September 24, 2018


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Canadian Implementation Network Survey
Gauging Interest in Establishing a National Network

Stemming from the growing global interest on the importance of effective evidence implementation, Canadian implementation experts are exploring the value of establishing a network and what purpose it may serve here in Canada. If you or any of your colleagues are interested and want to contribute, please follow the link below to find out more information and to fill out a brief survey.

New resource by Dr Anita Kothari
Integrated Knowledge Translation for Implementation Science

Anita Kothari highlights learnings, tensions and challenges from a Canadian approach designed to foster working with stakeholders to promote the implementation of research findings – a critical element of many implementation and improvement projects.

New article by Dr. Shannon Scott
The sustainability of Lean in pediatric healthcare: a realist review.
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R. Flynn, A. S. Newton, T. Rotter, et al.
Syst Rev 2018 Sep 11;7(1):137-018-0800-z
Lean is a quality improvement management system from the Toyota manufacturing industry. Since the early 2000’s, Lean has been used as an intervention for healthcare improvement. Lean is intended to reduce costs and improve customer value through continuous improvement. Despite its extensive use, the contextual factors and mechanisms that influence the sustainability of Lean in healthcare have not been well studied. Realist synthesis is one approach to “unpack” the causal explanations of how and why Lean is sustained or not in healthcare. We conducted a realist synthesis using the context (C) + mechanim (M) = outcome (O) heuristic, to further develop and refine an initial program theory with seven CMO hypotheses, on the sustainability of Lean efforts across pediatric healthcare. METHODS: Our search strategy was multi-pronged, iterative, and purposeful in nature, consisting of database, gray literature, and contact with three healthcare organizations known for Lean implementation. We included primary research studies, published and unpublished case studies or reports, if they included Lean implementation with a pediatric focus and sustainability outcome. We used the Normalization Process Theory and the National Health Services Sustainability Model, an operational definition for Lean and a comprehensive definition for sustainability as guidance for data extraction and analysis. Our initial program theory with was refined using a blend of abductive and retroductive analytical processes. RESULTS: We identified six published primary research studies, two published quality improvement case studies, and three unpublished quality improvement case reports. Five CMO hypotheses from our initial program theory were substantially supported after synthesis, “sense-making and value congruency,” “staff engagement and empowerment,” and the “ripple effect” or causal pathway between Lean implementation outcomes that served as facilitating or hindering contexts for sustainability. Overall, there was variation with the conceptualization and measurement of sustainability. CONCLUSIONS: This study is the first to examine Lean sustainability in pediatric healthcare using realist methods. Future research should examine whether the predictors of implementation are the same or different to sustainability and evaluate the underlying mechanisms that influence the sustainability of Lean. There is also a need for research to develop and test conceptual models and frameworks on sustainability. SYSTEMATIC REVIEW REGISTRATION: PROSPERO-CRD42015032252 .

New article by Dr. Kate Gerrish and Judith Palfreyman
Learning from a clinical microsystems quality improvement initiative to promote integrated care across a falls care pathway
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K. Gerrish, C. Keen and J. Palfreyman.
Prim Health Care Res Dev 2018 Aug 23:1-6
To identify learning from a clinical microsystems (CMS) quality improvement initiative to develop a more integrated service across a falls care pathway spanning community and hospital services. BACKGROUND: Falls present a major challenge to healthcare providers internationally as populations age. A review of the falls care pathway in Sheffield, United Kingdom, identified that pathway implementation was constrained by inconsistent co-ordination and integration at the hospital-community interface.ApproachThe initiative utilised the CMS quality improvement approach and comprised three phases. Phase 1 focussed on developing a climate for change through engaging stakeholders across the existing pathway and coaching frontline teams operating as microsystems in quality improvement. Phase 2 involved initiating change by working at the mesosystem level to identify priorities for improvement and undertake tests of change. Phase 3 engaged decision makers at the macrosystem level from across the wider pathway in achieving change identified in earlier phases of the initiative.FindingsThe initiative was successful in delivering change in relation to key aspects of the pathway, engaging frontline staff and decision makers from different services within the pathway, and in building quality improvement capability within the workforce. Viewing the pathway as a series of interrelated CMS enabled stakeholders to understand the complex nature of the pathway and to target key areas for change. Particular challenges encountered arose from organisational reconfiguration and cross-boundary working. CONCLUSION: CMS quality improvement methodology may be a useful approach to promoting integration across a care pathway. Using a CMS approach contributed towards clinical and professional integration of some aspects of the service. Recognition of the pathway operating at meso- and macrosystem levels fostered wider stakeholder engagement with the potential of improving integration of care across a range of health and care providers involved in the pathway.

