Tracking users’ functional or cognitive outcomes, self-assessment reports, the use of satisfaction surveys, peer reviews and external evaluation of quality, are all tools for monitoring – on a more or less regular basis – that LTC quality does not deviate from set, agreed quality objectives or practice standards. Some OECD countries (Germany, Netherlands, some Canadian provinces) are also developing policies for measuring LTC user satisfaction. As quality of life is increasingly seen as an important metric to measure LTC quality, its objective monitoring becomes desirable.
As in the case of health care, tools for monitoring LTC quality can take different forms. These range from self-assessed reports by individual providers to external evaluations and public reporting:
●
Self-assessment reports.●
Peer reviews.●
User experience and satisfaction surveys.●
External evaluation by external oversight (such as rating agencies and independent third-party agency) or government body.Self-assessment is an internal evaluation that providers can make, often following
instructions or guidelines specifying specific performance items (see also Chapter 7). This monitoring exercise gives providers much freedom regarding what information to monitor, and how to carry out the assessment. Self-assessment has been incorporated in accreditation procedures or information diffused in public reporting in Australia and Japan, however no country relies solely on self-assessed information in their quality monitoring process. For example, in Japan, providers can submit information on available services and management, while prefectural governors or contracted agencies, monitor other information from external reviews or inspections (JPHA, 2009). Self-assessment can cover issues such as occupational level and skill of personnel, the number of complaints received, national standards (protection, social activities, choice), and the results of care home residents interviews.
Peer reviews are quality monitoring methods that give an opportunity to providers to
benchmark and compare services with other providers. The assessment is done by a peer, on the basis of commonly understood or internal criteria. Peer reviews can cover internal records, and may extend to monitoring whether providers’ practice is in line with existing
guidelines or protocols. Recommendations for improvements remain confidential and shared between peers. To date, there is relatively little evidence of the use of peer reviews among LTC workers.
Some OECD countries (Canada, Spain, Iceland, the Netherlands, Germany, England and the United States) have developed policies to monitor the satisfaction or experience of LTC users and their families, however only a few monitor regularly this aspect of care and results are not consistently published. These surveys record the view of LTC users on different aspects of care and facilitate the identification of problem areas, offering an opportunity for care recipients to voice their opinions. Information collected in surveys can range from quality of overall services to specific aspects on quality of life. Efforts to standardise the measurement of LTC users’ experiences to overcome subjectivity biases give insightful, qualitative information regarding the process and outcomes of care from the perspective of the user. For example:
●
In the Netherlands (in 2006), the Ministry of Health developed questionnaires for measuring the experiences of patients in different types of health care facilities, including nursing homes and homes for the elderly (so-called CQ Index; Winters et al., 2010). The survey is administered by an accredited, independent organisation. The institutions are ranked and the information is available to the public. The dimensions included in the CQ Index are: care plan and evaluation; shared decision making; treatment; information; body care; meals; professional competency; living comfort; atmosphere; living environment and privacy; activities; autonomy; mental wellbeing; security; availability of personnel.●
Germany has implemented three surveys of LTC users’ satisfaction, covering both home care and institutional settings. The third report, published in 2012 shows an increase in the degree of satisfaction from 67% to 76% compared to the 2007 survey results published, although, on specific indicators, improvements have not been consistent.●
In Alberta (Canada), the Health Quality Council is mandated to report LTC residents’ experience and satisfaction with the quality of services they receive. There were two surveys, one covering resident (2007/08), and one covering family experience (2007/08 and 2010/11). The former collected information on patient and respondent characteristics; reported family experience and perception of nursing home activities and services; family member rating of the care provided to the resident; willingness to recommend the nursing home; and suggestions on how care and services provided at the nursing home could be improved.External evaluations are executed by evaluation agencies within the government (e.g. prefectures in Japan3) or by external bodies (e.g., the Care Quality Commission in England or the Aged Care Standards and Accreditation Agency in Australia), using a standardised assessment method or protocol. They are often used within licensing, accreditation and auditing processes. While this is by far the more expensive procedure, the evaluations provide an independent, objective assessment based on a set of evaluation criteria and standards. The Canadian Institute for Health Information has recently introduced new quality indicators such as the national standardised reporting system for LTC (so-called Continuing Care Reporting System) to which care organisations submit data.
Conclusions
This chapter started by reviewing the process of assessment of care needs of people with physical or cognitive limitations. While needs assessment processes seem to be well developed across OECD countries, this process is often used to facilitate decisions regarding
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the type of public benefits a person would be entitled to rather than to target care needs and guide care practices. Rather, across a growing number of OECD and EU countries, standardised tools and scales are used by clinicians to normalise the assessment of care needs and rank the level of physical, cognitive and functional needs and used to guide care decisions, resource allocation, or to support the development of quality indicators. Examples include RAI in the United States, Canada, Finland and Iceland; AGGIR in France; KATZ in Belgium or the Dutch national standard tool in the Netherlands. Such indexes help providers prepare care plans and can support co-ordination of care across settings.
While in some countries decisions about benefit entitlement take into account individual circumstances regarding a person’s socio-economic status or family support, one of the strengths of these standardisation instruments is that there is little room for subjectivity in the process of assessing nursing needs. This means that standardised assessment instruments are not incompatible with tailoring of care services to the unique circumstances of LTC users or to regional differences.
Despite the potential of standardisation of needs assessment processes, they have not yet been employed to develop standards of practice. Rather, use of nursing guidelines and protocols is still quite limited. Possible reasons are that LTC workers have relatively low qualification levels, fewer peer-learning opportunities and low technical support for turning systematic assessment of care practices into guidelines. A further possible explanation is that clinical guidelines have often been developed around specific diseases, making it hard to adapt to multiple complex conditions of the frail elderly.
There is a need to develop better guidance for the care of people with complex neuro- degenerative conditions such as dementia. Assessment tools still do not address well the complex needs of people with dementia and the assessment of cognitive impairment remains therefore under-diagnosed. A positive development is the development of clinical guidelines around dementia care (Canada, France, Sweden, and Germany). Some national dementia strategies (e.g., Belgium, Denmark, France, the Netherlands, Norway, Sweden, England and Scotland) stress the importance of specific care guidance for LTC providers.
Traditional mechanisms for monitoring that care is safe and effective, such as self- assessment by care providers, are increasingly being accompanied by independent external appraisals, including as part of processes of auditing and accreditation. Among others, Germany, Netherlands, and some Canadian provinces are also developing policies for measuring LTC user experiences.
Notes
1. For instance, to date, eight Canadian provinces and territories have mandated the implementation of RAI assessment tools in nursing homes and hospital-based continuing care.
2. Guidelines are often produced based on evidence and promote standardised process in assessment, planning of care, treatment, and management (Conn et al., 2006). Guidelines are usually composed of step-by-step recommendations. Steps start from identifying individuals showing symptoms or at risks for screening and assessment, diagnostic criteria, treatment options by severity and assessment for referrals for psychiatric care, psychotherapies and psychosocial interventions, pharmacological treatment, monitoring of side effects and drug interactions, deciding duration of therapy and monitoring of after-treatment, and education and prevention
3. In Japan, there is no national external body responsible for quality assurance and oversight of LTC services.
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