Quality measures for medication continuity in long-term care facilities, using a structured panel process

Nursing-sensitive quality indicators for quality improvement in Norwegian nursing homes - a modified Delphi study

BACKGROUND

Use of nursing-sensitive quality indicators (QIs) is one way to monitor the quality of care in nursing homes (NHs). The aim of this study was to develop a consensus list of nursing-sensitive QIs for Norwegian NHs.

METHODS

A narrative literature review followed by a non-in-person, two-round, six-step modified Delphi survey was conducted. A five-member project group was established to draw up a list of nursing-sensitive QIs from a preliminary list of 24 QIs selected from Minimum Data Set (2.0) (MDS) and the international Resident Assessment Instrument for Long-Term Care Facilities (interRAI LTCF). We included scientific experts (researchers), clinical experts (healthcare professionals in NHs), and experts of experience (next-of-kin of NH residents). The experts rated nursing-sensitive QIs in two rounds on a seven-point Likert scale. Consensus was based on median value and level of dispersion. Analyses were conducted for four groups: 1) all experts, 2) scientific experts, 3) clinical experts, and 4) experts of experience.

RESULTS

The project group drew up a list of 20 nursing-sensitive QIs. Nineteen QIs were selected from MDS/interRAI LTCF and one ('systematic medication review') from the Norwegian quality assessment system IPLOS ('Statistics linked to individual needs of care'). In the first and second Delphi round, 44 experts (13 researchers, 17 healthcare professionals, 14 next-of-kin) and 28 experts (8 researchers, 10 healthcare professionals, 10 next-of-kin) participated, respectively. The final consensus list consisted of 16 nursing-sensitive QIs, which were ranked in this order by the 'all expert group': 1) systematic medication review, 2) pressure ulcers, 3) behavioral symptoms, 4) pain, 5) dehydration, 6) oral/dental health problems, 7) urinary tract infection, 8) fecal impaction, 9) depression, 10) use of aids that inhibit freedom of movement, 11) participation in activities of interest, 12) participation in social activities, 13) decline in activities of daily living, 14) weight loss, 15) falls, and 16) hearing loss without the use of hearing aids.

CONCLUSIONS

Multidisciplinary experts were able to reach consensus on 16 nursing-sensitive QIs. The results from this study can be used to implement QIs in Norwegian NHs, which can improve the quality of care.

An Environmental Scan and Evaluation of Quality Indicators Across Canadian Kidney Transplant Centers

Background:

Kidney transplantation is the optimal treatment for an individual requiring kidney replacement therapy, resulting in improved survival and quality of life while costing the health care system less than maintenance dialysis. Achieving and maintaining a kidney transplant requires extensive coordination of several different health care services. To improve the quality of kidney transplant care, quality metrics or indicators that encompass all aspects of the individual’s journey to transplant should be measured in a standardized fashion.

Objective:

To identify, categorize, and evaluate strengths and weaknesses of kidney transplant quality indicators currently being used across Canada.

Design:

An environmental scan of quality indicators being used by kidney organizations and programs.

Setting:

A 16-member volunteer pan-Canadian panel with expertise in nephrology, transplant, and quality improvement.

Sample:

Transplant programs, as well as provincial transplant and kidney agencies across Canada.

Methods:

Indicators were first categorized based on the period of transplant care and then using the Institute of Medicine and Donabedian frameworks. A 4-member subcommittee rated each indicator using a modified version of the Delphi consensus technique based on the American College of Physician/Agency for Healthcare Research and Quality criteria. Consensus ratings were subsequently shared with the entire 16-member panel for additional comments.

Results:

We identified 46 measures related to transplant care across 7 Canadian provinces (9 referral and evaluation, 9 waitlist activity and outcomes, 6 hospitalization for transplant surgery, 12 posttransplant care, 6 organ utilization, 4 living donor). We rated 24 indicators (52%) as necessary to distinguish high-quality from low-quality care, most of which measured effective (n = 10) or efficient (n = 6) care. Only 7 (15%) of 46 indicators evaluated person-centered or equitable care. Fourteen common indicators were measured by 5 of 7 provinces, 10 of which were deemed “necessary,” measuring safe (n = 2), effective (n = 5), efficient (n = 2), and equitable (n = 1) care.

Limitations:

The panel lacked patient and allied health representation.

Conclusions:

There are a large number of kidney transplant quality indicators currently being used in Canada, some of which are common across provinces and focus primarily on measuring effective care. Person-centered and equitable care indicators were lacking, and only half of these indicators were deemed “necessary” for quality improvement. Our results should complement ongoing work to achieve national consensus on the standardization of quality indicators in kidney transplantation.

