Safer Care for Older Persons (in residential) Environments
SCOPE “Proof of Principle” Final Report
Better worklife…Better care
Knowledge Utilization Studies Program (KUSP)
University of Alberta
May 2012
Production of this final report has been made possible through a financial contribution from
Health Canada. The views expressed herein do not necessarily represent the views of Health
Canada.
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SCOPE Final Report, May 2012
Main Messages
Increasing complexity of care required for nursing home residents and the often low
value placed on their healthcare providers (primarily unregulated healthcare aides)
contribute to poor quality of worklife for healthcare providers. This, in turn, can result in
high rates of staff burnout and turnover, and less than optimal resident care.
The Safer Care for Older Persons (in residential) Environments (SCOPE) study
concluded that:
 Collaborative quality improvement (QI) can enhance the quality of worklife of
healthcare providers in long-term care facilities.
 QI support can also improve the quality of care to nursing home residents.
 To be successful, this type of QI initiative requires a concerted team effort among
frontline staff, managers, and administrators.
 Managerial support is key to QI team success.
 Facilitating an exchange of learning and care strategies among different nursing
homes can expedite improvements in care and potentially decrease costs.
 Collaboration and support among provincial decision makers and various
stakeholders are essential to widespread success.
Decision makers and stakeholders should consider the value of collaborative QI
initiatives in nursing homes as a means to:
 Improve recruitment and retention of healthcare providers, especially healthcare
aides.
 Enhance the care of frail elderly residents.
 Use routinely collected data from the Resident Assessment Instrument – Minimum
Data Set 2.0 to monitor the effects of QI activities on resident outcomes.
SCOPE Final Report, May 2012
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Executive Summary
Safer Care for Older Persons (in residential) Environments (SCOPE) was a two-year (20102012) pilot or proof of principle project conducted in seven nursing homes in Alberta and British
Columbia. The overall goal of this project was to improve the quality of worklife for healthcare
aides (HCAs) in nursing homes in Canada and to improve the safety and quality of care for frail
elderly Canadians living in these nursing homes.
Background
Almost one-half of Canadians in long-term care (LTC) facilities are frail elderly over 80 years of
age. Recent Canadian Institute for Health Information figures show that nation-wide in 2010/11,
approximately 60% of LTC residents had a diagnosis of dementia. This growing number of
nursing home residents with dementia has created job strain and job-related stress for
healthcare providers, leading to reduced job satisfaction and high staff turnover. Healthcare
providers’ quality of worklife in turn affects resident outcomes; for example, high staff turnover
has been linked to poor resident outcomes, such as decreased functional ability and pressure
ulcers.
The SCOPE Project
A 12-month collaborative quality improvement (QI) program was initiated in the participating
nursing homes. Teams of three to five staff were led by a healthcare aide and supported by a
senior sponsor. The teams selected one of three areas of care - behaviour management, pain
management, or pressure ulcer (skin care) management - and used a process to improve care
based on the Plan-Do-Study-Act model. Throughout the QI intervention, the teams were
supported through learning sessions, getting-started kits, access to clinical and QI experts,
coaching and change management techniques
The effect of the QI program on the work setting (context) and resident outcomes was assessed
using the SCOPE survey and the Resident Assessment Instrument – Minimum Data Set 2.0,
respectively. QI process data were also analysed.
Findings
1. The more successful QI teams showed greater team engagement, as well as stronger
senior leadership and support.
2. Teams placed more value on manager support than administrator support.
3. Most of the QI teams rated themselves highly on team performance.
4. Team success was higher with more frequent brief, informal team meetings (huddles) and
regular participation in team telephone calls.
5. Barriers to implementation included: time constraints, flu outbreaks, manager or staff
turnover, team members working different shifts, structural or regional issues, and lack of
buy-in from staff.
6. Some participating nursing homes reported an improvement in the work setting and use of
best practices by staff.
7. Some participating nursing homes reported an improvement in resident outcomes: less
aggressive behaviour, fewer pressure ulcers, and less daily pain.
Based on these results decision makers and stakeholders are encouraged to adopt policies,
practices, and structures that promote a collaborative culture of quality improvement in
residential/long-term care. This culture should include meaningful “bottom-up”, as well as
traditional “top down” QI strategies in order to achieve change at the care unit level.
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SCOPE Final Report, May 2012
Background
SCOPE was one of three studies in an
applied research program in long-term
care:
1. TREC, Translating Research in Elder
Care, examined the role of
organizational context in establishing
best practices in the long-term care
(LTC) environment in three Canadian
prairie provinces.
2. OPTIC, Older Persons Transitions in
Care, looked at the relationship
between nursing homes, emergency
departments, and medical transfer
services in British Columbia and
Alberta.
