The effectiveness of quality systems in nursing homes: a review - skin care instrument

Background-
The need for quality improvement and the increasing focus on the cost and suitability of health care have led to the implementation of quality systems by health care organizations.
In addition, the nursing home has also invested heavily in development.
The impact of the implementation of the quality system on health-related outcomes is unclear. Objective—
Evidence in the study literature about whether the quality system has an impact on the care process and on the satisfaction and health outcomes of long-term care residents. Methods—
Literature Review. Results—
21 empirical studies identified activities related to quality system activities such as implementation guidelines;
Provide feedback on results;
Assessment of residents' needs through care planning, internal audit and tuition fees;
And the resident ombudsman.
Only four articles describe the comparative study.
Selected articles are grouped according to the five key areas of quality.
Residents' opinions are rarely used to assess the effectiveness of the quality system.
The impact on the care process and long-term care residents' health outcomes was inconsistent, but there was some evidence in the control study that specific training and guidelines could affect outcomes at the patient level. Conclusions—
The design of most studies means that it is not possible to attribute the results entirely to the newly implemented quality system.
Due to the difficulty of designing randomized controlled studies in practice, future studies on the effectiveness of quality systems should not focus only on selected quality-related factors, but should also include qualitative and quantitative (multi-variable and multi-level) method.
Methods used to measure quality need to be improved.
Methods the exclusion and exclusion criteria search included all quality system activities in the nursing home, but excluded studies on the effectiveness of treatment interventions.
The scope of this study is limited to publications in English, Dutch and German.
To answer this research question, only empirical research on the quality system activities of nursing homes is included.
In addition, it is not possible to actually expect a randomized controlled trial and other research designs, such as pre-determinedtest/post-
Test study, time series and post
Only Test research.
Studies that did not include a description of the impact of quality system activities on process or outcome measures (resident satisfaction and resident health outcomes) were excluded.
Literature retrieval literature related to the effectiveness of the quality system in nursing homes was determined by several methods (Table 1 ).
View this table: View the inline View pop-up table 1 Overview of identification methods the first search in Medline, cumulative index (CINAHL) journal base for nursing and related health literature, cochrane Library-controlled trials register the cochrane EPOC review Register and the Dutch Institute of Health Services (NIVEL) the literature database from 1985 to the end of 1997 is based on free text keywords "quality system", "quality assurance", "quality improvement" or "quality control" and free text keywords "long-term care" or "Nursing Home ".
In addition, professional journals not found in the above-mentioned periodical bases are searched by hand.
Secondly, additional information (snowball method) was obtained from the references and colleagues of the identified articles ).
The authors analyzed the Selected literature and discussed the methodological features (study design, sample size, quality management activities and measuring instruments) generated by the implementation of quality management, as well as process and result measurement.
The authors grouped selected articles according to five key areas of the quality system (Table 2 ).
15 View this table: View the inline View pop-up table 2 five key areas of the quality system of healthcare organizations. The study was selected. The first search result was that only 6 of the 231 Related Publications met the inclusion and exclusion criteria.
Articles that have not selected other comments for the following reasons: they only describe the quality system activity but do not describe the impact (n = 101 ), the environment appears to be a hospital or a home care facility (n = 20), or the author has only commented on quality improvement or long-term care (n = 99 ).
Five references could not be tracked.
Another 15 articles were found from articles and colleagues' references, 4 of which were published shortly after the search period.
Of the 21 Selected studies, two were conducted in the UK, one in Canada and the rest in the United States.
Process and outcome measurements were used to evaluate effectiveness, both of which were used in three studies.
Of the 13 studies that measured the impact on the care process by developing care policies, all reported some improvements.
A number of improvements were also reported in 11 studies that assessed the results of residents.
The results are shown in Table 3, where the control trial is shown.
View this table: View inline View pop-up table 3 evidence of the effectiveness of quality management and quality system activities in nursing home research design for selected studies study design and data are different.
Comparative studies described: (1) effectiveness of specific educational programs 20, 21;
(2) the effectiveness of two different facilities and resident assessment processes for overall quality of care and problem testing 22;
And (3) the impact of working with the quality assurance cycle.
23 in 10 studies, the researchers usedtest/post-
Test design without control group, where pre-
Test and post-
The test cycle is less than 1 year.
5,24-32 conducted two longitudinal studies in nursing homes, followed up for several years, 3, 34 and 4 studies
Test the design only.
35-38 the number of nursing homes participating in selected studies ranges from one to 268, with 13 studies of 1-16 nursing homes and two of 60 nursing homes, and 6 nursing homes with more than 200 participants.
Selected studies and controlled trials of various focus areas were identified in the focus areas of "improving processes through quality improvement procedures" and "human resource management.
