September 22, 2014


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Abstracts

Canada has a national dementia plan (too bad it doesn’t have a strategy):
National dementia research and prevention plan Canada-flat-icon
2014

The new plan outlines investments, partnerships and initiatives already underway to stimulate dementia research and reduce the burden on families. These include two new efforts: a $31.5 million initiative to support collaborative dementia research across 20 expert teams and an awareness program to foster “dementia-friendly” communities.

New Article by Dr. Susan Slaughter
Identification of hearing loss among residents with dementia: Perceptions of health care aides.
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Slaughter SE, Hopper T, Ickert C, Erin DF.
Geriatric nursing (New York, N.Y.) 2014 Sep 8

Effective communication can be difficult when working with individuals with dementia and hearing loss. Given the high prevalence of both dementia and hearing loss among individuals in long term care, direct care providers in this setting, will almost certainly confront frequent communication challenges. To understand health care aide perspectives of caring for residents with dementia and hearing loss, 12 health care aides from five nursing homes participated in audio-recorded, semi-structured interviews. Transcripts were coded and themes were identified. Health care aides reported the difficulties in distinguishing the relative contributions of hearing loss and dementia to communication breakdowns. They reported that familiarity with residents helped them differentiate between sensory versus cognitive impairments in conversations with residents. Although able to identify strategies to support communication, communication difficulty complicated both their provision of care and support of quality of life for residents with dementia and hearing loss. Suggestions for practice and education are provided.

CALL FOR ABSTRACTS:
Integrating Health Policy into Doctoral Nursing Programs
27 January 2015 Coronado, CA
DEADLINE 31 October 2014

This conference offers PhD and DNP faculty strategies for integrating health policy into their programs and courses. Its interprofessional and interdisciplinary panels of speakers will propose core content and methods for developing faculty and student expertise in policy analysis and research. The conference fosters the work of the Robert Wood Johnson Foundation in building a culture of health, which assumes that health encompasses more than health care, and that health policy necessarily encompasses the broader social, economic, political, and cultural aspects of health. Faculty and students with beginning and advanced health policy knowledge are encouraged to attend.

CALL FOR PAPERS:
Academy for Professionalism in Health Care
7-9 May Louisville KY
DEADLINE 5 December

Organizers are looking for submissions exploring the contours of professionalism in health care toward the identification of its breadth, scope, and impacts on health care practices and education.

CALL FOR ABSTRACTS:
National Health Leadership Conference (NHLC)
15-16 June Charlottetown PE
DEADLINE 2 November

This conference is the largest national gathering of health system decision-makers in Canada including trustees, chief executive officers, directors, managers, department heads and other health leaders representing various sectors and professions in health regions, authorities and alliances, hospitals, long-term care organizations, public health agencies, community care, mental health and social services. As well, the conference draws participants from government, education and research organizations, professional associations, consulting firms and industry. The NHLC focuses on the key challenges and opportunities facing today’s health leadership in Canada and strives to provide an environment that will nurture the movement from knowledge to action.

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Publications

KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Practice & Methodology
Healthcare in Canada
Aging

KT

Using realist evaluation to open the black box of knowledge translation: a state-of-the-art review Canada-flat-icon
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Salter KL, Kothari A.
Implementation science : IS 2014 Sep 5;9(1):115

In knowledge translation, complex interventions may be implemented in the attempt to improve uptake of research-based knowledge in practice. Traditional evaluation efforts that focus on aggregate effectiveness represent an oversimplification of both the environment and the interventions themselves. However, theory-based approaches to evaluation, such as realist evaluation (RE), may be better-suited to examination of complex knowledge translation interventions with a view to understanding what works, for whom, and under what conditions. It is the aim of the present state-of-the-art review to examine current literature with regard to the use of RE in the assessment of knowledge translation interventions implemented within healthcare environments.MethodsMultiple online databases were searched from 1997 through June 2013. Primary studies examining the application or implementation of knowledge translation interventions within healthcare settings and using RE were selected for inclusion. Varying applications of RE across studies were examined in terms of a) reporting of core elements of RE, and b) potential feasibility of this evaluation method.ResultsA total of 14 studies (6 study protocols), published between 2007 and 2013, were identified for inclusion. Projects were initiated in a variety of healthcare settings and represented a range of interventions. While a majority of authors mentioned context (C), mechanism (M) and outcome (O), a minority reported the development of C-M-O configurations or testable hypotheses based on these configurations. Four completed studies reported results that included refinement of proposed C-M-O configurations and offered explanations within the RE framework. In the few studies offering insight regarding challenges associated with the use of RE, difficulties were expressed regarding the definition of both mechanisms and contextual factors. Overall, RE was perceived as time-consuming and resource intensive.ConclusionsThe use of RE in knowledge translation is relatively new; however, theory-building approaches to the examination of complex interventions in this area may be increasing as researchers attempt to identify what works, for whom and under what circumstances. Completion of the RE cycle may be challenging, particularly in the development of C-M-O configurations; however, as researchers approach challenges and explore innovations in its application, rich and detailed accounts may improve feasibility.

Evidence-based health care management: what is the research evidence available for health care managers? Canada-flat-icon
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Jaana M, Vartak S, Ward MM.
Evaluation & the health professions 2014 Sep;37(3):314-334

In light of increasing interest in evidence-based management, we conducted a scoping review of systematic reviews (SRs) and meta-analyses (MAs) to determine the availability and accessibility of evidence for health care managers; 14 MAs and 61 SRs met the inclusion criteria. Most reviews appeared in medical journals (53%), originated in the United States (29%) or United Kingdom (22%), were hospital-based (55%), and targeted clinical providers (55%). Topics included health services organization (34%), quality/patient safety (17%), information technology (15%), organization/workplace management (13%), and health care workforce (12%). Most reviews addressed clinical topics of relevance to managers; management-related interventions were rare. The management issues were mostly classified as operational (65%). Surprisingly, 96.5% of search results were not on target. A better classification within PubMed is needed to increase the accessibility of meaningful resources and facilitate evidence retrieval. Health care journals should take initiatives encouraging the publication of reviews in relevant management areas. © The Author(s) 2013.

CLAHRCs in practice: combined knowledge transfer and exchange strategies, cultural change, and experimentation.
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Soper B, Yaqub O, Hinrichs S, Marjanovich S, Drabble S, Hanney S, et al.
Journal of health services research & policy 2013 Oct;18(3 Suppl):53-64

The nine NIHR CLAHRCs are collaborations between universities and local NHS organizations that seek to improve patient outcomes through the conduct and application of applied health research. The theoretical and practical context within which the CLAHRCs were set up was characterized by a considerable degree of uncertainty, and the CLAHRCs were established as a natural experiment. METHODS: We adopted a formative and emergent evaluation approach. Drawing on in-depth, multi-method case studies of two CLAHRCs we explored how they pursued their remit by supporting efforts to increase the relevance and use of health research, and building relationships. RESULTS: Both CLAHRCs: strengthened local networks and relationships; built capacity in their local academic and NHS communities to undertake and use research that meets the needs of the service; developed research and implementation methodologies; and added to understanding of the complex relation between research and implementation. There was evidence of impact of CLAHRC projects on health and social care services. Informed by the literature on implementing collaborative research initiatives, knowledge transfer and exchange and cultural change, some key lessons can be drawn. CONCLUSION: The CLAHRCs pursued a strategy that can be categorized as one of flexible comprehensiveness; i.e. their programmes have been flexible and responsive and they have used a range of approaches that seek to match the diverse aspects of the complex issues they face. Key features include their work on combining a range of knowledge transfer and exchange strategies, their efforts to promote cultural change, and the freedom to experiment, learn and adapt. Although the CLAHRCs do not, by themselves, have the remit or resources to bring about wholesale service improvement in health care, they do have features that would allow them to play a key role in some of the wider initiatives that encourage innovation.

Strategies to promote uptake and use of intimate partner violence and child maltreatment knowledge: an integrative review.
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MacGregor JC, Wathen N, Kothari A, Hundal PK, Naimi A.
BMC public health 2014 Aug 21;14:862-2458-14-862

Intimate partner violence (IPV) and child maltreatment (CM) are major social and public health problems. Knowledge translation (KT) of best available research evidence has been suggested as a strategy to improve the care of those exposed to violence, however research on how best to promote the uptake and use of IPV and CM evidence for policy and practice is limited. Our research asked: 1) What is the extent of IPV/CM-specific KT research? 2) What KT strategies effectively translate IPV/CM knowledge? and 3) What are the barriers and facilitators relevant to translating IPV/CM-specific knowledge? METHODS: We conducted an integrative review to summarize and synthesize the available evidence regarding IPV/CM-specific KT research. We employed multiple search methods, including database searches of Embase, CINAHL, ERIC, PsycInfo, Sociological Abstracts, and Medline (through April, 2013). Eligibility and quality assessments for each article were conducted by at least two team members. Included articles were analyzed quantitatively using descriptive statistics and qualitatively using descriptive content analysis. RESULTS: Of 1230 identified articles, 62 were included in the review, including 5 review articles. KT strategies were generally successful at improving various knowledge/attitude and behavioural/behavioural intention outcomes, but the heterogeneity among KT strategies, recipients, study designs and measured outcomes made it difficult to draw specific conclusions. Four key themes were identified: existing measurement tools and promising/effective KT strategies are underused, KT efforts are rarely linked to health-related outcomes for those exposed to violence, there is a lack of evidence regarding the long-term effectiveness of KT interventions, and authors’ inferences about barriers, facilitators, and effective/ineffective KT strategies are often not supported by data. The emotional and sometimes contested nature of the knowledge appears to be an important barrier unique to IPV/CM KT. CONCLUSIONS: To direct future KT in this area, we present a guiding framework that highlights the need for implementers to use/adapt promising KT strategies that carefully consider contextual factors, including the fact that content in IPV/CM may be more difficult to engage with than other health topics. The framework also provides guidance regarding use of measurement tools and designs to more effectively evaluate and report on KT efforts.

Supporting Knowledge Translation Through Evaluation
Evaluator as Knowledge Broker
Canada-flat-icon
Donnelly C, Letts L, Klinger D, Shulha L.
Canadian Journal of Program Evaluation 2014;29(1)

The evaluation literature has focused on the evaluation of knowledge translation activities, but to date there is little, if any, record of attempts to use evaluation in support of knowledge translation. Th is study sought to answer the question: How can an evaluation be designed to facilitate knowledge translation? A single prospective case study design was employed. An evaluation of a memory clinic within a primary care setting in Ontario, Canada, served as the case. Th ree data sources were used: an evaluation log, interviews, and weekly e-newsletters. Th ree broad themes emerged around the importance of context, eff orts supporting knowledge translation, and the building of KT capacity.

A mixed-methods approach to investigating the adoption of evidence-based pain practices in nursing homes.
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Ersek M, Jablonski A.
Journal of gerontological nursing 2014 Jul;40(7):52-60

This mixed methods study examined perceived facilitators and obstacles to adopting evidence-based pain management protocols vis-a-vis documented practice changes that were measured using a chart audit tool. This analysis used data from a subgroup of four nursing homes that participated in a clinical trial. Focus group interviews with staff yielded qualitative data about perceived factors that affected their willingness and ability to use the protocols. Chart audits determined whether pain assessment and management practices changed over time in light of these reported facilitators and barriers. Reported facilitators included administrative support, staff consistency, and policy and procedure changes. Barriers were staff attitudes, regulatory issues, and provider mistrust of nurses’ judgment. Overall, staff reported improvements in pain practices. These reports were corroborated by modest but significant increases in adherence to recommended practices. Change in clinical practice is complex and requires attention to both structural and process aspects of care. Copyright 2014, SLACK Incorporated.

