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Falls and the importance of how standards of care are set PowerPoint PPT Presentation


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Falls and the importance of how standards of care are set. 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

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Falls and the importance of how standards of care are set

  • IngibjörgHjaltadóttir, cand. PhD

  • Faculty of Nursing, University of Iceland

  • Department of health Sciences, Lund University, Sweden


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  • The context of this presentation

  • Falls

  • Setting standards

  • The Delphi method

  • Falls in Icelandic nursing homes

  • Quality improvement in nursing homes


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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


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The Icelandic context

  • 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


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Falls

  • 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


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Cost of care in nursinghomes(Rantzo.fl., 2009)

Falls- $ 19.440– Swkr 133.200

20-30% of falls will lead to medium or severe injury

Restraints- $ 4146 – Swkr 28.400

Will lead to physical decline

Urinary incontinence- $ 5618– Swkr 38.500

Pressure ulcer- $ 2119 – Swkr 14.500


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Theimportance of standards

  • Standards of care are needed when working toward improvement of care

  • Standards need to be:

    • According to best practice

    • Incentive for improvement

    • Attainable


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The setting of standards?(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!


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Rantz, 2003; IngibjörgHjaltadóttir, 2010


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Delphi Method-Expert Panel

  • Named after the Oracle in Delphi

  • Delphi Method (1944; Helmer, DalkeyogRescher, 1950-60)

    • RAND Corporation 1950-1960

    • Originally developed to forecast about the use of technology in warfare at the beginning of the cold war


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Delphimethod

  • 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


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Delphimethod

  • 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


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Methodology

  • Used for nursing home RAI quality indicators in Missouri

  • Modified Delphi method (Rantzet.al. 2000)

    • 1996 (Rantz et al., 1997) – 3 rounds

    • 1998 (Rantz et al., 2000) – 2 rounds


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Expert panel in Iceland

  • 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


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Methodology

  • 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


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Methodology

  • 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


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RAI data for reference

  • 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


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Prevalence of falls 1999-2009

N=11.912


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Case mix index – Level of care needed

N=11.912


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How can we support nursing homes in improving care ?

  • A collaborationledbyProfessorMarilynRantzsince 1990 between:

  • TheSinclairSchool of Nursing at theUniversity of Missouri and nursinghomes in Missouri

  • Support and quality improvement work with nursing homes in Missouri


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Productive collaboration

  • 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


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The extend of support

  • 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


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Estimated savings due to reduction in quality problems

  • 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


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Thank you!


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