Quality indicators and quality improvement processes in Swiss nursing homes: a multi-study research project

Summary
As a growing number of persons live longer, the proportion of those reaching very old age and requiring 24h professional medical and social care in the last months or years of their life is rising. This puts increased pressure on nursing homes (NHs), which already face considerable challenges. Controversies about care quality offered by NHs are commonplace. Yet, what constitutes quality of NH care is not well-defined and the existing definitions are broad, multidimensional and difficult to operationalize. In practice, quality of care in NHs is often measured with quality indicators (QIs). QIs can be measured in different ways (e.g., using standardized data) and can target a broad variety of quality of care aspects (e.g., physical restraint use, occurrence of pressure ulcers). QIs are used to determine and monitor the level of quality of care provided by NHs and can support increased transparency and regulatory efforts. QIs can also stimulate quality improvement by enabling consumers to choose higher-performing NHs and incentivizing NHs to improve their care. QIs’ measurement properties (e.g., validity, reliability) should be thoroughly assessed before they are implemented to ensure their validity and usefulness. While robust quality measurement is needed, it is not sufficient to improve the quality of care provided by NHs. Measuring quality of care does not necessarily lead to the improvement of the care quality: QI results are often not used by NHs for quality improvement, NHs often do not know how to act to improve suboptimal QI results, and quality improvement efforts do not necessarily lead to better resident outcomes. Furthermore, the processes that lead to the provision of high quality of care are complex and influenced by various interconnected factors, beyond quality measurement and improvement efforts (e.g., leadership, staffing levels, organizational culture, expertise).
This thesis has 8 chapters, which address gaps in the literature regarding the measurement and improvement of quality of care in NHs. The overall aim of this thesis is to provide evidence to contribute to answer the question: “How can quality of care be measured, maintained and developed in NHs?”. It is guided by a theoretical framework from Berwick and colleagues exploring the links between quality measurements and improvement. This dissertation is a multi-study research project that includes a systematic review as well as a qualitative and multiple quantitative studies. It uses data from four different studies, which are all (except for the review) grounded in the Swiss NH setting.
Chapter 1 introduces the main themes of this dissertation. It starts with a short summary of the societal achievements and challenges linked to the current aging of the society and highlights the on-going need for NHs. It then discusses different definitions of quality of care, and provides an introduction to the theme of NH QIs as a way to measure and ultimately improve quality of care. QIs are defined and data collection, purposes and measurement properties are shortly discussed. Then, Berwick and colleagues’ theoretical framework for quality improvement is presented as the guiding framework of this thesis. It demonstrates that quality measurements are necessary but not sufficient for quality improvement. The theme of quality improvement in NHs is then briefly tackled. An overview of the Swiss NH setting, in which the majority of this thesis’ results are rooted, is presented. Finally, the introduction highlights the research gaps that the articles included in the thesis aimed to fill as well as the rational for this thesis.
Chapter 2 presents the aims of this thesis. This dissertation aimed to investigate the use of QIs and the improvement of quality of care in NHs. Particularly, this thesis aimed 1) to provide an overview of QIs used in the LTC sector and of their quality, both internationally and in Switzerland, 2) to explore the definition and the development of quality of care in NHs and NHs’ engagement in quality improvement activities, and 3) to investigate the influence of modifiable factors on one of the most widely-used NH QIs, the use of physical restraints.
The first article, presented in Chapter 3, systematically reviews the grey and peer-reviewed literature on publicly reported QIs for the LTC sector with the aims to report up-to-date information on the quality of care themes measured as well as on the quality of the currently used LTC QIs. Eight countries were reporting NH QIs, for a total of 94 QIs covering 31 themes. Most frequently measured themes were pressure ulcers, falls, physical restraints and weight loss. Using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument, we showed that only one QI set (i.e., the Australian set) reached high methodological quality. Overall, we concluded that only little information is available to the public and to researchers to correctly assess the QIs in use in the LTC sector. A more robust development, assessment and reporting of NH QIs are needed to strengthen the potential usages of such measurements for quality improvement of care in LTC facilities.