Engineering youth service system infrastructure: Hawaii’s continued efforts at large-scale implementation through knowledge management strategies.
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Nakamura BJ, Mueller CW, Higa-McMillan C, Okamura KH, Chang JP, Slavin L, et al.
Journal of clinical child and adolescent psychology 2014;43(2):179-189

Hawaii’s Child and Adolescent Mental Health Division provides a unique illustration of a youth public mental health system with a long and successful history of large-scale quality improvement initiatives. Many advances are linked to flexibly organizing and applying knowledge gained from the scientific literature and move beyond installing a limited number of brand-named treatment approaches that might be directly relevant only to a small handful of system youth. This article takes a knowledge-to-action perspective and outlines five knowledge management strategies currently under way in Hawaii. Each strategy represents one component of a larger coordinated effort at engineering a service system focused on delivering both brand-named treatment approaches and complimentary strategies informed by the evidence base. The five knowledge management examples are (a) a set of modular-based professional training activities for currently practicing therapists, (b) an outreach initiative for supporting youth evidence-based practices training at Hawaii’s mental health-related professional programs, (c) an effort to increase consumer knowledge of and demand for youth evidence-based practices, (d) a practice and progress agency performance feedback system, and (e) a sampling of system-level research studies focused on understanding treatment as usual. We end by outlining a small set of lessons learned and a longer term vision for embedding these efforts into the system’s infrastructure.

What Works Network: How to achieve more effective services: the evidence ecosystem (UK)
June 2014

This report by Prof Jonathan Shepherd for the What Works Network looks at how we can generate, translate and use evidence better. Recognising the importance of an evidence ecosystem to the production of effective policies and programmes, Shepherd sets out the challenges we face and the actions that we need to take.

Institute National de Santé Publique du Québec: Facilitating a Knowledge Translation Process Knowledge REview and Facilitation Tool Canada-flat-icon
March 2013

In public health, as in the field of health in general and in the social sciences, there is a significant gap between the knowledge available and the use of that knowledge. Despite the devotion of considerable effort over the course of recent years to implementing innovative strategies at the central, regional and local levels, there is still much to learn about how to increase knowledge use and there is a great need for tools and training that can further the development of better practices in the area of knowledge translation. Designed with a view to supporting action, this document first presents an overview of existing knowledge about the translation of knowledge in the health field. On the basis of the available literature, this knowledge review identifies the main elements to consider when attempting to implement more structured knowledge translation practices. This information is synthesized and a dynamic and integrated conceptualization of the knowledge translation process is presented in the next section. The document’s annexes include a tool for facilitating a knowledge transfer process and a summary diagram that illustrates at a glance the contents of this publication. While it is intended for public health actors, the contents of this document can be applied in a variety of contexts. Thus, it is addressed to a broad audience of managers, decision makers, stakeholders and public policy makers working in various activity sectors, as well as to professionals acting as liaison officers, knowledge translation officers, researchers or knowledge brokers in their respective sectors. Nevertheless, for public health actors, this document offers the advantage of using examples drawn from their reality and providing them with points of reference for their practices.

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Health Care Administration and Organization

Caregivers’ time utilization before and after the introduction of an electronic nursing documentation system in a residential aged care facility.
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Munyisia EN, Yu P, Hailey D.
Methods of information in medicine 2013;52(5):403-410

Despite increasing research on caregivers’ interaction with technology, there has been no attempt to investigate how the introduction of an electronic system in a residential aged care facility (RACF) may affect caregivers’ use of their time. OBJECTIVE: To assess how caregivers use their time before and after the introduction of an electronic documentation system in an RACF. METHODS: An observational work sampling study was undertaken with caregivers at two months before, and at 3, 6, 12 and 23 months after the implementation of an electronic documentation system. RESULTS: During the first 12 months after implementation, the proportion of time spent by personal carers on documentation increased, that on direct care reduced, and the proportion on communication remained unchanged. At 23 months, the proportion on documentation and direct care had returned to pre-implementation levels. The percentage of time spent on these activities by recreational activity officers remained unchanged at most measurement periods after implementation. Changes in proportions of time on other activities were not directly associated with the introduction of the electronic system. CONCLUSION: It may take over a year for some caregivers in an RACF to integrate the use of a newly introduced electronic documentation system into their daily work. Organisations implementing such systems should develop strategies that support and accelerate the caregivers’ integration of the new documentation practice into their routine activities. The electronic documentation system may not however, replace the role of verbal communication between caregivers in aged care service.

Impact of organisational characteristics on turnover intention among care workers in nursing homes in Korea: a structural equation model
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Ha JG, Man Kim J, Hwang WJ, Lee SG.
Australian Health Review 2014 Sep;38(4):425-431

The aim of the present study was to analyse the impact of organisational characteristics on the turnover intention of care workers working at nursing homes in Korea. Methods Study participants included 504 care workers working at 14 nursing homes in Korea. The variables measured were: high-performance work practices, consisting of five subfactors (official training, employment stability, autonomy, employee participation and group-based payment); organisational commitment, consisting of three subfactors (affective, normative and continuance commitment); organisational support; and turnover intention. The inter-relationship between high-performance work practices, organisational support, organisational commitment and turnover intention and the fit of the hypothetical model were analysed using structural equation modelling. Results According to our analysis, high-performance work practices not only had a direct effect on turnover intention, but also an indirect effect by mediating organisational support and commitment. The factor having the largest direct influence on turnover intention was organisational commitment. Conclusions The results of the present study suggest that to improve health conditions for frail elderly patients at nursing homes, as well as the efficiency of nursing homes through the continuance of nursing service and enhancement of quality of service, long-term care facilities should reduce the turnover intention of care workers by increasing their organisational commitment by actively implementing high-performance work practices. What is known about the topic? Considerable studies have shown that the adoption of high-performance work practices is related to an organisation’s performance and job satisfaction. In addition, previous studies found that job satisfaction is inversely related to the turnover intention of employees. What does this paper add? This paper identified that high-performance work practices are closely related to the turnover intention of care workers in nursing homes. These findings could improve our understanding of the factors that impact on labour management in nursing homes. What are the implications for practitioners? The turnover of care workers is one of the major managerial challenges for nursing home managers. The findings of this study suggest that managers should be focused on high-performance work practices to improve the efficiency of their organisations.

Validation of a clinical leadership qualities framework for managers in aged care: a Delphi study.
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Jeon YH, Conway J, Chenoweth L, Weise J, Thomas TH, Williams A.
Journal of clinical nursing 2014 Sep 11

To establish validity of a clinical leadership framework for aged care middle managers (The Aged care Clinical Leadership Qualities Framework). BACKGROUND: Middle managers in aged care have responsibility not only for organisational governance also and operational management but also quality service delivery. There is a need to better define clinical leadership abilities in aged care middle managers, in order to optimise their positional authority to lead others to achieve quality outcomes. DESIGN: A Delphi method. METHODS: Sixty-nine experts in aged care were recruited, representing rural, remote and metropolitan community and residential aged care settings. Panellists were asked to rate the proposed framework in terms of the relevance and importance of each leadership quality using four-point Likert scales, and to provide comments. Three rounds of consultation were conducted. The number and corresponding percentage of the relevance and importance rating for each quality was calculated for each consultation round, as well as mean scores. Consensus was determined to be reached when a percentage score reached 70% or greater. RESULTS: Twenty-three panellists completed all three rounds of consultation. Following the three rounds of consultation, the acceptability and face validity of the framework was confirmed. CONCLUSIONS: The study confirmed the framework as useful in identifying leadership requirements for middle managers in Australian aged care settings. The framework is the first validated framework of clinical leadership attributes for middle managers in aged care and offers an initial step forward in clarifying the aged care middle manager role. RELEVANCE TO CLINICAL PRACTICE: The framework provides clarity in the breadth of role expectations for the middle managers and can be used to inform an aged care specific leadership program development, individuals’ and organisations’ performance and development processes; and policy and guidelines about the types of activities required of middle managers in aged care. © 2014 John Wiley & Sons Ltd.

Home health agency work environments and hospitalizations.
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Jarrin O, Flynn L, Lake ET, Aiken LH.
Medical care 2014 Oct;52(10):877-883

An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living, thus putting patients at risk of additional health challenges and increasing care costs. OBJECTIVES: To determine the relationship between home health agency work environments and agency-level rates of acute hospitalization and discharges to community living. METHODS AND DESIGN: Analysis of linked Center for Medicare and Medicaid Services Home Health Compare data and nurse survey data from 118 home health agencies. Robust regression models were used to estimate the effect of work environment ratings on between-agency variation in rates of acute hospitalization and community discharge. RESULTS: Home health agencies with good work environments had lower rates of acute hospitalizations and higher rates of patient discharges to community living arrangements compared with home health agencies with poor work environments. CONCLUSION: Improved work environments in home health agencies hold promise for optimizing patient outcomes and reducing use of expensive hospital and institutional care.

Economic Evaluation of the 80% Baccalaureate Nurse Workforce Recommendation: A Patient-level Analysis.
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Yakusheva O, Lindrooth R, Weiss M.
Medical care 2014 Oct;52(10):864-869

Higher proportions of BSN-educated nurses were associated with improved outcomes in hospital-level studies. A recent Institute of Medicine report calls for increasing the proportion of BSN-educated nurses to 80% by 2020. Patient-level evidence of cost and quality implications of the 80% BSN threshold is needed for a business case to support these efforts. OBJECTIVES: To conduct the economic analysis of meeting the 80% BSN threshold on patient outcomes and costs, using linked patient-nurse data. RESEARCH DESIGN: Retrospective observational patient-level analysis of electronic data. Linear and logistic regression modeling with patient controls and diagnosis and unit fixed effects. SUBJECTS: A total of 8526 adult medical-surgical patients matched with 1477 direct care nurses from an Eastern US academic medical center, during June 1, 2011-December 31, 2011. MEASURES: Outcomes include hospital mortality, all-cause same-facility 30-day readmission, length-of-stay, and total hospitalization cost. BSN proportion is a continuous measure for the proportion of nurse assessment inputs into the patient’s electronic medical record made by BSN-educated nurses; a dichotomous indicator for BSN proportion is 0.8-1.0. RESULTS: Continuous BSN proportion was associated with lower mortality (OR=0.891, P<0.01). Compared with patients with <80% BSN care, patients receiving ≥80% of care from BSN nurses had lower odds of readmission (OR=0.813, P=0.04) and 1.9% shorter length-of-stay (P=0.03). Economic simulations support a strong business case for increasing the proportion of BSN-educated nurses to 80%. CONCLUSIONS: A combined approach of increasing the hospital-level BSN proportion to 80% and assuring a high BSN dose through individual patient-level staffing assignments is needed to achieve projected quality and costs benefits.

Supporting Direct Care Workers in Dementia Care: Effects of a Psychoeducational Intervention
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Barbosa A, Nolan M, Sousa L, Figueiredo D.
American Journal of Alzheimer’s Disease and Other Dementias 2014 September 18

An experimental study using a pre–posttest control group design was conducted to assess the effects of a person-centered care-based psychoeducational intervention on direct care workers’ stress, burnout, and job satisfaction. The intervention aimed to develop person-centered care competences and tools for stress management. Four aged care facilities were randomly assigned to a psychoeducational or an education-only intervention (control). Data were collected from 56 direct care workers (female, mean age 44.72 ± 9.02) through measurements of burnout (Maslach Burnout Inventory), job satisfaction (Minnesota Satisfaction Questionnaire-short form), and stress (Perceived Stress Scale) and focus-group interviews. Results showed significant positive effects in emotional exhaustion (P = .029) and positive but no significant effects in stress and job satisfaction. According to qualitative data, the experimental group perceived enhanced group cohesion, emotional management, and self-care awareness. Psychoeducational interventions may contribute to reduce direct care workers’ burnout. Further work is needed to determine the extent of its benefits.