 

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Grants & Awards

Alzheimer Society of Canada 2019 Research Competition

DEADLINE 9 November 2019
Funding available: Doctoral $22,000/yr, Post-Doctoral $41,500/yr, New Investigator $75,000/yr, and Research Grants $75,000/yr.

 

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Publications

KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Practice and Methodology
Aging

KT

Facilitating implementation of the Decision-Making Capacity Assessment (DMCA) Model: senior leadership perspectives on the use of the National Implementation Research Network (NIRN) Model and frameworks.
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S. Bremault-Phillips, A. Pike, L. Charles, et al.
BMC Res Notes 2018 Aug 23;11(1):607-018-3714-x
Dementia and other chronic conditions can compromise a person’s ability to make independent personal and financial decisions. In the wake of an ageing population and rising incidence of chronic conditions, the number of persons who may require Decision-Making Capacity Assessments (DMCAs) is likely to increase. Legislation (e.g., Trusteeship, Guardianship, Medical Assistance in Dying) also necessitates that DMCAs adhere to legislative requirements and principles. An intentional, explicit and systematic means of implementing standardized DMCA best-practices is advisable. This single exploratory case-study examined the perspectives of senior leaders and clinical experts regarding the utility of using the National Implementation Research Network (NIRN) Model to facilitate implementation, spread and sustainability of a DMCA Model. Participants learned about the NIRN Model and discussed its application during working and focus groups, all of which were audio-recorded, transcribed, and analyzed using thematic analysis. RESULTS: Participants found that the NIRN Model aligned well with the DMCA Model, and offered utility to support implementation, spread and sustainability of DMCA best-practices. Participants also noted barriers related to its language, inability to capture personal change, resource requirements, and complexity. It was recommended that a NIRN-informed DMCA-specific implementation framework and toolkit be developed and NIRN-champions be available to guide implementation.

Using Normalization Process Theory to Evaluate the Implementation of Montessori-based Volunteer Visits Within a Canadian
Long-term Care Home.

Non UofA Access

P. V. Hunter, L. Thorpe, C. Hounjet and T. Hadjistavropoulos.
Gerontologist 2018 Sep 14
Montessori-based interventions (MBIs) have potential to improve the life quality of long-term care residents with dementia. In this study, we aimed to understand the processes by which staff integrated a volunteer-led MBI into practice within a special dementia care unit, and to explore staff members ‘ perceptions of associated strengths and limitations. Research Design and Methods: This study relied on a qualitative descriptive design. Following a 3-month period of volunteer involvement, we conducted 21 interviews with staff members to document perceptions of the new program and subjected interview transcripts to qualitative content analysis, guided by normalization process theory. Results: During the implementation of the volunteer-led MBI, staff members developed a shared understanding of the intervention, a sense of commitment, practical ways to support the intervention, and opinions about the value of the residents. Overall, we found that the volunteer-led MBI was quickly and successfully integrated into practice and was perceived to support both residents and staff members in meaningful ways. Nevertheless, some limitations were also identified. Discussion and Implications: Volunteer-delivered MBIs are a useful adjunct to practice within a special dementia care unit. This article raises attention to some strengths and limitations associated with this approach.

The triple helix and user-driven centers of competence: Towards a new organizational model?