3. SCOPE, Safer Care for Older Persons (in residential) Environments was a two-year quality
improvement (QI) project that took place in seven urban nursing homes - two in Alberta, and
five in British Columbia, beginning in September 2010. It involved a collaborative approach
to QI based on similar models developed by the Institute for Healthcare Improvement for
their Breakthrough Series and by the Safer Healthcare Now!, Canadian initiative.
The objectives of the SCOPE project were to:
1. support staff in learning and using quality improvement methods to enhance the safety
and quality of care of nursing home residents, and
2. improve the quality of worklife for staff providing direct care to older persons in
participating nursing homes.
It was anticipated that achieving these objectives would also improve resident outcomes in the
areas of care on which the QI teams focused: pain, pressure sores, and declining behaviour.
The SCOPE project sought to answer several questions. Does the SCOPE process lead to
increased use of best practices to inform care provision? Does engaging staff in a QI initiative
improve resident outcomes and staff quality of worklife? How does organizational context
influence the degree of success of the teams in improving quality and safety of care? How does
organizational context affect staff and resident outcomes?
Context is the environment or setting where people receive healthcare services
or in the case of moving research evidence into practice, the environment or
setting where a proposed change is implemented. Appendix A outlines how
organizational context is measured.
“SCOPE enabled us to build the capacity and confidence of our point-of-care teams.
Team members have become champions for Quality Improvement and are
making a significant impact on the quality of care of our residents.”
-Don McLeod, VP for Organization Effectiveness, Bethany Care Society, Calgary
SCOPE Final Report, May 2012
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The Quality Improvement Initiative
SCOPE had two components that ran in parallel: a quality improvement (QI) arm and a research
arm.
The QI Arm
For the purposes of the project, each
nursing home formed one or more QI
teams consisting of two to three
healthcare aides and one to two
registered healthcare professionals. A
healthcare aide headed each team. In
each facility, a senior sponsor was
recruited to serve as a champion.
Teams selected one of three areas of
care to focus on: pain management,
behaviour management, or pressure
ulcer (skin care) management. The
teams then worked to improve that area
of care on their unit.
SCOPE QI Team Configuration
HCA
RN
QI
TEAM
HCA
Team Leader
Senior
Sponsor
HCA
RPT
HCA, healthcare aide; RN, registered nurse, and
Legend: HCA: Healthcare Aide; RN, registered nurse, and RPT, registered physiotherapist, represent the registered professional;
The 12-month QI intervention was
RPT, registered physical therapist, represent registered healthcare professionals.
designed on the Institute for Healthcare
Improvement, Breakthrough Series Collaborative Model. The model is a shared learning system
where teams aim to improve their work in care areas.
SCOPE Coaching and Change Management Support
COACHING & CHANGE
MANAGEMENT SUPPORT
SCOPE STAFF,
QI EXPERTS
AND CLINICAL
EXPERTS
Weekly QI Team Coaching
Online Access to Team Data
Monthly Feedback Reports
Monthly Joint Team Conference Calls
Change Packages
Emails
Throughout the SCOPE intervention, teams received QI training and support that included skill
development in QI techniques, provision of change packages, and regular coaching and
mentoring.
“I believe that this project is a wonderful opportunity to make beneficial changes on the frontline.”
-HCA team leader
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SCOPE Final Report, May 2012
Other key components included face-to-face learning sessions, action periods using the PlanDo-Study-Act cycle, a meeting of all provincial QI teams, and a final celebratory learning
congress.
The SCOPE Learning Collaborative Model
Recruitment of
7 sites (AB and BC) and
Formation of QI Teams
Selection of Areas of Focus
(3-Step Collaborative Process)
Tools/Resource Development
by Clinical & QI Expertsa
AP 1
LS1
AP 2
LS 2
AP 3
PTM
b
LC
COACHING & CHANGE MANAGEMENT SUPPORTS
E ma ils
S it e Vis it s
Ph o n e Ca lls
A s s e s s m e n ts
S e n i o r L e a d e r R e p o rt s
a
Co n feren c e Ca lls
Team Reports
Tools, e.g. change packets
b
Provincial Team Meetings consisted of regional face-to-face half-day sessions, one for BC and another for AB.
Legend: AB, Alberta; AP, Action Period; BC, British Columbia; LC, Learning Congress; LS, Learning Session;
PDSA, Plan-Do-Study-Act Cycle; PTM, Provincial Team Meeting; QI, Quality Improvement.
The Plan-Do-Study-Act (PDSA) cycle of rapid change was derived from the Model for
Improvement (developed by the Associates in Process Improvement), which also provided three
fundamental questions used to drive the QI teams’ work: What are we trying to accomplish?