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Health Care Innovation and Quality Assurance

Effects of skilled nursing facility structure and process factors on medication errors during nursing home admission.
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Lane SJ, Troyer JL, Dienemann JA, Laditka SB, Blanchette CM.
Health care management review 2014 Oct-Dec;39(4):340-351

Older adults are at greatest risk of medication errors during the transition period of the first 7 days after admission and readmission to a skilled nursing facility (SNF). PURPOSE: The aim of this study was to evaluate structure- and process-related factors that contribute to medication errors and harm during transition periods at a SNF. METHODOLOGY/APPROACH: Data for medication errors and potential medication errors during the 7-day transition period for residents entering North Carolina SNFs were from the Medication Error Quality Initiative-Individual Error database from October 2006 to September 2007. The impact of SNF structure and process measures on the number of reported medication errors and harm from errors were examined using bivariate and multivariate model methods. FINDINGS: A total of 138 SNFs reported 581 transition period medication errors; 73 (12.6%) caused harm. Chain affiliation was associated with a reduction in the volume of errors during the transition period. One third of all reported transition errors occurred during the medication administration phase of the medication use process, where dose omissions were the most common type of error; however, dose omissions caused harm less often than wrong-dose errors did. Prescribing errors were much less common than administration errors but were much more likely to cause harm. PRACTICE IMPLICATIONS: Both structure and process measures of quality were related to the volume of medication errors.However, process quality measures may play a more important role in predicting harm from errors during the transition of a resident into an SNF. Medication errors during transition could be reduced by improving both prescribing processes and transcription and documentation of orders.

Validity of the RAI-MDS for ascertaining diabetes and comorbid conditions in long-term care facility residents Canada-flat-icon
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Lix LM, Yan L, Blackburn D, Hu N, Schneider-Lindner V, Teare GF.
BMC health services research 2014 Jan 15;14:17-6963-14-17

This study assessed the validity of the Resident Assessment Instrument Minimum Data Set (RAI-MDS) Version 2.0 for diagnoses of diabetes and comorbid conditions in residents of long-term care facilities (LTCFs). METHODS: Hospital inpatient, outpatient physician billing, RAI-MDS, and population registry data for 1997 to 2011 from Saskatchewan, Canada were used to ascertain cases of diabetes and 12 comorbid conditions. Prevalence estimates were calculated for both RAI-MDS and administrative health data. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated using population-based administrative health data as the validation data source. Cohen’s κ was used to estimate agreement between the two data sources. RESULTS: 23,217 LTCF residents were in the diabetes case ascertainment cohort. Diabetes prevalence was 25.3% in administrative health data and 21.9% in RAI-MDS data. Overall sensitivity of a RAI-MDS diabetes diagnoses was 0.79 (95% CI: 0.79, 0.80) and the PPV was 0.92 (95% CI: 0.91, 0.92), when compared to administrative health data. Sensitivity of the RAI-MDS for ascertaining comorbid conditions ranged from 0.21 for osteoporosis to 0.92 for multiple sclerosis; specificity was high for most conditions. CONCLUSIONS: RAI-MDS clinical assessment data are sensitive to ascertain diabetes cases in LTCF populations when compared to administrative health data. For many comorbid conditions, RAI-MDS data have low validity when compared to administrative data. Risk-adjustment measures based on these comorbidities might not produce consistent results for RAI-MDS and administrative health data, which could affect the conclusions of studies about health outcomes and quality of care across facilities.

Improving accountability through alignment: the role of academic health science centres and networks in England.
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Ovseiko PV, Heitmueller A, Allen P, Davies SM, Wells G, Ford GA, et al.
BMC health services research 2014 Jan 20;14:24-6963-14-24

As in many countries around the world, there are high expectations on academic health science centres and networks in England to provide high-quality care, innovative research, and world-class education, while also supporting wealth creation and economic growth. Meeting these expectations increasingly depends on partnership working between university medical schools and teaching hospitals, as well as other healthcare providers. However, academic-clinical relationships in England are still characterised by the “unlinked partners” model, whereby universities and their partner teaching hospitals are neither fiscally nor structurally linked, creating bifurcating accountabilities to various government and public agencies. DISCUSSION: This article focuses on accountability relationships in universities and teaching hospitals, as well as other healthcare providers that form core constituent parts of academic health science centres and networks. The authors analyse accountability for the tripartite mission of patient care, research, and education, using a four-fold typology of accountability relationships, which distinguishes between hierarchical (bureaucratic) accountability, legal accountability, professional accountability, and political accountability. Examples from North West London suggest that a number of mechanisms can be used to improve accountability for the tripartite mission through alignment, but that the simple creation of academic health science centres and networks is probably not sufficient. SUMMARY: At the heart of the challenge for academic health science centres and networks is the separation of accountabilities for patient care, research, and education in different government departments. Given that a fundamental top-down system redesign is now extremely unlikely, local academic and clinical leaders face the challenge of aligning their institutions as a matter of priority in order to improve accountability for the tripartite mission from the bottom up. It remains to be seen which alignment mechanisms are most effective, and whether they are strong enough to counter the separation of accountabilities for the tripartite mission at the national level, the on-going structural fragmentation of the health system in England, and the unprecedented financial challenges that it faces. Future research should focus on determining the comparative effectiveness of different alignment mechanisms, developing standardised metrics and key performance indicators, evaluating and assessing academic health science centres and networks, and empirically addressing leadership issues.

An observational study: associations between nurse-reported hospital characteristics and estimated 30-day survival probabilities.
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Tvedt C, Sjetne IS, Helgeland J, Bukholm G.
BMJ quality & safety 2014 Sep;23(9):757-764

There is a growing body of evidence for associations between the work environment and patient outcomes. A good work environment may maximise healthcare workers’ efforts to avoid failures and to facilitate quality care that is focused on patient safety. Several studies use nurse-reported quality measures, but it is uncertain whether these outcomes are correlated with clinical outcomes. The aim of this study was to determine the correlations between hospital-aggregated, nurse-assessed quality and safety, and estimated probabilities for 30-day survival in and out of hospital. METHODS: In a multicentre study involving almost all Norwegian hospitals with more than 85 beds (sample size=30, information about nurses’ perceptions of organisational characteristics were collected. Subscales from this survey were used to describe properties of the organisations: quality system, patient safety management, nurse-physician relationship, staffing adequacy, quality of nursing and patient safety. The average scores for these organisational characteristics were aggregated to hospital level, and merged with estimated probabilities for 30-day survival in and out of hospital (survival probabilities) from a national database. In this observational, ecological study, the relationships between the organisational characteristics (independent variables) and clinical outcomes (survival probabilities) were examined. RESULTS: Survival probabilities were correlated with nurse-assessed quality of nursing. Furthermore, the subjective perception of staffing adequacy was correlated with overall survival. CONCLUSIONS: This study showed that perceived staffing adequacy and nurses’ assessments of quality of nursing were correlated with survival probabilities. It is suggested that the way nurses characterise the microsystems they belong to, also reflects the general performance of hospitals.

Quality Mobility Care in Nursing Homes: A Model of Moderating and Mediating Factors to Guide Intervention Development.
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Taylor J, Sims J, Haines TP.
Research in gerontological nursing 2014 Sep 12:1-8

The current qualitative study aimed to understand factors in mobility care to inform practice improvements. Data were collected at three nursing homes in Melbourne, Australia, via interviews with 11 senior staff and 15 residents, focus groups with 18 direct care staff, and observations of 46 mobility events. Thematic and content analysis of data occurred. Findings included factors (a) intrinsic to residents, (b) intrinsic to staff, and (c) extrinsic to residents and staff, such as equipment and organizational factors. A model describing associations between factors and their roles as moderators and mediators of resident mobility was generated. Staff assistance, residents’ mobility effort, and equipment used during mobility were posited as complete or partial mediators of resident mobility outcomes. Barriers that may compromise the quality of mobility care in nursing homes emerged. The model provides direction for improvements in mobility care that integrate safety, mobility optimization, and person- and relationship-centered care. Copyright 2014, SLACK Incorporated.

Schedule Control and Nursing Home Quality: Exploratory Evidence of a Psychosocial Predictor of Resident Care.
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Hurtado DA, Berkman LF, Buxton OM, Okechukwu CA.
Journal of applied gerontology 2014 Sep 2

To examine whether nursing homes’ quality of care was predicted by schedule control (workers’ ability to decide work hours), independently of other staffing characteristics. METHOD: Prospective ecological study of 30 nursing homes in New England. Schedule control was self-reported via survey in 2011-2012 (N = 1,045). Quality measures included the prevalence of decline in activities of daily living, residents’ weight loss, and pressure ulcers, indicators systematically linked with staffing characteristics. Outcomes data for 2012 were retrieved from Medicare.gov. RESULTS: Robust Linear Regressions showed that higher schedule control predicted lower prevalence of pressure ulcers (β = -0.51, p < .05). This association was independent of staff mix, staffing ratios, job satisfaction, and turnover intentions. CONCLUSION: Higher schedule control might enhance the planning and delivery of strategies to prevent or cure pressure ulcers. Further research is needed to identify potential causal mechanisms by which schedule control could improve quality of care. © The Author(s) 2014.

The long and bumpy road to outcome-oriented management of long-term care in Germany: implementation of the Resident Assessment Instrument in home-care services.
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Roth G, Wolter A, Stolle C, Rothgang H.
The International journal of health planning and management 2014 Jul-Sep;29(3):316-329

Although the quality of long-term care has improved, many problems still remain, and better processes seem to be necessary. Hence, outcome-oriented management is of particular importance. The Resident Assessment Instrument (RAI) is a tool that has been used successfully in many countries to improve quality of care. However, there are problems of implementation and it lacks information on the conditions of successful or failing information of the RAI. The aim of this article is to find out to what extent technical/qualification requirements help to introduce or lead to failure of the implementation of an assessment instrument like RAI. METHODS: Therefore, a cluster randomized controlled trial showed services using RAI intensively tend to have better outcomes after 12 months. But the effects depend on the success of the implementation. Using a factor analysis, an index was built to divide the care providers into “optimal” and “suboptimal” RAI users. RESULTS: Some factors that seem to lead to a rather successful implementation could be detected: A higher proportion of qualified staff, a lower perceived quantitative workload, a small size of care providers, the type of ownership (for-profit) and a late entry in study [Correction made here after initial online publication.]. CONCLUSION: The success or failure of the implementation of an outcome-oriented control instrument is determined by professional, organizational restrictions. The results show that a better implementation leads to better outcomes for clients. Copyright © 2013 John Wiley & Sons, Ltd.

Sensitivity and Specificity of the Minimum Data Set 3.0 Discharge Data Relative to Medicare Claims.
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The objective of this study was to determine whether the Minimum Data Set (MDS) 3.0 discharge record accurately identifies hospitalizations and deaths of nursing home residents. DESIGN: We merged date of death from Medicare enrollment data and hospital inpatient claims with MDS discharge records to check whether the same information can be verified from both the sources. We examined the association of 30-day rehospitalization rates from nursing homes calculated only from MDS and only from claims. We also examined how correspondence between these 2 data sources varies across nursing homes. SETTINGS: All fee-for-service (FFS) Medicare beneficiaries admitted for Medicare-paid (with prospective payment system) skilled nursing facility (SNF) care in 2011. RESULTS: Some 94% of hospitalization events in Medicare claims can be identified using MDS discharge records and 87% of hospitalization events detected in MDS data can be verified by Medicare hospital claims. Death can be identified almost perfectly from MDS discharge records. More than 99% of the variation in nursing home-level 30-day rehospitalization rate calculated using claims data can be explained by the same rates calculated using MDS. Nursing home structural characteristics explain only 5% of the variation in nursing home-level sensitivity and 3% of the variation in nursing home-level specificity. CONCLUSION: The new MDS 3.0 discharge record matches Medicare enrollment and hospitalization claims events with a high degree of accuracy, meaning that hospitalization rates calculated based on MDS offer a good proxy for the “gold standard” Medicare data. Copyright © 2014 AMDA – The Society for Post-Acute and Long-Term Care Medicine.