There is no research in the key areas of the quality assurance document.
A study describes the impact of the quality system.
33. in the focus area "standard-based process control", five studies assessed the effectiveness of the implementation of the new guidelines --
For example, prevention of pressure sore, proper use and reduction of the retention catheter, and reduction of the use of psychotropic substances --
All of this reported a decrease in the incidence of adverse events.
Studies related to the focus area "process improvement of quality improvement procedures" describe three different activities: (1) information feedback on patient-related quality indicators, (2) resident assessment tools (RAI) and (3) clinical audits that analyze resident needs and support the care planning process.
The feature is that all three activities take advantage of a quality cycle in which the caregiver evaluates, evaluates and improves the quality of care when necessary.
Information on the current situation was obtained and subsequently compared with the desired situation.
If there is any difference between the expectation and the actual situation, the change is implemented.
Results from a control study 23 showed a decrease in the occurrence of some adverse outcomes (constipation and dangerous activity), but for other outcome measures (urinary incontinence and potential skin rupture ), the incidence of adverse outcomes was the same as in the control group.
Another control study 22 showed that the assessment methodology helped to identify problems and that many process improvements would not occur without an external review.
In other studies, the authors acknowledge that it is not entirely clear to what extent the results can be attributed to the intervention, as there was no control group at the time and various other changes occurred.
Three studies in this focus area use internal audits to improve residents' satisfaction and health status.
For example, the effectiveness of the ongoing assessment review and assessment (care) plan was investigated in a pilot study.
5, 39 audit procedures apply to procedures in nine major clinical areas
For example, lying position, incontinence, drug consumption and autonomy of residents.
As a result of the audit, existing agreements and guidelines in the agency have been improved or new agreements and guidelines have been developed.
Assessing process improvements based on the number of institutions with clear policies in the nine areas involved --
For example, the standard policy is more comprehensive (missing components are reduced from 38% to 19% ).
Professionals in the institution determine the quality of care they provide and the quality of their cooperation with each other.
Improvements in tuition fees, work supervision or expertise in the form of peer review may affect the quality of care received by residents.
Of the 21 studies, 4 described and evaluated the implementation of training programmes for nurses and physicians.
The purpose of the training was to reduce the number of protective measures, prescription of 28 psychoactive drugs (control study), incidence of incontinence in 20, 21 and residents.
The results of the 24 two control studies showed that, with the help of specific training, significant improvements could be achieved compared to the control group.
In many countries, it has been agreed that residents can play an important role in the implementation and improvement of care.
A study investigated whether the nursing home resident ombudsman would lead to better results and better compliance with standards.
35 The researchers concluded that the presence of an ombudsman capable of visiting and resolving disputes on behalf of residents may improve the outcome of care, but there is no indication of better compliance with standards.
The control group was not included in this study.
Over the years, systematically improving the quality of care provided to the elderly has been an important agenda in the United States and Europe.
The research questions discussed in this review are: what quality system activities have significantly improved the outcomes associated with the provision of care in nursing homes and with residents?
More than 200 publications were identified using keywords related to quality assurance and long-term care or nursing homes, however, only 21 of them describe the implementation of quality system activities and their impact on the quality of care for residents, only 4 described the control group.
It can be concluded from these studies that specific training, specific resident assessment procedures, using a quality assessment cycle with the assistance of a quality assessment consultant can effectively improve the quality of care for specific aspects of the care process and certain health outcomes of the residents.
The results of the study without the control group can only be used as an indication of the subject of further study.
The link between quality system activities at the process level and the impact on residents' health outcomes has not yet been finalized.
Evidence of conformity-
Basic medicine, it is important to find more evidence of the effectiveness of quality management in the near future, or whether so much should be spent on activities that fail to demonstrate any improvement in quality management may be the quality of care or quality of life of the residents in dispute.
The huge differences in the number of publications and the number of effect studies suggest that the effects of most initiatives are not reported and their effects are not evaluated.
None of the identified research reports are primarily negative results, which may mean that there are some published biases.
This means that there is no valuable information and experience for other nursing homes, so it may be beneficial to investigate and investigate these unpublished activities.
Due to search strategies, some studies that assess quality system activities may be missed, which do not mention "quality" in the title or summary ".
In general, the studies identified involve quality system activities such as the implementation of guidelines, the provision of feedback, the assessment of residents' needs through care planning, internal audits and tuition fees, and the resident ombudsman.
A study reports the impact of the quality system.
The residents' opinions are clearly rarely used to assess the effectiveness of the quality system.
Given the high prevalence of dementia patients in nursing homes, this approach is difficult to implement.
One possibility is to ask the opinion of the relative (agent), but from the perspective of the resident, it is doubtful whether the relative can really speak.