Meyer M, Grant K, Kuusisto J.
World Scientific Reference On Innovation: World Scientific Publishing Co. Pte Ltd; 2018. p. 113-128
This chapter presents findings from a comparative study of user-driven competence centers and business-led research networks across a range of countries. More specifically, it explores the extent to which the centers studied pointing to potentially new organizational forms. We analyze the centers and networks drawing on the Triple Helix framework which differentiates knowledge, consensus, and innovation spaces. We find that a small number of more recent centers may have the potential to create innovation environments that integrate activities across the three Triple Helix spaces.

A review of the role of nurse leadership in promoting and sustaining evidence-based practice.
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M. Bianchi, A. Bagnasco, V. Bressan, et al.
J Nurs Manag 2018 Sep 10
This integrative review aims to explore how nursing leadership influences evidence-based practice in contemporary health care settings. BACKGROUND: Although managers and environmental ward culture have long been identified as being among the main barriers to evidence-based practice, there is little overall conceptualization and understanding of the specific role of nurse leaders in directly influencing and supporting this. EVALUATION: The team carried out an integrative literature review (n = 28) utilizing PubMed, CINAHL and the Cochrane Library (2006-2016). KEY ISSUES: The key role of leadership, the methodology used, and understanding and addressing barriers to or facilitators of the implementation of evidence-based practice emerged as key issues. CONCLUSION: Nurse managers have a particular influential role on the implementation of evidence-based practice in terms of providing a supportive culture and environment. For this they need to have an underlying knowledge but also to be aware of and address barriers to implementation, and understand the key role of nurse managers in creating and supporting the optimum environment. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers need to facilitate and enhance nurses’ use of evidence-based practice. Both managers and nurses need to have the necessary academic preparation, support and resources required for practising using an evidence base.

Enhancing policy implementation to improve healthcare practices: The role and strategies of hybrid national-local support structures
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E. Granstrom, J. Hansson, V. Sparring, M. Brommels and M. E. Nystrom.
Int J Health Plann Manage 2018 Aug 9
In this study, we followed a national initiative to enhance the use of quality indicators gathered in national quality registries (NQRs) for improvement of clinical practices in Swedish healthcare, more specifically by investigating the support strategies of regional support centers with national and local missions. The aim was to increase knowledge on the role, challenges, and strategies of support structures with mixed and complex missions in the healthcare system. METHODS: Documents and 25 semistructured interviews with staff at 6 regional support centers, ie, quality registry centers, formed this multiple case study. Data were analyzed using conventional content analysis. RESULTS: The centers’ strategies varied from developing the NQRs to become more suitable for improvement to supporting healthcare’s use of NQRs, from the use of task to process-oriented support strategies, and from taking on national responsibilities to responding to local initiatives. All quality registry centers engaged in initiatives inspired by the Breakthrough Series approach. Some used preexisting change concepts or collaborated with local development units. A main challenge was to overcome a lack of formal mandate to act in the healthcare organizations they served. CONCLUSIONS: Support functions with mixed and complex missions have to use a variation of strategies to reach relevant actors and achieve changes. This study provides valuable input for policy and decision-makers on the support strategies used and challenges of support functions with complex missions situated in-between national and local levels of the healthcare system, here denoted hybrid national-local support structures.

Population Health: The Translation of Research to Policy

Robert Wood Johnson Foundation Health & Society Scholars, edited by Robert A. Hiatt Sept 2018
The Robert Wood Johnson Foundation Health & Society Scholars (HSS) program was designed to build the nation’s capacity for research, leadership, and policy change, while addressing the multiple determinants of population health. One of its goals was to produce a cadre of scientific leaders who could contribute to this research and spearhead action to improve overall population health and eliminate health inequities. This report takes a case study approach using six diverse examples of science to policy translation generated by Scholars in the HSS program from 2003 to 2016. Because the HSS program was discontinued in 2017, the Milbank Memorial Fund published these case studies in the hope that many audiences, including students, would use them to learn about the connection between research, decision making, and policy.

