Samir K. Sinha – Implementation Science Team lead and chair of the Health Standards Organization's National Long-Term Care Services Standard Technical Committee – sheds light on the development of the long-term care national standards. Sinha also discusses what the standards hope to achieve for improved quality of care and quality of life across the sector.

Key Takeaways

• The Health Standards Organization (HSO) and Canadian Standards Association Group (CSA Group) are leading the creation of two new standards that aim to provide evidence-informed guidance on how individual (long-term care) LTC homes – in partnership with federal, provincial and territorial governments – can deliver safe, reliable and high-quality LTC services.
• The HSO standard clearly articulates the importance of providing resident-centred care that consciously adopts the perspectives and preferences of residents, emphasizing a shift across the LTC sector that puts the residents' needs first.
• Ongoing research that engages residents, family members, essential care partners, LTC homes and staff is essential to help us better understand what is happening in homes, what needs to be done moving forward and how to deliver the best possible care across varying settings and contexts.

Introduction

As both the lead of an Implementation Science Team (through the Strengthening Pandemic Preparedness in Long-Term Care research program [HEC 2022]) and chair of Health Standards Organization's (HSO's) National Long-Term Care Services Standard Technical Committee (HSO National Long-Term Care Services Standard n.d.) that is tasked with co-designing new standards for care and services provided by Canada's long-term care (LTC) homes, Samir Sinha was invited to share his insights and perspectives on LTC in Canada through this featured Q&A session. Sinha discusses how the pandemic has impacted LTC, what the development of national standards hopes to achieve for quality of life and quality of care and the role of research and evidence-informed decision making to move the sector forward.

The pandemic has had such a devastating impact on residents, family members/caregivers and staff in LTC. What have we learned from the pandemic and what is going to be its legacy for how we offer LTC in the future?

Sadly, this pandemic has yet to end, even though I think many would like to think it's over and are desperate to get back to things as they once were. As I answer this, Canada has officially entered its seventh wave of COVID-19 infections, and once again we see cases and, sadly, deaths on the rise across Canada's LTC settings. The good news is that this latest wave is not as devastating as the first two; we have really seen the miraculous impact that vaccinations and strong infection prevention and control (IPAC) measures can have.

I think the first two waves helped all Canadians truly realize how poorly supported our LTC systems are. Never enshrined in the creation of our beloved medicare system in the '60s or our Canada Health Act (1985) in the '80s, LTC has long remained the poor cousin of other parts of our public healthcare system. It is part of the reason why nurses, allied health professionals and personal support workers in publicly funded LTC homes make far less than the same professionals working in our publicly funded hospitals. It is no wonder that the majority of Canada's LTC homes were struggling to recruit and retain staff even before the pandemic hit. The slightly more than 200,000 residents of these homes are mostly frail older persons, often living with dementia, which makes their care needs complex and requires a staffing skill mix that provides quality of care and quality of life. As well, it is hard for these individuals to advocate for their own care needs. We largely ignored and did not truly appreciate the critical role that devoted families and friends of LTC residents have played as essential care partners – until we locked them out. The fact that many residents in provinces like Ontario lived in older, more cramped buildings and with two, three or four to a room only further contributed to the rapid spread of COVID-19 in these settings. Finally, we also came to realize the negative impact that not prioritizing these settings early and adequately can have as demonstrated when Canada earned the dubious distinction of leading the world with 80% of its first-wave deaths recorded in LTC homes – twice the international Organisation for Economic Co-operation and Development (OECD) average (CIHI 2020).

The mounting tragedies witnessed in Canada's LTC settings triggered new and necessary reviews (CIHI 2021; Estabrooks et al. 2020; NIA 2021; Stall et al. 2021), research (Brown et al. 2021; Sepulveda et al. 2020; Stall et al. 2020) and enquiries (Marrocco et al. 2021) that led in some cases to new measures, funding and commitments to improve the overall system. However, I honestly think that the wholesale change that many have been long advocating for continues to elude us. I think what has frightened some politicians away from making the necessary changes to fix a long-neglected system will require more money and more fundamental changes than there is political will to see through. Nevertheless, Canadians are now more enlightened about the state of our LTC systems than they have ever been. Canada's LTC homes have more advocates and researchers helping to better understand and action evidence-informed changes to how we deliver LTC services, and we have a growing aging population that will continue to demand improvements in this area of care for years to come.