An Environmental Scan of Ambulatory Care Quality Indicators for Patients With Advanced Kidney Disease Currently Used in Canada

BACKGROUND

Quality indicators can be used to identify gaps in care and drive frontline improvement activities. These efforts are important to prevent adverse events in the increasing number of ambulatory patients with advanced kidney disease in Canada, but it is unclear what indicators exist and the components of health care quality they measure.

OBJECTIVE

We sought to identify, categorize, and evaluate quality indicators currently in use across Canada for ambulatory patients with advanced kidney disease.

DESIGN

Environmental scan of quality indicators currently being collected by various organizations.

SETTING

We assembled a 16-member group from across Canada with expertise in nephrology and quality improvement.

PATIENTS

Our scan included indicators relevant to patients with chronic kidney disease in ambulatory care clinics.

MEASUREMENTS

We categorized the identified quality indicators using the Institute of Medicine and Donabedian frameworks.

METHODS

A 4-member panel used a modified Delphi process to evaluate the indicators found during the environmental scan using the American College of Physicians/Agency for Healthcare Research and Quality criteria. The ratings were then shared with the full panel for further comments and approval.

RESULTS

The environmental scan found 28 quality indicators across 7 provinces, with 8 (29%) rated as "necessary" to distinguish high-quality from poor-quality care. Of these 8 indicators, 3 were measured by more than 1 province (% of patients on a statin, number of patients receiving a preemptive transplant, and estimated glomerular filtration rate at dialysis start); no indicator was used by more than 2 provinces. None of the indicators rated as necessary measured timely or equitable care, nor did we identify any measures that assessed the setting in which care occurs (ie, structure measures).

LIMITATIONS

Our list cannot be considered as an exhaustive list of available quality indicators at hand in Canada. Our work focused on quality indicators for nephrology providers and programs, and not indicators that can be applied across primary and specialty providers. We also focused on indicator constructs and not the detailed definitions or their application. Last, our panel does not represent the views of other important stakeholders.

CONCLUSIONS

Our environmental scan provides a snapshot of the scope of quality indicators for ambulatory patients with advanced kidney disease in Canada. This catalog should inform indicator selection and the development of new indicators based on the identified gaps, as well as motivate increased pan-Canadian collaboration on quality measurement and improvement.

TRIAL REGISTRATION

Not applicable as this article is not a systematic review, nor does it report results of a health intervention on human participants.

An Environmental Scan and Evaluation of Home Dialysis Quality Indicators Currently Used in Canada

Background

Quality indicators are important tools to measure and ultimately improve the quality of care provided. Performance measurement may be particularly helpful to grow disciplines that are underutilized and cost-effective, such as home dialysis (peritoneal dialysis and home hemodialysis).

Objective

To identify and catalog home dialysis quality indicators currently used in Canada, as well as to evaluate these indicators as a starting point for future collaboration and standardization of quality indicators across Canada.

Design

An environmental scan of quality indicators from provincial organizations, quality organizations, and stakeholders.

Setting

Sixteen-member pan-Canadian panel with expertise in both nephrology and quality improvement.

Patients

Our environmental scan included indicators relevant to patients on home dialysis.

Measurements

We classified existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks.

Methods

To evaluate the indicators, a 6-person subcommittee conducted a modified version of the Delphi consensus technique based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for further examination. We rated items from 1 to 9 on 6 domains (1-3 does not meet criteria to 7-9 meets criteria) as well as a global final rating (1-3 unnecessary to 7-9 necessary) to distinguish high-quality from low-quality indicators.

Results

Overall, we identified 40 quality indicators across 7 provinces, with 22 (55%) rated as "necessary" to distinguish high quality from poor quality care. Ten indicators were measured by more than 1 province, and 5 of these indicators were rated as necessary (home dialysis prevalence, home dialysis incidence, anemia target achievement, rates of peritonitis associated with peritoneal dialysis, and home dialysis attrition). None of these indicators captured the IOM domains of timely, patient-centered, or equitable care.

Limitations

The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals.

Conclusions

These results provide Canadian home dialysis programs with a starting point on how to measure quality of care along with the current gaps. This work is an initial and necessary step toward future collaboration and standardization of quality indicators across Canada, so that home dialysis programs can access a smaller number of highly rated balanced indicators to motivate and support patient-centered quality improvement initiatives.

An Environmental Scan of Canadian Quality Metrics for Patients on In-Center Hemodialysis

Background:

Quality metrics or indicators help guide quality improvement work by reporting on measurable aspects of health care upon which improvement efforts can focus. For recipients of in-center hemodialysis (ICHD) in Canada, it is unclear what ICHD quality indicators exist and whether they adequately cover different domains of health care quality.

