In recent years an increasing number of nursing homes have been implementing quality assurance activities to monitor and improve quality of care. This study assesses the effect that such activities have on undesirable clinical outcomes in nursing homes. It was observed that the implementation of many quality assurance activities, as well as the involvement of a client council in a nursing home, significantly reduces the number of undesirable outcomes. This suggests that such activities can have a positive impact on improving quality of care in nursing homes.

Background: Measuring quality of care in nursing homes has always posed a variety of problems. In recent years, increasing numbers of nursing homes internationally have begun to implement quality management systems (QMS), which include a variety of quality assurance (QA) activities to improve the quality of care provided to their clients. These QA activities include systematic care planning, practice guidelines, and client councils. Quality of care in nursing homes is an important issue in Canada; recently, there has been discussion about making the use of the Resident Assessment Instrument (a tool for measuring client health status, care experience, and outcomes) a legal requirement in Canadian nursing homes to better monitor quality of care. This study examines the relationship between QMS and QA activities and the prevalence of undesirable client outcomes in nursing homes.

Methods: This study utilizes nursing home data from the Netherlands that were gathered in two steps. The first step, conducted in 1994-1995, was a survey of a random sample of 50% of all Dutch nursing homes (n=159) to ascertain the prevalence of QMS and QA activities in these homes. This sample was surveyed again in 1998 to measure changes in the development and implementation of the QMS and QA activities. Information on nursing home characteristics (i.e. total bed capacity and occupancy rate), resident characteristics (i.e. age, sex, functional status and psychological diagnosis), and quality indicators as measured by five undesirable outcomes (prevalence of incontinence, pressure ulcers, urethral catheterization, restricted mobility and behavioural problems) was gathered from the survey data and a Dutch national long-term care registry. The relationship between quality improvement efforts and undesirable outcomes was ascertained through statistical analyses.

Results: Of the total number of nursing home residents, 74% were women and the average age was 81 years old. Between 1995 and 1998, the number of QA activities implemented by the nursing homes surveyed increased by 30%. However, none of these nursing homes had implemented all of the QA activities to constitute a complete QMS. The most common QA activity in nursing homes was the systematic use of care planning (91%) and two-thirds of the nursing homes publicized improvement efforts (e.g. annual quality reports). Practice guidelines for medical therapies and equipment use were used in 37% of the nursing homes, while 63% had a client council. It was observed that the implementation of QMS in 1994/1995 reduced the number of undesirable outcomes by 0.5% and that the involvement of client councils reduced the number of undesirable outcomes by 6%. However, the increase in QA activities between 1995 and 1998 was observed to have no significant effect on the five undesirable outcomes.

Conclusions: This study indicates that the implementation of some quality assurance activities may result in the decrease in the number of undesirable health outcomes that affect nursing home residents. While the increase in QA activities showed no effect on undesirable outcomes, this is likely because the implementation of such activities is relatively new. Furthermore, it may be necessary for many QA activities to be in place and constitute a full QMS before they have a significant effect on undesirable outcomes. This study is timely given that Ontario has recently initiated a public reporting website of nursing home inspection findings, deficiencies, and verified concerns in efforts to increase transparency of care and improve quality. In an industry where measuring quality of care is a challenge, steps towards improving clinical outcomes will be highly beneficial.

Reference: Wagner C, Ikkink K, van der Wal G, Spreeuwenberg P, de Bakker D, Groenewegen P "Quality management systems and clinical outcomes in Dutch nursing homes". Health Policy, 2006, 75, 230-240.

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