Reliability of the interRAI Long Term Care Facilities (LTCF) and interRAI Home Care (HC).
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Kim H, Jung YI, Sung M, Lee JY, Yoon JY, Yoon JL.
Geriatrics & gerontology international 2014 Aug 27

Sharing clinical information across care settings is a cornerstone to providing quality care to older people with complex conditions. The purpose of the present study was to examine the reliability of the interRAI Long Term Care Facilities (interRAI LTCF) and the interRAI Home Care (interRAI HC), comprehensive and integrated assessment instruments with common core items, in Korea, an Asian county where comprehensive geriatric assessment is not widely used in long-term care. METHODS: The Korean version of the instruments was developed through field tests, as well as multiple iterations of translations, back-translations and expert reviews. For the reliability test, a random sample of 908 older people in 27 long-term care hospitals or nursing homes, or at home with home care, were assessed by regular staff, among which a subsample of 534 people were dually assessed. The Cronbach’s alphas of seven major composite scales in the instruments were examined for internal consistency. Interrater reliability was tested using agreement, kappa coefficients and interclass correlation coefficients. RESULTS: The internal consistencies of all key measures were adequate (Cronbach’s alpha ≥0.75). The overall mean kappa statistics of the items in the interRAI LTCF and those in the interRAI HC were 0.78 and 0.89, respectively. All key common items in the interRAI LTCF and the interRAI HC had almost perfect (κ ≥ 0.81) or substantial (0.61 ≤ κ ≤ 0.80) interrater reliability. CONCLUSIONS: The findings show the interRAI LTCF and the interRAI HC have adequate reliability for assessing the function and health of frail older adults across various long-term settings, which can promote continuity of care for the aged.© 2014 The Authors.

Implementing living room theatre activities for people with dementia on nursing home wards: a process evaluation study.
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van Haeften-van Dijk AM, van Weert JC, Droes RM.
Aging & mental health 2014 Sep 11:1-12

Objectives: A new communication method, the ‘Veder Method’, was implemented in the Netherlands. This method uses theatrical stimuli in combination with proven person-centred communication methods. Care staff was trained to apply the Veder Method in a ‘living room theatre activity’ for people with dementia. This study evaluates the implementation of the Veder Method on psychogeriatric nursing home wards. Methods: Facilitators and barriers to train staff and implement the Veder Method in psychogeriatric nursing homes were identified by conducting semi-structured interviews with 12 stakeholders who were involved in the implementation, and five focus groups with 35 trained care staff. The interviews and focus groups were transcribed verbatim, and two independent researchers analysed the content of the transcripts. The Implementation Process Evaluation (IPE) Framework was used to categorize the data and the 7s-model to contextualize the qualitative findings. Results: A structured overview of facilitators and barriers in different stages of the implementation process is presented. Positive reactions in residents and more reciprocity in caregiver-resident contact motivated trained care staff to work with the Veder Method. An action plan, executive support, the visibility of the method in the organization and a pioneer group that initiated implementation were essential for successful implementation. High work pressure for the care staff was a hindering factor. Conclusion: Respondents experienced the added value of the Veder Method. The facilitators and barriers to implementation we identified in this study can help to implement and disseminate the successful Veder Method and other person-centred communication methods in psychogeriatric nursing homes effectively.

Quality improvement in nursing homes.
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Dyck MJ, Schwindenhammer T, Butcher HK.
Journal of gerontological nursing 2014 Jul;40(7):21-31.

The purpose of this evidence-based administrative guideline is to provide quality improvement knowledge and strategies for nursing homes. Nursing homes, including all departments (i.e., administration, nursing, social services, dietary, activities, housekeeping, laundry, finance, maintenance, and any others), can use this administrative guideline as a team to develop, define, implement, and evaluate their own quality improvement program. Interdisciplinary collaboration is part of a good quality improvement program and needs to incorporate not only nursing home providers, but also patients and their families.

Pilot trial of Stop Delirium! (PiTStop)–a complex intervention to prevent delirium in care homes for older people: study protocol for a cluster randomised controlled trial.
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Heaven A, Cheater F, Clegg A, Collinson M, Farrin A, Forster A, et al.
Trials 2014 Feb 5;15:47-6215-15-47

Delirium (or acute confusion) is a serious illness common in older people, in which a person’s thinking and perceptions may be affected. Reducing delirium is important because of the considerable distress it causes, and the poor outcomes associated with it, such as increased admissions to hospital, falls, mortality and costs to the National Health Service (NHS). Preventing delirium is possible using multicomponent interventions; successful interventions in hospitals have reduced it by one-third. However, there is little research to guide practice in care homes, where it is common because of the clustering of known risk factors (older age, frailty, and dementia). In previous work we developed a multicomponent intervention to prevent delirium in care homes, called Stop Delirium! The intervention was based upon evidence from the research literature relating to the prevention of delirium and on strategies to change professional practice. Before starting a large costly trial of Stop Delirium!, this pilot study will test and help improve the design and feasibility of the trial protocol. METHODS/DESIGN: We plan to conduct a cluster randomised pilot trial in 14 care homes (independent residential and nursing). Following recruitment of residents (over 60 years, consenting or with consultee agreement, able to communicate in English, and not in palliative care) participating homes will be randomised, stratified by size of home and proportion of residents with dementia. Stop Delirium! will be delivered to intervention homes over 16 months, with controls receiving usual care. The primary outcome measure will be the presence of delirium on any day during a one-month post-intervention period.We will collect data to determine 1) recruitment and attrition rates, 2) feasibility of various outcomes measurements, and 3) feasibility of capturing health resource use (resident diaries and by examining health records). We will estimate the between-cluster variation for the primary outcome, delirium occurrence. DISCUSSION: This pilot study will refine methods for the definitive trial. The lessons learnt will also contribute to implementing National Institute for Health and Clinical Excellence (NICE) delirium guidelines, which recommend multicomponent interventions for delirium prevention. TRIAL REGISTRATION: ISRCTN27972532.

Impact of infection preventionists on Centers for Medicare and Medicaid quality measures in Maryland nursing homes.
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Wagner LM, Roup BJ, Castle NG.
American Journal of Infection Control 2014 Jan;42(1):2-6

Health care-associated infections are the leading cause of morbidity and mortality in US nursing homes (NHs). The objective of the research is to assess the impact of Maryland NH infection preventionists (IPs) on NH quality measures. METHODS: Two hundred thirty-four NHs were queried through mailed survey. These survey data were then linked with 2008 quality data from Nursing Home Compare and the On-line Survey Certification of Automated Records. RESULTS: Three of the 8 quality measures examined-influenza vaccination for both short- and long-stay residents and pressure ulcer prevention in high-risk residents-were significantly associated with the number of IPs. None of the quality measures were shown to be significant with IPs who received specialized training on infection prevention and management compared with those who did not receive specialized training. CONCLUSION: IPs play a critical role in preventing and managing health care-associated infections in nursing homes, especially in the areas of influenza vaccination and pressure ulcer prevention among high-risk nursing home residents. Quality measures that reflect the effects of IP training may not have been elucidated yet. Further research is needed to support the IP role in order for policy to advocate for increased IP funding. Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach.
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Lin H.
Journal of health economics 2014 Sep;37:13-24

This paper revisits the relationship between nurse staffing and quality of care in nursing homes using an instrumental variables approach. Most prior studies rely on cross-sectional evidence, which renders causal inference problematic and policy recommendations inappropriate. We exploit legislation changes regarding minimum staffing requirements in eight states between 2000 and 2001 as exogenous shocks to nurse staffing levels. We find that registered nurse staffing has a large and significant impact on quality of care, and that there is no evidence of a significant association between nurse aide staffing and quality of care. A comparison of the IV estimation to the OLS estimation of the first-difference model suggests that ignoring endogeneity would lead to an underestimation of how nurse staffing affects quality of care in nursing homes. Copyright © 2014 Elsevier B.V. All rights reserved.

Care workers in long-term care for older people: challenges of quantity and quality
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Chen H, Lisa.
European Journal of Social Work 2014 06;17(3):383-401

This article, drawing on a qualitative study in England, the Netherlands and Taiwan, explores how countries with very different care systems address the challenge of securing sufficient numbers of care workers with appropriate skills in ageing care. The analysis exposes the salient features of care systems, ageing-care markets and the ageing-care workforce in the three countries. To support the analysis, examples of how the countries attempt to recruit and retain ageing-care workers are provided. Key findings are that to secure an adequate number of skilled ageing-care workers, job satisfaction, coherence between care and labour policies and equal working conditions across sectors are vital. A quality ageing-care worker requires regular professional supervision and support, resources for ongoing training and career development opportunities. Most importantly, securing a sufficient number of ageing-care workers and ensuring they have appropriate skills are not isolated challenges but are interlinked and require collaboration between a range of care actors.

Explaining the success or failure of quality improvement initiatives in long-term care organizations from a dynamic perspective. Canada-flat-icon
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Etheridge F, Couturier Y, Denis JL, Tremblay L, Tannenbaum C.
Journal of applied gerontology 2014 Sep;33(6):672-689

The purpose of this study was to better understand why change initiatives succeed or fail in long-term care organizations. Four case studies from Québec, Canada were contrasted retrospectively. A constipation and restraints program succeeded, while an incontinence and falls program failed. Successful programs were distinguished by the use of a change strategy that combined “let-it happen,” “help-it happen,” and “make-it happen” interventions to create senses of urgency, solidarity, intensity, and accumulation. These four active ingredients of the successful change strategies propelled their respective change processes forward to completion. This paper provides concrete examples of successful and unsuccessful combinations of “let-it happen,” “help-it happen,” and “make-it happen” change management interventions. Change managers (CM) can draw upon these examples to best tailor and energize change management strategies in their own organizations. © The Author(s) 2013.

Consensus on quality indicators to assess the organisation of palliative cancer and dementia care applicable across national healthcare systems and selected by international experts
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van Riet Paap J, Vernooij-Dassen M, Droes RM, Radbruch L, Vissers K, Engels Y.
BMC health services research 2014 Sep 17;14(1):396

Large numbers of vulnerable patients are in need of palliative cancer and dementia care. However, a wide gap exists between the knowledge of best practices in palliative care and their use in everyday clinical practice. As part of a European policy improvement program, quality indicators (QIs) have been developed to monitor and improve the organisation of palliative care for patients with cancer and those with dementia in various settings in different European countries. METHOD: A multidisciplinary, international panel of professionals participated in a modified RAND Delphi procedure to compose a set of palliative care QIs based on existing sets of QIs on the organisation of palliative care. Panellists participated in three written rounds, one feedback round and one meeting. The panel’s median votes were used to identify the final set of QIs. RESULTS: The Delphi procedure resulted in 23 useful QIs. These QIs represent key elements of the organisation of good clinical practice, such as the availability of palliative care teams, the availability of special facilities to provide palliative care for patients and their relatives, and the presence of educational interventions for professionals. The final set also includes QIs that are related to the process of palliative care, such as documentation of pain and other symptoms, communication with patients in need of palliative care and their relatives, and end-of-life decisions. CONCLUSION: International experts selected a set of 23 QIs for the organisation of palliative care. Although we particularly focused on the organisation of cancer and dementia palliative care, most QIs are generic and are applicable for other types of diseases as well.

