Falls and the importance of how standards of care are set

1. 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

2. The context of this presentation • Falls • Setting standards • The Delphi method • Falls in Icelandic nursing homes • Quality improvement in nursing homes

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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!

9. Rantz, 2003; IngibjörgHjaltadóttir, 2010

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

25. Prevalence of falls 1999-2009 N=11.912

26. Case mix index – Level of care needed N=11.912

27. 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

28. 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

29. 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

30. 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

31. Thank you!