International Journal for Quality in Health Care Advance Access originally published online on March 2, 2007
International Journal for Quality in Health Care 2007 19(3):177-182; doi:10.1093/intqhc/mzm002
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How is quality being monitored in Australian residential aged care facilities? A narrative review
Queensland University of Technology, Institute of Health & Biomedical Innovation, KELVIN GROVE, QLD, Australia
Address reprint requests to Maria O'Reilly, Queensland University of Technology, Institute of Health & Biomedical Innovation, KELVIN GROVE, QLD, Australia. E-mail: m2.oreilly{at}qut.edu.au
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Abstract |
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Abstract
Purpose of paperBackground. ‘Quality of Care’ is a difficult concept to measure, particularly within the context of residential aged care, which involves lifestyle issues as much as health issues. Recent years have seen an increased focus on quality within residential aged care. Yet, Australia does not have a structured and comprehensive quality monitoring system within this sector.
Problem. While the Australian Accreditation Standards have been credited with contributing to improving care since their introduction in 1998, they are only considered to represent minimum (rather than optimal) standards of quality, and they do not sufficiently focus on clinical outcomes. Further, individual facilities might only be assessed against these standards every 3 years; within that time, there is much scope for quality variations to go unnoticed.
Implications. This paper contends that collecting and analysing comprehensive clinical data from aged care facility residents constitutes an essential step in the process of monitoring quality in this environment. Such data can be used to formulate indicators of quality, that is, to create markers to highlight areas of clinical care that might be of questionable (or exceptional) quality, enabling more detailed investigations of care practices within a facility.
Conclusions. The above processes could thus fill the current gap in quality monitoring that exists within the Australian residential aged care system, thus ensuring the provision of best-practice care to this vulnerable population.
Keywords: aged, residential facilities, quality of care, quality indicators, outcome and process assessment
Since mid-1980s, numerous changes to the Australian aged care system have been implemented in an effort to improve management and care practices within residential facilities. Concerns about quality within residential aged care facilities are regularly raised in the media as questionable care practices or carer behaviour are exposed, but monitoring quality in this context remains problematic and poorly addressed. The USA has introduced, and continued to refine, a compulsory system of assessment within its nursing homes, aimed at monitoring quality of care and clinical outcomes. Known as the Minimum Data Set/Resident Assessment Instrument, it is a comprehensive system of forms, which must be completed at prescribed intervals to meet a number of purposes such as care planning, casemix funding and quality monitoring. The process incorporates the use of Quality Indicators as a means of implementing quality assurance and improvement within residential aged care; these are markers that make use of assessment data to indicate either the presence or the absence of potentially poor care practices or outcomes. The Minimum Data Set data are consequently used not only to monitor residential aged care quality on a national level, but also used to provide individual facilities with reports indicating their progress in terms of clinical care benchmarks, thus enabling them to determine areas for attention in their quality improvement cycles. To date, a comparable system of quality assessment does not exist within Australian residential aged care facilities, neither do established benchmarks of quality for this setting.
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Purpose of paper |
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The purpose of this paper is to investigate and comment on the current state of quality monitoring within the Australian residential aged care system. This includes an examination of the concept of quality of care and its measurement, as well as an exploration of international examples of quality assessment in residential aged care.
Literature search strategy
In examining the above issues, literature was initially located through searching the CINAHL, Medline, Web of Science and PsychINFO databases, using the keywords ‘Nursing Homes’, ‘Long Term Care’, ‘Quality of Care’, ‘Quality Indicators’, and ‘Minimum Data Set’—either alone or in combination. ‘Australia’ was also added to searches to specifically locate activity within Australia, although Internet searches proved more successful for the latter. Other search strategies included searches for specific authors, cross-referencing citations from articles and searching government websites from Australia, USA, UK, Canada and New Zealand.
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Aged care in Australia |
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The evolution of the aged care system within Australia is not dissimilar to that of other developed nations. Prior to mid-1980s, ‘aged care’ really meant ‘residential care’. That is, services provided to older people requiring support, largely occurred within the context of residential facilities, and admission to these settings often occurred because nothing else was available [1–4]. Residential facilities had been subsidized by the Commonwealth Government since 1962, but the funding was not highly regulated [5]. As a result, there were some very poor quality facilities with unscrupulous practices. Lack of eligibility criteria and the paucity of community care also led to a number of ‘social’ admissions, related more to social isolation and lack of social support than to the need for care and assistance [3, 5, 6].