Therefore, the observation of participants in dementia residents may be an appropriate but time-consuming way to measure satisfaction with quality of care.
However, there are studies that measure "consumer satisfaction," 40 but have nothing to do with quality system activities.
After a critical assessment of selected studies, some key issues have arisen.
In most cases, the design of the study makes it impossible to attribute the results entirely to the newly implemented quality system activities
For example, research on the impact of RAI.
Results are generally not quantified in detail.
In addition, interventions are often not described in sufficient detail to allow the agency manager or caregiver to repeat the intervention in order to achieve the same effect.
There is also often no indication of which factors or elements are critical to achieving (positive) results.
It is concluded from the literature that at present, there is no clear answer to what quality system activities should be used by nursing homes to improve the care provided to residents.
From the control study, there is some evidence that activities directly related to the ability of professionals, such as training and guidelines, can affect the outcome of patient levels.
It may be that nursing staff in nursing homes lack training in the specific knowledge and ability required to care for an increasing number of elderly residents with disabilities and greater co-morbidity.
The use of additional training and guidelines can reduce the uncertainty of caregivers.
In addition, there are indications that RAI has some positive effects on the health outcomes of residents, but the study design does not allow further conclusions to be drawn.
RAI provides a systematic approach for caregivers that includes treatment advice and guidelines.
In order to obtain more certainty about the effectiveness of quality system activities, future research should at least includetest/post-
Test design and control group.
The results show that it is possible to establish a randomized controlled trial for some quality system activities.
In practice, it seems more difficult to design a randomized controlled study to evaluate a more complex overall quality system.
Therefore, future research on the effectiveness of quality systems can also be based on multiple or multi-level methods --
For example, the difference between the different institutions was initially determined which results related to the residents (corrected for the resident's case combination, subsequently, the differences in structure and process features between agencies were investigated in more detail.
This will make it possible to identify influential organizational and environmental factors or factor models, and identify which elements of the quality system are most effective and in which cases are most effective.
Another possibility is to combine the process and effect assessment with the random of the nursing home rather than the residents.
Finally, it may also be necessary to evaluate the quality system in combination with qualitative and quantitative research methods.
Examples of qualitative methods include participant observation, on-site visits and interviews, or certification procedures.
The data collected through these methods can be combined and analyzed at a more conceptual level to help us understand the mechanisms between the organizational structure, the care process and the outcomes of the residents.
Referee Kane RL.
Improve the quality of long-term care. JAMA 1995; 273:1376–80.
Openurlcrosspubpubmedweb of science Phillips CD, Morris JN, Hoth C and others.
The Association of resident assessment tools (RAI) with changes in functioning, cognitive and psychosocial conditions.
The Soc atr Soc 1997; 45:986–93.
OpenUrlPubMedWeb of science steel K, Sherwood S, Libu MW.
Future: one person-
Specific and standardized means of assessment.
1997 age aging;
26 (SUPL 2): 83-5.
OpenUrlAbstract/free all TextEvans JG, Bond J.
The challenge of age research.
1997 age aging;
26 (SUPL 4): 43-6.
Dickinson E, Brocklehurst J.
Improving the quality of long-term care for the elderly: lessons learned from the care program.
Quality of medical care 1997; 6:160–4.
OpenUrlFREE full Text audio Ribbe MW, Ljunggren G, K, etc.
Nursing homes in 10 countries: a comparison between the state and the environment.
1997 age aging;
26 (SUPL 2): 3-12.
Bartlett H.
Nursing homes for the elderly: quality and policy issues.
Harwood Academic Press Co. , Ltd. , 1993.
Walker AJ.
Peer review organization for use and quality control.
Medical insurance: a strategy for quality assurance.
Washington: Institute of Medicine/National Academy of Sciences Press, 1990. ↵Donabedian A.
Effectiveness of quality assurance.
International health care 1996; 4:401–7. ↵Grol R.
Research and development of quality of care: development of research agenda.
Quality of medical care 1996; 5:235–42.
OpenUrlFREE full Text ↵ Klazinga NS.
Quality management of Dutch medical specialist care.
O'Sullivan: Belvedere, 1996. ↵Øvretveit J.
Comparison of health service quality methods in the UK, the US and Sweden and the use of organizational audit frameworks.
Eur J Publ Health 1994; 4:46–54.
OpenUrlAbstract/free full Text EFQM, FQM.
European model of selfappraisal.
Brussels: EFQM, 1992.
Alimcasparie AF, the company EM, Wagner, etc.
The quality system of health care institutions in the Netherlands.
1997. health policy; 42:255–67.
C. , Bakker DH de, of OpenUrlCrossRefPubMedWeb Science GmbH Wagner, the company.
In instellingen kwaliteitssystemen: de standing 1995 van zaken (quality system in medical institutions: advanced of 1995 ).
