There is so much more to improving quality than increasing inspections -
and inspections need to focus on what really matters: management
responsibility. In the Sixties, Seventies and Eighties of the last century W. Edwards Deming was teaching auto manufacturers that you cannot inspect in quality, it has to be built in. Catching defects at inspection is too late. The Japanese listened and their auto industry overtook the American industry in quality, sales and profits - in that order. Quality drove sales which in turn drove profits.
Seeking admission to a long term care (nursing) home for yourself or a loved one in
Ontario, Canada is a process regulated by the Province of Ontario Ministry of Health and Long Term Care. The process is administered by the local CCAC (Community Care Access Centre) in the area where the person seeking admission
resides.
The above link will tell you how to do the next step: contact the CCAC (Community Care Access Centre) in the area where the person seeking admission resides. A care coordinator will help you determine
eligibility and whether an LTC home is the right decision. If it is, they will
then tell you to choose up to five homes. That is when your work really begins.
Assuming
all the above is now behind you, the rest of this article provides pointers for
some things to look at when making comparisons between homes.
Points
to compare between LTC homes
You can find a list of LTC homes in say, the Newmarket area, at the Ministry of Health and Long Term Care web page: Reports on Long-Term Care Homes. Go to the web page and click on the link, 'Find by location'. This takes you to the page Search for LTC Homes By Location
Enter
whatever town is of interest to you into City/Town and click next.
This
takes you to the page Long-Term Care Homes
Search Results. If you entered 'Newmarket' you would see a list of 4
homes to choose from and compare, each with a link that takes you to that
home's report page with two tabs, one for the home profile, the other for the
home's inspection reports in descending chronological order. You may want more
of a choice. In that case, instead of specifying the town, enter the
county/district.
Inspection Reports
The
inspection reports should be of particular interest to you.
1 Resident
Quality Inspection reports are reports from annual inspections by the
Ministry of Health and Long Term Care, and are the most thorough. Inspection
findings are presented as Written Notifications (WN). A WN may conclude with
a Voluntary Plan of Correction (VPC) or, more seriously, a Compliance Order, Director Referral or Work and Activity Order:
DR –
Director Referral
CO –
Compliance Order
WAO –
Work and Activity Order
Not all
WN's are equal. Use common sense to distinguish something like stained
upholstery or missing ceiling tiles or wrong menu courses from noncompliance that poses risk of harm to
residents as with improper control of drugs and medication and broken wheel
chairs or doors not locking with the correct protocols allowing dementia
residents to wander.
2 Critical
Incident Inspection reports are typically as a result of a resident
experiencing some harm. When this happens, the home administrator is required
by law to report the incident within a fixed period of time. The Ministry will
look at the report and decide whether or not to follow up with an inspection to
more fully investigate what happened and whether the home is following all
required procedures.
3 Complaints
inspection reports are as a result of Ministry follow up on an official
complaint lodged by a resident or family member. Complaints are often made in
confidence. There is a strict code against retaliation and abuse.
Sample list of inspection reports
In my casual observations I have found there is
generally, on average, an inverse proportion between the number of critical
incident and complaint reports and the length of the wait period for admission. It would appear that the most desirable and well-run homes typically have the longest queues for
admission.
Health Quality Ontario Reports
In
addition to the inspection reports which are focused purely on compliance with
the Long Term Care Homes Act and associated regulations, there are some other
important indicators that you will want to look at that focus more on quality of life. Health Quality Ontario (HQO) currently reports publicly on four quality indicators for individual long-term
care homes. These indicators relate to four health topics:
Click 'By Home' and then enter the first few words of
the home name to get a list to choose from. Choose the desired home and click 'Search'.
You will
see a table that shows how the home compares with the provincial average on
each quality of life indicator. You can also see whether the home is improving
over the previous year's performance and how it compares with the optimal
benchmark.
Example of Health Quality Indicators
So now,
you have looked at inspection reports and quality indicators for some homes and
discovered that comparing homes in this way is not a trivial undertaking.Once you find a 'maybe' home, phone the home
and arrange a tour. Web sites for most CCAC's offer a list of questions to enquire
on. You can find a very comprehensive tour checklist here: www.nursinghomeratings.ca/downloads/NursingHomeTourChecklist.pdf
Most
people who do the tour do not ask questions. Don't be timid or afraid. You
don't have to ask every question on the check-list, but know beforehand which
are the important questions for you. If you do not feel comfortable asking in
front of other people, confirm that you can phone later and ask your questions.
There is
a lot of information here. I sincerely hope this is not too confusing. Just
take your time to work through the steps.
