Ingibjörg Hjaltadóttir, cand. PhD
Faculty of Nursing, University of Iceland
Department of health Sciences, Lund University, Sweden

 The context of this presentation
 Falls
 Setting standards
 The Delphi method
 Falls in Icelandic nursing homes
 Quality improvement in nursing homes

Quality of Care, Residents’ Health status, functional profile and Survival in Nursing Homes
Doctoral studies at Lund University Sweden
Supervisors:
Professor Ingalill Rahm Hallberg and
Dr. Anna Kristensson Ekwall
III Setting quality standards for care in nursing homes
IV Quality of care over the years 1999-2009

 Resident Assessment Instrument (RAI) used for all nursing home residents from 1996
 RAI measures health and care needs of residents
 20 RAI Quality Indicators (QI) are computed from RAI assessments (Zimmerman et.al., 1995)
 Nursing homes have had access to their own Quality
Indicators and the national mean values since 1996

 Prevention of Falls Network Europe:
“An unexpected event in which the participants come to rest on the ground, floor, or lower level”
 RAI Quality Indicators: % of residents that have fallen in the last 30 days
 Falls are very prevalent in hospitals and nursing homes
 They can lead to suffering, increased mortality risk and increased cost

(Rantz o.fl., 2009)
Falls- $ 19.440– Sw kr 133.200
20-30% of falls will lead to medium or severe injury
Restraints- $ 4146 – Sw kr 28.400
Will lead to physical decline
Urinary incontinence- $ 5618– Sw kr 38.500
Pressure ulcer- $ 2119 – Sw kr 14.500

 Standards of care are needed when working toward improvement of care
 Standards need to be:
 According to best practice
 Incentive for improvement
 Attainable

(Zimmerman et.al., 1995; Donabedian, 2003)


Quality standard decided by experts


Comparison between peers
Comparison to the distribution of quality measures in an area (percentiles) 10%, 25%, 50%, 75% and 90%
Comparison to means
Comparisons between peers can be problematic!

60
50
%
40
80
70
30
20
10
0
Missouri 2003
25% Missouri
Median Missouri
75% Missouri
25% Iceland
Median Iceland
75% Iceland
Iceland 2009
Rantz, 2003; Ingibjörg Hjaltadóttir, 2010



Named after the Oracle in Delphi
Delphi Method
(1944; Helmer, Dalkey og Rescher, 1950-60)
 RAND Corporation 1950-1960
 Originally developed to forecast about the use of technology in warfare at the beginning of the cold war

 The method has been deweloped in different ways
 Modified Delphi (McKenna 1994)
 Real-time Delphi (Beretta 1996)
 Policy Delphi (Crisp o.fl. 1997)
 Now used mostly in:


Research and planning in business
Research in medicine, nursing and health care

 The aim is to reach a consensus from individual panel members
 The work is anonymous and panel members can revise their opinions
 The aim is to minimize the bandwagon effect i.e. that a
“strong” member of the group can “control” the opinions of others
 The experts will work 2 or more rounds



Used for nursing home RAI quality indicators in
Missouri
Modified Delphi method (Rantz et.al. 2000)


1996 (Rantz et al., 1997) – 3 rounds
1998 (Rantz et al., 2000) – 2 rounds

 12 members in an expert panel





2 Nursing home directors (RN)
3 Nursing home project nurses
3 Clinical nurse specialist in geriatric nursing
3 Geriatricians (MD)
1 Medical doctor


The expert panel met for one day and completed two
Delphi rounds determining standards for 20 Quality
Indicators
The experts had Icelandic data for reference

 1. round
 The experts discussed each Quality Indicator in relation to:
 What is an achievable score indicating good resident outcomes and good-quality of care
 What would be thresholds (standards) that would indicate poor outcome for the residents and need for improvement
 Each expert then wrote down their opinion anonymously

 2. round
 The results from the first round were presented anonymously
 Each expert again wrote down his opinion anonymously
 When a consensus has been reach further rounds are not needed

 20 Quality Indicators from 47 nursing homes
 Newest assessment for each residents in the year 2009
 Excluded data:
 First assessments and re-admittance assessments
 Nursing homes with less than 10 assessments
 N=2247

% 50
40
30
20
10
0
90
80
70
60
Use of nine or more different medications
Missouri lower
Missouri higher
10% Iceland
25% Iceland
Median Iceland
75% Iceland
90% Iceland
Expert lower
Expert higher

% 50
40
30
20
10
0
90
80
70
60
Use of nine or more different medications
Missouri lower
Missouri higher
10% Iceland
25% Iceland
Median Iceland
75% Iceland
90% Iceland
Expert lower
Expert higher

% 50
40
30
20
10
0
90
80
70
60
Use of nine or more different medications
Missouri lower
Missouri higher
10% Iceland
25% Iceland
Median Iceland
75% Iceland
90% Iceland
Expert lower
Expert higher

% 50
40
30
20
10
0
90
80
70
60
Use of nine or more different medications
Missouri lower
Missouri higher
10% Iceland
25% Iceland
Median Iceland
75% Iceland
90% Iceland
Expert panel lower
Expert panel higher

80
70
60
% 50
40
30
20
10
0
Prevalence of antianxiety/hypnotic use
Missouri lower
Missouri higher
10% Iceland
25% Iceland
Median Iceland
75% Iceland
90% Iceland
Expert panel lower
Expert panel higher

%
15
10
5
0
25
20
Missouri 2003
Prevalence of falls
Iceland 2009
25% Missouri
Median Missouri
75% Missouri
25% Iceland
Median Iceland
75% Iceland

%
15
10
5
0
25
20
Prevalence of falls
Missouri lower
Missouri higher
10% Iceland
25% Iceland
Median Iceland
75% Iceland
90% Iceland
Expert panel lower
Expert panel higher

N=11.912
Prevalence of falls 1999-2009

N=11.912
Case mix index – Level of care needed

 A collaboration led by Professor Marilyn Rantz since 1990 between:
 The Sinclair School of Nursing at the University of
Missouri and nursing homes in Missouri
 Support and quality improvement work with nursing homes in Missouri

 Professional support from specialists in geriatric nursing
 Education for nursing home staff on:
 Certain topics in geriatric nursing
 The use of Quality Indicators
 The use of thresholds/ standards of care
 Education on how to use evidence based knowledge
 Quality improvement teams established in the nursing homes

 Over a year there were from 1 to 10 visits of nursing specialist to the nursing homes
 Most often 1 to 4 times
 The visit would last for 2 to 3 hours
 Over the year there would be from 1 to 10 telephone calls
 Most often 5 to 10 calls

 Estimated savings in 60 nursing homes with quality problems over the year 2006
 $ 1.550.000 – Sw kr 10.600.000
 Cost of specialist support
$ 550.000 – Sw kr 3.700.000
 Net savings were
$ 1.000.000 – Sw kr 6.900.000