How will we know that a change is an improvement? What changes can we make that will result
in improvement?
The Research Arm
To learn about organizational context, research use, and staff outcomes (e.g., job satisfaction),
healthcare aides in each facility were surveyed before (2010) and after the intervention (2011).
Additional data were collected to learn about the facility, how the teams worked, the QI process,
and changes in the quality of care to residents.
Information collected within the SCOPE research arm included:
 SCOPE Survey: data on organizational context, staff outcomes, and quality of worklife.
 Staffing data and facility and unit profiles.
 QI Data: Monthly assessment of QI processes such as team readiness for change and
barriers to change.
 Resident Assessment Instrument – Minimum Data Set (RAI-MDS 2.0) collected routinely
on admission and quarterly from 2009 to 2011 to track resident outcomes. See Appendix
B.
The QI and resident outcome data were also used in feedback reports to the teams within the
PDSA cycles.
1
http://www.apiweb.org/services.html
SCOPE Final Report, May 2012
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Study Results
Quality of Team Process
Most of the QI teams gave high ratings to their performance as a team. This included
assessments of team spirit, standing up for each other, pitching in to help each other,
discussion of resident care assignments, and sharing of ideas and information. The teams
identified several facilitators and barriers to successful performance. The facilitators were strong
team communication, team motivation, team work, and manager support. The perceived
barriers were time constraints, leadership issues, change issues, external regional issues, lack
of buy-in from the staff, and difficulty engaging staff in the initiative.
7.5
Team Performance Ratings During the QI Intervention
STRONGLY AGREE 7
TEAM SPIRIT AMONG MEMBERS
6.5
DEPENDENCE ON EACH OTHER
MODERATELY AGREE 6
STAND UP FOR EACH OTHER
PITCH IN TO HELP EACH OTHER
5.5
SLIGHTLY AGREE 5
4.5
NEUTRAL 4
A
B
C
D
E
NURSING HOMES
F
G
Quality of Worklife
Comparing SCOPE survey scores before and after the QI initiative, ratings of the work setting
and the use of best practices showed a trend towards improvement in some of the participating
nursing homes. Positive change in practice measures included: using data to assess and
improve on performance, thinking about best practice and how to do it (conceptual research
use), and the perception of the amount of time healthcare aides have to deliver care on their
unit.
Conceptual Research Use in SCOPE Units.
3.8
SCOPE
Units
3.7
Non-SCOPE
Units
3.6
Pre-SCOPE
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Post-SCOPE
SCOPE Final Report, May 2012
Quality of Care and Resident Outcomes
The quality of care also showed an improvement in resident outcomes in some of the SCOPE
units. The figure below illustrates how staff in one nursing home focused on improving skin care
using a resident turning schedule. The proportion of resident turns completed increased to
100% during the intervention and was maintained at that level throughout the following 5
months.
Percentage
of Turning,
Turns Completed
Completion
of Resident
Facility X, Mar–Oct 2011.
100%
100%
80%
91 %
60%
20%
30%
1
3
5
7
9
Time
11
13
15
17
In a number of facilities, the targeted resident outcomes also showed improvements in the RAI
quality indicators. These RAI indicators will continue to be monitored for further changes over
time.
Trends in the Resident Outcomes During SCOPE
QI
Team
Facility
1
A
2
Topic
Area
Skin
Trend over the
course of
SCOPE
Decreasing
RAI QI indicator
Stage 2-4 Pressure Ulcer
A
Pain
Stable
Mild to Severe Pain, Daily
3
A
Behaviour
Stable
Declining Behavioural Symptoms
4
B
Behaviour
Improving
Declining Behavioural Symptoms
5
B
Pain
Decreasing
Mild to Severe Pain, Daily
6
C
Behaviour
Got worse
Declining Behavioural Symptoms
7
D
Pain
Improving
Mild to Severe Pain, Daily
8
E
Behaviour
Improving
Declining Behavioural Symptoms
9
F
Pain
Stable
Worsening Pain
10
G
Skin
Improved
Stage 2-4 Pressure Ulcer
SCOPE Final Report, May 2012
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Key Learnings
1. The QI initiative strengthened the QI teams’ knowledge and capacity to achieve change.
2. The QI teams valued engagement and support from managers and senior leaders.
3. The teams found the QI advisors’ coaching helpful.
4. Using facility (local) RAI-MDS 2.0 data helped track team progress on their QI activities.
5. Quality of care and worklife showed highly promising trends toward improvement with QI
support.
Good communication and frequent team huddles were essential in the QI team’s success.
Where to from here?
