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Citizen Watch Continuing Care in Alberta and the Seniors' Action and Liaison Team www.continuingcarewatch.com
February 3, 2009 From: Citizen Watch on Continuing Care in Alberta and SALT Subject: MLA Bulletin 7, 2008 Health Quality Council Long Term Care Survey
In 2003 and 2004, Albertans with family members in nursing homes were asked how they would rate satisfaction with the facility on a scale of 1 to 5, and asked for up to 3 reasons for the rating. Just over half of the family members of long term care facilities were satisfied or very satisfied, and nearly a quarter were dissatisfied, with the services provided. The HQCA reported "Satisfaction with long term care services provided to family members was already ranked at the very low-end of the list of health care service areas evaluated, and is becoming worse." Access to long term care was also notably more difficult in 2004 than in 2003. (Satisfaction with Health Care Services: A Survey of Albertans Final Report 2004 http://www.hqca.ca/index.php?id=87) On December 10, 2008, the Health Quality Council of Alberta (HQCA) released the Long Term Care Resident and Family Experience Survey results. In 2007 and 2008, the HQCA interviewed 3,415 nursing home residents and received written survey questionnaires from 7,943 family members responsible for a resident about their experiences at over 170 long term care facilities throughout Alberta. The 2008 Survey is a sophisticated pair of instruments, carefully constructed, tested and administered. They were modelled on surveys developed by the American Agency for Healthcare Research and Quality's Consumer Assessment of Healthcare Providers and Systems (CAHPS) program, to report on the experience of patients and their families with health care services. The Survey results have received very little public attention. There has been no public response from the Ministry of Health and Wellness, the health regions or the Health Service Board, or the facility operators, and very little media attention (the Lethbridge Herald editorial on December 12, 2008 was headlined "Room for Improvement"). In this Bulletin, we offer some comments about what the survey tells us about the care in our nursing homes and what it doesn't tell us. As always, we'd appreciate your comments. Sincerely, Carol Wodak, on behalf of the Seniors' Action and Liaison Team, and Citizen Watch (780) 417-1705; email to contributions@continuingcarewatch.com
MLA Bulletin 7, January 2009
from Citizen Watch on Continuing Care and SALT
www.continuingcarewatch.com 2008 Health Quality Council Long Term Care Survey
"The many facets of health care quality can be divided into two major categories: one involves the clinical aspects of care, while the other reflects patients' experiences with health care services." 1 Family satisfaction surveys in Alberta nursing homes are not new. Health regions 2 and facility operators 3 have used this technique for some time. The results are familiar to anyone who has discussed a concern with a facility operator, and is told "But most of our residents/families are satisfied with our care". The HQCA Survey results: The Survey's overall care ratings showed that 44% reporting "best care possible", 42% "average", and 14% "worst". Other responses show that respondents believe that staff always or usually treated residents with courtesy and respect, and really cared about the residents. Facility characteristics (temperature, noise levels, and cleanliness) got mostly "always" and "usually" ratings. Meals got very low ratings. Questions about whether there were enough staff, or whether staff responded quickly to calls for help, did not get such positive ratings. One-third of family respondents reported being unhappy with the care provided, while 58% of the residents reported "not being unhappy" with the care. "Patients enter the situation with expectations, and the perceived difference between expectation and experience offers net satisfaction in simple encounters. When experience is greater than expectations, the experience is satisfactory." 4 31% of the family respondents did not complain about care concerns to staff because of possible repercussions to the resident. 33% reported that resident medical belongings (glasses, hearing aides, dentures) had been lost or damaged. Only 24% of the residents were cognitively able to complete the one-on-one interviews, and some required several sessions to do so. The report noted that "It is not clear whether cognitively able residents are representative of residents who, for various reasons, cannot speak for themselves. Residents with dementia clearly have different and more significant care needs. . ." In the News Release, the Council recommended that improving the number and availability of staff, improving communication between staff and residents, ensuring that the nursing home environment was comfortable, and improving staff responsiveness to calls for help, were among the actions that could be considered. It is not clear whose responsibility this is, or where the resources will come from. Measuring "quality of care", particularly in long term care settings, is a complex subject. The results of this survey do not add much to our understanding of the quality of care in our nursing homes. The difficulty is not that the personal experience has been assessed, but that it is assessed in the absence of other and more reliable indicators of the quality, timeliness and adequacy of care. "Patients may be in a position to assess the interpersonal interactions they have with healthcare staff and the adequacy of communication with service providers; however, they have little technical expertise in assessing the adequacy with which clinical procedures are performed. Hence, the patient is in a position to assess only one aspect of the delivery of healthcare services, and that aspect may not be the most important one to consider in the case of those with acute or clinically unstable chronic conditions." 5
