1. Enhancing the Quality and Safety Standards for Older People in Canadian Hospitals Belinda Parke et al. Belinda Parke et al. Enhancing the Quality and Safety Standards for Older People in Canadian Hospitals
is the cohort aged 80 years and over. This group is projected et al. 2008); and discharge processes (Bauer et al. 2009). Even • Statement two: Hospitals ensure that the older person and/ hensiveness of the content associated with the descriptive summa-
to account for 3.3 million people by 2036, thereby quadru- with mounting evidence, there is a lag in moving to consistent or family member and/or caregiver be meaningfully informed ries for each quality and safety standard (see Table 1).
pling the number of centenarians living in Canada (Canadian best practices. and involved in all aspects of care, decision-making and
Institute for Health Information 2011a). Even though older The challenge of providing safe, high-quality, cost-effective policies. Results of the Electronic Survey
adults represent 15% of the current population, by 2036 they healthcare to older adults in hospital is not unique to Canada. All • Statement three: Hospitals ensure processes that are individu- Overall, response rates of 63.6% and 56.5% were achieved for
could account for one quarter of Canadians (Statistics Canada developed countries with an aging demographic are confronted alized to support transition within the hospital and discharge groups one (meeting participants; n = 21/33) and two (non-meeting
2010). with increasing healthcare demands and limited resources. Some home. participants; n = 13/23), respectively. Appendix C (available at
Chronic health conditions become more prevalent with age senior-friendly care programs in Australia (Davy et al. 2009; • Statement four: Hospitals facilitate and support a culture of http://www.longwoods.com/content/23238) shows that experts
and are thought to contribute to increased use of healthcare Ngian et al. 2008), Taiwan (Chiou and Chen 2009) and the respect for older adults. endorsed the standard statements and descriptive summaries. In
services (Canadian Institute for Health Information 2011b; United States (Boltz et al. 2010, 2012; Mezey et al. 2004; Mion • Statement five: Hospitals provide an environment that comparing the groups, we noted that there was greater agree-
Terner et al. 2011). Older adults are three times more likely et al. 2003) have shown promise. Similarly in some Canadian maximizes and protects function. ment in group two than in group one. Where there was differ-
to be hospitalized than the population as a whole, and their provinces, there are initiatives and programs in senior-friendly ence, it was in relation to the placement of topics within the
length of stay in hospital is significantly longer. They account care that are noteworthy (Huang and Larente 2011; Hubert et Using empirical evidence, substantive descriptive summaries standards. For example, several participants noted that family
for one third of all acute care hospitalizations and almost half al. 2004; Parke and Brand 2004; Parke et al. 2012; Stevenson (see Appendix B, available at http://www.longwoods.com/ involvement was absent from standard one, but this topic was
of all hospital days (Canadian Institute for Health Information et al. 2012; Wong et al. 2010b, 2011). Uniting the collective content/23238) and corresponding topics (see Table 1) for each encapsulated in a later standard statement. The greatest discrep-
2012). Older adults are also more likely to receive in-patient care organizational and hospital system experiences of implementing standard statement were written. ancy in agreement was found for standard statement one. In this
when seen in the emergency department (Canadian Institute for senior-friendly hospital innovations across Canadian provincial Phase three, an electronic survey with attendees from phase case, five participants from group one wanted clarity regarding
Health Information 2011a). jurisdictions into one set of national standards is timely. two along with a second group o f experts who did not attend the medication reconciliation, an expanded number and type of
There is growing agreement that, for most older people, round-table meeting, validated the appropriateness and compre- professional interdisciplinary team members, a definition
hospitals provide a difficult if not hazardous healthcare experi- What Canadian Experts Tell Us
ence (Baker et al. 2004; Merten et al. 2013) characterized by In phase one of the project, a series of three workshops engaged
risk, vulnerability and contributory factors that lead to prevent- a network of 177 inter-professional experts, key stakeholders TABLE 1.