 

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Health Care Administration and Organization

The Meanings of the Unlicensed Assistive Personnel Role in Nursing Homes: A Triadic Job Analysis Perspective.
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T. Band-Winterstein, I. I. Doron, L. Zisberg, K. Shulyaev and A. Zisberg.
J Nurs Manag 2018 Sep 12
This study described and analyzed how older residents, professional nurses, and unlicensed assistive personnel (UAP) perceive the meaning and content of the job carried out by UAP in nursing homes (NHs), as a basis for job analysis. BACKGROUND: Increasing numbers of NH beds and financial restraints have led UAP to become a significant part of the long-term-care service system, yet in numerous contexts the UAP job remains misunderstood and underexplored. METHOD: The research employed a qualitative-phenomenological methodology. Data were collected from 50 semi-structured in-depth interviews with 18 UAP, 15 certified nurses, and 17 older NH residents. RESULTS: We identified six content dimensions in the participants’ descriptions regarding the meanings of the roles and duties of the UAP: (1) care for the physical environment, (2) bodily-physical care, (3) psycho-social interpersonal care, (4) professional hierarchy and boundaries, (5) UAP personal traits, and (6) UAP skills, or the need for training and professional education. CONCLUSIONS: Future job definition and formal regulation of UAP should place more focus on the personal characteristics of UAP, as a prerequisite to enter the job. IMPLICATIONS FOR NURSING MANAGEMENT: The study takes a step forward toward better defining the professional boundaries delineating the meaning of the UAP position.

Supervisory relationships in long-term care facilities: A comparative case study of two facilities using complexity science.
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A. Escrig-Pinol, K. N. Corazzini, M. B. Blodgett, C. H. Chu and K. S. McGilton.
J Nurs Manag 2018 Sep 10
This study aims to understand the factors that contribute to supervisory nurse performance in long-term care facilities. BACKGROUND: Long-term care facilities have been faced with staffing challenges and increasing resident care needs, resulting in suboptimal quality of care. Nursing leadership has been identified as a key factor in the provision of high-quality care. METHODS: The comparative case study employed a complexity science framework to compare two facilities. The facilities were chosen based on the level of perceived supervisory support staff received from their supervisors, and 10 participants were recruited from each facility at various levels of management and staff (n = 20). Data were collected in 2015 using semi-structured interviews. FINDINGS: The quality and quantity of supervisory relationships was central to shaping the effectiveness of the supervision. Effective supervisory support was characterized by frequent and high-quality supervisor-staff interactions. Effective nurse supervisors acknowledged self-organisation as beneficial, and worked in environments that encouraged fluidity of roles. CONCLUSIONS: The findings suggest that effective nurse supervisors and supervisory support fosters improved work environments and the staff’s ability to respond to residents’ needs in a timely, effective and compassionate manner. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers who provide effective supervisory support can improve the quality of care provided to their residents.

Interpersonal Conflict and Organizational Commitment Among Licensed Practical Nurses.
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C. N. Loes and M. B. Tobin.
Health Care Manag (Frederick) 2018 Apr/Jun;37(2):175-182
The shortage of nursing professionals in the United States is unquestionable. This shortage, which is predicted to continue into the foreseeable future, is a particularly salient problem within the nursing profession. This is especially true for long-term care facility administrators who not only are faced with the challenge of increasing numbers of aging residents but also regularly struggle with turnover among more cost-effective nursing staff, such as licensed practical nurses (LPNs). The primary purpose of this study was to examine whether perceived interpersonal conflict influences organizational commitment among LPNs. To accomplish this, we analyzed responses from 1165 LPNs throughout a Midwestern state who were queried on their perceptions of interpersonal conflict and organizational commitment in their work settings. Considering a wide range of potential confounding influences such as age and years working as an LPN, for example, we found that higher perceived interpersonal conflict was associated with significantly lower levels of organizational commitment. The implications of these findings, along with recommendations for nurse administrators to reduce LPN turnover, are discussed in the article.

