Quality of Service Approach In The Nursing Homes of New Brunswick

By Vicky Knight, Roberte Vautier

A Need is Established

The nursing homes of New Brunswick have always strived to provide the best possible care to their residents. Previous to 1980, the primary focus of nursing homes was on acute care based on a medical model. In the late 1980s, however, it became evident that the needs of residents and their families were changing. Nursing homes were not only places where acute care and other healthcare services were provided, but were also residents' homes. In addition, the complexity of residents' mental and physical needs was increasing. A holistic multidisciplinary approach would be essential to meet the complex needs of this new nursing home resident.

As part of the government initiatives the Department of Health and Community Services had a number of studies carried out to look at restructuring the province's entire health care system, not just the nursing home sector. It was evident that linkages among the various components of the province's health care system needed to be enhanced, in order to best meet the needs of the people of the province. As a result of these studies, issues where improvements would be beneficial to nursing homes were identified.

A Resident-Focused, Quality Of Service Approach Adopted

An overall residents-focused management approach was adopted to improved residents services through the ''Quality of Service'' program. The primary goal of the Quality of Service is to guide the implementation of a service delivery model that supports and enhances the resident-focused approach adopted within their work place.

The Philosophy of the Quality of Service approach is that the resident is the primary focus of all aspects of the operation of a nursing home.

The Mission: It is essential to have acceptable results in resident and family satisfaction by creating and maintaining optimum and continued assurance for resident safety, health, autonomy, independence and dignity to ensure Quality of Service

Peat Marwick Stevenson & Kellogg's (KPMG) Quality Management approach and methodology were used to develop the nursing home Quality of Service program. It is based on three pillars:

Commitment
the management team demonstrates ongoing commitment and conviction to Quality Management and is involved in making it work.
Processes
activities are be organised to follow clearly defined and documented procedures, performance standards and measures, or processes.
People
all staff is involved and make a commitment to the Quality Management approach to ensure its effectiveness.

In order to implement a resident-focused model, the following essential elements of Quality Management had to be addressed:

Quality of Service Pilot Project

Throughout the piloting of the Quality of Service approach in New Brunswick, nursing homes evaluated the effectiveness and the benefits of this approach. Five nursing homes across the province were selected to participate in the pilot. Criteria used to select pilot homes included willingness to participate size, region and language.

The final report was produced in June 1994.

A Resident Services Steering Committee was established and continues to implement changes and co-ordinate the implementation and sustaining the Quality of Service throughout the province.

Implementation of Quality of Service throughout NB Nursing Homes

The New Brunswick Association of Nursing Homes (NBANH) acted as the coordinator and facilitator offering resources and strategies for planning and implementing Quality of Service. The New Brunswick Department of Health and Community Services allocates resources and funding to support the coordination by NBANH in implementing the Quality of Service program. The program was developed and implemented concurrently in both official languages. The New Brunswick Community College, Moncton Campus, was retained to provide the education services in both official languages.

Implementation Process

Before a nursing home implements the Quality of Service program, several key activities need to take place, including: awareness sessions, site team education and training, planning the activities, training sessions of process owners, training of all staff, implementation of the Matrix Index Performance Reporting System (MIPR) and continuous quality improvement activities. MIPR is a computer software system designed to convert effectiveness, efficiently and appropriateness in the planning and delivery of resident services. MIPR was developed so that performance in key areas could be measured and monitored and the results reported in a formal standardised manner.

The MIPR system uses multiple measures to determine organisational performance in relation to defined outcomes. The MIPR system measures organisational performance from the perspective of: resident/ family/ staff/ community, financial results, external services suppliers.

Data is collected through MIPR and was intended for use primarily by the management of the homes in making decisions related to the home's operations. The purpose of the tool is to help nursing homes in their planning process. Eleven outcomes as defined in the mission statement and sixteen indicators were identified to monitor the performance of the key processes. Additional diagnostic measures were identified to monitor performance and determine areas for improvements.

Linking Process

In partnership with the Canadian Council in Health Services Accreditation, the NHS, NBANH, and one of the Quality Service instructors from NBCC Moncton have developed an evaluation tool to link the two approaches, the AIM ( Achieving Improved Measurement) Standards and the Quality of Service. Before implementing the evaluation tool, the document is being tested as a pilot project with three anglophone and three francophone nursing homes. Implementation of the new evaluation tool is expected to be finalized during Fall 2001.

