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Developing criteria for elderly nursing homes: the case of Lebanon Ramzi Nasser Qatar University, Doha, Qatar, and
Jacqueline Doumit Notre Dame University, Zouk Mikael, Lebanon
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211 Received 13 February 2009 Revised 17 August 2009 3 November 2009 Accepted 11 November 2009
Abstract Purpose – The purpose of this study is to establish a set of measurable criteria for elderly nursing homes (ENHs) in Lebanon. Donabedian’s model known by structure/process/outcome was used as the driving conceptual framework for the study. Design/methodology/approach – The study reports on a panel discussion where administrators, caregivers and specialists, separately established and exchanged key information on best practice approach. The work was carried out in the summer of 2008, using the consensus panel method. A group of expert opinions (Dalkey) made up of elderly home administrators and caregivers, policy makers, and academics discussed specific key issues related to elderly health and quality of life. Findings – A total of 40 criteria were retained along seven main dimensions: types of elderly homes; funding; health services; boarding services; activities; structures; and elderly rights. Research limitations/implications – A major limitation in this study is that elderly were not part of the consensus making process. Thus, including elderly in the process would have substantiated and added validity to the established criteria. Practical implications – The criteria developed in this study can be turned into key performance standards for elderly homes in Lebanon, other Mediterranean and Arab countries. These criteria would greatly benefit elderly homes if validated and used as guidelines for quality care. Originality/value – The study is original in the sense that it seeks to establish measures for criteria, a blueprint, and benchmarks for ENH standards. Keywords Performance levels, Quality awareness, Nursing homes, Elderly people, Elder care, Lebanon Paper type Research paper
Introduction In Lebanon, elderly reliance on private care has largely increased over the decade. The expansion of health related services, management and oversee of Elderly Nursing Homes (ENH’s) has demanded greater accountable measures by these institutions. Elderly persons and their guardians stipulate a greater quality service, transparency, suitable structures, and a functional health care system. Hence, ENHs in Lebanon face the challenges of providing quality care in a new era of administrative accountability and accreditation systems. The study was funded by the World Health Organization (Grant No. EM08058111).
International Journal of Health Care Quality Assurance Vol. 24 No. 3, 2011 pp. 211-222 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/09526861111116651
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Representatives from the World Health Organization (WHO); Lebanon office, the Ministry of Public Health (MoPH), and the Ministry of Social Affairs (MoSA) have suggested that ENH quality assurance and standards are much-called measures for health services. The work of the MoPH with the Australian consultants on the Overseas Project Cooperation of Victoria resulted in the development and implementation of a national accreditation program for hospitals (El-Jardali, 2007). This impetus, supported by WHO, the MoPH, and the MoSA brought interest to the development of procedures and key performance standards to upraise quality for ENHs. Despite the call for surveillance of ENHs, the development of standards and guidelines has not materialized within Lebanon in a foreseen national strategy. If translated into policy, it would envision a plan to develop standards as guidelines to upraise ENHs in promoting elderly wellbeing. Thus, the establishment of criteria is a first step in the development of quality assurance measures across ENHs (Cesarotti and Di Silvio, 2006). Elderly health systems in the US (Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), 2007), England (Department of Health, 2003), Australia (Braithwaite et al., 1993), and other Western countries follow strict administrative practice, and high standards (Sewell, 1997). The recognition of performance measures as indicators to evaluate and assess institutional performance within ENHs (Joint Commission for the Accreditation of Healthcare Organizations ( JCAHO), 1989, cited in Idvall et al., 1997; Proctor and Campbell, 1999), they underline the outcome-based approach to quality service. In Lebanon, survey studies by the National Commission of Elderly Affairs, sponsored by both MoSA and United Nations Population Fund (UNFPA), and Doumit and Nasser (n.d.) study; identified a number of measures used as indicators for the betterment of elderly life in ENHs but made little pathway among policy makers to develop a national elderly health strategy. The current synergy among the different Ministries and WHO underlines the awareness and need of elderly homes base-line information to better the structures, outcomes and processes of elderly lives. According to Waltz and Sylvia (1991), previous literature has been criticized by a lack of conceptual framework guiding the selection of outcome indicators. Hence, the approach used in this work is to build on available evidence in the field and literature, along a theoretical framework expressed in Donabedian’s (2005) model known by structure/process/outcome for quality assessment. Donabedian’s dimensions characterize a system in terms of resources, organization, and operational aspects of the healthcare delivery system. Process measures referred care, including elderly health assessment procedures, feeding, and daily care outcomes related to elderly quality of life and wellbeing (Mularski, 2006). Unique to Donabedian’s model is that it provides a framework to evaluate structure, skills, and activities within ENHs and subsequently the establishment of criteria that result in objective measures and key performance indicators (Fahey et al., 2003). The importance of the structure, processes, and outcome framework for service users in ENHs cannot be overly stressed. Evidence of facilities, resources, policies, activities, are outcome measures used as indicators for performance. The authors sought out criteria drawing from recent literature and existing consensus documents of the University of Wisconsin-Madison Center for Health Service Research and Analysis
