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2012 Conference Presentation

Markets/regulationOutcomes and quality Canada

6 September 2012

Improving quality in long term care: regulation, public reporting or quality improvement

Walter Wodchis, Faculty of Medicine, University of Toronto, Canada
Kevin Walker, Faculty of Medicine, University of Toronto, Canada
Whitney Berta, Faculty of Medicine, University of Toronto, Canada
Larry Chambers, Faculty of Medicine, University of Toronto, Canada
Katherine McGilton, Faculty of Medicine, University of Toronto, Canada


Background: Regulations, public reporting and quality improvement (QI) collaborative are three different approaches to influence the quality of care provided in Long Term Care (LTC) facilities. Ontario, Canada has been a particularly active area for all three approaches to improving quality. A new Long Term Care Act was proclaimed in 2010; public reporting of LTC quality began with a voluntary group of LTC facilities in 2009 moving to mandatory reporting in 2012; and the provincial quality council – Health Quality Ontario (HQO) – is supporting a provincial QI collaborative.

Objective: This research project had two objectives. The first was to determine if there were baseline differences in the staff-reported organizational supports for QI implementation between Homes that did and did not voluntarily participated in HQO’s QI collaborative and Public Reporting programs. The second objective was to evaluate the incremental change in these supports attributable to the introduction of the new legislation and participation in Public Reporting and the QI collaborative.

Data and Methods: Surveys were distributed to all staff in a sample of LTC Homes in 2009 with a follow-up in 2011. Staff perceptions of organizational supports for QI implementation, based broadly on three areas of the Malcolm Baldrige National Quality Awards criteria (leadership, employee focus and customer focus) were collected using a survey of a representative (geographically and by ownership) sample of 72 LTC Homes. This staff survey was rerun in the fall-winter of 2011-2012 in 69 of the 72 homes. Comparisons were made using home and staff level results between participants and non-participants in public reporting and the QI collaborative. Changes in results over time were also evaluated. Data analysis included bivariate and multivariate modelling accounting for the clustering of staff within Homes.

Results: Twenty-two of the 69 LTC Homes with data from both 2009 and 2011 enrolled in the QI program and 24 enrolled in public reporting. Baseline results suggest that homes where staff reported more quality improvement activities were more likely to join the QI program. Homes that volunteered for public reporting similarly had higher staff ratings of home-level quality improvement activities, provided care that was more resident centered and had slightly higher staff satisfaction compared to homes that did not volunteer for public reporting. There were very few changes over time among participants and non-participants in either QI or public reporting.

Policy Implications: Quality improvement strategies may take a considerable amount of time to realize observable changes in staff engagement and the quality of care provided in LTC homes. There were some indications that the homes who already had supportive QI activities were most likely to join and benefit from the supports of the QI collaborative. This study does not support the effectiveness of quality improvement or public reporting as effective mechanism either to raise overall quality and particularly not to raise quality among under-performing homes.


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