IHI: Comparing Lean and Quality Improvement
2014

People often want to know about the relationship between the IHI approach to quality improvement and Lean, and how they can best utilize one or both approaches to improve their own care systems. This white paper aims to address these issues, and argues that because both methods are complementary ways of approaching improvement, it is not necessary to choose one over the other as a guide to action. The white paper provides a brief overview of the issues and some key definitions, followed by more detailed descriptions of Lean and the IHI approach to quality improvement (referred to as “IHI-QI” throughout the paper). For each approach, we discuss the key conceptual foundations, the principles that lead the way to improved system performance, the project roadmaps typically followed under each approach, and the tools that characterize them in practice. We also point out the fundamental congruence between the two approaches, as well as key differences. Finally, we suggest ways that practitioners of both Lean and IHI-QI can use the principles and methods of the other to extend their capabilities.
After reading this paper, you will have clear answers to the following questions:
-What are the basic concepts and principles of IHI-QI and Lean?
-How are they similar (in history and approach)? How are they different?
-For what purposes is IHI-QI the most appropriate approach? For what purposes is Lean the best approach?

NHS White Paper: The new era of thinking and practice in change and transformation: A call to action for leaders of health and care (UK)
July 2014

This new White Paper from NHS Improving Quality examines leading trends in change and transformation from multiple industries across the world. As leaders of health and care we operate in a world where change needs to happen at a faster rate and become more disruptive – our thinking and actions need to challenge the status quo, which will not serve us for the future. Many of the ways we go about improving health and care (in the NHS and elsewhere) were designed in a different mindset for a different set of circumstances. Given the radical and complex nature of our transformational challenge, these ‘tried and tested’ methods increasingly won’t deliver what we need to deliver for patients. In this White Paper, we identify the profound implications and opportunities for leaders of health and care. They include a fundamental rethink about what organisational and system change means, including:
Who does it (many change agents, not just a few) Where it happens (increasingly ‘at the edge’ of organisations and systems) The skills and mindsets that change agents need. It also means embracing disruption and ‘disruptors’ in our organisations and wider systems to create an environment where innovation is encouraged; no longer seeking to ‘overcome resistance to change’ but welcoming difference, diversity and dissent as core operating principles of our organisations. The White Paper concludes with a call to action: join the new breed of leaders across the world who are rewriting the rules of change and leading change from the future to get different results.

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Research Practice & Methodology

Estimating return on investment in translational research: methods and protocols.
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Grazier KL, Trochim WM, Dilts DM, Kirk R.
Evaluation & the health professions 2013 Dec;36(4):478-491

Assessing the value of clinical and translational research funding on accelerating the translation of scientific knowledge is a fundamental issue faced by the National Institutes of Health (NIH) and its Clinical and Translational Awards (CTSAs). To address this issue, the authors propose a model for measuring the return on investment (ROI) of one key CTSA program, the clinical research unit (CRU). By estimating the economic and social inputs and outputs of this program, this model produces multiple levels of ROI: investigator, program, and institutional estimates. A methodology, or evaluation protocol, is proposed to assess the value of this CTSA function, with specific objectives, methods, descriptions of the data to be collected, and how data are to be filtered, analyzed, and evaluated. This article provides an approach CTSAs could use to assess the economic and social returns on NIH and institutional investments in these critical activities.

Surveying multiple health professional team members within institutional settings: an example from the nursing home industry.
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Clark MA, Roman A, Rogers ML, Tyler DA, Mor V.
Evaluation & the health professions 2014 Sep;37(3):287-313

Quality improvement and cost containment initiatives in health care increasingly involve interdisciplinary teams of providers. To understand organizational functioning, information is often needed from multiple members of a leadership team since no one person may have sufficient knowledge of all aspects of the organization. To minimize survey burden, it is ideal to ask unique questions of each member of the leadership team in areas of their expertise. However, this risks substantial missing data if all eligible members of the organization do not respond to the survey. Nursing home administrators (NHA) and directors of nursing (DoN) play important roles in the leadership of long-term care facilities. Surveys were administered to NHAs and DoNs from a random, nationally representative sample of U.S. nursing homes about the impact of state policies, market forces, and organizational factors that impact provider performance and residents’ outcomes. Responses were obtained from a total of 2,686 facilities (response rate [RR] = 66.6%) in which at least one individual completed the questionnaire and 1,693 facilities (RR = 42.0%) in which both providers participated. No evidence of nonresponse bias was detected. A high-quality representative sample of two providers in a long-term care facility can be obtained. It is possible to optimize data collection by obtaining unique information about the organization from each provider while minimizing the number of items asked of each individual. However, sufficient resources must be available for follow-up to nonresponders with particular attention paid to lower resourced, lower quality facilities caring for higher acuity residents in highly competitive nursing home markets. © The Author(s) 2014.

Using the Nominal Group Technique: how to analyse across multiple groups
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McMillan SS, Kelly F, Sav A, Kendall E, King MA, Whitty JA, et al.
Health Services and Outcomes Research Methodology 2014;14(3):92-108

The nominal group technique (NGT) is a method to elicit healthcare priorities. Yet, there is variability on how to conduct the NGT, and limited guidance on how to analyse a diverse sample of multiple groups. This paper addresses some of this ambiguity, and explores whether different approaches to analysis provide the same outcome/s. Conceptual papers and empirical studies were identified via PubMed and informed an adapted version of the NGT. Twenty-six nominal groups were conducted, which provided in-depth knowledge on how to best conduct this method. Pilot group data were used to compare different analysis methods and to explore how this impacted on reported outcomes. Data analyses for large data-sets are complex; thematic analysis is needed to be able to conduct across group comparisons of participant priorities. Consideration should be given not just to the strength, i.e. sum of votes, or relative importance of the priority, but to the voting frequency, i.e. the popularity of the idea amongst participants; our case study demonstrated that this can affect priority rankings for those ideas with the same score. As a case study, this paper provides practical information on analysis for complex data sets. Researchers need to consider more than one analysis process to ensure that the results truly reflect participant priorities. A priority that has a high score may not necessarily reflect its popularity within the group; the voting frequency may also need to be considered.

A data-adaptive strategy for inverse weighted estimation of causal effects
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Zhu Y, Ghosh D, Mitra N, Mukherjee B.
Health Services and Outcomes Research Methodology 2014;14(3):69-91

In most nonrandomized observational studies, differences between treatment groups may arise not only due to the treatment but also because of the effect of confounders. Therefore, causal inference regarding the treatment effect is not as straightforward as in a randomized trial. To adjust for confounding due to measured covariates, the average treatment effect is often estimated by using propensity scores. Typically, propensity scores are estimated by logistic regression. More recent suggestions have been to employ nonparametric classification algorithms from machine learning. In this article, we propose a weighted estimator combining parametric and nonparametric models. Some theoretical results regarding consistency of the procedure are given. Simulation studies are used to assess the performance of the newly proposed methods relative to existing methods, and a data analysis example from the Surveillance, Epidemiology and End Results database is presented.

Moving improvement research closer to practice: the Researcher-in-Residence model
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Marshall M, Pagel C, French C, Utley M, Allwood D, Fulop N, et al.
BMJ quality & safety 2014 Oct;23(10):801-805

The traditional separation of the producers of research evidence in academia from the users of that evidence in healthcare organisations has not succeeded in closing the gap between what is known about the organisation and delivery of health services and what is actually done in practice. As a consequence, there is growing interest in alternative models of knowledge creation and mobilisation, ones which emphasise collaboration, active participation of all stakeholders, and a commitment to shared learning. Such models have robust historical, philosophical and methodological foundations but have not yet been embraced by many of the people working in the health sector. This paper presents an emerging model of participation, the Researcher-in-Residence. The model positions the researcher as a core member of a delivery team, actively negotiating a body of expertise which is different from, but complementary to, the expertise of managers and clinicians. Three examples of in-residence models are presented: an anthropologist working as a member of an executive team, operational researchers working in a front-line delivery team, and a Health Services Researcher working across an integrated care organisation. Each of these examples illustrates the contribution that an embedded researcher can make to a service-based team. They also highlight a number of unanswered questions about the model, including the required level of experience of the researcher and their areas of expertise, the institutional facilitators and barriers to embedding the model, and the risk that the independence of an embedded researcher might be compromised. The Researcher-in-Residence model has the potential to engage both academics and practitioners in the promotion of evidence-informed service improvement, but further evaluation is required before the model should be routinely used in practice.

Patients-people-place: developing a framework for researching organizational culture during health service redesign and change.
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Gale NK, Shapiro J, McLeod HS, Redwood S, Hewison A.
Implementation science 2014 Aug 20;9(1):106

Organizational culture is considered by policy-makers, clinicians, health service managers and researchers to be a crucial mediator in the success of implementing health service redesign. It is a challenge to find a method to capture cultural issues that is both theoretically robust and meaningful to those working in the organizations concerned. As part of a comparative study of service redesign in three acute hospital organizations in England, UK, a framework for collecting data reflective of culture was developed that was informed by previous work in the field and social and cultural theory. METHODS: As part of a larger mixed method comparative case study of hospital service redesign, informed by realist evaluation, the authors developed a framework for researching organisational culture during health service redesign and change. This article documents the development of the model, which involved an iterative process of data analysis, critical interdisciplinary discussion in the research team, and feedback from staff in the partner organisations. Data from semi-structured interviews with 77 key informants are used to illustrate the model. RESULTS: In workshops with NHS partners to share and debate the early findings of the study, organizational culture was identified as a key concept to explore because it was perceived to underpin the whole redesign process. The Patients-People-Place framework for studying culture focuses on three thematic areas (‘domains’) and three levels of culture in which the data could be organised. The framework can be used to help explain the relationship between observable behaviours and cultural artefacts, the values and habits of social actors and the basic assumptions underpinning an organization’s culture in each domain. CONCLUSIONS: This paper makes a methodological contribution to the study of culture in health care organizations. It offers guidance and a practical approach to investigating the inherently complex phenomenon of culture in hospital organizations. The Patients-People-Place framework could be applied in other settings as a means of ensuring the three domains and three levels that are important to an organization’s culture are addressed in future health service research.

Anonymizing Health Data Case Studies and Methods to Get You Started
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El Emam K, Arbuckle L
O’Reilly Media; 2013

With this practical book, you will learn proven methods for anonymizing health data to help your organization share meaningful datasets, without exposing patient identity. Leading experts Khaled El Emam and Luk Arbuckle walk you through a risk-based methodology, using case studies from their efforts to de-identify hundreds of datasets. Clinical data is valuable for research and other types of analytics, but making it anonymous without compromising data quality is tricky. This book demonstrates techniques for handling different data types, based on the authors’ experiences with a maternal-child registry, inpatient discharge abstracts, health insurance claims, electronic medical record databases, and the World Trade Center disaster registry, among others.
-Understand different methods for working with cross-sectional and longitudinal datasets
-Assess the risk of adversaries who attempt to re-identify patients in anonymized datasets
-Reduce the size and complexity of massive datasets without losing key information or jeopardizing privacy
-Use methods to anonymize unstructured free-form text data
-Minimize the risks inherent in geospatial data, without omitting critical location-based health information
-Look at ways to anonymize coding information in health data
-Learn the challenge of anonymously linking related datasets

IHE: Economic Evaluation of Complex Health System Interventions Canada-flat-icon
2014

A discussion paper on Economic Evaluation of Complex Health System Interventions: A Discussion Paper has been produced in response to a request from and in partnership with CIHR Institute of Health Services and Policy Research (CIHR IHSPR). The discussion paper provides guidance to those tasked with conducting an economic evaluation of complex health system interventions. The guidance will be an elaboration of existing National guidelines for economic evaluation and serve as a discussion paper to aid investigators conducting economic evaluations of complex health interventions. This paper is intended to be a starting point for health system and policy researchers who wish to understand some of the fundamentals of economic evaluation and its application complex interventions.