Objectives:

To identify and evaluate current Canadian ICHD quality metrics to document a starting point for future collaborations and standardization of quality improvement in Canada.

Design:

Environmental scan of quality metrics in ICHD, and subsequent indicator evaluation using a modified Delphi approach.

Setting:

Canadian ICHD units.

Participants:

Sixteen-member pan-Canadian working group with expertise in ICHD and quality improvement.

Measurements:

We classified the existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks.

Methods:

Each metric was rated by a 5-person subcommittee using a modified Delphi approach based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for additional comments.

Results:

We identified 27 metrics that are tracked across 8 provinces, with only 9 (33%) tracked by multiple provinces (ie, more than 1 province). We rated 9 metrics (33%) as “necessary” to distinguish high-quality from low-quality care, of which only 2 were tracked by multiple provinces (proportion of patients by primary access and rate of vascular access-related bloodstream infections). Most (16/27, 59%) indicators assessed the IOM domains of safe or effective care, and none of the “necessary” indicators measured the IOM domains of timely, patient-centered, or equitable care.

Limitations:

The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals, with more representation from academic sites.

Conclusions:

Quality indicators in Canada mainly focus on safe and effective care, with little provincial overlap. These results highlight current gaps in quality of care measurement for ICHD, and this initial work should provide programs with a starting point to combine highly rated indicators with newly developed indicators into a concise balanced scorecard that supports quality improvement initiatives across all aspects of ICHD care.

Trial Registration:

not applicable.

Development and Validation of Nine Deprescribing Algorithms for Patients on Hemodialysis to Decrease Polypharmacy

Background:

Polypharmacy is ubiquitous in patients on hemodialysis (HD), and increases risk of adverse events, medication interactions, nonadherence, and mortality. Appropriately applied deprescribing can potentially minimize polypharmacy risks. Existing guidelines are unsuitable for nephrology clinicians as they lack specific instructions on how to deprescribe and which safety parameters to monitor.

Objective:

To develop and validate deprescribing algorithms for nine medication classes to decrease polypharmacy in patients on HD.

Design:

Questionnaires and materials sent electronically.

Participants:

Nephrology practitioners across Canada (nephrologists, nurse practitioners, renal pharmacists).

Methods:

A literature search was performed to develop the initial algorithms via Lynn’s method for development of content-valid clinical tools. Content and face validity of the algorithms was evaluated over three interview rounds using Lynn’s method for determining content validity. Canadian nephrology clinicians each evaluated three algorithms (15 clinicians per round, 45 clinicians in total) by rating each algorithm component on a four-point Likert scale for relevance; face validity was rated on a five-point scale. After each round, content validity index of each component was calculated and revisions made based on feedback. If content validity was not achieved after three rounds, additional rounds were completed until content validity was achieved.

Results:

After three rounds of validation, six algorithms achieved content validity. After an additional round, the remaining three algorithms achieved content validity. The proportion of clinicians rating each face validity statement as “Agree” or “Strongly Agree” ranged from 84% to 95% (average of all five questions, across three rounds).

Limitations:

Algorithm development was guided by existing deprescribing protocols intended for the general population and the expert opinions of our study team, due to a lack of background literature on HD-specific deprescribing protocols. There is no universally accepted method for the validation of clinical decision-making tools.

Conclusions:

Nine medication-specific deprescribing algorithms for patients on HD were developed and validated by clinician review. Our algorithms are the first medication-specific, patient-centric deprescribing guidelines developed and validated for patients on HD.

Population-based Cancer Screening: Measurement of Coordination and Continuity of Care

BACKGROUND

European guidelines for the quality of screening programs for breast and colorectal cancer describe process, structure, and outcome indicators. However, none of them specifically evaluate coordination and continuity of care during the cancer screening process.

OBJECTIVES

The aim of this study was to identify and adapt care quality indicators related to the coordination and continuity of the cancer screening process to assess nursing care in cancer screening programs.

METHODS

The indicators proposed in this study were selected in 2 phases. The first consisted of a literature review, and the second was made by consensus of an expert group. An electronic literature search was conducted, through June 2016. From a total of 225 articles retrieved, 14 studies met inclusion criteria, and these 14 documents were delivered to the group of experts for evaluation and to propose a final list of agreed-upon indicators.

RESULTS

The group of experts selected 7 indicators: adequacy and waiting time derivation of participants, delivery and availability of the report of the process, understanding professionals involved in the process, and satisfaction and understanding of participants.

CONCLUSIONS

These indicators should help identify areas for improvement and measure the outcome of coordination and continuity of care.