(Zimmerman et al., 1995), the Minimum Data Set in all US Medicare/Medicaid certified nursing homes, and the standard handbooks that assess ENHs in England (Department of Health, 2003). The criteria were selected and organized nominally to include: . types of ENHs; . funding; . health services; . boarding services; . activities; . structures; and . elderly rights. The seven issues that were conceptualized in this study were grounded from the field and used to carry out the panel discussion and fit within Donebedian’s framework of structures, processes, and outcomes. The study surveyed a representative sample of administrators and practitioners of ENHs (known as the panel). All administrators of the 46 registered ENHs in Lebanon were invited to a one-day panel discussion. A second panel discussion invited the caregivers and support team in ENHs. The objectives of the study were to: . establish indicator measures for elderly living in ENHs; . provide face validity for the criteria measures judged by elderly home administrators and caregivers; and . provide recommendations and future direction in the development of criteria for ENHs. Method The method used in this study combined evidence from elderly wellbeing literature and expert perspectives. A panel of experts was invited to attend a roundtable discussion made up of elderly home administrators, caregivers, specialists, public health practitioners, association members, researchers, and academics. They were asked to provide a perspective on a set of criteria for ENHs and explore aspects related to ENH structures, skills, activities, and knowledge. Specifically, the expert panel provided face validity for each of the seven aspects mentioned earlier. The method in this study follows the consensus panel method (Campbell and Cantrill, 2001) were issues are quantified having limited evidence. This method is used to develop appropriate criteria (Ashton et al., 1994) and quality indicators (Campbell et al., 1998). It has experts or practitioners establish consensus on issues in a one-shot approach. The authors (group facilitators) with participants debate a topic, advance a view, discuss and share information. The debate is considered nominal to the extent that not one idea or discourse emerges. The panel members review, suggest, and generate quality improvement criteria for ENHs. The study employed two panel discussions. The first panel had administrators, the second panel had caregivers and support team of ENHs. A set of themes were
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presented separately to both panels. This approach prompted professional views, perspectives, and discussions that were carried out in an academic setting. A closed roundtable with administrators and specialists was held in one session while another was held with caregivers. The panel was given nominal questions or propositions about the seven main issues dealing with structure, skills, activities, and knowledge. In the discussion each idea was mulled over to generate a wider perspective and consensus over an issue. The panel was presented with questions and suggestions substantiated by the research literature, and Doumit and Nasser’s (2008) field results. Investigators provided the panel with detailed background information and field data. One investigator introduced the panel to the conceptual framework and objectives followed with a set of factual information like the number of ENHs in Lebanon and the type of available services. Seven dimensions were posted on the wall for all participants to see. The panel was asked to brainstorm, develop recommendations, discuss, provide relevancy, consider alternatives, and provide rationale for each of the criteria as a consensus building activity. Each of these aspects and issues were discussed again with the elderly caregivers. The expert panel responses was used to collate opinions (Dalkey, 1969). Several perspectives and views presented a variety of perspectives that were nominally organized (Robert-Davis and Read, 2001). Sample Present in the first panel discussion were one representative from the MoPH, one representative from the MoSA, one representative from the National Commission of Elderly Affairs, one representative from the National Service Center, and 15 administrators including geriatricians: two physicians and one nurse. The second panel discussion included the Syndicate of Hospitals president, one representative from the MoSA, one representative from the UNFPA, one representative from the National Commission of Elderly Affairs, six registered nurses, three practical nurses, two physiotherapists and one social worker. Data collection The data collection method was performed through simultaneous field observation and video recording. The content was obtained from the working sessions and reflections made by the panel that focus on the quality of life criteria. The main instruments in this study were the researchers. They questioned, probed, suggested, and recorded field information. Investigators presented information regarding criteria and asked administrators, caregivers, and policy makers to list which criteria exist, suggest new ones, and provide measures as guidelines for ENHs. Results The results of the study were organized around seven main issues: (1) types of ENHs; (2) funding; (3) health services;
(4) (5) (6) (7)
boarding services; activities (social, spiritual, physical and mental); structures; and elderly rights.
