-stand mobility innovation by HCAs with residents in long-term care. METHOD In-person interviews were conducted with four leaders across three long-term care facilities. Seven focus groups with 27 HCAs were conducted across the three facilities. All participants were asked to rank the eight interventions involved in the trial according to their perceived effectiveness and, for the leaders, their perceived ease of implementation. Focus group and interview questions asked participants to discuss the relative merits of each KT intervention. Two research assistants coded all of the transcripts independently using content analysis. RESULTS Both HCAs and their leaders perceived reminders, followed by discussion groups, to be the most effective KT interventions to sustain practice change. Healthcare aide champions were deemed least effective by both leaders and HCAs. Leaders identified both the focus group discussion and audit and feedback posters in the study as the most difficult to implement. Participants valued interventions that were strategically visible, helped to clarify misconceptions about the new care innovation, supported teamwork, and made visible the resident benefits of the care innovation. Logistical issues, such as staff scheduling and workload, influenced the perceived feasibility of the various KT interventions. CONCLUSIONS Understanding how care staff in long-term care settings perceive KT interventions can inform the choice of future use of these interventions to move research evidence into practice.