How do care staff in residential aged care facilities conceptualise their non-verbal interactions with residents with dementia and what relevance has this for how residents’ preferences and capacity for decision-making are understood?
Non UofA Access

N. Cameron, D. Fetherstonhaugh, M. Bauer and L. Tarzia.
Dementia (London) 2018 Sep 6:1471301218798422
This paper considers the significance of how staff in residential aged care facilities interpret the non-verbal communication and behaviour of residents vis-a-vis their assessments of residents’ preferences and ability to participate in decision-making. It highlights the risks associated with staff members’ failure to interpret residents’ non-verbal communication and behaviour with reference to residents’ backgrounds and prior experiences. It also considers how non-verbal communication implemented by staff may impact residents’ emotional state and, as a consequence, decision-making abilities. Drawing on interview data with aged care staff from Queensland and Victoria, it demonstrates that care staff in residential facilities appear to rely heavily on non-verbal signals in assessing the decision-making capacity and preferences of residents with dementia. It also indicates that many staff fail to consider residents’ non-verbal communication and behaviour with due consideration of residents’ individual histories.

Perceived barriers and facilitators in providing palliative care for people with severe dementia: the healthcare professionals’ experiences.
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M. H. Midtbust, R. E. Alnes, E. Gjengedal and E. Lykkeslet.
BMC Health Serv Res 2018 Sep 12;18(1):709-018-3515-x
Dementia has become a major public health issue worldwide due to its rapidly increasing prevalence and an increasing number of dementia-related deaths in long-term care facilities. The aim of this study was to examine health professionals’ experiences of potential barriers and facilitators in providing palliative care for people with severe dementia in long-term care facilities. METHODS: This was a qualitative descriptive study. The data were collected from four focus groups and 20 individual in-depth interviews with healthcare professionals from four Norwegian nursing homes. The data were analysed by thematic text analysis, as described by Braun and Clarke. RESULTS: The major findings indicate that healthcare professionals experience a lack of continuity as the main barrier to facilitating palliative care. Time pressure and increased efficiency requirements especially affect the weakest and bedridden residents with dementia. The healthcare professionals feel conflicted between wanting to spend more time caring for each individual resident and feeling pressure to help everyone. Although resources are scarce, dying residents are always given priority by healthcare professionals, either by the hiring of extra personnel or the reorganization of tasks in a way that facilitates someone staying with the terminal resident. Advanced care planning was highlighted as a facilitator in providing palliative care, but the extensive use of temporary staff among nurses and doctors and the relocation between the sheltered and long-term wards threaten the continuity in planning and providing palliative care. CONCLUSIONS: The findings indicate that healthcare professionals experienced several structural barriers that prevented the provision of palliative care to people with severe dementia in long-term care facilities. Increasing demands for economic rationality lead to a lack of continuity of care. Organizational changes, such as measures to increase the competence and the proportion of permanent employees and the prevention of burdensome end-of-life transitions, should be implemented to improve continuity and quality of care.

Care professional’s experiences about using Liverpool Care Pathway in end-of-life care in residential care homes.
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S. Andersson, O. Lindqvist, C. J. Furst and M. Brannstrom.
Scand J Caring Sci 2018 Mar;32(1):299-308
Residential care homes (RCHs) play an important role in end-of-life care, being the most common place of death for elderly people in several European countries. Care pathways such as the Liverpool Care Pathway for the Dying Patient (LCP) are used to improve and ensure quality care at the end of life. There is a lack of scientific evidence supporting the use of care pathways. DESIGN: A descriptive qualitative study. OBJECTIVE: The aim was to describe care professionals’ experiences of using the Liverpool Care Pathway for the Dying Patient in the care of dying residents in residential care homes. METHODS: Five focus group interviews and two individual interviews with enrolled nurses (n = 10), Registered Nurses (n = 9) and general practitioners (n = 5) were carried out and analysed using qualitative content analysis. RESULTS: Care professionals expressed that they became confident through a shared approach to care, were supported to tailor the care according to the residents’ individual needs, were supported to involve family members in decision-making and care and became more aware of the care environment. CONCLUSION: The results of this study indicate that the LCP might be a useful tool for care professionals in improving end-of-life care in RCHs through increased attention to the goals of care, the individual needs of residents and family involvement.