The comments on the seven main issues during the panel discussion made by administrators, caregivers, and specialists, gave perceptible criteria and measures for ENH. The seven sections below present the content analysis field notes and video recordings of the two sessions. Types and classification of ENHs Many administrators considered classifying ENHs into three types: (1) those ENHs that receive independent elderly (middle old elderly); (2) those who received dependent or sick elderly (older old); and (3) those who received all types of elderly (middle old and older old). One administrator and physiotherapist suggested one type of ENH with different units as Dementia Special Care or Terminal Care Unit. Each unit may have its own standards and criteria. Administrators agreed that nursing homes generally should not provide services for hospitals in terms of medical treatment and intensive care procedures. Financial aspects/funding Elderly home administrators suggested the need to have subsidized financial support from both ministries MoSA and MoPH. The current cost rate per elderly was between 600,000 and 900,000 Lebanese Liras equivalent to US$400 to $600 per month in today’s currency exchange prices. The National Health Insurance sponsored by MoPH covers each elderly with $300 a month. MoSA welfare system reimburses a lower rate of $80 per month. Both MoSA and MoPH do not cover costs for medical care and treatment. The cost for each elderly home is established as a criterion to assess whether ENHs have the budget to cover those elderly unable to fund their stay. Furthermore, ENH administrators suggested that financial statements, elderly home budgets, and elderly financial files are administrative elements that ENH maintain for each elderly as necessary documents for the assessment of administrative service costs. Caregivers and administrators suggested equal treatment across conditions. Two of the administrators informed the panel that fee paying elderly are provided with better services, and single rooms – it was evident among discussants that differences in services are dependent whether elderly pay or not. Health services Administrators as well as caregivers suggested that specialists from the relevant professions like social workers, physiotherapists, psychologists, dieticians, and others as vital human resources for ENHs. Many administrators complained about the lack of specialized nursing staff needed to support the elderly, and underlined the importance of in-house professional development. In line with Bolton et al. (2001) findings,
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administrators underlined the development of a sound administrative public policy related to nurse staffing grounded on empirical evidence. They also recommended pre-measures such as ratios of specialized nurses and helpers to elderly residents (Buerhaus and Needleman, 2000). They pointed to the high ratio of elderly caregivers to residents in their institutions. Administrators added that a needs assessment tool to measure cognitive impairment, nutritional status, physical functioning, and elderly wellbeing. As suggested by Caramanica et al. (2003) elderly quality care management has largely depended on actions of health care providers associated with safety and structure of ENHs. Boarding services Administrators suggested that elderly in long-term stay are provided regular meals and continuous feeding assistance with timely snacks and drinks combined with specialized diets. They stressed on several important components of a well kept ENH, these include: . accessible facilities, accessible grounds, accessible activity areas, rooms, and toilets, . safety, tidiness, and hygiene; . maintain a home-like environment for elderly residents that engages them in daily living activities; . provision of proper environmental conditions as in lighting, noise-free settings, designated sleeping hours, acclimatized environment (heating-cooling/ winter-summer), grab rails, and space for movement; . availability/provision of proper equipment such as wheel chairs, walkers, adjustable beds, and medical measurement tools; and . a maintained elderly resident files, an up to date record, diagnostics and health screening results. Records kept within a centrally located administrative unit, regularly updated by a geriatric physician or registered nurse. Activities Administrators and caregivers complained about the lack of family involvement in elderly activities and care. Both underlined the importance of family and friendship visits. Elderly care administrators said that visits are restricted to the time frame established by the ENH, and that certain responsibilities including frequency of visitations should be attached to the contract between the guardians and ENHs. Many guardians (families) rarely provide the necessary emotional support. Both caregivers and administrators considered that homes should provide activities rendering the elderly completely independent. They believed that elderly lives would be greatly enhanced if the elderly were drawn to activities that stimulated their interests. They also considered the importance of voluntary help in elderly activities including the type of activities in and outside the ENH such as cooking, gardening and other functions that take into consideration the physical and the mental state of the elderly. Hence, all types of activities whether social, physical, mental, and spiritual are