How would you characterize the problem the new LTC standards are seeking to fix?

I think that most Canadians were likely not aware that Canada had LTC standards prior to the pandemic. The existing HSO Standard (HSO 2020) was first developed over a decade ago to help enable the voluntary accreditation of the majority of Canada's LTC homes against one national standard, the way all Canadian hospitals are accredited, which has been helpful. National standards have the ability to become so much more: form the basis of legislation, policy and governance while also helping individual homes engage in continuous quality improvement efforts.

In 2020, the Standards Council of Canada (SCC), a federal Crown corporation, selected HSO and the Canadian Standards Association Group (CSA Group) to oversee the development of new complementary National LTC Standards that address the way care is delivered in a home and also how homes are built and operated. This has created an enormous opportunity to create new national standards that reflect where Canada needs to move toward in the provision of LTC (Box 1). Overall, the broad engagement by HSO and CSA Group to gather expert input will lead to the creation of two new standards that aim to provide evidence-informed guidance on how individual LTC homes, in partnership with federal, provincial and territorial govern-ments, can deliver safe, reliable and high-quality LTC services (HSO National Long-Term Care Services Standard 2021).

What were the biggest challenges in developing the standards? What is the role of evidence (in the development, implementation and evaluation of the standards)?

One of the biggest challenges in developing the new standards has been ensuring that as many Canadians as possible were given an opportunity to participate in their creation. More than 20,000 Canadians participated in the creation of both the HSO and CSA Group National LTC Standards, which speaks to both the interest and willingness of Canadians to contribute to improving Canada's LTC systems. We have been particularly proud of how many residents, front-line workers, families and essential care partners have provided their input to ensure that the new standards truly reflected their lived experiences of both receiving and providing LTC services.

The other biggest challenge has been having the necessary bandwidth to adequately review all of the feedback and available evidence to support the creation of more comprehensive and truly evidence-informed standards. As we are keen for the new standards to enable evidence-informed implementation and evaluation, we are spending a great deal of time ensuring that they are made very accessible so that every home can participate in evaluating their own performance and areas for improvement using existing data that are already routinely collected in the provision of LTC. So, in short, the role of evidence has and will be essential in every aspect of the development, implementation and evaluation of these standards.

The draft standard that you recently released talked about resident-centred care. What does this mean, and what is it going to take to realize it?

The draft HSO standard for LTC defines resident-centred care as an approach to care that consciously adopts the perspectives of residents as participants in, and beneficiaries of, trusted health and social services systems. Resident-centred care further ensures that an individual's preferences for care are used to guide decision making and is based on the philosophy of person-centred care.

I was really pleased that this became a key takeaway for many from the release of the draft HSO standard. This represented a real reorientation of focus across LTC systems, where we sometimes forget that it is the residents' needs (and not necessarily staff's, the organizations' that provide LTC or the government's) that should come first. There was no debate among our technical committee members around this, and the decision to create such a strong focus was greatly aided by the fact that our committee includes LTC residents, who were able to guide us on how to structure this work in a way that was enabling to all necessary stakeholders involved in providing safe, high-quality LTC.

Through the development of the new HSO standard, I think we have found a good way to clearly articulate the importance of providing resident-centred care. We make it clear that LTC homes are a place where people both live and work, and by creating the right conditions of work, we can create and truly enable resident-centred care. Nevertheless, it will require jurisdictions to appropriately fund and enable this care by encouraging a culture of continuous quality improvement.

There is a view that we simply have the wrong model for delivery of LTC, with too much emphasis on large-scale residential care facilities. What are your thoughts on this? Do the standards in any way address this?

The HSO standard aims to address the delivery of safe, reliable and high-quality LTC services in a home, no matter the size. The complementary CSA Group standard will address the design and operation of LTC homes.

There is growing evidence that smaller, well-staffed home-like settings that offer residents single-room accommodations, such as the Green House LTC model (The Green House Project n.d.), can deliver better resident, staff and system outcomes, especially during the COVID-19 pandemic (Zimmerman et al. 2021). This is a model that is getting a greater level of attention in the development of new LTC homes in both Quebec and Alberta. While some jurisdictions, such as Ontario, are encouraging the building of much larger homes, you can still implement a Green House LTC model with single-room accommodations and other home-like features in larger, traditional settings as well. The challenge is that some places focus solely on the hardware, forgetting that this small home-like model of care does not work unless homes are adequately staffed to provide truly resident-centred care. While the HSO standard will speak to the right software that is needed to power safe and high-quality LTC, the CSA Group standard will further address the hardware that needs to be properly considered in the design and operation of LTC homes.

