World Health & Population

World Health & Population 18(1) December 2019 : 61-67.doi:10.12927/whp.2019.26058
New Models Of Care

Promoting Quality Improvement in Long-Term Care: A multi-site collaboration to improve outcomes with pneumonia, falls, bacteriuria and behavioural issues in dementia

John Puxty, Rosemary A. Brander, Susanne Murphy and Vaughan Byrnes


The Bridges to Care for Long-Term Care research project aimed to facilitate improvements in outcomes for long-term care residents through the provision of knowledge-to-practice and quality improvement resources by trained facilitators. Point-of-care staff reported improved communication and collaboration, improved use of scope of practice and implementation of best practice knowledge. Overall, participating long-term care homes demonstrated an enhanced capacity for common care issues of the elderly (pneumonia, falls, bacteriuria and behavioural and psychological symptoms of dementia) and the ability to effectively engage in quality improvement processes with efficient and effective use of healthcare resources.

The long-term care (LTC) sector is a crucial component of our healthcare system and has distinct challenges. Physicians and LTC health professionals are increasingly challenged in responding to higher-acuity and more advanced disease processes. An additional concern is how to best minimize the occurrence of common safety issues and risks, such as nosocomial infections (Wagnar and Rust 2008). Research has revealed that the context of LTC homes in Ontario may include stagnant approaches to care, a lack of teaching resources, suboptimal quality of resident life and a lack of positive nursing role models (Gates et al. 2009).

A review of the literature combining the major headings of LTC, nursing homes and quality improvement (QI) revealed 140 scholarly publications. The search was refined to focus on research that had targeted issues such as professional roles, general methodologies for QI in LTC and reducing the potentially avoidable use of emergency rooms and acute care hospitals. Despite variability in topic areas and methodologies for implementation, there were common themes that influenced the design and implementation of the Bridges to Care initiative:

  • There is an opportunity and willingness for process and practice improvement within LTC (Ouslander et al. 2009).
  • The uptake of comprehensive evidence-based tools and multiple risk-based processes may be problematic (ColonEmeric et al. 2006; Ouslander et al. 2009).
  • Change must be supported and endorsed at all levels of care within facilities (Capezuti et al. 2007).
  • LTC staff and practitioners need additional supports in both initiating and incorporating new QI strategies into their normal work processes for sustainable change (Davies and Cripacc 2008).

The Centre for Studies in Aging and Health (CSAH) at Providence Care provided project leadership. This project was designed to foster improved care within LTC through facilitated introduction of evidence-based resources within a resident-centred collaborative care model linked to a QI framework. The project research question was, what is the effectiveness of a QI model for knowledge-to-practice resource delivery on collaborative practice, staff satisfaction, knowledge translation and resident outcomes?

Ethics Approval

The Queen's University Research Ethics Board, Providence Care Research Review Committee, Kingston, Ontario, and Research Ethics Boards of Lakehead University, Thunder Bay, and the University of Ottawa approved the project.


The research project was divided into five broad phases: (1) the recruitment of LTC homes, (2) the preparation of knowledge-to-practice resources (preliminary phase), (3) the learning collaborative (first workshop), (4) the initiation of the change process (action) and (5) the sharing of results (second workshop). Six LTC homes were recruited within three LHINs: South East, Champlain and North West, Ontario. Each site identified its internal QI team: a point-of-care staff caregiver (non-regulated), a regulated staff member and a manager. Each site also identified external facilitators to its QI initiative. Funds were supplied for appointment of a local resource consultant to facilitate the improvement initiative at the LTC home level and to liaise and coordinate interactions between local teams and CSAH.

The QI projects were defined for each home, and plans evolved to create resource tool kits for each topic (preliminary phase; topics included pneumonia, falls, bacteriuria and behavioural and psychological symptoms of dementia [BPSD]). Resource tool kits included recommended assessment and decision support tools, best practice guidelines, evidence summaries, fact sheets and electronic informational links to other resources. The tool kits were created in both electronic and hard copy formats, with selected resources translated into French, with this need determined by the homes that would use them.