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Healthcare in Canada

Policy silences: why Canada needs a National First Nations,
Inuit and Métis health policy.
Canada-flat-icon
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Lavoie JG.
International journal of circumpolar health 2013 Dec 27;72:22690

Despite attempts, policy silences continue to create barriers to addressing the healthcare needs of First Nations, Inuit and Métis. The purpose of this article is to answer the question, if what we have in Canada is an Aboriginal health policy patchwork that fails to address inequities, then what would a Healthy Aboriginal Health Policy framework look like? METHODS: The data collected included federal, provincial and territorial health policies and legislation that contain Aboriginal, First Nation, Inuit and/or Métis-specific provisions available on the internet. Key websites included the Parliamentary Library, federal, provincial and territorial health and Aboriginal websites, as well as the Department of Justice Canada, Statistics Canada and the Aboriginal Canada Portal. RESULTS: The Indian Act gives the Governor in Council the authority to make health regulations. The First Nations and Inuit Health Branch (FNIHB) of Health Canada historically provided health services to First Nations and Inuit, as a matter of policy. FNIHB’s policies are few, and apply only to Status Indians and Inuit. Health legislation in 2 territories and 4 provinces contain no provision to clarify their responsibilities. In provinces where provisions exist, they broadly focus on jurisdiction. Few Aboriginal-specific policies and policy frameworks exist. Generally, these apply to some Aboriginal peoples and exclude others. CONCLUSION: Although some Aboriginal-specific provisions exist in some legislation, and some policies are in place, significant gaps and jurisdictional ambiguities remain. This policy patchwork perpetuates confusion. A national First Nation, Inuit and Métis policy framework is needed to address this issue.

PHAC: Mapping Connections: An understanding of neurological conditions in Canada Canada-flat-icon
2014

This publications presents the findings from the most comprehensive study of neurological conditions ever to be conducted in Canada. The National Population Health Study of Neurological Conditions, is a four-year, $15 million undertaking, led by the Public Health Agency of Canada in partnership with Neurological Health Charities Canada, a collaborative of 24 charities representing individuals and families impacted by neurological conditions across the country. The study examined 14 neurological conditions including Alzheimer’s disease and other dementias. Neurological conditions (diseases, disorders, and injuries) can directly affect Canadians of all ages. Such conditions can be severe or mild, progressive or non-progressive, or uncontrolled or controlled. As these conditions may lead to symptoms and functional deficits that are often chronic in nature, they can have profound impacts on the life and well-being of affected individuals, their families, caregivers, and communities. Because the prevalence and incidence of some of the most common neurological conditions tend to increase with age, both the number of individuals facing these challenges and the cost of associated care are expected to rise as the Canadian population ages. Worldwide, the focus on neurological conditions, the aging population, and the recognition of their impacts is increasing. In this context, the National Population Health Study of Neurological Conditions (the ‘Study’) was initiated, with the long-term goal of reducing the burden of neurological conditions in Canada through an increase in understanding of these conditions in a Canadian context. The table below presents the Study partners, components, focus areas, and original 14 neurological conditions selected for inclusion. In addition to these selected neurological conditions, the Study also subsequently provided some coverage of migraine, spinal cord tumour, Rett syndrome, and stroke.

StatsCan: Insights on Canadian Society – Canadians with unmet home care needs Canada-flat-icon
September 2014

This article provides information about Canadians who need assistance at home or home-care services, but who do not receive any (unmet needs) and about those who already receive assistance or home-care services, but could use more services (partly met needs). The article also examines the possible consequences of the lack of assistance or of home care on the well-being and mental health of Canadians.

CAHS: Improving access to oral health care for vulnerable people living in Canada Canada-flat-icon
2014

The Canadian Academy of Health Sciences identified improving access to oral health care in Canada as a subject for an assessment. This report identifies a number of issues, which can be distilled to the following core problems:
-Vulnerable groups living in Canada have both the highest level of oral health problems and the most difficulty accessing oral health care; and
-The public and private oral health care systems in Canada are not effective in providing reasonable access to oral health care for all vulnerable people living in Canada.
These findings are relevant to seniors living in residential settings.

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Aging

Experience of media presentations for the alleviation of agitation and emotional distress among dementia patients in a long-term nursing facility.
Non UofA Access
Chung J, Choi SI, Kim J.
Dementia (London, England) 2014 Sep 7

Although the cause and the cure for dementia remain unknown, it is clear that environmental factors can offer relief of cognitive impairment and encourage emotional stability. The purpose was to explore dementia patients’ experiences of a media presentation including images of nature. Combining a qualitative approach with quantitative data analysis, the project exposed 23 participants to slide show presentations of fascinating natural scenes over 4 weeks. The patients’ feelings and experiences of the media presentations were investigated using semistructured interviews and daily chart reviews in which weekly behavioral changes. The experience of natural scenes in dementia patients’ everyday atmosphere became a new and positive aspect of life at the long-term nursing facility, although the quantitative data did not significantly change during the project. This treatment could provide dementia patients with a nurturing relationship, making nature a supportive part of their everyday experience. © The Author(s) 2014

Disability and care needs among older Americans.
Non UofA Access
Freedman VA, Spillman BC.
The Milbank quarterly 2014 Sep;92(3):509-541

Nearly half of elderly Medicare beneficiaries have difficulty performing daily activities without assistance or receive help with such activities. This help is most often from informal caregivers. Substantial numbers of older adults living at home or in supportive settings other than nursing homes experience adverse consequences related to unmet need. With continuing care shifts away from nursing homes, strategies are needed to improve community-based long-term care services and supports to aid both older adults and the informal caregivers who provide most care. CONTEXT: The cost of late-life dependency is projected to grow rapidly as the number of older adults in the United States increases in the coming decades. To provide a context for framing relevant policy discussions, we investigated activity limitations and assistance, care resources, and unmet need for a national sample of older adults. METHODS: We analyzed the 2011 National Health and Aging Trends Study, a new national panel study of more than 8,000 Medicare enrollees. FINDINGS: Nearly one-half of older adults, or 18 million people, had difficulty or received help in the last month with daily activities. Altogether, 1 in 4 older adults receiving help lived in either a supportive care (15%) or a nursing home (10%) setting. Nearly 3 million received assistance with 3 or more self-care or mobility activities in settings other than nursing homes, and a disproportionate share of persons at this level had low incomes. Nearly all older adults in settings other than nursing homes had at least 1 potential informal care network member (family or household member or close friend), and the average number of network members was 4. Levels of informal assistance, primarily from family caregivers, were substantial for older adults receiving help in the community (164 hours/month) and living in supportive care settings (50 hours/month). Nearly all of those getting help received informal care, and about 3 in 10 received paid care. Of those who had difficulty or received help in settings other than nursing homes, 32% had an adverse consequence in the last month related to an unmet need; for community residents with a paid caregiver, the figure was nearly 60%. CONCLUSIONS: The older population-especially those with few economic resources-has substantial late-life care needs. Policies to improve long-term services and supports and reduce unmet need could benefit both older adults and those who care for them.

Decision-making factors affecting different family members regarding the placement of relatives in long-term care facilities.
Non UofA Access
Huang YC, Chu CL, Ho CS, Lan SJ, Hsieh CH, Hsieh YP.
BMC health services research 2014 Jan 17;14:21-6963-14-21

The aim of this research was to investigate factors affecting different family members’ decisions regarding the placement of relatives in long-term car (LTC) facilities in Taiwan. The objective was to investigate the correlations between family members’ personal traits, the living conditions of residents in the LTC facilities, and family members’ experiences with LTC facilities. METHODS: This study selected family members visiting residents in LTC facilities as research subjects and used a structured questionnaire to perform face-to-face interviews. This study used nonlinear canonical correlation analysis (OVERALS) to categorize the decision-making factors affecting family members’ choices of LTC facilities. RESULTS: The results showed that when making decisions about the placement of family members, spouses chose facilities according to their own life experiences, children considered medical treatment convenience, grandchildren preferred to collect relevant information on facilities, and other relatives preferred to decide based on introductions from government departments. CONCLUSIONS: These results help clarify how different family roles affect decision-making processes regarding the choice of LTC facilities. In particular, spouses and female relatives require an interventional service mechanism that provides consultation or referral information.

Client safety in assisted living: perspectives from clients, personal support workers and administrative staff in Toronto, Canada. Canada-flat-icon
Non UofA Access
Speller B, Stolee P.
Health & social care in the community 2014 Sep 1

As the population ages, the demand for long-term care settings is expected to increase. Assisted living is a suitable and favourable residence for older individuals to receive care services specific to their needs while maintaining their independence and privacy. With the growing transition of older individuals into assisted living, facilities need to ensure that safe care is continually maintained. The purpose of this study was to determine the gaps and strengths in care related to safety in assisted living facilities (ALFs). A qualitative descriptive research design was used to provide a comprehensive understanding of client safety from the perspectives of clients, administrative staff and personal support workers. Interviews were conducted with 22 key informants from three ALFs in Toronto, Ontario throughout July 2012. All interviews were semi-structured, audio-recorded and transcribed verbatim. Initial deductive analysis used directed coding based on a prior literature review, followed by inductive analysis to determine themes. Three themes emerged relating to the safety of clients in ALFs: meaning of safety, a multi-faceted approach to providing safe care and perceived areas of improvement. Sub-themes also emerged including physical safety, multiple factors, working as a team, respecting clients’ independence, communication and increased education and available resources. The study findings can contribute to the improvement and development of new processes to maintain and continually ensure safe care in ALFs. © 2014 John Wiley & Sons Ltd.

The influence of sleep disruption and pain perception on indicators of quality of life in individuals living with dementia at home.
Non UofA Access
Hodgson N, Gitlin LN, Huang J.
Geriatric nursing (New York, N.Y.) 2014 Sep 2

This cross-sectional study evaluated the influence of sleep quality and pain perceptions on different dimensions of quality of life in community-dwelling persons with dementia. Evaluations of pain were collected using Visual Analog Scale (VAS), sleep disruption using Pittsburg Sleep Quality Index (PSQI) items, and quality of life indicators using the DemQOL-Proxy in 88 persons with dementia and their family caregivers. Lower overall quality of life was associated with the presence of pain and symptoms of sleep disruption when controlling for mental status, age, and number of health conditions. Pain and sleep symptoms were differentially associated with different aspects of QoL. As symptoms negatively impact quality of life but are modifiable, better clinical procedures are needed to prevent and also identify and treat symptoms of pain and sleep disturbance in community-dwelling persons with dementia. Copyright © 2014 Elsevier Inc. All rights reserved.

The Effectiveness of a Pressure Ulcer Intervention Program on the Prevalence of Hospital Acquired Pressure Ulcers: Controlled Before and After Study.
Non UofA Access
Mallah Z, Nassar N, Kurdahi Badr L.
Applied Nursing Research : ANR 2014 Jul 26

Pressure Ulcers (PUs) are associated with high mortality, morbidity, and health care costs. In addition to being costly, PrUs cause pain, suffering, infection, a lower quality of life, extended hospital stay and even death. Although several nursing interventions have been advocated in the literature, there is a paucity of research on what constitutes the most effective nursing intervention. OBJECTIVES: To determine the efficacy of multidisciplinary intervention and to assess which component of the intervention was most predictive of decreasing the prevalence of Hospital acquired pressure ulcers (HAPU) in a tertiary setting in Lebanon. DESIGN: An evaluation prospective research design was utilized with data before and after the intervention. The sample consisted of 468 patients admitted to the hospital from January 2012 to April 2013. RESULTS: The prevalence of HAPU was significantly reduced from 6.63% in 2012 to 2.47. Sensitivity of the Braden scale in predicting a HAPU was 92.30% and specificity was 60.04%. A logistic multiple regression equation found that two factors significantly predicted the development of a HAPU; skin care and Braden scores. CONCLUSION: The multidisciplinary approach was effective in decreasing the prevalence of HAPUs. Skin care management which was a significant predictor of PUs should alert nurses to the cost effectiveness of this intervention. Lower Braden scores also were predictive of HAPUs. Published by Elsevier Inc.