What do you expect to be the impact of the new LTC standards?

I took on the role of chairing the development of the new HSO standard partly because, in my view, we had the right confluence of factors that could allow for this new standard (along with the new complementary CSA Group standard) to have demonstrable impact in the provision of resident-centred LTC across Canada. The federal government's expressed support for the standard development work, including oversight of the SCC and funding from Health Canada, have allowed us to truly engage a record number of people in its creation. The further commitment of $3 billion in the 2021 federal budget to support implementation of national LTC standards will assist provincial and territorial governments to further advance their ability to deliver safe, reliable and high-quality LTC. Developing the new HSO standard in partnership with national groups, such as the Canadian Institute for Health Information and Healthcare Excellence Canada (HEC); key federal, provincial and territorial government partners; and several other key stakeholder organizations, has fostered a highly collaborative process (with the specific input of over 20,000 Canadians). This incredibly high level of engagement will ensure that the new HSO standard truly reflects and enables the achievement of what matters most to those living, working and interested in the provision of LTC services.

At the end of the day, our hope is that once the HSO standard is implemented across the country (along with appropriate funding and support for the provision of LTC), residents, their families and staff can all speak to the high quality of care that they routinely experience and/or are proud to deliver.

Why are research and improvement initiatives such as the ones featured in this special issue important?

Research and improvement initiatives are a critical way to help us better understand what is required to provide safe, reliable and high-quality LTC. The incredible research that has been enabled over the past few years – with new dedicated funding via the Canadian Institutes of Health Research in partnership with HEC through its LTC Implementation Science Teams initiatives (HEC 2022) – has allowed us to better understand (in an evidence-based way) things that we had little insight into before the pandemic. Research, especially research that engages residents, family members, essential care partners, LTC homes and staff as partners at the table, helps us better understand what is actually happening, why it is happening and what likely needs to be done to make sure that the right things happen moving forward. Improvement work – including quality improvement and implementation science – is essential, as providing LTC is not easy and requires an understanding of how to deliver the best possible care across varying settings and contexts. What is clear is that LTC is an area of the healthcare research landscape that has historically not easily attracted funding and, thus, the necessary attention of researchers prior to the pandemic. Subsequent funding and infrastructure (e.g., the LTC Implementation Science Teams program) have helped to demonstrate that LTC is an area ripe for much more scholarly and improvement work.

We have an obligation to improve quality of care and quality of life for those living and working in our LTC homes. I look forward to working with others across the country to advance the provision of LTC in Canada, enabled by the new evidence-informed National LTC Standards.

Réflexion sur le cheminement vers l’élaboration de nouvelles normes nationales pourles soins de longue durée 

Résumé

Samir K. Sinha – directeur de l’équipe en science de la mise en œuvre et président du Comité technique de la norme sur les soins de longue durée de l’Organisation des normes en santé – fait la lumière sur l’élaboration des normes nation- ales dans les soins de longue durée et présente ce qu’on attend d’elles pour l’amélioration des soins et de la qualité de vie dans le secteur.

Disclaimer

This work is supported by Healthcare Excellence Canada (HEC). HEC works with partners to spread innovation, build capability and catalyze policy change so that everyone in Canada has safe and high-quality healthcare. The views expressed herein are those of the authors and do not necessarily represent the views of HEC.

HEC is an independent, not-for-profit charity funded primarily by Health Canada.

The views expressed herein do not necessarily represent those of Health Canada. Unmodified use or reproduction of this publication is permitted within Canada for non-commercial purposes only. This publication is provided "as is" and is for informational/educational purposes only. It is not intended to provide specific medical advice or replace the judgment of a healthcare professional. Those preparing and/or contributing to this publication disclaim all liability or warranty of any kind, whether express or implied.

This work is supported by the Canadian Institutes of Health Research (CIHR). At CIHR, we know that research has the power to change lives. As Canada's health research investment agency, we collaborate with partners and researchers to support the discoveries and innovations that improve our health and strengthen our healthcare system.

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