The first workshop was held in Kingston over two days in November 2009, and all invited LTC home teams participated. The focus was to share information and training in best practices for the core topic areas and in QI methodologies, and to begin a process of a creating a learning collaborative network for the project.

Over a three-month period (action phase), LTC home teams applied the QI strategies designed for their topics. Each team refined aim statements for their QI projects, outcome targets, processes to achieve these outcomes and metrics to monitor progress to targets (Table 1). They applied rapid-cycle improvement methodology using the Plan-Do-Study-Act cycle. Feedback and discussion occurred between participating LTC homes, facilitators, resource consultants and the CSAH team through monthly videoconferences, webcasts and teleconferences.

The second workshop was held in March 2010 in Kingston, with representatives from all participating LTC homes. Homes demonstrated QI in action by presenting highlights, challenges and successes for their individual projects.

Table 1. Quality indicators as selected by long-term care homes for individual projects
Hospitalization rates of residents with pneumonia
Time from identification to treatment of pneumonia
Staff and family satisfaction surveys
Behaviours and psychological symptoms of dementia
Quality and content of communication and collaboration among staff around behaviours associated with dementia
Staff and family satisfaction surveys
Frequency of occurrence and type of undesired behaviours associated with dementia
Compliance with a post-falls assessment tool and implementation of physiotherapy assessment and treatment after a fall
Falls rate over a three-month period, from January to March 2010


Table 2. Average Collaborative Practice Assessment Tool scores
  Workshop 1 (n = 35) Workshop 2 (n = 21) Difference p Value
Goals, mission 5.7 6.1 +0.4 .020*
Relations 6.0 6.3 +0.3 .343
Leadership 5.7 6.0 +0.3 .185
Roles and responsibility 5.4 5.2 -0.2 .154
Communication 5.7 5.8 +0.1 .516
Community linkages 5.4 5.6 +0.2 .554
Decision-making 5.1 5.1 0.0 .964
Patient involvement 6.3 6.2 -0.1 .564
*Statistically significant at p < .05 level.


Table 3. Average scores from the Bridges to Care workshop evaluation
  First Workshop (n = 27) Second Workshop (n = 18) p Value
Goals, mission 6.1 +0.4 .020*
Relations 6.3 +0.3 .343
Leadership 6.0 +0.3 .185
Roles and responsibility 5.2 -0.2 .154
Communication 5.8 +0.1 .516
Community linkages 5.6 +0.2 .554
Decision-making 5.1 0.0 .964
Patient involvement 6.2 -0.1 .564
BPSD = behavioural and psychological symptoms of dementia.
*Statistically significant at p < .05 level.




The Collaborative Practice Assessment Tool (CPAT) is a standardized and validated tool (Schroder et al. 2010) that measures levels of collaboration between members of a healthcare team. The CPAT results showed increases in six of the eight domains of collaborative practice, with a statistically significant increase in the area of "goals, mission and meaningful purpose" (Table 2).

For all four topics combined, there were overall improvements for all three domains of knowledge: general knowledge, ability to identify and application to practice (Table 3). However, when each topic area was considered separately, differences were noted. Statistically significant increases were seen in all three domains for pneumonia, for two domains (knowledge and application to practice) for falls and a single domain (application to practice) for bacteriuria. Although there were trends to improvement in BPSD, they did not reach statistical significance. Project participants reported significantly better knowledge of the QI process, as would be expected, but no increased confidence. There was also a significant increase in participants' likelihood of recommending LTC to others as a place of work, and significance (p = .061) in their own increased workplace satisfaction.

Five of six participating LTC homes reported on the process and outcomes at the second workshop (Table 4). One LTC home was unable to report due to a number of staff changes, resulting in a disruption of the original QI team. Each of the five reporting LTC homes met or exceeded its QI target. All LTC homes reported ongoing sustainable activities.

