Quality management in residential care by result-oriented performance indicators

Why was this example implemented?

Long-term care facilities are often lacking transparency concerning performance, results and costs of their activity. It is therefore difficult to assess quality of services or care homes, particularly when it comes to steering change and improvement. However, market mechanisms, new forms of purchaser-provider relationships, the tendency to assess outcome quality, rather than structural standards (see Nies et al, 2010) and the changing role of users/residents and public purchasers who want to know what they get for their money have called for efforts to overcome these shortcomings.

However, in the daily practice of care homes, systematic management using key performance indicators is taking place only in a rudimentary manner: data collection and satisfaction surveys are rare, while resistance of staff who fear losing autonomy and control is widespread, as well as a general apprehension about comparisons and transparency. Monitoring quality of results and quality assurance in the context of yearly inspections are mainly used to satisfy the regulator, but the implementation of quality management systems has started to increase awareness for quality development, also by means of strategic planning in care homes.

A first step of the project had been to map the more classical indicators for the quality of care. Apart from literature and US experiences (see US DHHS, 2008), indicators used in the Netherlands (ActiZ et al, 2007), the National Minimum Standards and Key Lines of Regulatory Assessment (KLORA) in England and the German guidelines for inspections of care homes and home care services (MDS, 2009) were important sources for this purpose. Furthermore, attempts to measure quality of life of service users were identified (Schalock, 2008; Nolan, 2006). A comprehensive approach for care homes with respective mechanisms to enable stakeholders to reflect upon such indicators and to implement them in daily practice has been missing until now.

Addressing links between quality of care, quality of life, economic performance, leadership and the social context have therefore been at the heart of this project. This included sifting and validating existing indicators (Delphi questionnaire, validation workshops with care home managers) as well as proposals for new types of indicators (quality of life, social context) and training designs for potential users. It was not an explicit aim of this project to develop indicators that can be used across the whole range of LTC services and facilities. However, the current list of indicators could be used to further develop a ‘whole system’ approach with shared indicators across the ‘chain of care’.

Description

The project started with a conceptual analysis of quality of life and quality of care, followed by a gathering of experiences with existing quality frameworks in residential care for older people in the participating countries of the project (AT, DE, LU, NL, SI, UK), in particular: the North-Rhine Westphalia Referenzmodelle (MAGS, 2006), the MDK assessment criteria (MDS, 2008), the Dutch quality framework for responsible care (ActiZ et al, 2007), E-Qalin, and the CSCI framework for regulation (CSCI, 2008), based on the Department of Health National Minimum Standards for Care Homes (now revised: see CQC) and My Home Life in the UK. The project consortium then clustered the indicators that were selected and reviewed them using several criteria such as feasibility, validity/soundness, comparability and ability to steer change.

Based on these criteria, the validation of the 91 indicators that had been selected by experts and practitioners consisted of consensus building with experts in the field (policy‐makers, inspectors, commissioners, service providers and representatives of user organisations as well as researchers) by means of the Delphi method. During three rounds a total number of 56 experts of seven countries (AT, DE, IT, LU, NL, SI, UK) provided feedback on the usefulness and the applicability of each indicator. This process also showed that thinking in terms of results-oriented indicators in LTC is still at the very beginning – in particular user organisations (patient advocacies, pensioner organisations) that would be ready to engage in this validation process were hard to find. Ultimately, only a small number of indicators from the original list were completely rejected by experts involved in the Delphi survey.

In parallel, validation workshops with managers and staff of care homes for older people were organised with 34 practitioners representing 25 care homes in Austria, Germany and Luxembourg. These workshops were to test the applicability and discriminatory value of the selected indicators in care homes that had experience with working with an existing quality management system.

While some indicators were rejected or reformulated during these processes, experts also provided suggestions for new or additional indicators that were found more useful and feasible.

Finally, all results were discussed, mutually agreed and eventually compiled in the Handbook  “Measuring progress: indicators for care homes” which can be downloaded here. in English, German and Dutch (translations in Czech and Spanish are under way).

What are/were the effects?

The Handbook is for use in the context of quality management systems, accreditation systems and/or as a single tool for quality improvement with result-oriented indicators. It contains 94 indicators that are presented in a systematic way for service providers, managers, staff, regulators and other stakeholders in care homes. This list should be seen as a menu from which practitioners can choose individual key performance indicators according to their characteristics and needs. Related suggestions for practice in care homes – e.g. to work with no more than 10-15 indicators at a time –  are also provided in the Handbook. These are mainly focusing on leadership skills and training needs to implement systematic improvement processes. Such processes, underpinned by selected result-oriented performance indicators, can be used as a mechanism to define, measure, assess and improve quality in long-term care, in particular in residential care facilities.