SCOPEOut is a one-year follow-up to the proof of principle project
aimed at measuring the dynamics of spread and sustainability of the
SCOPE-initiated:
 quality improvement activity,
 clinical care,
 quality of worklife, and
 attitudes to uptake research-informed practices
All 7 SCOPE facilities are participating in SCOPEOut .
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SCOPE Final Report, May 2012
Appendices
Appendix A. The Alberta Context Tool
Context is the environment or setting where people receive healthcare services or in the case of
moving research evidence into practice, the environment or setting where a proposed change is
implemented. The SCOPE Survey uses the Alberta Context Tool (ACT) which measures
variables that can have an effect on an organization’s environment. The three core dimensions
of context looked at based on the PARIHS framework are culture, leadership, and evaluation,
(http://www.parihs.org).
Other dimensions we looked at include organizational slack, formal interactions, informal
interactions, structural and electronic resources, and social capital.
The Alberta Context Tool Framework
Leadership
Plus:
• Organizational slack
(time, space, staff)
Context
Culture
• Formal interactions
• Informal interactions
• Resources
Evaluation
(Feedback)
• Social capital
Appendix B. The RAI-MDS 2.0
The Resident Assessment Instrument – Minimum Data Set 2.0 is used to assess the needs and
risks of residents in long-term care. It measures 24 indicators for quality of care, e.g.
behavioural patterns, physician functioning, and nutrition.2 The SCOPE Project used the RAIMDS indicators for the selected care areas in behaviour, pain, and skin ulcers.
Some of the RAI-MDS 2.0 Quality Indicators used in SCOPE.
QI indicator
Percentage of residents with...
DAILY PAIN
Mild to severe daily pain on a daily basis
BEHD 4
Declining behavioural symptoms
PRU 05
Stage 2-4 Pressure ulcers
PAN 01
Worsening pain
2
Hutchinson et al., The Resident Assessment Instrument-Minimum Data Set 2.0 quality indicators: a systematic review BMC Health
Services Research 2010, 10:166.
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Acknowledgement
SCOPE is grateful for the participation and enthusiasm of the administrative and care staff of the following
nursing homes:
Bethany Care Society, Capital Care Lynnwood, The Gateby, Noric House,
Pleasant Valley Manor, Trinity Care Centre, Westview Place
Principal Investigator
Carole A. Estabrooks, RN, PhD, FCAHS, FAAN
Professor & Canada Research Chair in Knowledge Translation, Faculty of Nursing, University of Alberta
Co-Investigators
Peter G. Norton, MD, PhD, FRCPSC
Greta G. Cummings, RN, PhD, FCAHS
Lisa Cranley, RN, PhD
Professor, Department of Family
Medicine, University of Calgary
Professor, Faculty of Nursing
University of Alberta
Postdoctoral Fellow, Faculty of Nursing
University of Alberta
Research Team
Debbie Barnard
Marlies van-Djik
Project Manager, University of Alberta
Julia Arsenault
QI Consultant, BC Patient Safety & Quality Council (formerly
with Safer Healthcare Now)
Quality Improvement Advisor, University of Alberta
Peter George Tian
Carole Taylor
Project Coordinator, University of Alberta
Quality Improvement Advisor, University of Alberta
Mehvash Qureshi
Research Assistant, University of Alberta
Decision Makers
Alberta
Caroline Clark
British Columbia
Joanne Konnert
Executive Director, Seniors Health, Alberta Health Services,
Edmonton
Vice President, Tertiary Services, Interior Health Authority,
British Columbia
Belle Gowriluk
Cindy Regier
Director, Supportive Living Services, Alberta Health
Services, Calgary
Director, Residential Services, Interior Health Authority,
British Columbia
Funding
Funding for this project is provided through a contribution agreement with Health Canada (CA# 6804-152009/9180076). We gratefully acknowledge the British Columbia Quality Council and the Canadian
Institutes of Health Research--Institute of Aging (201102MPA-248060-MPA-CBAA-55100) for their
financial contribution to the project.
Production of this final report has been made possible through a financial contribution from Health
Canada. The views expressed herein do not necessarily represent the views of Health Canada.
Contact Details
Carole A. Estabrooks, RN, PhD, FCAHS, FAAN
Safer Care for Older Persons (in residential) Environments (SCOPE)
Knowledge Utilization Studies Program, Faculty of Nursing, University of Alberta
5-007 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta T6G 1C9
Telephone: (780-) 492-3451 or 492-6187; Fax: (780-) 492-6186
Email: carole.estabrooks@ualberta.ca
Webpage: http://www.trec.ualberta.ca/en/SCOPE.aspx; http://www.kusp.ualberta.ca
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SCOPE Final Report, May 2012