Table 4. QI strategies and outcomes
Site Area of QI Focus Aim Statement Process Outcome at Three Months
Pneumonia Reduce hospitalization with pneumonia by 30% within three months Implement Alberta Care Plan and Assessment Tool
Educate registered staff, PSWs, family, residents and staff
No hospitalizations with pneumonia despite five diagnosed cases
BPSD Educate 100% in use of three question template Educate staff and implement use of three question template at daily reports Stream-lined communication at daily reports
Increased staff satisfaction
Established secondary QI initiative at mealtime
BPSD Improve atmosphere in dining room at meal times Turn off the radio during mealtimes
Repaint the dining room
Nutrition and dementia information/staff training
delivered to resident care and dining room staff
Eliminate stress factors such as drug trolley
Improvement in dining room atmosphere by 75%
Improved awareness of resident-specific needs by 60%
Reduction of stress level in dining room by 75%
Falls Reduce number of harmful falls in one year Introduce PFAT
Improve post-fall documentation and care plan
100% completion of PFAT at 3/12 months
PT assessment and treatment linked to PFAT
Falls Reduce number of harmful falls by 6% in three months Implement PFAT and PFOT with post-fall medication and PT assessment 100% completion of PFAT and PFOT at 3/12 months
55% reduction of harmful falls
BPSD = behavioural and psychological symptoms of dementia; PFAT = post-fall assessment tool; PFOT = post-fall observation tool; PSW = personal support worker; PT = physiotherapy; QI = quality improvement.


Qualitative data from focus groups supported that the roles and responsibilities of team members as adopted in the QI change processes were effective in ensuring success. There were three key themes from the LTC home teams:

  1. The fact that they worked in "real teams on real issues," as opposed to using "fictitious" case studies, was very pertinent to their ability to apply their knowledge in their own working environments.
  2. Project processes enabled a safe environment where there was a "meeting of equals" to share ideas and design team-built strategies in a spirit of mutual respect.
  3. Group facilitators were highly credible, and physician engagement augmented the team's ability to move forward in their local QI processes.

Finally, staff satisfaction surveys were completed by two of the LTC home teams. The results showed that most staff members on each of the teams were highly satisfied with knowledge of their team's projects, the usefulness of the tools they chose and the implementation of those tools, and the levels of education and communication surrounding changes made as part of the project. Open-ended comments from staff showed a belief that the changes made led to improved communication and early identification and treatment of patients with particular need.


At the end of three months, all participating LTC homes reported significant improvements in sustainable collaborative resident-centred care processes within the focus of their QI initiatives. These improvements were associated with improved resident care outcomes in terms of reductions in hospitalization with pneumonia, serious falls and troublesome behaviours associated with dementia.

These benefits are first attributable to the homes being strongly engaged in the development of their QI learning and applications from onset. They identified their own projects, their own teams, many of their own resources and the way and means of implementing best practices that would work within their own environments. They also identified and refined the measures and targets to determine their own successes. They worked with their teams on real issues and expressed feelings of ownership concerning their project.

Benefits are also attributable to the provision of combining facilitated knowledge-to-practice and QI processes through the use of internal champions, resource consultants and external facilitators. Home participants repeatedly stated that this personal contact and support were key to their success in moving resources from a "shiny tool kit gathering dust on a shelf " to successful changes in collaborative care practices. A number of complementary improvements in both collaborative care processes and the working environment were demonstrated:

  • Increased knowledge, attitudes and skills of the participating individuals were confirmed in common care issues of the elderly in LTC and in QI processes.
  • All homes reported that participants were empowered to use their new skills and to act as a both a resource and support to other staff members in improved collaborative care practices. The unregulated staff reported feelings of empowerment and being active contributors to the QI processes.
  • There was evidence of an increased inter-professional approach to resident care in terms of clarification of scopes of practice and in both team and improved inter-organizational communication and collaboration. Respective roles and scopes of practice of champions within the process appear to have been enhanced beyond the team members' usual respective areas of influence.
  • Improved health and safety outcomes for residents resulted within the three QI topic areas. This was likely a result of both access to and the expanded use of evidence-based, residentcentred, collaborative practice resources offered through the project. Participants accessed these resources through a variety of formats, including a web-based repository.
  • There was evidence of efficient and effective use of both onsite and external health human resources through the transfer of evidence into relevant care plans that optimize clinical decision-making and care delivery skills of a variety of healthcare providers.
  • Sites that collected data reported that staff, family and resident satisfaction improved concerning the quality of care within LTC. This included an increased appreciation by staff that LTC homes are desirable places in which to work.
  • The Bridges to Care initiative was conceptualized and designed as a pilot project; this limits some of the generalizability of the results. The small sample of LTC homes limits the analysis and generalizability of the findings, although three distinct geographical communities were included. In addition to this, the relative contributions of the various components of the process have not been examined as independent variables. Future research might examine the relationships between the different components and levels of support provided and the outcomes examined through this initiative.