Registration and Accreditation
All LTC homes in Ontario have to be registered with the Ministry of Health and Long Term Care and are subject to inspections by the Ministry. In addition, some homes seek accreditation from bodies such as CARF and Accreditation Canada. These are standards bodies that assert with accreditation that a long term care home has certain procedures and protocols in place and abides by them. These operational procedures and protocols are in addition to those required for registration by the Ministry of Health and Long Term Care. The Ministry does not require accreditation but encourages LTC homes to acquire accreditation by granting certain funding premiums to accredited homes. Intuitively one would think that this should be a good thing. However, when it comes to complaints and critical incidents there are both accredited and non-accredited homes with a high rate of these inspections just as there are both accredited and non-accredited homes with a low rate. I recommend placing a higher reliance on your own due diligence in reviewing inspection reports rather than merely presuming that an accredited home will automatically have a better record in this regard than a non-accredited home.
I base the above advice on a statistical analysis that I did comparing accredited and non-accredited homes. You can review the two-part analysis in the following videos.
A report titled, Home solutions to our care crisis, was published in the United Kingdom by the Papworth Trust in November, 2012. The report is the distillation of 640 responses from their English Housing Survey conducted to see how unsuitable housing can affect people's lives. A secondary aim of the survey was to help increase awareness of home adaptations as a solution to the care crisis for the disabled being experienced in the UK.
Home adaptations would include such things as: bathroom conversions, grab rails, kitchen alterations, ramps and level access, widening doorways.
One in 4 respondents reported that they could not get around their home safely.
Two in 5 people said that a lack of facilities for the disabled in their home meant they needed help to do everyday things like cooking.
Two thirds of people who had not received a government Disabled Facilities Grant (DFG) had never heard of it.
Here in Ontario, or Canada generally, do we have any reason to think that we would not get responses similar to those in the UK?
Financial benefits of home adaptations
Analysis by the London School of Economics suggests that the annual spend on governmental Disabled Facilities Grants of around £270 million is worth up to £567 million in health and social care savings and quality of life gains. Put differently, every £1 spent on Disabled Facilities Grants is worth over £2 in care savings and quality of life gains.
A study by Bristol University, on behalf of the Office of Disability Issues, found that home adaptations can help prevent or defer entry into residential care. Just 1 year’s delay means a saving up to £26,000 per person, less the cost of the adaptation (which averages £6,000). (Can somebody tell me the cost per person per year for long-term care in Ontario?)
Falls by older people in the UK cost over £1 billion a year. A fractured hip can cost the state an estimated £28,665. Compare this with the cost of installing grab rails, one effective way of reducing risk of falls.
In Wales, the Government has estimated that a programme to help older people remain living independently in their own homes has saved the NHS and social care budgets over £101 million since it was set up 10 years previously.
Home Adaptations: A Cost or an Investment with a Return?
There is a common mindset that presumes any initiative requiring money is a money-grabbing cost to the tax payer that should be fought tooth and nail. It should be evident from the above that judicious implementation of home adaptations is actually an investment that should produce a return in both financial savings and quality of life.
(This report titled, Home solutions to our care crisis, was published in the United Kingdom by the Papworth Trust in November, 2012. Does anyone know of any similar studies conducted anywhere in Canada, especially Ontario?)
Most of us have heard friends, acquaintances or people more remote from us tell horror stories about some or other events that have taken place in a long-term care home, or read something in the newspapers.
Someone I was speaking to recently was shocked to see how much disrespect was shown by family members of a home resident toward the personal support worker who was attending to their loved one in the home.
CUPE Ontario published this video on YouTube two weeks ago. It is a powerful statement providing a window from the point of view of nurses and personal support workers.
Following,
are my comments after reading that blog post.
It's an
interesting analogy, comparing senior living and nursing homes with
hotels/motels but, like most analogies, it limps in some important respects
apart from the obvious differences in populations.
1. The
hotel/motel industry in the USA is highly competitive as operators try to fill
beds that are often empty; every Ontario LTC Home has a rather long waiting
list that is largely controlled by the local CCAC which affords special
consideration for the most needy, driven in turn by the need for hospitals to
vacate beds occupied by non-acute-care patients.
2. The
Ontario Long-Term Care Act has resulted in a highly regulated licencing system
and corresponding reporting (CIHI, HQO) and inspection systems that ensure, at
least in intent, a minimum standard of care and quality of life for residents
along with a Residents' Bill of Rights. I don't think that the US hotel system
has anything close, does it?
3. The
real or imagined need for most Ontario LTC home operators to have a good,
strong public relations image has resulted in the quest for accreditation to a standard in certain operational aspects over
and above the requirements for a licence from the Ministry. At least one LHIN,
I am told, has made accreditation mandatory. Interestingly, a statistical
analysis that I did showed no positive correlation between accreditation and
regulatory compliance in the 82 homes making up the two LHINs of my study. See
LTC Homes and Accreditation, parts 1 and 2 at tcmc Quality Management Serviceson YouTube.
The thing
that drove the changes in the USA hotel industry is identified as the
interstate highway system. Why? Because it channelled and redirected
travellers. I would propose that the equivalent for Ontario seniors is the role
played by the CCAC's; that, and the about-to-explode-with-boomers population of
seniors. As a result, the change that I anticipate will be the creation of many
more for-profit LTC homes as private enterprise sees long waiting lists and a
booming senior population as a business opportunity.