conditions that improve the quality of life among elderly living in ENHs. WHO’s study on patient-family centered care recommended the need for social workers to offer assistance and guidance for elderly residents and their guardians. WHO’s study had concluded that elderly interact the most with nurses, physicians, therapists, chaplains, pharmacists, volunteers, and others (WHO, 2005). The interaction should reflect quality time for elderly and such discussions and interaction should be encouraged. Administrators suggested that elderly bring certain possessions with them in order to feel ”at home” and cope better with their new living conditions. Structures and facilities Distribution of elderly according to choice, gender, socioeconomic strata, mental status, or those undergoing treatment are key issues that administrators have paid little attention to in Lebanese ENHs. Functional facilities as handrails, telephones, medical supplies, wheelchairs, accessible toilets, walkers are criteria measured per resident are criteria that could be used to provide some indication of quality service. Both administrators and caregivers considered safety as a vital component for the ENH structure as suggested by Mueller and Karon (2004) that safety issues are important quality indicators for ENHs. Many administrators showed concern for cramming of elderly in single rooms, mixing of sick, demented, or suffering from terminal diseases; they suggested that criteria should indicate the standards and specifications of passage for movement, the number of elderly per room, safety in mobility, and movement within the confined spaces. Elderly rights Administrators and caregivers were asked by one of the investigators whether elderly wishes and views were respected. One administrator explained that although decisions or attitudes are judgmental, they could not be easily turned into simple and measurable criteria. However, administrators were concerned that elderly personalized services were generally not available in a number of ENHs as in personal clothing, private room phones or free movement in or outside the ENHs. One caregiver inquired whether elderly should set their own criteria for free movement, when to eat, what to wear, who to choose as roommates, and how to engage in activities. Administrators felt that little has been done in ways to deal with death. It was suggested that elderly homes maintain the spiritual and personal space for each elderly. A key aspect outlined by caregivers was the lack of written policies that honor the rights of elderly, specifically those bed-ridden or dying. Discussion This study sought to identify concerns and issues dealing with structures, processes, and activities in ENHs. As a result 40 criteria were retained; many of those are now in use by various health care organizations around the world as competency measures for accreditation. Perspectives and ideas reported by health care administrators and caregivers in the study can be transformed into criteria that produce quality services. The study used a group consensus approach to generate ideas about measures to improve the quality of life. There were seven main issues that identify the criteria
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required by administrative and nursing staff to meet the needs of elderly people being cared for in ENHs. It is evident that the criteria established were not exhaustive. Further involvement of the ministries can be crucial in the development of a national policy on elderly public health and enforce regulatory guidelines. Although, the attempt was to develop measurable indicators, we were faced by a number of needs called for by both administrators and caregivers. For example, administrators were complaining about insufficient financial subsidies, but, as we learned later from MoPH, a large number of ENHs were not willing to provide government financial documents even to receive more assistance. These and other needs often drove the discussion away from the intended scope but refocused through moderator interventions. A number of criteria were