The changes instigated over the last two decades are regarded to have had a largely positive impact on the direction of aged care within Australia, although a number of problems still remain [4, 5, 7]. Initiatives of these reforms relevant to residential care have included a standardized system of assessment (Resident Classification Scales) to determine resident care needs (and associated funding) and a formal system of Accreditation to ensure quality service delivery (also required to maintain funding). Further, requiring assessment by an Aged Care Assessment Team prior to admission to residential care has eliminated the so-called ‘social admission’. Consequently, the residential care population has become frailer and more functionally impaired, with a considerably shorter length of stay [3, 4]. The increasing frailty of the population creates a further imperative to ensure quality service delivery. However, concerns remain regarding the adequacy of quality monitoring within residential aged care facilities.
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The dilemma about quality |
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‘Quality of care’ is not easy to define, given that it is something that involves interactions between humans, such that at least part of it is an abstract [8–11]. There is no one single measurement that definitively assesses quality of care [9, 11–13]; it is also somewhat subjective, in that everyone has different conceptions about the nature of quality [12]. Despite its ambiguities, quality of care is an important concept to operationalize, so that the standards of health care facilities can be objectively judged and compared.
Donabedian [8, 9, 14] suggested that three areas of care could be scrutinized to draw conclusions about the quality of care in a facility: structure, process and outcome. He emphasized that these were not attributes of quality per se, but that they represented areas of focus for assessment [9]. Structure refers to the setting in which the care occurs, including physical layout and resources, human resourcess and organisational framework. Process, as the name suggests, refers to what is actually done in providing the care. Outcome refers to the results of care. These three areas of care are interlinked, in that sound structures facilitate good processes, which in turn facilitate positive outcomes—the endpoint of care [8–10, 14]. Donabedian [9] postulated that the quality improvement is enabled by receiving feedback about the above three aspects of care and responding to that feedback. He described this feedback as being in the form of indicators of quality.
Indicators of quality
Indicators of quality are not direct or definitive measures of quality; rather, as their name suggests, they indicate areas of care requiring greater scrutiny [15–19]. Donabedian [9] suggested that the stronger the causal relationship between structure, process and outcome, the more valid the item as an indicator of quality and the more confidence that could be placed in the quality assessment [9, 10]. This is particularly so when using outcomes as indicators of quality, given that outcomes represent the result of all inputs into care, including the patient's own, hence knowledge of a strong causal relationship between existing structures and processes and the final outcome enables confidence in assuming that the care provided was largely responsible for the outcome achieved [8, 9, 14, 20]. In an international review of quality monitoring within health care systems, Mainz contended that quantifiable clinical indicators of quality were a necessity [19]. However, while recent years had seen an increased focus on quality within health care, he suggested that very few systems effectively utilized such indicators.
Elements of successful quality assessment
Because quality of care is a multi-dimensional concept, no single area of assessment can provide an accurate indication of quality [12–14, 19]. Thus, an effective assessment should contain as many items as needed to cover all areas considered relevant to quality care, in the context being assessed [14]. To this end, it is necessary to develop assessments with quality measurement in mind, as reliance on standard medical records as a source of information often results in inadequate data [14]. However, if a quality assessment is too long and too complex, then whole sections might be poorly completed by assessors [21]. Moreover, the instrument needs to be constructed so as not to be perceived as a burden [22, L. M.Spencer, unpublished results]. When a trial quality assessment in Britain resulted in a low participation rate due to the extra time needed to complete it, Hughes et al. [22] suggested that quality measures should be integrated into routine clinical practice, without substantial addition of workload, although they acknowledged that this was difficult to achieve.
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The current state of assessment in Australian residential care facilities |
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Resident classification scales
The Australian Society for Geriatric Medicine [7] described the Resident Classification Scales as the ‘antithesis of a funding system that generates incentives for quality health outcomes’ (p.46). This criticism refers to short falls of the Resident Classification Scales that have not been corrected, despite multiple revisions, that the system focuses only on what care is provided, rather than best-practice requirements, and that deterioration in function is rewarded by attracting more money. Essentially, the funding system provides no incentives for improvements in quality care practices [6, 23]. Thus, as the Resident Classification Scales is a funding tool, it only provides an indication of care needs, with no potential for assessing outcomes of care [7]. The Australian Government recently commissioned a review of the Resident Classification Scales [24] and, as a result of this review, a new assessment tool—the Aged Care Funding Instrument—has been developed and trialed [25], and is to be introduced throughout the country in 2007. However, although the assessment system has been changed to reduce the paperwork burden, it remains a funding-only tool and, as such, continues to have no bearing on quality.
