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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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slide1

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
slide2

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
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

the icelandic context
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
falls
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
cost of care in nursing homes rantz o fl 2009
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

the importance of standards
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
the setting of standards zimmerman et al 1995 donabedian 2003
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!

delphi method expert panel
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
delphi method
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
delphi method12
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
methodology
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
expert panel in iceland
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
methodology15
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
methodology16
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
rai data for reference
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
how can we support nursing homes in improving care
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
productive collaboration
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
the extend of support
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
estimated savings due to reduction in quality problems
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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