Utrecht: Neville, 1995. ↵Boyce N.
Results data are used to measure the quality of health care.
International health care 1996; 2:101–4.
MJ rantz MJ, Mehr DR, Conn VS, etc.
Assessing the quality of nursing in nursing homes: improving the basis for outcomes of hospitalized patients.
Quality of Nurs 1996; 4:1–9.
Pizzinn JS, Ellenson, Dr. roskic.
Use of standardized indicators as a tool for quality improvement: application at Penn nursing home.
M. L. Med Qual 1993; 2:72–8.
Fairstein, rose N.
Quality of Care for host families: a comparison between Israel and Florida.
Health care of 1992; 3:225–44.
Souavorn J, Soumerai SB, Everitt DE, etc.
A randomized trial to reduce the use of psychiatric drugs in nursing homes.
N. Engl J. Med 1992; 327:168–73.
Scientific openurlcross pubpubmedweb ray WA, Taylor JA, Meador KG, etc.
Reduce the use of anti-psychiatric drugs in nursing homes.
A trial of debate over provider education.
Intern Med 1993; 153:713–21.
The Department of Health of OpenUrlCrossRefPubMedWeb Science GmbH Gustafson.
Lessons learned from early attempts to implement the CQI principle in the regulatory system.
Bull 1992 Bull; 4:333–9.
OpenUrl shopmohide EA, tegwell resolution, calfield PA, etc.
Random trials of quality assurance in nursing homes. Med Care 1988; 6:554–65.
Openurl schschnelle JF, Newman D, White M, etc.
Through the application of industrial quality control, the self-control of the residents of the nursing home is maintained.
Gerontology. ; 1:114–21.
OpenUrl Dragon Suntken, Starr B Ermer-Seltun J, wait.
Use AHCPR pressure sore prevention and treatment guidelines to implement a comprehensive skin care plan in a care setting.
Mouth/Wound Management 19962:20–32. ↵Moseley CB.
Impact of Federal Regulations on urinary tract insertion in Virginia nursing home.
M. J. Med Qual 1996; 4:222–6.
OpenUrlChambers R of Campbell Knight F.
Pilot study of introducing audit into nursing homes.
1996 age aging; 25:465–9.
Richmond I, Trujillo D, Schmelzer J, et al.
The least restrictive alternatives: do they really work?
Quality of Care 1996; 1:29–37.
Coronary heart disease, Zimmerman D, Bernabei R, et al.
Improve the quality of nursing homes using inpatient assessment tools.
1997 age aging;
26 (SUPL 2): 77-81.
OpenUrlAbstract/free all TextHawes C, Ministry of Railways, cross, etc. The OBRA-
87 regulations on nursing homes and implementation of resident physician assessment documents: Impact on process quality.
J Am Geriatr Soc 1997; 45:977–85.
Scientific OpenUrlPubMedWeb fries BE, Hawes C, Morris JN, etc.
The impact of the National Resident assessment tool on selected health conditions and problems.
The Soc atr Soc 1997; 45:994–1001.
V, Intrator O, French fries of OpenUrlPubMedWeb Science dommor, etc.
Inpatient changes related to the introduction of inpatient assessment tools.
The Soc atr Soc 1997; 45:1002–10.
OpenUrlPubMedWeb of science
From quality assurance of long-term care to quality management.
Four-Turn Bull Market 1991: 207 months.
RI shorr RI, fought with RL, Ray WA
Changes in the use of anti-psychiatric drugs in nursing homes during the implementation of OBRA87 regulations. JAMA 1994; 271:358–62.
Scientific openurlcrosspubmedweb Cherry RL.
Quality of care in community presence and nursing homes: ombudsman as a complementary role.
Soc 1993 of health Behav; 34:336–45.
JM, tototolos E, of openurlcrossrefpmedweb Science journal Levine. A quality-
The guiding method of pressure sore management in nursing institutions.
1994 Gerontology; 3:413–7.
OpenUrl such as bidsemla TP, Parak, Poddig B, etc.
Effect of the comprehensive settlement Act 1987 on the prescription of anti-psychiatric drugs for residents of nursing homes.
The Soc atr Soc 1994; 42:648–52.
RP, Shiverick BN, Zimmerman D of OpenUrlPubMedWeb Science Limited Fitzgerald.
Apply performance measures to long-term care.
J Qual increased by 1996; 7:505–17.
OpenUrl shopchalliner Y.
Introducing quality assurance in long-term care for the elderly: a difficult and valuable process?
Quality of medical care 1997; 6:153–9.
OpenUrlFREE full text campen C van, Sixma H, Friele RD, etc.
Quality of care and patient satisfaction: a review of measuring instruments.
Health Care Res Rev 1995; 52:109–33.