Quality management systems and clinical outcomes in Dutch nursing homes

Abstract

The objective of the article is to explore the impact quality management systems and quality assurance activities in nursing homes have on clinical outcomes. The results are based on a cross-sectional study in 65 Dutch nursing homes. The management of the nursing homes as well as the residents (N = 12,377) participated in the study. Primary survey-data about the implementation of quality management systems and quality assurance activities were collected in 1994/1995 and in 1998, and were combined with information on resident characteristics and the prevalence of undesirable clinical outcomes. The results demonstrate that there are differences between nursing homes in the prevalence of undesirable clinical outcomes. In the nursing homes with the lowest scores, undesirable outcomes occur approximately 10 times less often than in nursing homes with the highest scores. The multi-level analysis has demonstrated that the differences in outcomes are mainly caused by differences between residents and, to some extent, also by differences between nursing homes. Resident characteristics explain 48% of the differences between residents and 72% of the differences between nursing homes. The size of the nursing home, the involvement of a client council and the implementation of a quality management system could explain a small part of the remaining variation in the number of undesirable outcomes. It seems that the implementation of a quality management system and the involvement of a client council had significant influence on the number of undesirable outcomes. Approximately 50% of the undesirable outcomes cannot be explained by the selected resident characteristics, the size of the nursing home and the implementation of quality management systems or quality assurance activities.

Introduction

This article explores the impact quality management systems (QMS) and quality assurance (QA) activities in nursing homes have on clinical outcomes. During the past 10 years, nursing homes in various countries have made a start with the systematic implementation and evaluation of care planning [1], [2], [3], [4], practice guidelines [5], [6], [7], [8], [9], quality indicators [10], [11], client councils and quality management systems [12], [13], [14], [15] to improve the quality of care provided [16], [17] and adapt to the changing needs of nursing home residents [18]. In several countries, the government has also imposed legal requirements to improve the quality of nursing home care. The American Congress, for example, introduced the Omnibus Budget Reconciliation Act (OBRA) in 1987. This contains specific guidelines regulating the use of psychotropic drugs and physical restraints in long-term care facilities [19], [20], and mandates the use of the Resident Assessment Instrument (RAI) for care planning. Moreover, nursing homes are obliged by this act to create a quality improvement team. In Canada and Iceland, for instance, the government has also mandated the use of the RAI to improve the process of care planning and to monitor the quality of care [11]. In The Netherlands, the Dutch parliament introduced the Care Institutions Quality Act in 1996 (http://www.minvws.nl). The aim of this Quality Act is to ensure that the care provided is of a high standard.

Nursing homes and other health care organizations must therefore, develop a quality management system and implement QA-activities. A quality management system comprises the entire process of formulating requirements, collecting information, assessing outcomes and adjusting policies at all levels of an organization [15]. In The Netherlands, the first nursing homes started in 1990 with the development and implementation of more systematic QA-activities, such as systematic care planning, practice guidelines and a quality policy for the entire nursing home. In 1995 and 2000 still only 5% of the health care organizations had fully implemented a quality management systems, others were still working on the implementation and the systematic improvement of their care processes [21].

The basic assumption underlying the implementation of quality management systems is that effective and efficient care processes will lead to appropriate care and positive outcomes. However, in nursing homes it is not always possible to improve or maintain the health status of elderly residents. Therefore, the quality of life of nursing home residents could be an important outcome measure, but, until now there have been no relevant health-related quality of life measures that could indicate appropriate care [22]. In earlier research undesirable clinical outcomes, such as mortality, pressure sores, incontinence or indwelling catheters, have been used to assess the quality of nursing home care [10], [11], [23], [24], [25], [26], [27]. These clinical outcomes are undesirable because of their negative influence on the health status of residents. In other research, the relationship between quality of care and organizational determinants have been investigated [28], [29], [30], [31], [32], [33], [34]. Over the years, research results have shown that differences in clinical outcomes could partly be explained by organizational determinants, such as economic status, size, bed-occupancy, nursing home staffing and environmental determinants, such as per capita income, bed supply and competition [28], [33], [34], [35], [36], [37].

Quality management systems and QA-activities are designed to improve clinical outcomes for residents by improving the process of health care provision. Studies which have examined the impact of the implementation of specific QA-activities on the process and outcomes of care have found some evidence that specific further training of professionals, practice guidelines and individual care planning have a positive impact on resident-related outcomes [1], [3], [38] or staff work satisfaction [39]. To date, however there is scarce evidence that quality management system improve clinical outcomes in nursing home residents to any great extent.

In this article is studied the relationship between quality management systems and the prevalence of undesirable clinical outcomes. The central research question was: Do nursing homes with a quality management system have less undesirable clinical outcomes than nursing homes without a quality management system?