Results-oriented indicators can thus help to steer effectiveness and cost-efficiency as well as quality of care and quality of life in care homes. This can be done simply by involving relevant stakeholders in reflecting upon how specific results can be enhanced, by acting upon shortcomings and controlling for success. For instance, if the “Percentage of residents who had a fall incident in the past 30 days” (in particular those with an ensuing hospital stay) can be reduced by some simple measures, costs can be reduced considerably. The same is true if management could control for the “Average percentage of working time lost due to sickness of staff” related to staff satisfaction or “Average direct financial resources available for health promotion-related training, meetings and infrastructures per staff”. When it comes to measuring quality of life of residents, families/friends and staff, most indicators will be based on survey data. Notwithstanding the methodological problems that may be connected to these, such data may indicate progress or decline – and respective measures can be taken by management and staff.

The costs for introducing such approaches are relatively low, if compared to the overall costs of a care home. Apart from some introductory training and the introduction of quality management, which has become a necessary precondition in many countries anyway, no major investment is necessary. However, participative leadership and a supportive management are needed to facilitate systematic ‘controlling of results’ in care homes that would go beyond merely economic controlling.

The effects of this project will have to be seen over time. While the Handbook was downloaded more than 2,500 times during the first six months, a tangible impact will be difficult to retrieve. In the meantime, the Handbook is being used in E-Qalin training to strengthen the assessment of outcome quality and to facilitate systematic control in care homes. In the future, it will be necessary to make improvements more visible by means of a systematic approach using result-oriented indicators. Once data from the various organisations involved is available, it will be possible to produce tangible evidence that working with result-oriented indicators may trigger positive outcomes for residents, staff and management.

What are the strengths and limitations?

Strengths

• With 94 indicators and guidelines about their use, the Handbook is a comprehensive tool to assess and improve outcomes in care homes, involving all staff in working with performance indicators.
• The list of indicators was validated and tested by representatives of care home providers, policy-makers, regulators, inspectors and user organisations.

Weaknesses

• The results of this project might be a first step towards better comparability (mainly in a regional context), but it will take a long time to achieve real benchmarking processes, due to huge differences in regulatory frameworks, management approaches and cultural specificities within and between Member States.

Opportunities

• The indicators and the Handbook resulting from this project might be used to underpin more normative frameworks such as the “European Charter of the rights and responsibilities of older people in need of long-term care and assistance” or the voluntary "Quality Framework for Social Services in Europe" with practical tools to realise abstract aims.
• The indicators may also be a basis for further development of inter-agency working, for cross-organisational performance assessment in LTC and for improving structures, processes and results along the ‘chain of care’.
• The indicators and the Handbook may underpin first steps of regulatory bodies to move from inspecting merely structural and some process indicators to assessing results in care homes.

Threats

• Stakeholders such as care home providers might be hesitant to integrate work with result-oriented indicators into their already existing quality management approach and/or to link it with the national regulatory framework. It will thus be necessary to show that this kind of decision is short-sighted in view of the cost-savings potential linked to result-oriented performance indicators. 

Credits

Links to other INTERLINKS practice examples

• Outcome indicators for rating the quality of care provided by care homes for older people
• RAI-benchmarking: An instrument for leadership and development
• The E-Qalin quality management system

External Links and References

• ActiZ et al (2007) Kwaliteitskader Verantwoorde zorg Verpleging, Verzorging en Zorg Thuis (langdurige en/of complexe zorg).
• Commission for Social Care Inspection/CSCI (2008) Annual quality assurance assessment. Care homes for Older People Guidance. London: CSCI (for updates see CQC).
• E-Qalin (2009) Manual United Kingdom, Version 3.0. Bad Schallerbach: E-Qalin GmbH.
• Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen/MDS (2009) Grundlagen der MDK-Qualitätsprüfungen in der stationären Pflege. Qualitätsprüfungs-Richtlinien, MDK-Anleitung, Transparenzvereinbarung. Essen: MDS.
• Nolan, M., Brown, J., Davies, S., Nolan, J. and J. Keady (2006) The Senses Framework: Improving care for older people through a relationship-centred approach. Sheffield: University of Sheffield.
• Ministerium für Arbeit, Gesundheit und Soziales des Landes Nordrhein‐Westfalen (Hg.) (2006) Referenzmodelle zur Förderung der qualitätsgesicherten Weiterentwicklung der vollstationären Pflege 2004–2006 – Qualitätsmaßstäbe für die vollstationäre Pflege – Version 1.0. Düsseldorf: MAGS NRW.
• Schalock, R. L., Bonham, G., S. and M. A. Verdugo (2008) ‘The conceptualization and measurement of quality of life: Implications for program planning and evaluation in the field of intellectual disabilities’ in: Evaluation and Program Planning, Vol. 31: 181-190.
• US Department of Health and Human Services (US DHHS) (2008) MDS 2.0 Public Quality Indicator and Resident Reports. 
• Quality management by result-oriented indicators. Towards benchmarking in residential care for older people. Project information.
• European Centre for Social Welfare Policy and Research (Coordinator) (2010) Measuring Progress: Indicators for Care Homes. Vienna, Bad Schallerbach, Utrecht, London, Dortmund, Essen, Düsseldorf: European Centre, E-Qalin, Vilans, City University, Uni Dortund, MDS, MGEPA NRW (also available in Dutch and German language here.
• Policy Brief