identified by the panel but were difficult to include in the list, such as the physician’s assessments, patients perspectives, and attitudes. Zingmond et al. (2007) explained that these measures are not easily observable and generalized within ENHs. A number of indicators were not evident and did not generate consensus, or missed altogether by administrators and caregivers. In one case the panel members diverged somewhat to lay concerns specific to their institutions, as to engage MoPH and MoSA; however, the moderators were cautious to set the discussion back to the intended course. In summary, the key criteria and indicators raised by the panel are summarized in Table I. Building measures and criteria is not new to public health in Lebanon. More recent attempt by the MoSA in partnership with the Population Development Strategic Program of the United Nations and the National Committee of Elderly Affairs for the collection of data through year 2005-2006 has not led to a published report. A pressing need calls for a national and integrative data base on a set of validated criteria for ENHs. These criteria if turned into competencies and standards can contribute to quality improvement for ENHs. There is a need for a well informed team with a multi-disciplinary strategy involving health professionals, decision-makers (within the Ministries of Public Health and Social Affairs), academicians, specialists, social workers, clinicians, ENH leaders, public and private sectors, not only to review, rate, validate, and prioritize the quality and importance of criteria, in terms of their applicability, appropriateness, and adequacy (Johnson et al., 2006) but also to provide elderly with the quality service they expect and to translate these expectations into performance standards with the appropriate level of practice for each criterion (Clare, 1996). Anecdotal evidence suggests that policy makers need elderly home standards in order to increase government accountability. Thus, an inter-judge agreement measure as to whether the criteria were applicable, appropriate, or adaptable would provide further evidence to the construct validity of the criteria. In future studies, elderly opinion is a vital component to the effectiveness and quality of care (Langemo et al., 2002). Once indicators or criteria are conceptualized as we have done in this study, operationally defining these criteria will help us measure, them in real life conditions (Quality Indicator Study Group, Society for Health Care Epidemiology of America, 1995) as to establish a standard for ENH quality. Hence, this project has several key operational outcomes that could help in the implementation of a mechanism for establishing quality indicators. Future work would suggest:
Themes
Consensualized aspects
Classification of ENHs
For independent elderly For dependent elderly One type of ENH which accommodate to all types of elderly with specialized units within each home Subsidized by Ministry of Social Affairs and Ministry of Public Health Elderly as a fee paying Annual budget Costs per elderly Income from other sources Availability of specialists Geriatricians Physiotherapists Social Workers Psychologists Specialized training Specialized/qualified nurses Dietitian On-going training for caregivers Ratio of geriatricians to elderly Ratio of caregivers to elderly Ratio of specialized/qualified nurses to elderly Availability of assessment tools for elderly Availability of a varied diet Availability of recreation/activity areas Number of elderly per room Number of rooms Appropriate lighting Appropriate/types of heating and cooling Accessibility of all utilities Elderly panel records Number of visits by family members and friends Number of social activities at the ENH Outside/inside voluntary involvement in services Availability of physical activities Availability of mental activities Availability of spiritual activities Telephone Bell Accessibility Wheelchairs Walkers Adjustable beds Water beds Availability of medical measurement tools as sphygmomanometer, height scale, weight scale Specialized units for different elderly conditions Observable treatment of elderly Ability of elderly to move from one place to another Policies written to the rights
Financial aspects/funding
Health services
Boarding services
Activities
Structures and facilities
Elderly rights
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Table I. Consensualized criteria classified within each “elderly home” aspects
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normative standards, those defined by administrators and caregivers; elderly assessment of quality indicators in ENHs; and involvement of both ministries, MoSA and MoPH in the process of implementing standards, surveillance and programmatic system appraisals.