The impact of facility ownership on nurses’ and care workers’ perceptions of missed care in Australian residential aged care
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Julie Henderson, Ian Blackman, Eileen Willis, et al.
Aust J Soc Issues 2018 08/19; 2018/09;0(0)
The Australian government has reduced restrictions on ownership of residential aged care facilities (RACF) as part of aged care reform enabling the growth of private-for-profit ownership. This study explores the impact of private-for-profit ownership through comparison of perceptions of the volume of missed care in government, private-not-profit and for-profit RACF in Australia. Data were collected through development and administration of a MISSCARE survey to 3,206 nurses and personal care workers (PCW) working in RACF and hospitals providing aged care services. Employees working within government owned facilities reported levels of missed care that are significantly lower than privately owned facilities on six activities: moving patients who cannot walk; assisting residents? toileting within 5Â min of request; assisting resident mouth care; assessing skin integrity; answering call bells within 5Â min and wound care. Staffing levels were identified as the most common reason for missed care across all settings. Of the 27 factors identified as causing missed care, government employees reported significantly lower scores for 16 items. Further research is needed on the impact of facility ownership upon capacity of nurses and personal care workers to deliver care.

Continuing care in rural Alberta: A scoping review
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Julia Brassolotto, Carly-Ann Haney, Lars Hallstrom and David Scott.
The Canadian Geographer / Le Geographe canadien 2018 09/13; 2018/09
Across Canada the demand for continuing care services is increasing. However, little is known about the implications this has for rural communities. This scoping review identifies several key themes in the literature related to continuing care in Alberta. These include contextual factors, quality assurance and improvement, and workforce issues. We identify the ways in which rural dynamics are included in, or omitted from, this literature and recommend areas for future research on rural continuing care provision. Further research on residential care services in rural communities should work towards bridging the rural health, academic, and organizational literature on continuing care. This synthesis will help to position rurality as a determinant of health and to situate continuing care services in specific rural settings.

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Health Care Innovation and Quality Assurance

The OptimaMed intervention to reduce inappropriate medications in nursing home residents with severe dementia: results from a quasi-experimental feasibility pilot study.
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M. Wilchesky, G. Mueller, M. Morin, et al.
BMC Geriatr 2018 Sep 4;18(1):204-018-0895-z
Medication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either “generally”, “sometimes” or “exceptionally” appropriate for NH residents with severe dementia. METHODS: A quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents’ families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran’s-Q tests. RESULTS: The KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a “sometimes appropriate” medication post-intervention were 0.81 (95% CI: 0.71-0.92) and 0.83 (95% CI: 0.74-0.94), respectively. CONCLUSION: A simple KE intervention using a medication review guidance tool categorizing medications as being either “generally”, “sometimes” or “exceptionally” appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention.

Exploring role clarity in interorganizational spread and scale-up initiatives: the ‘INSPIRED’ COPD collaborative.
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O. Ly, S. L. Sibbald, J. Y. Verma and G. M. Rocker.
BMC Health Serv Res 2018 Sep 3;18(1):680-018-3474-2
Role clarification is consistently documented as a challenging process for inter professional healthcare teams, despite being a core tenet of interprofessional collaboration. This paper explores the role clarification process in two previously unexplored contexts: i) in the dissemination phase of a quality improvement (QI) program, and ii) as part of interorganizational partnerships for the care of chronic disease patients. METHODS: A secondary analysis using asynchronous purposive coding was conducted on an innovative pan-Canadian Chronic Obstructive Pulmonary Disease QI program. RESULTS: Our study reveals that the iterative structure of QI initiatives in the spread phase can offer numerous unique benefits to role clarification, with the potential challenge of time commitment. In addition, the role clarification process within interorganizational partnerships proved to be relatively well-structured, characterized by three phases: relationship conceptualization or early contact, familiarization, and finally, role division. Common strategies in the last stage included the establishment of working groups and new information-sharing networks. CONCLUSION: This article characterizes some ways in which providers and organizational partners negotiate their roles in a changing professional environment. As the movement towards integrated care continues, issues of role clarity are assuming increasing importance in healthcare contexts, and understanding role dynamics can provide valuable insight into the optimization of QI initiatives.