MLA Bulletin 7, 2008 Health Quality Council Long Term Care Survey, page 2 of 4
Why was the Survey done? The Highlights reports that the HQCA survey was not intended to provide "customers" with information about any particular facility; its purpose was to help the "stakeholders" see what they are doing well, and what needs improvement. The Technical reports include the range of responses among the Health Regions to each of the questions, and also gave results indicating differences in ratings between the 25% of facilities with the highest ratings, and the 25% with the lowest ratings. The facilities are not identified in the public reports. The Survey results include the range of responses to each of the questions among the Health Regions. Individual facility specific reports showing a comparison to regional and provincial averages were prepared, but they are not available to the public. 6 Residents and families who responded to the Survey don't know how well "their" facility rates, or whether their individual experience means they were just lucky or not. What do we need to know to assess the quality of our nursing homes? Surveys of customer satisfaction are one of the nine "programs" by which quality is to be measured in the Continuing Care Health Service Standards 7 . The other measures which must be considered include reportable incidents and near misses, and a comparison of care needed with care actually provided, Consider the results of our review of nursing home safety in the MLA Bulletin 6, which documented the frequency of incidents of preventable "unintentional harm" (falls, adverse drug events, infections, pressure ulcers, resident aggression). What did we learn from these Surveys? The range of responses to every question indicates that there is no consensus among residents and families about their experience in our nursing homes. This is not surprising; needs and preferences are individual, and any facility may or may not be appropriate for an individual. Facility operators, health regions, and the government, again have information about the "hospitality concerns" of residents and their families. These are the same concerns identified in the 2003 and 2004 Satisfaction Surveys. Although some facilities appear to be rated generally "better" than others, that information is not available to current residents and their families, or to those trying to choose a facility. But what about the care? The care concerns described to the Government and to Auditor General in 2003 8 , and the MLA Task Force in 2005, remain. A 2006 analysis of documented calls, letters and emails to Citizen Watch (An Inside Look at the Continuing Care Experience) 9 reflected similar concerns from families and staff about the "consistent critical shortage of qualified professional and non-professional care staff". These same concerns about staffing and the effect on care were identified yet again in a 2008 report to Alberta Health senior officials by Health Care Aides. 10 Who is going to take responsibility to improve the care? How long will it take? For more information about nursing home staffing in Alberta, see: Concerns regarding "Hours of care" in Continuing Care Facilities http://www.continuingcarewatch.com/pdf/Hours%20of%20Care.pdf Long Term Care Staffing Background http://www.continuingcarewatch.com/pdf/Long%20Term%20Care%20Staffing%20Ba ckground.pdf
MLA Bulletin 7, 2008 Health Quality Council Long Term Care Survey, page 3 of 4
References Health Quality Council of Alberta Long Term Care Resident and Family Experience Survey reports, http://www.hqca.ca/index.php?id=60 News Release http://www.hqca.ca/assets/pdf/LTCSurvey/HQCA_LTC_NR_Final.pdf Update on CAHPS Nursing Home Surveys: Provincial Surveys of 173 nursing homes Alberta, Canada http://www.cahps.ahrq.gov/content/community/Events/files/T-5ST_Cooke.pdf Satisfaction with Health Care Services: A Survey of Albertans Final Report 2004 (Health Services Satisfaction Survey 2004, HQCA Technical Report) from http://www.hqca.ca/index.php?id=87
Endnotes
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American Agency for Healthcare Research and Quality, Consumer Assessment of Healthcare Providers and Systems CAHPS Program Brief https://www.cahps.ahrq.gov/content/resources/QI/RES_QI_Intro.asp?p=103&s=31 Calgary Long-term Care Resident Satisfaction Survey Health Service Delivery Highlights, Volume 6, Summer 2000 http://www.calgaryhealthregion.ca/qshi/hsau/Population_Health/Highlights/6/ltc.pdf Alberta Continuing Care Association, Family Surveys in 2003 and 2006. A research model of health care competition and customer satisfaction Asoh and Rivers, Health Services Management Research November 2007 http://hsmr.rsmjournals.com/cgi/reprint/20/4/244.pdf Health Canada Quest for Quality in Canadian Health Care: Continuous Quality Improvement http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2000-qual/quest-quete-eng.pdf Update on CAHPS Nursing Home Surveys: Provincial Surveys of 173 nursing homes Alberta, Canada http://www.cahps.ahrq.gov/content/community/Events/files/T-5-ST_Cooke.pdf Alberta Health and Wellness, Continuing Care Health Service Standards http://www.continuingcare.alberta.ca/download/Continuing-Care-Standards-2008.pdf Creating Protections for Better Lives of Vulnerable Seniors http://www.continuingcarewatch.com/pdf/Creating%20Protections%20pdf.pdf and http://www.continuingcarewatch.com/2003_audit_request.php An Inside Look at the Continuing Care Experience: An Analysis of Family Feedback, August 2006 http://www.continuingcarewatch.com/AnalysisFamilyFeedback.pdf Alberta Health Care Activists Presented Senior Government Officials Workers' Concerns Over Staffing Levels in Long Term Care Facilities November 20 2008 http://www.usw.ca/program/content/5448.php; referenced in an Alberta New Democrat Press Release January 28 2009 http://ndpopposition.ab.ca/site/index.cfm?fuseaction=page.details&ID=8001&t=8&i=16
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MLA Bulletin 7, 2008 Health Quality Council Long Term Care Survey, page 4 of 4