Accreditation
Outcome Standards for residential care in Australia were introduced in 1987 [2, 21]; prior to this, assessment of residential care quality had been poorly addressed. Implementing the Outcome Standards included the use of Standards Monitoring Teams, which were Government-appointed bodies responsible for assessing residential care facilities' compliance with the Standards. The Standards Monitoring process resulted in improved quality of care within residential care facilities [6]. This system was further strengthened by the introduction of the Aged Care Standards and Accreditation Agency in 1998 that compels residential aged care facilities to seek Accreditation in order to maintain Government funding [3, 6].
While there is support for the Accreditation Standards, there is also an acknowledgement that, as minimum standards, they merely represent the level below which no service provider should fall [7]. Further, clinical care forms only a part of the Standards, and the Australian Society for Geriatric Medicine [7] noted there are numerous gaps in the clinical care section; with some outcomes vaguely defined and a number of significant health issues for this population missing from consideration (e.g. management of depression, prevention of hip fractures). Accreditation assessment is based on documentation review [6], but the Standards do not currently require the collection of basic measurable outcomes such as the number of in-house acquired pressure ulcers, the percentage of residents with urinary tract infections or the rate of falls. In his analysis of the Australian system, Rosewarne [6] noted that while Accreditation singled out those facilities at the upper and lower extremes of quality, there was very little discrimination between the majority of facilities, which fell in the middle.
Thus, the two major forms of assessment and monitoring within the Australian residential aged care system are separate from each other, and based on administrative outcomes over clinical outcomes, thereby limiting the detailed assessment of quality of care. In their review of the residential care funding arrangement, the Australian Productivity Commission [26] recommended that funding should be tied to the achievement of national benchmarks of quality; this suggests an alternative to the current funding structure, which allocates funding on the basis of the care provided, whether it is best-practice or not, and facilities are directed towards preventing a fall in quality below a minimum standard, rather than striving to achieve an optimum standard [7].
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Quality indicators for residential aged care |
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Residential aged care is unique in the context of health care, in that as well as providing clinical services, residential aged care facilities also provide a place to live; hence, it is not surprising that perceptions of what constitutes quality of care would encompass a broader range of issues than in more traditional health care organisations, such as acute hospitals. Within residential aged care facilities, concepts of quality of life and quality of care tend to overlap [27–31]. Further, Marquis [11] advocated that the focus of quality assessment in aged care should be on resident outcomes, rather than service outcomes, as tends to be the case in Australia at present. Quality of life is itself difficult to define and measure, thus adding to the challenges inherent in assessing quality of care in this context. However, Clark and Bowling [32] suggested that quality of life in residential care could be ascertained by looking at measurable indicators such as general health, functional status, mental health, comfort, emotional wellbeing, privacy, choice and autonomy.
In focus group discussions with residents and staff of Australian residential aged care facilities, Doyle and Carter [27] found that the areas considered most important in meeting the Residential Care Standards for health were ‘doctor of choice, food, mobility and dental care’ (p.4). When talking to residents of British nursing homes, Raynes [29] found that their views of quality care were less about the ‘nursing’ and more about the ‘home’. Of the 12 characteristics of quality in nursing homes identified by Raynes, most were psychosocial or environmental in nature, with two referring to staff attributes and staffing patterns.
Glaser [30] suggested that, at an individual level, comprehensive clinical assessment was a necessary component of good quality care in nursing homes, and that it should be used to provide measures against which individual, as well as facility-level care is evaluated. After interviewing clinical nurses and aged care facility managers in Australia, Courtney and Spencer [15] identified a list of six measurable indicators of quality clinical care in residential aged care facilities: pressure ulcer rates, incontinence rates, hydration management, rates of infection, skin integrity and polypharmacy. Spencer (unpublished results) also interviewed residents and families, and further to the six clinical areas already mentioned, other areas identified for quality assessment included a number related to quality of life.