In Chapter 4, we aimed to report the reliability and between-provider variability of the first six Swiss NH QIs. These cover four themes: pain, polypharmacy, physical restraint use and weight loss. We also aimed to report the prevalence rate of each QI. Using a convenience sample of 152 Swiss NHs from a cross-sectional study, two methods not yet applied to NH QIs – intraclass correlation and rankability – were employed to assess some of these QIs’ measurement properties. Our findings show that all QIs have fine reliability and between-provider variability properties, except for polypharmacy and self-reported pain, which are less able to reliably distinguish care differences between NHs, limiting their usability for public reporting and provider comparison. The methods used worked well and can be used to evaluate other NH QI sets. This chapter was published in 2020 in the International Journal of Environmental and Public Health.
Chapter 5 examines qualitatively how managers from top-performing Swiss NHs define, maintain and improve quality of care. Using a sub-sample of facilities having participated in the Swiss Nursing Homes Human Resources Project study (SHURP 2018), a cross-sectional study aiming at exploring quality of care and work environment in Swiss NHs (2018-2019), we interviewed upper- and middle-management of top-performing NHs to explore the role of leadership regarding quality of care provision and improvement. This study confirms that a person-centered approach for both residents and staff is essential for the provision of high quality of care and that the most effective managers seem to personify “person-centeredness”, lead with commitment and promote quality-focused working conditions. Improving quality is an active, continuous and participative process, rooted in everyday practice and it is regularly and consciously checked. This study provides evidence on how NH leaders contribute to the provision and improvement of high quality of care. This chapter was published in 2021 in BMC Health Services Research.
Chapter 6 describes the involvement in quality improvement activities of NHs and of nurses in expanded roles, i.e., nurses with skills and a role beyond those of regular registered nurses (RNs). A sample of n = 115 NHs and n = 104 nurses in expanded roles from the SHURP 2018 study was used. While quality improvement interventions are the subject of much research, evidence on the engagement of NHs in daily quality improvement activities is lacking. Especially, we aimed to investigate the extent to which Swiss NHs were using data to improve their care. Most Swiss NHs stated that they were involved in a large number of quality improvement activities and minority of NHs had a low involvement. We further showed that nurses in expanded roles contribute substantially to quality improvement programs in Swiss NHs, but that a higher involvement is seen in nurses with a higher educational level, especially in data-driven activities. This article provides first evidence on the level of engagement and about the types of quality improvement activities done by both Swiss NHs and nurses in expanded roles, contributing to an emerging field.
The final article of this thesis, presented in Chapter 7, focuses on one of the quality of care aspects most frequently measured in NHs: physical restraint use. Using routinely collected resident data and data from the SHURP 2018 study, a socio-technical approach was applied to explore the relationship between physical restraint use in NH units and the use of surveillance technologies (e.g., GPS, camera) as well as staff opinions about the appropriateness of using restraint use. Surveillance technologies have been hypothesized to reduce physical restraint use in NH residents and they are already broadly used in NHs, but evidence is scarce. Our findings show that the use of physical restraints was not related to the use of surveillance technologies in NH units. As such, further research is needed to guide broader implementation of surveillance technologies in NHs. Additionally, it has also been hypothesized that negative staff opinions regarding the appropriateness of using physical restraints was correlated with a lesser use of restraints. Contrary to this hypothesis, we found that staff opinion that their units’ physical restraint use was inappropriate was associated with higher odds of residents being restrained. This shows that staff might know and assess correctly when they are overusing restraints or using them too quickly. This chapter was published in 2022 in the Journal of the American Geriatrics Society.
Chapter 8 synthesizes and discusses this dissertation’s major findings in light of relevant literature. Discussion points include the concept of quality of NH care, the relevance of using QIs in the NH sector and ways residents can and should be further included in the quality discussion. Furthermore, the use of QIs for quality improvement as well as the lack of expertise in NHs to deal with such data is tackled. Finally, methodological weaknesses and strengths of all studies included are presented and implications for future research, policy and practice are discussed. This thesis contributes to the field of NH quality measurements and improvement by providing new insights regarding several aspects related to these themes.