Measures & Instruments for Quality Improvement in Senior Living: A Critical Review

A Critical Review of Measures and Instruments for Quality Improvement Maribeth Bersani, Senior Vice-President, Argentum Sheryl Zimmerman, Professor, University of North Carolina at Chapel Hill Pat Giorgio, President/CEO, Evergreen Estates

The Importance of Quality Improvement in

Assisted Living

A Critical Review of Measures and Instruments for Quality Improvement in Assisted Living Funded by the Center for Excellence in Assisted Living

Aims 

Conduct a comprehensive scan and review of tools (measures and instruments) suitable for quality improvement in assisted living and related residential care settings  Include tools that have been used in assisted living and other health and long-term care settings, because …  … few tools have been developed specifically for assisted living  … tools developed in other settings may potentially be used or adapted for assisted living

Key Domains for Quality Improvement ď ś

Person-centered care

Key Domains for Quality Improvement ď ś

Person-centered care

ď ś

Medication management

Key Domains for Quality Improvement 

Person-centered care



Medication management



Care coordination/transitions

Key Domains for Quality Improvement 

Person-centered care



Medication management



Care coordination/transitions



Resident/patient outcomes

Key Domains for Quality Improvement 

Person-centered care



Medication management



Care coordination/transitions



Resident/patient outcomes



Workforce

Key Areas Within Each Domain Person-centered care

Resident/patient outcomes

• Resident-direction

• Physical function (activities of daily living)

• Homelike atmosphere

• Psychosocial well-being (cognition, affect, quality of life)

• Close relationships

• Satisfaction

• Staff empowerment (e.g., collaborative decision making)

• Medical events (e.g., falls)

Medication management

Workforce

• Medication risk (prescribing)

• Turnover

• Medication self-administration

• Consistent assignment (e.g., staffing models, caregiver time)

• Medication errors (administration)

• Stress, burnout

• Medication reconciliation

• Satisfaction

Care coordination/transitions • Information transmission (e.g., timeliness) • Tracking/response to information (e.g., proactive)

• •

Efficiency (e.g., unnecessary readmissions, duplication) Patient experience

Sample Key Words for Scan • Tools: tool, measure, instrument, survey, interview,

•

•

•

• Settings of care: long-term care, assisted living, residential

inventory, questionnaire, scale, index, profile, toolkit,

care, board and care, senior housing, home care, home and

protocol, evaluation, assessment, test

community based, other

Person-centered care: resident direction (e.g., autonomy);

•

Resident/patient outcomes: function (e.g., mobility);

homelike atmosphere (e.g., home); close relation-

psychosocial well-being (e.g., depression);

ships (e.g., familiarity); staff empowerment

satisfaction; medical events (e.g., falls)

Medication management: risk (e.g., prescribing);

•

Workforce: turnover (e.g., separation); consistent

self-administration (e.g., capacity); errors

assignment (e.g., ratio); stress, burnout

(e.g., preparation); reconciliation (e.g., orders)

(e.g., burden); satisfaction

Coordination/transitions: information transmission (e.g., timeliness); tracking/response (e.g., communication); efficiency (e.g., readmission); patient experience (e.g., distress)

Literature Search and Advisory Panel 





Research librarian: created every possible combination of search terms related to tools, settings, and domains/key areas, and searched numerous peer-reviewed databases, grey literature reports, Google sites, and websites Panel: fourteen experts provided input on grey literature, Google sites, websites, and overall format Research team: reviewed the information from all sources; those that identified relevant tools resulted in search of information about the tool, and synthesis and critique

Inclusion and Exclusion Criteria Inclusion Criteria “Tools” include measures and instruments that generate a score: 

Measure: Not based on scales or indices; includes a numerator and a denominator



Instrument: Based on scales or indices; includes more than two items that are aggregated in some way

The tool measures a key area within the five domains Tools that measure end-of-life care and outcomes are included because they relate to transitions Eligible tools were developed or used in the last ten years in at least one target setting in the United States Exclusion Criteria Tools used for screening Tools used for care planning, including those to assess resident preferences

Tools used for clinical care Tools exclusively relevant to hospital and/or home care Tools related exclusively to outcomes for informal (family) caregivers Tools used in qualitative studies, editorials, dissertations, conference abstracts, and op-ed pieces

Synthesis and Critique Quantitative Scoring Strategy SCORING FOR INSTRUMENTS Component