Barriers to physical activity and restorative care for residents in long-term care: a review of the literature. Canada-flat-icon
Non UofA Access
Benjamin K, Edwards N, Ploeg J, Legault F.
Journal of Aging and Physical Activity 2014 Jan;22(1):154-165

Despite the benefits of physical activity, residents living in long-term care (LTC) are relatively sedentary. Designing successful physical activity and restorative care programs requires a good understanding of implementation barriers. A database search (2002-2013) yielded seven studies (nine articles) that met our inclusion criteria. We also reviewed 31 randomized controlled trials (RCTs) to determine if the authors explicitly discussed the barriers encountered while implementing their interventions. Eleven RCTs (13 articles) included a discussion of the barriers. Hence, a total of 18 studies (22 articles) were included in this review. Barriers occurred at resident (e.g., health status), environmental (e.g., lack of space for physical activity), and organizational (e.g., staffing and funding constraints) levels. These barriers intersect to adversely affect the physical activity of older people living in LTC. Future studies targeting physical activity interventions for residents living in LTC are needed to address these multiple levels of influence.

Comparing the resident populations of private and public long-term care facilities over a 15-year period: a study from Quebec, Canada Canada-flat-icon
Non UofA Access
Bravo G, DuBois M, Dubuc N, Demers L, Blanchette D, Painter K, et al.
Ageing & Society 2014;FirstView:1-14

In the province of Quebec, Canada, long-term residential care is provided by two types of facility: privately owned facilities in which care is privately financed and delivered and publicly subsidised accredited facilities. There are few comparative data on the residents served by the private and public sectors, and none on whether their respective population has changed over time. Such knowledge would help plan services for older adults who can no longer live at home due to increased disabilities. This study compared (a) the resident populations currently served by private and public facilities and (b) how they have evolved over time. The data come from two cross-sectional studies conducted in 1995–2000 and 2010–2012. In both studies, we randomly selected care settings in which we randomly selected older residents. In total, 451 residents from 145 settings assessed in 1995–2000 were compared to 329 residents from 102 settings assessed in 2010–2012. In both study periods, older adults housed in the private sector had fewer cognitive and functional disabilities than those in public facilities. Between the two study periods, the proportion of residents with severe disabilities decreased in private facilities while it remained over 80 per cent in their public counterparts. Findings indicate that private facilities care today for less-disabled older adults, leaving to public facilities the heavy responsibility of caring for those with more demanding needs. These trends may impact both sectors’ ability to deliver proper residential care.

Outcome instruments to measure frailty: a systematic review.
Non UofA Access
de Vries NM, Staal JB, van Ravensberg CD, Hobbelen JS, Olde Rikkert MG, Nijhuis-van der Sanden MW.
Ageing research reviews 2011 Jan;10(1):104-114

Frailty is one of the greatest challenges for healthcare professionals. The level of frailty depends on several interrelated factors and can change over time while different interventions seem to be able to influence the level of frailty. Therefore, an outcome instrument to measure frailty with sound clinimetric properties is needed. A systematic review on evaluative measures of frailty was performed in the databases PubMed, EMBASE, Cinahl and Cochrane. The results show numerous instruments that measure the level of frailty. This article gives a clear overview of the content of these frailty instruments and describes their clinimetric properties. Frailty instruments, however, are often developed as prognostic instruments and have also been validated as such. The clinimetric properties of these instruments as evaluative outcome measures are unclear. Copyright © 2010 Elsevier B.V. All rights reserved.

Dementia in relation to family caregiver involvement and burden in long-term care.
Non UofA Access
Cohen LW, Zimmerman S, Reed D, Sloane PD, Beeber AS, Washington T, et al.
Journal of applied gerontology 2014 Aug;33(5):522-540

To better understand the process and outcomes of family involvement for long-term care residents with varying stages of dementia, we analyzed family and staff data for 467 residents of 24 residential care/assisted living and nursing-home settings. Adjusted analyses found that although the amount of family visitation did not significantly vary by resident cognitive status (15 versus 20 visits/month to persons with and without dementia, respectively), the nature of the visit did. Families of cognitively intact residents spent more time in activities related to social and community engagement, such as taking residents on trips and calling and writing letters (p < .001), while families of more impaired residents spent more time on care-related activities, including tasks related to nutrition (p < .027), mobility (p = .001), and discussing care with staff (p = .007), the latter of which was associated with greater burden (p < .001). Staff identified similar patterns but perceived less family involvement. © The Author(s) 2013.

Use of Medications of Questionable Benefit in Advanced Dementia
Non UofA Access
Tija J, Briesacher BA, Peterson D, Liu Q, Andrade SE, Mitchell SL
JAMA Internal Medicine 2014

Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients’ goals of care should guide the prescribing of medication during such terminal illness. Medications that do not promote the primary goal of care should be minimized. Objectives To estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia, identify resident- and facility-level characteristics associated with such use, and estimate associated medication expenditures. Design, Setting, and Participants Cross-sectional study of medication use by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database linked to the Minimum Data Set (460 facilities) between October 1, 2009, and September 30, 2010. Main Outcomes and Measures Use of medication deemed of questionable benefit in advanced dementia based on previously published criteria and mean 90-day expenditures attributable to these medications per resident. Generalized estimating equations using the logit link function were used to identify resident- and facility-related factors independently associated with the likelihood of receiving medications of questionable benefit after accounting for clustering within nursing homes. Results Of 5406 nursing home residents with advanced dementia, 2911 (53.9%) received at least 1 medication with questionable benefit (range, 44.7% in the Mid-Atlantic census region to 65.0% in the West South Central census region). Cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most commonly prescribed. In adjusted analyses, having eating problems (adjusted odds ratio [AOR], 0.68; 95% CI, 0.59-0.78), a feeding tube (AOR, 0.58; 95% CI, 0.48-0.70), or a do-not-resuscitate order (AOR, 0.65; 95% CI, 0.57-0.75), and enrolling in hospice (AOR, 0.69; 95% CI, 0.58-0.82) lowered the likelihood of receiving these medications. High facility-level use of feeding tubes increased the likelihood of receiving these medications (AOR, 1.45; 95% CI, 1.12-1.87). The mean (SD) 90-day expenditure for medications with questionable benefit was $816 ($553), accounting for 35.2% of the total average 90-day medication expenditures for residents with advanced dementia who were prescribed these medications. Conclusions and Relevance Most nursing home residents with advanced dementia receive medications with questionable benefit that incur substantial associated costs.

World Alzheimer Report 2014: Dementia and Risk Reduction
2014

The World Alzheimer Report 2014, Dementia and Risk Reduction: An analysis of protective and modifiable factors critically examines the evidence for the existence of modifiable risk factors for dementia. It focuses on sets of potential modifiable risk factors in four key domains: developmental, psychological and psychosocial, lifestyle and cardiovascular conditions. The report makes recommendations to drive public health campaigns and disease prevention strategies.

C.D. Howe Institute: Paying for the Boomers: Long-Term Care and Intergenerational Equity Canada-flat-icon
2014

Provincial governments should not expand public healthcare to cover the growing costs of long-term care (LTC), according to a new C.D. Howe Institute report. In “Paying for the Boomers: Long-Term Care and Intergenerational Equity,” authors Dr. Åke Blomqvist and Dr. Colin Busby say that such a move would put too much financial stress on future taxpayers.

Dementia 2014: Opportunity for change (UK)
September 2014

Dementia 2014: Opportunity for change is Alzheimer’s Society’s third annual report looking at the quality of life for people with dementia in England, Wales and Northern Ireland. As with our previous reports, Dementia 2013: The hidden voice of loneliness and Dementia 2012: A national challenge, it provides a snapshot of how well people are living with their dementia, what support they are receiving, and what barriers they face to living well. The evidence presented in Dementia 2014 shows that some progress has been made towards improving the quality of life for people with dementia and their carers, but that much more needs to be done. The report focusses on what now needs to happen to effect the changes that are necessary to bring real improvement to the lives of people with dementia. Most importantly, the government must address the artificial divide between health and social care in order to improve quality of life for people with dementia.

Dementia UK: second edition
September 2014

Dementia UK: Second edition shows that there will be 850,000 people living with dementia in the UK by 2015 and that dementia costs the UK £26 billion a year. The research, commissioned through King’s College London and the London School of Economics, provides the most detailed and robust picture to date of prevalence and economic impact of dementia in the UK. It updates the findings of the 2007 Dementia UK report, which led to landmark changes in how dementia was prioritised across the UK. An accurate understanding of dementia prevalence and cost in the UK is an important lever for policy development, influencing, commissioning and service design.

Government of Canada – Action for Seniors Report Canada-flat-icon
2014

The Action for Seniors report provides an overview of the many programs and resources available for seniors, ranging from help to combat elder abuse to government support such as ensuring seniors’ financial security. More than 22 federal departments and agencies collaborated to create the report, which reflects the interdisciplinary nature of seniors’ issues that cut across the various departments and agencies.

AARP: Family Caregivers Providing Complex Chronic Care to People with Cognitive and Behavioral Health Conditions (US)
August 2014

Family caregiving is difficult and stressful. Providing care and support to people with cognitive or behavioral health conditions is doubly challenging. This paper reports on results from a national survey showing that caregivers of family members with challenging behaviors were more likely to perform more than one medical/nursing task, such as managing medications, and often do so with resistance from the person they are trying to help. Yet they receive little or no instruction or guidance on how to do this important work. This analysis offers recommendations for assisting family caregivers who play this dual role.

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Events

Non UofA

Conference Board of Canada: Health Summit 2014: Aging, Chronic Disease, and Wellness
23-24 October Toronto ON

The 2014 Summit will focus on two interrelated issues that represent the most complex challenges to system sustainability and that will affect the health of all Canadians, now and in the future:
-The system is misaligned with an aging population
-The current delivery model is ill-equipped to address chronic care and prevention

Health Data Users Day
18 November Halifax NS

Join members of your community and experts from other regions for thought-provoking presentations and discussions. Learn about experiences and successes—large and small—with using data effectively for better decision-making in the health system.

Online

AcademyHealth: Publish or Perish? Meet the Editors Webinar
Thursday 2 October 11:30-13:00 MT Costs: $250 for non-members, free for members
For UofA folks: if there’s enough interest in sharing costs, I’m happy to book a room etc–just email me thane@ualberta.ca

This skill and career development webinar is designed to help authors improve their success rate of being published in top journals in the field of health services research and have a better understanding of what each journal publishes. Specifically, panelists will try to improve authors’ understanding of the respective journals’ peer review process and give useful hints about how to design and write a strong manuscript. Finally, speakers will help authors differentiate among the journals (e.g., what types of subjects and presentation format each journal prefers and which groups compose its audience). At the conclusion of the session, participants will be able to:
-Understand each journal’s submission and review priorities and processes
-Recognize how to present research in a way that increases its probability of acceptance
-Know what journals consider to be “fatal flaws” and their various grievances when it comes to submissions
Presenters: Gregory Curfman, M.D., Executive Editor, New England Journal of Medicine; Edward Livingston, M.D., Deputy Editor, JAMA; Patrick S. Romano, M.D., M.P.H., Co-Editor in Chief, Health Services Research; TBD, Health Affairs

CFHI: EIHR (Evidence-Informed Healthcare Renewal) Portal – An Orientation
Thursday 25 September 10:00-11:00 MT
Presenters: John Lavis, Robyn Tamblyn

If you are a healthcare policy analyst, decision maker or leader interested in connecting evidence to practice and policy, then this session is for you. Join us as we provide an orientation to the Evidence-Informed Healthcare Renewal (EIHR) Portal. The EIHR Portal, an initiative of the Evidence-Informed Healthcare Renewal (EIHR) Roundtable, is managed through a collaboration between the McMaster Health Forum, and the Canadian Institutes of Health Research (CIHR). The Portal is a continuously updated repository of policy-relevant documents that address renewing, reforming or strengthening governance, financial and delivery arrangements within health systems in Canada. It contains 25 types of documents, including jurisdictional reviews, stakeholder position papers, and intergovernmental communiqués. The documents address priority areas, as identified by Canadian federal, provincial and territorial governments, such as primary healthcare, patient safety, health human resources and performance indicators (e.g., timely access).