IMPLICATIONS FOR PRACTICE

The results provided a common set of indicators to evaluate the coordination and continuity of care for cancer screening and to consequently assess the contribution of nursing care in cancer screening programs. The identification and adaptation of these quality indicators will help to identify areas for improvement and measure the effect of coordination and continuity of care.

Feasibility of a hemodialysis safety checklist for nurses and patients: a quality improvement study

BACKGROUND

Patients with end-stage renal disease are at high risk for medical errors given their comorbidities, polypharmacy and coordination of care with other hospital departments. We previously developed a hemodialysis safety checklist (Hemo Pause) to be jointly completed by nurses and patients. Our objective was to determine the feasibility of using this checklist during every hemodialysis session for 3 months.

METHODS

We conducted a single-center, prospective time series study. A convenience sample of 14 nurses and 22 prevalent in-center hemodialysis patients volunteered to participate. All participants were trained in the administration of the Hemo Pause checklist. The primary outcome was completion of the Hemo Pause checklist, which was assessed at weekly intervals. We also measured the acceptability of the Hemo Pause checklist using a local patient safety survey.

RESULTS

There were 799 hemodialysis treatments pre-intervention (13 January-5 April 2014) and 757 post-intervention (5 May-26 July 2014). The checklist was completed for 556 of the 757 (73%) treatments. Among the hemodialysis nurses, 93% (13/14) agreed that the checklist was easy to use and 79% (11/14) agreed it should be expanded to other patients. Among the hemodialysis patients, 73% (16/22) agreed that the checklist made them feel safer and should be expanded to other patients.

CONCLUSIONS

The Hemo Pause safety checklist was acceptable to both nurses and patients over 3 months. Our next step is to spread this checklist locally and conduct a mixed methods study to determine mechanisms by which its use may improve safety culture and reduce adverse events.

Unintentional Discontinuation of Chronic Medications for Seniors in Nursing Homes: Evaluation of a National Medication Reconciliation Accreditation Requirement Using a Population-Based Cohort Study

Transitions of care leave patients vulnerable to the unintentional discontinuation of medications with proven efficacy for treating chronic diseases. Older adults residing in nursing homes may be especially susceptible to this preventable adverse event. The effect of large-scale policy changes on improving this practice is unknown.The objective of this study was to analyze the effect of a national medication reconciliation accreditation requirement for nursing homes on rates of unintentional medication discontinuation after hospital discharge.It was a population-based retrospective cohort study that used linked administrative records between 2003 and 2012 of all hospitalizations in Ontario, Canada. We identified nursing home residents aged ≥66 years who had continuous use of ≥1 of the 3 selected medications for chronic disease: levothyroxine, HMG-CoA reductase inhibitors (statins), and proton pump inhibitors (PPIs).In 2008 medication reconciliation became a required practice for accreditation of Canadian nursing homes.The main outcome measures included the proportion of patients who restarted the medication of interest after hospital discharge at 7 days. We also performed a time series analysis to examine the impact of the accreditation requirement on rates of unintentional medication discontinuation.The study included 113,088 adults aged ≥66 years who were nursing home residents, had an acute hospitalization, and were discharged alive to the same nursing home. Overall rates of discontinuation at 7-days after hospital discharge were highest in 2003-2004 for all nursing homes: 23.9% for thyroxine, 26.4% for statins, and 23.9% for PPIs. In most of the cases, these overall rates decreased annually and were lowest in 2011-2012: 4.0% for thyroxine, 10.6% for statins, and 8.3% for PPIs. The time series analysis found that nursing home accreditation did not significantly lower medication discontinuation rates for any of the 3 drug groups.From 2003 to 2012, there were marked improvements in rates of unintentional medication discontinuation among hospitalized older adults who were admitted from and discharged to nursing homes. This change was not directly associated with the new medication reconciliation accreditation requirement, but the overall improvements observed may have been reflective of multiple processes and not 1 individual intervention.

Development of clinical pharmacy key performance indicators for hospital pharmacists using a modified Delphi approach

BACKGROUND

Key performance indicators (KPIs) are quantifiable measures of quality. There are no published, systematically derived clinical pharmacy KPIs (cpKPIs).

OBJECTIVE

A group of hospital pharmacists aimed to develop national cpKPIs to advance clinical pharmacy practice and improve patient care.

