Healthcare Quarterly Vol.16 No.1 2013 27

Enhancing the Quality and Safety Standards for Older People in Canadian Hospitals Belinda Parke et al.

26 Healthcare Quarterly Vol.16 No.1 2013

is the cohort aged 80 years and over. This group is projected to account for 3.3 million people by 2036, thereby quadru-pling the number of centenarians living in Canada (Canadian Institute for Health Information 2011a). Even though older adults represent 15% of the current population, by 2036 they could account for one quarter of Canadians (Statistics Canada 2010).

Chronic health conditions become more prevalent with age and are thought to contribute to increased use of healthcare services (Canadian Institute for Health Information 2011b; Terner et al. 2011). Older adults are three times more likely to be hospitalized than the population as a whole, and their length of stay in hospital is significantly longer. They account for one third of all acute care hospitalizations and almost half of all hospital days (Canadian Institute for Health Information 2012). Older adults are also more likely to receive in-patient care when seen in the emergency department (Canadian Institute for Health Information 2011a).

There is growing agreement that, for most older people, hospitals provide a difficult if not hazardous healthcare experi-ence (Baker et al. 2004; Merten et al. 2013) characterized by risk, vulnerability and contributory factors that lead to prevent-able adverse outcomes (Lawton et al. 2012; Tingle 2011) and dissatisfaction (Bridges et al. 2010). Safety considerations that affect older people disproportionately in hospital include complications from falls, delirium, malnutrition, dehydration, decubitus ulcers and adverse drug effects (Inouye et al. 1993). The complexity of older adults’ care needs can have a signifi-cant impact on their recovery and hospital operations as these people transition out of hospital (Naylor et al. 2011; Parke and Chappell 2010). Functional decline during their hospital stay is a major problem that is sometimes not readily reversed (Boyd et al. 2008; Covinsky et al. 2003; Creditor 1993; Gill et al. 2010; Landefeld 2006; Sager et al. 1996). Associated system outcomes from functional losses include increases in length of stay, community care requirements, hospital readmissions and the likelihood of nursing home placement (Kortebein 2009; Landefeld 2006; Rudberg et al. 1996).

There is also evidence that compliance with medical quality indicators such as Assessing Care of Vulnerable Elders (ACOVE) for hospital care is significantly lower than compliance with quality indicators for general adult hospital care (Arora et al. 2007). This care gap is recognized in numerous health regions in Canada, which is illustrated in a recent self-assessment process undertaken by Ontario hospitals (Wong et al. 2011). Factors relevant to quality hospitalization for older people include the documentation of baseline functional status (Wakefield and Holman 2007); early mobilization (Brown et al. 2004; Mundy et al. 2003); cognitive screening (Parke et al. 2011; Wong et al. 2010); delirium prevention (Rudolph et al. 2011); falls preven-tion (Oliver 2007); the promotion of continence (Ostaszkiewicz

et al. 2008); and discharge processes (Bauer et al. 2009). Even with mounting evidence, there is a lag in moving to consistent best practices.

The challenge of providing safe, high-quality, cost-effective healthcare to older adults in hospital is not unique to Canada. All developed countries with an aging demographic are confronted with increasing healthcare demands and limited resources. Some senior-friendly care programs in Australia (Davy et al. 2009; Ngian et al. 2008), Taiwan (Chiou and Chen 2009) and the United States (Boltz et al. 2010, 2012; Mezey et al. 2004; Mion et al. 2003) have shown promise. Similarly in some Canadian provinces, there are initiatives and programs in senior-friendly care that are noteworthy (Huang and Larente 2011; Hubert et al. 2004; Parke and Brand 2004; Parke et al. 2012; Stevenson et al. 2012; Wong et al. 2010b, 2011). Uniting the collective organizational and hospital system experiences of implementing senior-friendly hospital innovations across Canadian provincial jurisdictions into one set of national standards is timely.

What Canadian Experts Tell Us In phase one of the project, a series of three workshops engaged a network of 177 inter-professional experts, key stakeholders and opinion leaders (see Appendix A at http://www.longwoods.com/content/23238). These experts prioritized items within and across five dimensions: care systems/processes of care; physical environment/design; policies, procedures and organizational support; social climate/emotional and behavioural environment; and ethics in clinical care and research (Liu et al. 2010; Parke and Chappell 2010). Priorities identified from the workshops included these: processes related to arrival and departure from hospital, clinical topics, educational awareness, approaches to care, organizational leadership and the built environment. This information informed phase two, the national round-table meeting held in April 2011.