Scoring Reliability 2 (good) if reliability coefficients generally ≥ 0.80 (test-retest, inter-rater, internal consistency) 1 (fair) if reliability coefficients generally 0.60–0.79 0 (poor) if reliability coefficients generally <.60 or no information Criterion validity 2 (good) if reliability coefficients generally ≥ 0.60 (convergent, discriminant, predictive, concurrent) 1 (fair) if reliability coefficients generally 0.40–0.59 0 (poor) if reliability coefficients generally <.40 or no information Interpretability/utility 2 (good) if range of scale is used and reflects potentially actionable items 1 (fair) if range of scale is used or reflects potentially actionable items 0 (poor) if range of scale is not used and does not reflect potentially actionable items SCORING FOR INSTRUMENTS AND MEASURES Component Scoring Ease of use 2 (good) if not time intensive to train/administer and has simple scoring 1 (fair) if not time intensive to train/administer or has simple scoring 0 (poor) if time intensive to train/administer and scoring is not simple Benchmarks for long- term care 2 (good) if benchmarks existed 0 (poor) if no benchmarks existed

Results ď ś

ď ś

The peer-reviewed literature search generated 9,048 nonduplicative citations; the grey literature search generated 361 sources in addition to websites of 51 organizations Reviewing all sources, assuring that the tool met eligibility criteria, and omitting duplications, resulted in 254 tools: 136 measures and 118 instruments

Results Number of Tools (Measures and Instruments) Identified For Each Domain

Domain

Tools

Measures

Instruments

Person-centered care

22

1

21

Medication management

24

20

4

Care coordination/transitions

32

28

4

Resident/patient outcomes

69

28

41

Workforce

107

59

48

Considerations to Recommend Tools 

Relevance



Efficacy



Cost



Time demands

Person-Centered Care: 6 tools Name

Description

Source of Information, Process to Obtain

Culture Change Scale (CCS)

48 items assessing six sub-scales: 1) system-wide culture change; 2) resident choice; 3) organizational design; 4) empowering supervision; 5) job design; and 6) decision-making.

Sample items include "the environment encourages new ideas; how often can residents eat what they really want; my job duties allow me to enough time to do my job properly." Scores are provided on a 5 point Likert scale and mean scores are derived.

STAFF INTERVIEW

Toolkit for PersonCenteredness in Assisted Living (PC-PAL Resident)

49 items to assess person-centered practices in assisted living and similar long-term care settings, addressing the domains of well-being and belonging (18 items), individualized care and services (12 items), social connectedness (10 items), and atmosphere (9 items). Items are scored on a 4 point Likert scale. Scores for each area and overall are obtained, with higher scores indicating more person-centeredness.

RESIDENT QUESTIONNAIRE

Toolkit for PersonCenteredness in Assisted Living (PC-PAL Staff)

62 items to assess person-centered practices in assisted living and similar long-term care settings, addressing the domains of workplace practices (23 items), social connectedness (16 items), individualized care and services (8 items), atmosphere (8 items), and caregiverresident relationships (7 items). Items are scored on a 4 point Likert scale. Scores for each area and overall are obtained, with higher scores indicating more person-centeredness.

STAFF QUESTIONNAIRE

Toolkit for Person-Centeredness in Assisted Living (PC-PAL) Sample Items (of 49 that assess four domains) I. Well-Being and Belonging These questions are about things that relate to your feelings of well-being and belonging in this assisted living community.

To what extent do you disagree or agree thatâ&#x20AC;Ś

Strongly disagree Disagree

Agree

Strongly agree

Donâ&#x20AC;&#x2122;t know

1

I feel a sense of belonging here.

1

2

3

4

DK

2

My needs for private space are met.

1

2

3

4

DK

3

It feels like home.

1

2

3

4

DK

4

Outdoor areas are easy to get to, and are safe, attractive, and have comfortable seating.

1

2

3

4

DK

5

The activities here are meaningful to me.

1

2

3

4

DK

6

There are opportunities and a place here for me to practice the religious or spiritual beliefs I choose.

1

2

3

4

DK

Medication Management: 10 tools Name Medication Tracking Tool (Advancing Excellence) Nursing Home Compare Percent of Residents Receiving Antipsychotic Medication (long-stay) Nursing Home Compare Percent of Residents Who Are Newly Administered Antipsychotic Medications (short-stay)

Description

Source of Information, Process to Obtain

Six rates related to antipsychotic use in nursing homes: rate of residents on PRNs, for those with dementia, more than one antipsychotic, gradual dose reduction (GDR) attempted, GDR with dose reduction, GDR with medication discontinued.