Every year since the completion of the pilot project, more nursing homes have come on board with the resident-focused Quality of Service approach and today about ninety percent (90%) of nursing homes participate in the Quality of Service program. Evaluation and monitoring of the coordination of activities related to the implementation of the Quality of Service continues. The evaluation focuses on the internal resources, what exists in the nursing home and what activities are carried out.

Outcomes Identified

The whole model was based on outcomes that related to residents, staff and the nursing homes as an entity. It also provides provincial data. The implementation of the quality of services has tremendously improved the structure and the work environment in the nursing homes. The communication lines have improved, front-line staff are more empowered, there is more cohesive management teams, staff have realised the benefit of education and training, co-operation, teamwork and partnering is recognised, and everyone contributes to the continuous improvement of service.

The following testimonies from four nursing homes reflected the benefit that the Quality of Service program has brought them. (Manoir Edith B. Pinet, Paquetville; Manoir de Grand Sault, Grand Sault, Dr. V. A. Snow Centre, Hampton and Rexton Lions Nursing Home in Rexton.)

Quality of Service: A Small Nursing Home's Perspective

Rexton Lions Nursing Home a thirty (30) bed facility is located in Rexton, New Brunswick.

The Mission Statement hangs in the entrance of the Rexton Lions Nursing Home. It is a message to all that enter that the facility has strong values, committed to providing care in a continuous quality improvement environment.

Living the Mission Statement is a day to day goal in this thirty bed nursing home which uses the Quality of Service program as a framework to provide, monitor and improve care. With the employment of a staff of forty (40), there is ensured privilege of caring for the elderly of three distinct cultures; English, French and Mic Mac. This home has been accredited by the Canadian Council of Health Services Accreditation since 1984. The Quality of Service program was introduced in 1997.

The tools of the Quality of Service program (indicators, diagnostics, meetings and copious amounts of paper) have been simplified to meet all needs. The focus is on nurturing in each other an attitude of teamwork and resident centered care, an attitude from which all other activity stems. A small multi-functional group, representing all departments, meets informally each morning for approximately 10 minutes. Concerns of the day are expressed and everyone carries away a sense of what others are doing and how the connection as a team is made. This same umbrella group meets monthly on a more formal basis wearing the hats of the many committees with their individual terms of reference. Like any staff, there are issues, but commitment is the chief component that fosters the spirit throughout the facility.

Quality of Service : A Rural Nursing Home's Perspective

Service quality in long-term care, like in other industries, is based on a model that supports and enhances a client-based approach. A workplace service quality model shows accountability by measuring results based on clients - both internal and external. The model's philosophy recognises client-based services as its main focus and the holistic multidisciplinary approach necessary to meet their needs.

In 1997, efforts to improve and ensure quality care and services resulted in Service Quality. Manoir Edith B. Pinet, a 30 bed facility located in Paquetville, New Brunswick, decided to use this approach to complement its existing in-house program. But, due to its very structured nature, it was quickly apparent that this multi-process evaluation model was not consistent with the facility's management philosophy. Timing was a major challenge. Management had developed an evaluation system where priorities were selected by staff members themselves. Every one of the 16 staff members responsible for some thirty different processes had the mandate to evaluate if the processes needed to be revised and redeveloped according to measurable objectives. In order for the quality initiatives to be integrated, the facility was using an open door approach to quality improvement.

Quality measurement can be done with surveys, questionnaires, interviews or with other indicators that assess whether objectives have been met. Experiences with evaluation processes clearly indicated that the subject who performs the measurement is central to the value that is attributed to the activity. In long-term care facilities, quality improvement principles are successful to the extent that the facility is creative in adapting to its needs and those of the residents and their families.

In 1998, an external quality measurement tool - the Pilot Group- was developed. The Pilot Group is comprised of residents' relatives who have volunteered to evaluate the overall satisfaction level of residents and their families. At Manoir Édith B. Pinet, this group included five individuals who formed the group for at least one year. The Pilot Group's mandate is to measure the overall satisfaction of residents and identify areas where quality must be improved and to take part in an ongoing dialogue with administration in order to meet the facility's major strategic directions. Group members are called quality officers. Each group member must then select five individuals among the residents' close friends and family to study a questionnaire. One acts as the team leader. It is those five sub-groups that carry out the evaluation process.