Three most important topics for each standard statement as selected by each of the two groups
able adverse outcomes (Lawton et al. 2012; Tingle 2011) and and opinion leaders (see Appendix A at http://www.longwoods.
dissatisfaction (Bridges et al. 2010). Safety considerations com/content/23238). These experts prioritized items within and Standard Statement Topics Priority Topics Priority Topics
that affect older people disproportionately in hospital include across five dimensions: care systems/processes of care; physical per Group 1*† per Group 2*
complications from falls, delirium, malnutrition, dehydration, environment/design; policies, procedures and organizational Statement one
decubitus ulcers and adverse drug effects (Inouye et al. 1993). support; social climate/emotional and behavioural environment; Medication safety, maximizing independent functional ability, optimizing mobility, Maximizing functional ability (79), Maximizing functional ability (39),
The complexity of older adults’ care needs can have a signifi- and ethics in clinical care and research (Liu et al. 2010; Parke fall prevention, delirium, optimize nutrition and hydration, pain assessment optimizing mobility (22), medication safety (21),
cant impact on their recovery and hospital operations as these and Chappell 2010). Priorities identified from the workshops and management, minimize restraints, minimize catheter use, prevent sleep delirium (22) optimizing mobility (17)
deprivation, prevent pressure ulcers, infection control practices, adjusting care
people transition out of hospital (Naylor et al. 2011; Parke and included these: processes related to arrival and departure from approaches for persons with dementia and mental health issues
Chappell 2010). Functional decline during their hospital stay hospital, clinical topics, educational awareness, approaches to
Statement two
is a major problem that is sometimes not readily reversed (Boyd care, organizational leadership and the built environment. This Older adult and family involvement in decision-making, respecting the contents of Older adult and family involvement Older adult and family involvement
et al. 2008; Covinsky et al. 2003; Creditor 1993; Gill et al. information informed phase two, the national round-table the advance directive, ensure culturally appropriate care in decision-making (103), respecting in decision-making (63), respecting
2010; Landefeld 2006; Sager et al. 1996). Associated system meeting held in April 2011. the contents of the advance the contents of the advance
outcomes from functional losses include increases in length of In phase two, thirty-four Canadian experts knowledgeable directive (55), ensure culturally directive (31), ensure culturally
stay, community care requirements, hospital readmissions and in hospital systems and the issues older people face in hospital appropriate care (31) appropriate care (23)
the likelihood of nursing home placement (Kortebein 2009; participated in a round-table meeting (following Ethical Board Statement three
Landefeld 2006; Rudberg et al. 1996). review and approval). Representation from across Canada System linkages between hospital and community, process for transfer of System linkages between hospital Proactive and appropriate planning
accountability between services, proactive and appropriate planning for and community (81), proactive and for community support or discharge
There is also evidence that compliance with medical quality included professional groups and key stakeholder organizations
community support or discharge location appropriate location (45), system linkages
indicators such as Assessing Care of Vulnerable Elders (ACOVE) (hospitals [acute and post-acute], long-term care and commu- between hospital and community
for hospital care is significantly lower than compliance with nity care), as well as experts in knowledge transfer and exchange, (37), process for transfer of
quality indicators for general adult hospital care (Arora et al. and not-for-profit organizations that serve older people and accountability between services (35)
2007). This care gap is recognized in numerous health regions in caregivers. Statement four
Canada, which is illustrated in a recent self-assessment process To generate ideas relevant to drafting quality standard state- Respect older person’s rights; eliminate ageist policies, procedures and staff Planning for community support or Eliminate ageist policies, procedures
undertaken by Ontario hospitals (Wong et al. 2011). Factors ments, experts attending the round-table meeting deliberated attitudes; provide staff education to promote age-sensitive care; elder abuse discharge location (59), process for and staff attitudes (37), respect older
relevant to quality hospitalization for older people include the on the question, what standards would improve the quality transfer of accountability between person’s rights (36), provide staff
services (49) education to promote age-sensitive
documentation of baseline functional status (Wakefield and and safety of older adults in Canadian hospitals? This meeting care (32)
Holman 2007); early mobilization (Brown et al. 2004; Mundy resulted in five draft, overarching standard statements:
Statement five
et al. 2003); cognitive screening (Parke et al. 2011; Wong et al.
Ensure purchasing decisions and alterations to the physical environment account n/a n/a
2010); delirium prevention (Rudolph et al. 2011); falls preven- • Statement one: Hospitals provide quality care to maintain and/or for the physical, cognitive and functional needs of older people
tion (Oliver 2007); the promotion of continence (Ostaszkiewicz enhance the well-being and the functional status of older adults.
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.
†
26 Healthcare Quarterly Vol.16 No.1 2013 Healthcare Quarterly Vol.16 No.1 2013 27