CHART ABSTRACT

As per name

CHART ABSTRACT

As per name

CHART ABSTRACT

Medication Tracking Tool (Advancing Excellence) www.nhqualitycampaign.org/goals.aspx

Information about each resident who is prescribed an antipsychotic

List of clinicians prescribing antipsychotic Details about each antipsychotic prescription

Care Coordination/Transitions: 17 tools Name

Description

Care Transitions Measure (CTM-15, CTM-3)

15 items assessing care transitions in relation to goals, potential health care needs, site of care, information, understanding, warning signs and symptoms, written plan of care, selfcare, confidence, and purpose, side effects, and administration of medications. Items are scored on a 4 point Likert scale. A 3 item version is available and recommended for public reporting.

Family Perception of Physician-Family Caregiver Communication (FPPFC)

7 items assessing family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long-term care. Sample items include “the doctor always spoke to you, other family caregivers, or the resident about [his/her] wishes for medical treatment at the end of life, and the doctor always kept you or other family caregivers informed about the resident’s condition.” Items are scored on a 4 point Likert scale and a mean score is derived.

Avoidable Re-hospitalization The number of unplanned readmissions to any hospital divided by the number of Rate, 30-day Adjusted hospitalizations in that period, adjusted for patient characteristics. (and annualized)

Source of Information, Process to Obtain RESIDENT INTERVIEW

FAMILY INTERVIEW

CHART ABSTRACT

Care Transitions Measure (CTM-3) Transition Following Hospitalization

Strongly disagree Disagree

Agree

Strongly agree

1

The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital.

1

2

3

4

2

When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.

1

2

3

4

3

When I left the hospital, I clearly understood the purpose for taking each of my medications.

1

2

3

4

Resident/Patient Outcomes: 35 tools Name

Description

Source of Information, Process to Obtain

Nursing Home Compare Percent of Residents Who SelfReport Moderate to Severe Pain (long, short-stay)

As per name

CHART ABSTRACT

Nursing Home Compare Percent of High Risk Residents With Pressure Ulcers (long, short-stay)

As per name

CHART ABSTRACT

Nursing Home Compare Percent of Low Risk Residents Who Lose Control of Their Bowels or Bladder (long-stay)

As per name

CHART ABSTRACT

Percent of Residents Who Self-Report Moderate to Severe Pain Nursing Home Compare, Short Stay Version Denominator Description All short-stay residents with an assessment where the information was recorded and pain was present Numerator Description Short-stay residents with an assessment where the assessment meets either or both of the following two conditions: 1. Resident reports daily pain with at least one episode of moderate or severe pain; both of the following conditions must be met:

â&#x20AC;˘ Almost constant or frequent pain â&#x20AC;˘ At least one episode of moderate to severe pain 2. Resident reports very severe/horrible pain of any frequency

Workforce: 28 tools Name

Description

Consistent Assignment Tracking Tool (Advancing Excellence)

Tracks the number of caregivers each resident has for the month and calculates the percent of residents meeting a nursing homes target number.

Eaton Instrument for Measuring Turnover

Number of new employees (full or part time) divided by the number of employees in that category over a 12-month period.

National Nursing Assistant Survey (Management/ Supervision; Percent of respondents reporting perceptions of 10 items related to management/ Organizational supervision; 29 related to organizational commitment/job satisfaction; 14 items in workplace Commitment/Job environment.

Satisfaction; Workplace Environment sections only)

Source of Information, Process to Obtain

CHART ABSTRACT

RECORD REVIEW

STAFF INTERVIEW

Consistent Assignment Tracking Tool (Advancing Excellence) www.nhqualitycampaign.org/goals.aspx

List of residents

List of caregivers Record of each residentsâ&#x20AC;&#x2122; caregivers, separately for long- and short-stay, during the first and second half of the month

Implementation: Plan, Do, Study, Act Continuous quality improvement

Administer the instrument/measure

Modify efforts (if necessary)

Meet with staff, residents, families

Re-administer the instrument/measure

Jointly plan for change

CONCLUSIONS AND GAP ANALYSIS



Resident acuity in relation to staffing levels



Overall measurement of quality

FINAL REPORT and TOOLS Center for Excellence in Assisted Living: http://www.theceal.org/ Sheps Center for Health Services Research University of North Carolina at Chapel Hill http://www.shepscenter.unc.edu/

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