The questionnaire provides feedback about the participants' satisfaction. It help evaluate the level of satisfaction with regards to service quality criteria in reference to eye-opening themes such as staff behaviour toward residents, environment, professional services and care, and individual concerns. The result of the questionnaire is communicated to the staff responsible for each sector during a town hall type meeting.

Participants are then invited to talk about issues that have not been dealt with during the discussion.

After a reasonable period of time for recommendations and/or decisions to have been implemented, participants are invited to a follow-up meeting to assess the corrective actions implemented. At the end of the process, a thank-you letter with a commitment to benefit from the experience is sent to each member of the Pilot Group.

The benefits of this evaluation method include the confidentiality of the exercise. Staff members and managers have no way of finding out the identity of any sub-group participants. The leader is the spokesperson for the group of people who will be unknown to management. Another benefit is that participation in the questionnaire is voluntary. These two elements ensure the accuracy of the quality measurement. Any intimidation that survey participants could be subjected to is non-existent. One risk of this type of evaluation, though, is that the facility must be ready to act on the results and make necessary changes.

Quality of service: A Medium Size Nursing Home's Perspective

Dr. V. A .Snow is a fifty (50) bed facility located in Hampton, New Brunswick. The tray cart rolled out the kitchen door at 12 o'clock noon sharp one Monday last June. One of the housekeeping staff pushed it to the south end. Every available member of the nursing and housekeeping staff followed it down. They were there to help feed the residents.

This was new for the Dr V.A Snow Centre. Trays used to go to the North and South ends at the same time and the few staff on those ends helped with the feeding. But there was a problem. The standard for food to go from the kitchen to the resident was 15 minutes. Auditing showed that it was sometimes 25 minutes before residents received their food and this had to be corrected.

The Quality of Service Program provided the tool. Everyone had been taught how to use the quality improvement tools and now was the time to put them to work. A group from four departments met one afternoon for a brainstorming session which concluded that the reason for not meeting the standards was that two carts were rolling at the same time and there were not enough people to help with the feeding. The solution seemed obvious. Send one cart south and have everyone available help feed. Then send the other cart north thirty minutes later and repeat the process. This was tried at noon for two months and the results were monitored. With a few changes standards were consistently met and in August it was implemented at breakfast and supper.

Standards are now being met but more importantly resident services have improved and barriers have been removed between departments.

Quality of Service: A Medium Size Nursing Home's Perspective

The Grand Fall Manor ( Manoir de Grand Sault) is a seventy-two bed facility located in Grand Fall New Brunswick who provides for residents with a high level of dependency. The implementation of the Quality of Service program in November 1996, with a coordination team giving information and education sessions to residents, their families, employees, volunteers and members of the Board of Directors.

Teams were created for the analysis of the various processes or work systems identified by the program. A high level of motivation developed among the employees, which gave rise to a remarkable level of teamwork and co-operation. Although there were no evidence of problem as far as teamwork and co-operation are concerned it is this type of performance that ensured its success

Management became actively involved in the program in order to facilitate and support the changes required for the improvement of various processes. Staff, volunteers and professional employees were contributed by changing some of the work methods in order to improve the system as a whole. The number of volunteers along with increased family participation has enabled the employees to provide the residents a lot more help than was previously possible.

Once the program was implemented, a performance control approach with a structured system of standardized data was introduced (MIRP). This provided better preparation on a continuous basis, summaries and quarterly computerized reports on potential problems and identified strengths and weaknesses. Reports are compared every three months among some nursing homes, and these reports are posted in the nursing homes before being sent on a voluntary basis to other departments.

Conclusion

The Quality of Services program improved planning, organization, coordination and delivery of direct and indirect resident services. The approach required a structural and cultural change to created an integrated approach in the majority of nursing homes. The development of leadership was build and enabled to support the achievement of goals to focus on continuous improvement. Needless to say education and training are the keys to the success of the Quality and Service program.