Thus, when considering quality assessment for residential aged care facilities, indicators of quality should encompass areas of clinical care directly related to residents' physical health, as well as quality of life and lifestyle-related issues, such as activities and family involvement.
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Implications for the Australian System |
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‘... it is essential to develop clinical indicators directly related to the care standards covered in the accreditation process if quality of care is to improve further.’ [6, p.134–5]Despite the Australian residential aged care system being highly regulated and subject to multiple assessments, there is a gap in terms of determining the quality of care practices being utilized. There is no real emphasis on clinical outcomes in either the Resident Classification Scales or Accreditation assessment. Moreover, as the key quality assessment, for the majority of facilities, Accreditation is only conducted once in 3 years. Clearly, more timely assessment and feedback would be preferable for monitoring quality of care. Although the Accreditation Agency requests that each individual aged care facility develop their own individual approach to collecting quality indicator data and implementing benchmarking activities, the ideal of optimal quality clinical care for all residents is not enforced. Further, there is no requirement for specific quality data to be gathered across all facilities nationally so that comparisons could be made. Collecting objective assessment data in terms of outcomes, particularly in relation to clinical care indicators, would help aged care agencies and service providers to demonstrate how they have improved over time, as well as contributing to the continued improvement of standards within the aged care system as a whole [7]. Indeed, Bruen [4] suggested that in a system such as Australia's, where demand exceeds supply (thus minimising competition), the mandatory use of such quality assessment is essential for ensuring ongoing quality improvement.
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Developing an Australian quality assessment |
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‘It is widely agreed that the key to evaluation of quality, effectiveness and outcome of care of older people is the use of comprehensive assessment ...’ [29, p.263]While it might be tempting to suggest that the Minimum Data Set/Resident Assessment Instrument be introduced into Australia, given it is a lengthy assessment developed for a different aged care system (i.e. The USA), it is reasonable to consider developing a similar type of assessment, focussed more specifically on the needs of the Australian system. Certainly, the Australian Federal Government has not indicated its intent to adopt the Minimum Data Set/Resident Assessment Instrument. Doyle and Carter [27] recommended the development of an Australian quality assessment containing objective indicators of quality, to be used in conjunction with subjective assessments. However, despite indicating their desire to develop such an instrument, it does not appear to have eventuated. The Victorian State Government has recently introduced a small suite of quality indicators to be used within its state-run residential aged care facilities [33, 34], but their use remains limited to the state of Victoria. A joint project between the Queensland University of Technology and an Australian national aged care service provider has developed an assessment of quality based on holistic clinical outcomes [35]. It is hoped that, following psychometric analysis (currently underway), this assessment could be utilized within the service provider's network in the first instance, and then more widely throughout Australia.
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Conclusion and recommendations |
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The development of Australian aged care over the last two decades has resulted in progressively frailer residents in residential aged care facilities, presenting further challenges to the system to provide good quality of care [3]. The key to quality care is the collection of clinical outcome and process data in order to properly judge the quality of care being provided [4, 7, 19]. It is imperative to be able to standardize, benchmark, trend and compare this data for it to be meaningful. When facilities use facility-specific non-standardized assessment forms, comparisons of resident and facility characteristics are difficult if not impossible; changes cannot be tracked readily over time and outcomes are difficult to measure. To evaluate and improve care delivery, it is also important to compare resident and facility characteristics and outcomes. When these characteristics and outcomes are compared across facilities, it is possible to identify other facilities that achieve better outcomes with similar residents. These types of comparisons encourage clinicians to question previously accepted practices and stimulate them to design better ways of caring for residents and to subsequently improve outcomes [36].
Thus, there is a need for an Australian assessment tool for routine use that encompasses the mental, physical and social characteristics of older people, and allows the measurements to be compared across all facilities. The current Australian residential aged care system consists of two streams of assessment, documentation and reporting, which do not effectively ‘speak to each other’ and do not assess quality of care in any systematic manner [7]. In the absence of an assessment system that combines quality with funding, quality should not be abandoned as too difficult to tackle. Rather, what is needed is a quality-monitoring tool that is comprehensive and resident focussed, while requiring the minimum of time and effort to complete. The quality of care aspect of the Minimum Data Set/Resident Assessment Instrument provides an excellent example of standardized quality assessment, and while it might not necessarily be appropriate to transplant it to the Australian system, an assessment utilizing a similar approach and tailored to Australian needs would be a useful addition to residential aged care in this country.
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