Thus, in reporting outcomes and established a set of criteria as essential aspects for the functioning of ENHs. The criteria (measures) proposed by this consensus process are viewed as an early step to establish standards offer their services to dependent, semi-independent, and independent elderly to improve their care by stimulating further discussion, innovation, testing, and refinement. Additional works suggest underwriting procedures and key performance standards that involve experts, practitioners, and academics to integrate elderly heath care information across the different health services as in hospitals, clinics and elderly homes. This work is preliminary in the establishment of criteria as measures of ENH quality. Enforcing these measures suggests a set of policies, laws, and regulations to ensure consistency across health services (Fleishman et al., 1996). The results of this study are preliminary and future work should promote resident elderly voices that engage family members in the process of quality care through participation and development of the ENH criteria. References Ashton, C.M., Kuykendall, D.H., Johnson, M.L., Wun, C.C., Wray, N.P., Carr, M.J., Slater, C.H., Wu, L. and Bush, G.R. (1994), “A method of developing and weighting explicit process of care criteria for quality assessment”, Medical Care, Vol. 32, pp. 755-70. Bolton, L., Jones, D., Aydin, C., Donaldson, N., Brown, D., Lowe, M., McFarland, P. and Harms, D. (2001), “A response to California’s mandated nursing ratios”, Journal of Nursing Scholarship, Vol. 33 No. 2, pp. 179-84. Braithwaite, J., Makkai, T., Braithwaite, V. and Gibson, D. (1993), Raising the Standard: Resident Centred Nursing Home Regulation in Australia, Aged and Community Service Development and Evaluation Reports, No. 10, AGPS, Canberra. Buerhaus, P.I. and Needleman, J. (2000), “Policy implications of research on nurse staffing and quality of patient care”, Editor’s Note, Policy, Politics and Nursing Practice, Vol. 1 No. 1, pp. 5-15. Campbell, S. and Cantrill, J. (2001), “Consensus methods in prescribing research”, Journal of Clinical Pharmacy and Therapeutics, Vol. 26, pp. 5-14. Campbell, S., Roland, M., Quayle, J., Buetow, S. and Shekelle, P. (1998), “Quality indicators for general practice: which ones can general practitioners and health authority managers agree are important and how useful are they?”, Journal of Public Health Medicine, Vol. 20, pp. 414-21. Caramanica, L., Cousion, J.A. and Petersen, S. (2003), “Four elements of a successful quality program: alignment, collaboration, evidence based practice; and excellence”, Nursing Administration Quarterly, Vol. 27 No. 4, pp. 336-43. Cesarotti, V. and DiSilvio, B. (2006), “Quality management standards for facility services in the Italian health care sector”, International Journal of Health Care Quality Assurance, Vol. 19 No. 6, pp. 451-62. Clare, A. (1996), “Developing standards of care to meet older patients needs”, Nursing Standards, Vol. 10 No. 20, pp. 44-7.
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Sewell, N. (1997), “Continuous quality improvement in acute health care: creating a holistic and integrated approach”, International Journal of Health Care Quality Assurance, Vol. 10 No. 1, pp. 20-6. Waltz, C.F. and Sylvia, B.M. (1991), “Accountability and outcome measurement: where do we go from here?”, Clinical Nurse Specialist, Vol. 5 No. 4, pp. 202-3. World Health Organization (WHO) (2005), WHO Definition of Palliative Care, 2005, available at: www.who.int/cancer/palliative/definition/en/ (accessed June 1, 2008). Zimmerman, D., Karon, S., Arling, G., Ryther Clark, B., Collins, T., Ross, R. and Sainfort, F. (1995), “Development and testing of nursing home quality indicators”, Health Care Financial Review, Vol. 16 No. 4, pp. 107-28. Zingmond, D., Wilber, K., MacLean, C. and Wenger, N. (2007), “Measuring the quality of care provided to community dwelling vulnerable elders dually enrolled in Medicare and Medicaid”, Medical Care, Vol. 45 No. 10, pp. 931-8. Further reading Caplin, D.A., Rao, J.K., Fillou, F., Bale, J. and Van Orman, C. (2006), “Development of performance indicators for the primary care management of pediatric epilepsy: expert consensus recommendations based on the available evidence”, Epilepsia, Vol. 47 No. 12, pp. 2011-9. Corresponding author Ramzi Nasser can be contacted at:
[email protected]
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