The participating LTC homes were positively influenced in the education and training of staff, with commitments for sustainability and spread within their sites and throughout their regions. All participating LTC homes reported success in achieving their primary QI outcomes.

About the Author(s)

John Puxty, MB, ChB, FCRP, Director, Centre for Studies in Aging and HealthProvidence Care, Kingston, ON

Rosemary A. Brander, PhD (candidate), PT, Senior Researcher and Program Evaluator, Centre for Studies in Aging & HealthProvidence Care, Kingston, ON

Susanne Murphy, BScOT, MSc, Lecturer and Fieldwork Coordinator, Occupational Therapy Program, School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, ON

Vaughan Byrnes, BA, MSc, Research Associate, John Hopkins University, Baltimore, MD


We wish to thank HealthForceOntario for the Interprofessional Collaboration Education Fund 2008–2009 research grant and all project partners for their input and collaboration. Key collaborators included the Seniors Research Health Transfer Network, the Regional Geriatric Program of Eastern Ontario, the Centre for Education and Research in Aging and Health at Lakehead University, the Ontario Health Quality Council, the Registered Nurses' Association of Ontario and St. Lawrence College, in Kingston.


Capezuti, E., J. Taylor, H. Brown, H.S. Strothers III and J.G. Ouslander. 2007. "Challenges to Implementing an APN-Facilitated Falls Management Program in Long-Term Care." Applied Nursing Research 20: 2–9.

Colon-Emeric, C., A. Schneck, J. Gorospe, J. McArdle, L. Dobson, C.A. DePorter et al. 2006. "Translating Evidence-Based Falls Prevention into Clinical Practice in Nursing Facilities: Results and Lessons Learned from a Quality Improvement Collaborative." Journal of the American Geriatrics Society 54(9): 1414–19.

Davies, S.A. and C.G. Cripacc. 2008. "Supporting Quality Improvement in Care Homes for Older People: The Contribution of Primary Care Nurses." Journal of Nursing Management 16: 115–20.

Gates, K., E.J. Santos, M. Nguyen, I. Granovskaya, A. Servidio and M. Turzansiki. 2009. "Gerontology Education Initiatives in the Health Sciences: Seeking Advice from Students and Seniors in Focus Group Conversations." Perspectives 33(3): 6–13.

Ouslander, J.G., M. Perloe, J.H. Givens, L. Kluge, T.A. Rutland and G. Lamb. 2009. "Reducing Potentially Avoidable Hospitalizations of Nursing Home Residents: Results of a Pilot Quality Improvement Project." Journal of the American Medical Director's Association 10: 644–52.

Schroder, C., J. Medves, M. Paterson, V. Byrnes, C. Chapman, A. O'Riordan et al. 2010. "Development and Pilot Testing of the Collaborative Practice Assessment Tool (CPAT)." Journal of Interprofessional Care 25(3): 189–95.

Wagnar, L.M. and T.B. Rust. 2008. "Safety in Long-Term Care Settings: Broadening the Patient Safety Agenda to Include Safety in Long-Term Care." Healthcare Quarterly 11(Special Issue): 31–34.


This article originally appeared in Healthcare Quarterly 15(2) April 2012: 70–4. doi:10.12927/hcq.2012.22910. <>.


Be the first to comment on this!

Note: Please enter a display name. Your email address will not be publically displayed