In phase two, thirty-four Canadian experts knowledgeable in hospital systems and the issues older people face in hospital participated in a round-table meeting (following Ethical Board review and approval). Representation from across Canada included professional groups and key stakeholder organizations (hospitals [acute and post-acute], long-term care and commu-nity care), as well as experts in knowledge transfer and exchange, and not-for-profit organizations that serve older people and caregivers.

To generate ideas relevant to drafting quality standard state-ments, experts attending the round-table meeting deliberated on the question, what standards would improve the quality and safety of older adults in Canadian hospitals? This meeting resulted in five draft, overarching standard statements:

• Statement one: Hospitals provide quality care to maintain and/or enhance the well-being and the functional status of older adults.

Belinda Parke et al. Enhancing the Quality and Safety Standards for Older People in Canadian Hospitals

• Statement two: Hospitals ensure that the older person and/or family member and/or caregiver be meaningfully informed and involved in all aspects of care, decision-making and policies.

• Statement three: Hospitals ensure processes that are individu-alized to support transition within the hospital and discharge home.

• Statement four: Hospitals facilitate and support a culture of respect for older adults.

• Statement five: Hospitals provide an environment that maximizes and protects function.

Using empirical evidence, substantive descriptive summaries (see Appendix B, available at http://www.longwoods.com/content/23238) and corresponding topics (see Table 1) for each standard statement were written.

Phase three, an electronic survey with attendees from phase two along with a second group o f experts who did not attend the round-table meeting, validated the appropriateness and compre-

hensiveness of the content associated with the descriptive summa-ries for each quality and safety standard (see Table 1).

Results of the Electronic Survey Overall, response rates of 63.6% and 56.5% were achieved for groups one (meeting participants; n = 21/33) and two (non-meeting participants; n = 13/23), respectively. Appendix C (available at http://www.longwoods.com/content/23238) shows that experts endorsed the standard statements and descriptive summaries. In comparing the groups, we noted that there was greater agree-ment in group two than in group one. Where there was differ-ence, it was in relation to the placement of topics within the standards. For example, several participants noted that family involvement was absent from standard one, but this topic was encapsulated in a later standard statement. The greatest discrep-ancy in agreement was found for standard statement one. In this case, five participants from group one wanted clarity regarding medication reconciliation, an expanded number and type of professional interdisciplinary team members, a definition

TABLE 1. Three most important topics for each standard statement as selected by each of the two groups

n/a = not applicable. *The score for each topic is in parentheses. †Since group 1 had more participants than group 2, the raw scores are higher overall.

Standard Statement Topics Priority Topics per Group 1*†

Priority Topics per Group 2*

Statement one Medication safety, maximizing independent functional ability, optimizing mobility, fall prevention, delirium, optimize nutrition and hydration, pain assessment and management, minimize restraints, minimize catheter use, prevent sleep deprivation, prevent pressure ulcers, infection control practices, adjusting care approaches for persons with dementia and mental health issues

Maximizing functional ability (79), optimizing mobility (22), delirium (22)

Maximizing functional ability (39), medication safety (21), optimizing mobility (17)

Statement twoOlder adult and family involvement in decision-making, respecting the contents of the advance directive, ensure culturally appropriate care

Older adult and family involvement in decision-making (103), respecting the contents of the advance directive (55), ensure culturally appropriate care (31)

Older adult and family involvement in decision-making (63), respecting the contents of the advance directive (31), ensure culturally appropriate care (23)

Statement threeSystem linkages between hospital and community, process for transfer of accountability between services, proactive and appropriate planning for community support or discharge location

System linkages between hospital and community (81), proactive and appropriate

Proactive and appropriate planning for community support or discharge location (45), system linkages between hospital and community (37), process for transfer of accountability between services (35)

Statement fourRespect older person’s rights; eliminate ageist policies, procedures and staff attitudes; provide staff education to promote age-sensitive care; elder abuse

Planning for community support or discharge location (59), process for transfer of accountability between services (49)

Eliminate ageist policies, procedures and staff attitudes (37), respect older person’s rights (36), provide staff education to promote age-sensitive care (32)

Statement fiveEnsure purchasing decisions and alterations to the physical environment account for the physical, cognitive and functional needs of older people

n/a n/a