The blog
ends by asking the question (of US operators), who will step up and create a
national "One Voice" organization for all Senior Living operators?
The Ontario equivalent is, do seniors' organizations need something beyond
OLTCA, OANHSS and the like? It's a good discussion, no doubt, but I don't see
the evidence, nor do I hear the public saying that we have an urgent need for
one unifying association for Long-Term Care Homes and seniors' care
organizations. The pressing discussion in Canada seems to be reported in the
latest CMA poll: Canadians want a national strategy for seniors health care:doctors report.
The Spring 2014 issue of Healthcare Management Forum has an excellent article by Chattergoon, Darling, Devitt and Klassen on taking Lean Six Sigma principles developed by Toyota and others for the manufacturing industry and applying them with great success to Healthcare, in this case the Toronto East General Hospital (TEGH) and, especially, its Emergency Department (ED). From such a leap, it surely must be a relatively small step to applying these same Principles in other Healthcare arenas such as Long-Term Care Homes.
The central message can be summed up in this quotation from the article's abstract: "enabling continuous improvement in an organization is about an entire cultural shift—not just a series of rapid improvement events."
A culture of continuous improvement evolved organically at TEGH in three key phases:
Phase 1: Setting the stage.
The organization made a commitment to quality and value explicit in its vision and through its strategy, creating a department dedicated to improvement and innovation - the TEGH Improvement System (TIS).
Phase 2: Team-driven performance management.
The leadership team promoted and modelled a "huddle philosophy", which allowed units, departments, and programs to identify new improvement opportunities, monitor performance on improvement projects, and sustain gains. The voice of the patient, obtained through interviews and videos, was made a cornerstone of the huddle philosophy.
Phase 3: The daily management system and cross-appointment model.
A daily management system, called Management Made Easy (MME), was created to allow units, programs, and portfolios to identify and proactively address improvement opportunities before they blew up into large-scale problems. A cross-appointment model was adopted where staff members outside of the TIS team were given weekly-portion appointments to the TIS team to be coached and acquire experience with the TIS team through involvement on improvement projects. Conversely, TIS team members are also given 'portion' appointments to work on improvement projects in departments such as surgery or medicine, thereby giving coaching exposure to entire teams.
Successes.
TEGH can boast about a number of successes as a result of this culture of continuous improvement, most notably that of having the lowest Emergency Department wait times for admitted patients in Toronto Central LHIN (from being one of the worst) and reduced length of stay for patients with chronic obstructive pulmonary disease by 46% through improved quality-based procedures (QBPs); all this while seeing improved staff satisfaction ratings.
The organization has documented a list of telling "lessons learned". At the top of the list is the need to adapt and translate LEAN improvement principles from their original industrial and manufacturing context to the local situation at TEGH.
All Long-Term Care Homes have got the on-going challenges of heading off resident complaints at the pass and preventing avoidable critical incidents. Many have got these pain points satisfactorily under control. Many others are struggling with this challenge and finding that they are triggering unwanted inspections from the Ontario Ministry of Health and Long-Term Care.
As an
Executive Director, or as Chairman of the Board, or Coordinator for Continuous
Quality Improvement, or a member of the Quality Committee, or just a staff
member with the good of our residents at heart - am I concerned with the number
of Ministry of Health and Long-Term Care (MOHLTC) inspections for complaintsand critical incidents? If this is an area for concern then one or more of
three things is probably not happening as well as they should:
Firstly:
Are we measuring all
the right things? Of course, we are measuring for CIHI and HQO and our own
Board meetings, but have we got the metrics in place to red flag the likelihood
of an avoidable critical incident occurring, to red flag the future likelihood
of one or more resident complaints that could trigger an inspection? In the
field of quality management we call this type of metric KPIs, Key Performance
Indicators. KPIs are the organization’s "vital signs", the vital few
metrics that report on the health of the organization in living out its mandate
from and to society. KPIs should not be confused with the kind of quality
indicators that are reported to HQO such as falls, wounds and restraints,
although KPIs might well incorporate some of those metrics.
Secondly:
Are we monitoring
effectively? Assuming that we actually do measure those KPIs, are we reporting
them in an accountable manner to the right people who are best positioned to
effect change – change in our processes and change in our culture? Managers and
others in positions of responsibility who are not being fed the information
they need to do their job need to report this as a concern up the management
chain. Without KPIs you are flying blind.
Thirdly:
Are we managing
efficiently and effectively? Assuming that we are reliably measuring and
monitoring KPIs, are the process owners and managers sufficiently trained,
mandated, empowered, resourced and accountable to take the actions necessary to
enhance the Quality Management System (QMS) and foster a culture of quality to
prevent the bad stuff happening? If not, that is fodder for a KPI in itself and
needs to be reported as a resourcing issue to senior management. Managers and
others in positions of responsibility who feel they need training need to do
whatever it takes to get it; if your department is at risk for non-compliance
because you are lacking resources then that needs to be reported, repeatedly if
necessary.