CFHI: Shifting Culture, Shifting Care: From ‘Usual Care’ to Good Chronic Care
Presenters: Dr. Brian Goldman & Dr. Jeffrey Turnbull
Friday 3 October 10:00-11:00 MT

The success of the healthcare system depends on our ability to develop chronic care in concert with acute care. It requires changes structurally, institutionally and culturally. This session explores the barriers, the challenges and creative solutions associated to this shift.

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Courses

Removing ‘Expressive Behaviours’ in Dementia Care
Wednesday 22 October 11:00-17:00
2-140 ECHA, University of Alberta

On behalf of the Institute for Continuing Care Education and Research (ICCER) and Alzheimer Society of Alberta and Northwest Territories, we invite you to attend an afternoon workshop led by Dr. David Sheard, Chief Executive and Founder of Dementia Care Matters. Participants will work through how to:
-Remove all negative labeling language within continuing care facilities
-Spread the ground-breaking traffic lights system to understand behaviours
-Focus on feelings before describing a person’s actions
-Open staff fears and feelings about ‘behaviours’
-Eliminate the presence of almost all anti-psychotic usage
-Become a good interpreter in searching for the meaning behind the ‘behaviours’

Navigating the evidence maze: better searching, sifting, and critical analysis of research
Wednesday 29 October 2014 Robina Australia Costs: Aus$300

Workshop Objectives:
-Be able to describe what EBM is and how it improves patient care
-Comprehend how skills in critical appraisal and EBM can be implemented in a clinical setting
-Improve skills to translate a clinical query into an answerable question and apply this to your query
-Enhance computer search skills to find and access relevant evidence from the literature on the web

Online

QCV 100: An Introduction to Quality, Cost, and Value in Health Care
Online course you can take anytime, requires 45 minutes

From IHI, this course will provide you with an overview of value in health care. We’ll start by distinguishing between cost and value, and understanding how both of these concepts relate to quality.After completing this course, you will be able to:
1. Explain the potential harm of low-value tests and procedures.
2. Distinguish between cost and value in health care.
3. Define resource stewardship in health care.
4. Describe the ethical case for resource stewardship in health care.
5. Identify common barriers to resource stewardship and enablers of inappropriate resource use.

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News

Scientists urge government to fund basic research Canada-flat-icon

A survey of 12 countries, including Canada, shows that scientists are concerned about the drop in government support of basic science in favour of applied research that leads to short-term benefits.

B Vitamins Fail to Prevent Alzheimer’s

Many people take B vitamins in the hopes of warding off Alzheimer’s disease and keeping the mind sharp. But a new analysis found that taking B vitamins did not slow mental decline with aging or prevent the onset of Alzheimer’s.

Quebec shortchanges seniors Canada-flat-icon

Quebec’s elderly are being shortchanged and neglected by the provincial government, which increasingly is dumping the responsibility for their care on the shoulders of stressed-out family members and private non-profit groups, concludes a new study by the Institute for Research on Public Policy.

High staff turnover plagues BC home care sector Canada-flat-icon

It is a constant battle for the home care sector to retain staff, as caregivers often move into a unionized hospital or residential care home position where the wage for the same work jumps from about $16 to $20 an hour.

Bathurst nursing home opens sensory therapy room for residents Canada-flat-icon

The so-called Snoezelen room at the Villa Chaleur Inc. uses sound, light and touch to help promote relaxation and stress management.

Eskasoni working for own long-term care facility Canada-flat-icon

Nova Scotia’s largest Mi’kmaq community is working to create its own long-term care facility for its aging population. But some aboriginals feel long-term care homes ‘reminiscent of residential schools’

And in another story, First Nations elder care is left in the hands of family members Canada-flat-icon

First Nations communities in Nova Scotia are working hard to keep their aging family members out of nursing homes and connected to their culture. According to the Department of Health and Wellness, as of Aug. 22 there were 7,821 people in long term care in Nova Scotia, including people in assisted living residential care facilities and nursing homes — 60 of those are of aboriginal descent.

They’re informal, but these workers are essential Canada-flat-icon

Unpaid caregivers provide more than 80 per cent of care required by individuals with long-term conditions. These informal workers contribute an estimated $5-billion of unpaid labour a year to the health-care system. One report pegged this figure at closer to an annual $25-billion if all the wide-ranging tasks performed by caregivers are included in the calculation.

Dementia patients ‘face unfair care tax’ (UK)

Dementia patients in the UK face a “care tax” because they are left to sort out much of the care they need themselves, experts say.

Ottawa to fund research on dementia, other neurodegenerative diseases Canada-flat-icon

The federal government announced funding for a national research program to look into dementia and other neurodegenerative diseases. The Canadian Consortium on Neurodegeneration in Aging will bring together 340 researchers who are part of 20 teams across Canada, Health Minister Rona Ambrose said.

Alberta Auditor General urges action on management of chronic diseases Canada-flat-icon

Alberta must take action “immediately” on how patients with chronic diseases like asthma, arthritis and diabetes are treated, Auditor General Merwan Saher says in a new report.

Dementia Friends is coming to Canada Canada-flat-icon

Dementia Friends is a unique program originally launched in Japan as “Dementia Supporters” and more recently as “Dementia Friends” in the UK. It has been hugely successful in making day to day life better for thousands of people with dementia.

CIHR and partners launch the Canadian Consortium on Neurodegeneration in Aging Canada-flat-icon

Rona Ambrose, Minister of Health, announced the launch of the Canadian Consortium on Neurodegeneration in Aging (CCNA), a national initiative aimed at tackling the growing onset of dementia and related illnesses and improving the lives of Canadians with these illnesses, as well as their families and caregivers. Led by Dr. Howard Chertkow, a cognitive neurologist and co-founder and director of the Jewish General Hospital / McGill Memory Clinic, the CCNA brings together 20 research teams and experts from across Canada to focus research on three themes:
-delaying the onset of dementia and related illnesses
-preventing these illnesses from occurring
-improving the quality of life of Canadians living with these illnesses and their caregivers

Dementia treatment research needs to be sped up, Ottawa summit hears Canada-flat-icon

Leading researchers and industry experts gathered in Ottawa to discuss how to accelerate the development of new treatments and technologies to help people with dementia, their families and caregivers.

The King’s Fund: Our priorities for the next government–an illustrated guide (UK)

With the general election coming at a pivotal time for health and social care, we set out our view of the twelve key challenges and priorities for the next government.

How Sweden cares for its elderly population

The system for looking after older people in England is “horribly fragmented”, Care Minister Norman Lamb has said during a visit Sweden to see how the elderly are cared for there. The country takes a very different approach, with care packages based around what is requested by individuals.

World Dementia Council announce drive to speed up dementia research and increase investment

The World Dementia Council has announced the next steps in its drive to speed up dementia research and increase investment. The plans were agreed at its second meeting at the Organisation for Economic Cooperation and Development in Paris in July.

Special film screenings to get people with dementia singing in the rain (UK)

A project in Lancaster giving those with dementia and their family members the chance to go out and enjoy movies together is proving a hit. And they got to watch one of my all time favourite movies, Singing in the Rain. That is so cool!!

Some opportunities for academics to gain attention for their research. Canada-flat-icon

There are more opportunities than ever for academics to gain attention for their research.

Home care’s where the heart is Canada-flat-icon

To get home care in Canada, you either need to be educated and connected enough to wring service out of the system, or you need to be wealthy enough to pay for it.

Health Canada: Advisory Panel launches Public Consultation on Healthcare Innovation Canada-flat-icon

The Panel has been specifically asked to recommend five ways the federal government could better support innovation that improves care for patients and strengthens the healthcare system, without raising the overall cost to taxpayers, and while respecting jurisdictional roles.

Nursing homes vow to cut antipsychotic use in dementia patients (US)

Nursing homes are promising to reduce their use of antipsychotic medications on dementia patients 25 percent by 2016 and 30 percent by 2017. The public-private National Partnership to Improve Dementia Care announced its new goals on Friday as part of a wider effort to “re-think” care of elderly people with cognitive impairments.

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Resources

Mental Health of Older Adults and Dementia Clinical Academic Group Care Pathways

This online Care Pathways tool describes the journey a person will take once a diagnosis has been made and the anticipated care provided for by our services, within an appropriate time frame that has been written and agreed by a multi-disciplinary team of nurses, doctors, consultants and service users. The pathways are underpinned by high quality research and agreed best practice standards that are measurable at each stage of the patient journey.

Building Collaborative Teams: A workshop guide for service managers and facilitators

This publication, created by Integrated Care and Support Pioneers Programme, is designed as a ‘getting started’ guide for managers who are bringing different teams together. It’s intended to be used at the beginning, when one or more teams plan to work in a more integrated way. It contains tools and exercises to help team members better understand each other’s role, attitude and values. It will help you to create a joint action plan for working together, which will be co-produced during a series of workshops.

Evidence for Success Guide

This guide, from Evaluation Support Scotland, offers easy to follow, step-by-step guidance and resources to support organisations to use evidence to influence policy and practice. It is for anyone who wants to use evidence to improve policy and practice, regardless of the level of experience they have in doing so. Therefore, it is intended that this guide will also be of value to a wide range of stakeholders, including: practitioners, service managers, funders and commissioners, and policy makers and planners.

Sense about Science

With a database of over 6,000 scientists, from Nobel prize winners to postdocs and PhD students, we work in partnership with scientific bodies, research publishers, policy makers, the public and the media, to change public discussions about science and evidence. Through award-winning public campaigns, we share the tools of scientific thinking and scrutiny. Our growing international Voice of Young Science network engages hundreds of early career researchers in public debates about research and evidence. Our activities and publications are used and shaped by community groups, civic bodies, patient organisations, information services, writers, publishers, educators, health services and many others.

NHS: Dementia Toolkit (UK)

Dementia Revealed What Primary Care Needs to Know A Primer for General Practice is a guide created to help GPs perform better on the timely diagnosis of dementia and to offer advice on post-diagnostic support for the person with the diagnosis or their carer(s), including emotional support and practical task-based help and specific interventions such as cognitive stimulation therapy.

CIHI: Your Health System Canada-flat-icon

Explore 37 indicators to better understand your health system and the health of Canadians. Search by hospital, city, health region, province or territory.

Building Respect for LGBT Older Adults (US)

This tool was developed by the Administration for Community Living and Administration on Aging, with support from many groups. The tool is intended for long term care and other aging service providers as an introduction to LGBT aging. This tool is split up into six modules, each approximately 10 minutes long. We recommend that you watch them in order. They do not need to be watched all at once.

Running self-help groups in sheltered and extra care accommodation for people who live with dementia-A guide (UK)

This resource is intended for those who already have some knowledge of running groups and activities, and wish to run self-help groups for people who are either living with dementia or worried about their memory. It is primarily aimed at those working with people living in sheltered or extra care housing, but it is hoped it will be of benefit to others working in the field of dementia care. As the groups were delivered on site in the housing schemes, it does cover issues associated with running similar groups for people living in their own homes but who are geographically dispersed, such as transport.

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