METHODS

A cpKPI working group established a cpKPI definition, 8 evidence-derived cpKPI critical activity areas, 26 candidate cpKPIs, and 11 cpKPI ideal attributes in addition to 1 overall consensus criterion. Twenty-six clinical pharmacists and hospital pharmacy leaders participated in an internet-based 3-round modified Delphi survey. Panelists rated 26 candidate cpKPIs using 11 cpKPI ideal attributes and 1 overall consensus criterion on a 9-point Likert scale. A meeting was facilitated between rounds 2 and 3 to debate the merits and wording of candidate cpKPIs. Consensus was reached if 75% or more of panelists assigned a score of 7 to 9 on the consensus criterion during the third Delphi round.

RESULTS

All panelists completed the 3 Delphi rounds, and 25/26 (96%) attended the meeting. Eight candidate cpKPIs met the consensus definition: (1) performing admission medication reconciliation (including best-possible medication history), (2) participating in interprofessional patient care rounds, (3) completing pharmaceutical care plans, (4) resolving drug therapy problems, (5) providing in-person disease and medication education to patients, (6) providing discharge patient medication education, (7) performing discharge medication reconciliation, and (8) providing bundled, proactive direct patient care activities.

CONCLUSIONS

A Delphi panel of hospital pharmacists was successful in determining 8 consensus cpKPIs. Measurement and assessment of these cpKPIs will serve to advance clinical pharmacy practice and improve patient care.

Development of a hemodialysis safety checklist using a structured panel process

BACKGROUND

The World Health Organization created a Surgical Safety Checklist with a pause or "time out" to help reduce preventable adverse events and improve communication. A similar tool might improve patient safety and reduce treatment-associated morbidity in the hemodialysis unit.

OBJECTIVE

To develop a Hemodialysis Safety Checklist (Hemo Pause) for daily use by nurses and patients.

DESIGN

A modified Delphi consensus technique based on the RAND method was used to evaluate and revise the checklist.

SETTING

University-affiliated in-center hemodialysis unit.

PARTICIPANTS

A multidisciplinary team of physicians, nurses, and administrators developed the initial version of the Hemo Pause Checklist. The evaluation team consisted of 20 registered hemodialysis nurses.

MEASUREMENTS

The top 5 hemodialysis safety measures according to hemodialysis nurses. A 75% agreement threshold was required for consensus.

METHODS

The structured panel process was iterative, consisting of a literature review to identify safety parameters, individual rating of each parameter by the panel of hemodialysis nurses, an in-person consensus meeting wherein the panel refined the parameters, and a final anonymous survey that assessed panel consensus.

RESULTS

The literature review produced 31 patient safety parameters. Individual review by panelists reduced the list to 25 parameters, followed by further reduction to 19 at the in-person consensus meeting. The final round of scoring yielded the following top 5 safety measures: 1) confirmation of patient identity, 2) measurement of pre-dialysis weight, 3) recognition and transcription of new medical orders, 4) confirmation of dialysate composition based on prescription, and 5) measurement of pre-dialysis blood pressure. Revision using human factors principles incorporated the 19 patient safety parameters with greater than or equal to 75% consensus into a final checklist of 17-items.

LIMITATIONS

The literature review was not systematic. This was a single-center study, and the panel lacked patient and family representation.

CONCLUSIONS

A novel 17-item Hemodialysis Safety Checklist (Hemo Pause) for use by nurses and patients has been developed to standardize the hemodialysis procedure. Further quality improvement efforts are underway to explore the feasibility of using this checklist to reduce adverse events and strengthen the safety culture in the hemodialysis unit.

Defining quality outcomes for complex-care patients transitioning across the continuum using a structured panel process

BACKGROUND

No standardised set of quality measures associated with transitioning complex-care patients across the various healthcare settings and home exists. In this context, a structured panel process was used to define quality measures for care transitions involving complex-care patients across healthcare settings.

METHODS

A modified Delphi consensus technique based on the RAND method was used to develop measures of quality care transitions across the continuum of care. Specific stages included a literature review, individual rating of each measure by each of the panelists (n=11), a face-to-face consensus meeting, and final ranking by the panelists.

RESULTS

The literature review produced an initial set of 119 measures. To advance to rounds 1 and 2, an aggregate rating of >75% of the measure was required. This analysis yielded 30/119 measures in round 1 and 11/30 measures in round 2. The final round of scoring yielded the following top five measures: (1) readmission rates within 30 days, (2) primary care visit within 7 days postdischarge for high-risk patients, (3) medication reconciliation completed at admission and prior to discharge, (4) readmission rates within 72 h and (5) time from discharge to homecare nursing visit for high-risk patients.

CONCLUSIONS

The five measures identified through this research may be useful as indicators of overall care quality related to care transitions involving complex-care patients across different healthcare settings. Further research efforts are called for to explore the applicability and feasibility of using the quality measures to drive quality improvement across the healthcare system.