The relationship between nursing home quality and costs: Evidence from the VA.
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K. Carey, S. Zhao, A. L. Snow and C. W. Hartmann.
PLoS One 2018 Sep 19;13(9):e0203764
Ensuring quality of care in nursing homes is a public health priority, yet how nursing home quality relates to cost is not well understood. This paper addresses this relationship for 132 VA community living centers (nursing homes), for fiscal years 2014 and 2015. We estimated cost models using the VA Decision Support System which tracks total direct costs and nursing direct costs for individual resident segments of care. We summed residents’ total costs and nursing costs to the community living center level for each year. Annual facility costs then were regressed on quality of care measured with composite scores based on 13 distinct adverse events. Results indicated that higher quality was associated with higher predicted cost. However, we did not find evidence that higher costs were driven by high nurse staffing levels.

Nursing home adoption of the National Healthcare Safety Network Long-term Care Facility Component.
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A. W. Dick, J. M. Bell, N. D. Stone, A. M. Chastain, M. Sorbero and P. W. Stone.
Am J Infect Control 2018 Sep 15
Health care-associated infections pose a significant problem in nursing homes (NHs). The Long-term Care Facility Component of the National Healthcare Safety Network (NHSN) was launched in 2012, and since then, enrollment of NHs into NHSN has been deemed a national priority. Our goal was to understand the characteristics of NHs reporting to the NHSN compared to other NHs across the country. METHODS: To meet this goal, we quantified the characteristics of NHs by NHSN enrollment status and reporting consistency using the Certification and Survey Provider Enhanced Reporting (CASPER) data linked to NHSN enrollment and reporting data. RESULTS: Of the 16,081 NHs in our sample, 262 (or 1.6% of NHs) had enrolled in NHSN by the end of 2015; these early adopting facilities were more likely to be for-profit and had a higher percentage of Medicare residents. By the end of 2016, enrollment expanded by more than 5-fold to 1,956 facilities (or 12.2% of NHs). In our analysis, the characteristics of those later adopting NHs were more similar to NHs nationally than the early adopters. Specifically, bed size and hospital-based facilities were related to both early and late adoption of NHSN. CONCLUSIONS: The types of NHs that have enrolled in NHSN have changed substantially since the program began. The increased enrollment was likely due to the Centers for Medicare & Medicaid (CMS)-funded “C. difficile Infection (CDI) Reporting and Reduction Project” that incentivized Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) to support NH enrollment and participation in NHSN. Further understanding of a facility’s ability to enroll in and maintain reporting to NHSN, and how this relates to infection prevention staffing and infrastructure in NHs and infection rates among NH residents, is needed.

Development of the Care Environment Scale-Long-Term Care.
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M. Boltz, K. H. Lee, J. Shuluk and M. Secic.
Clin Nurs Res 2018 Sep 18:1054773818801485
A critical dimension of Quality Assurance and Performance Improvement (QAPI) activity in long-term care is an analysis of the care environment, that is, the way care and services are organized. The purpose of this study was to develop and pilot test a psychometrically sound tool that long-term care staff could use to assess the care environment and guide performance improvement activity. Focus groups with 57 interdisciplinary participants in five nursing homes developed initial items, with excellent content validity (item content validity index = 1.0) evaluated by an expert panel. Pilot testing of internal consistency of the Care Environment Scale-Long-Term Care (CES-LTC) was conducted in a web-based administration of the items by 425 interdisciplinary staff members in 30 nursing homes and four assisted living facilities. The CES-LTC is internally consistent (Cronbach’s alpha = .90) and accounts for approximately 71.6% of the total variance. The three factors extracted from the exploratory factor analysis are Institutional Values ( k = 6), Access to Resources ( k = 10), and Person-Centered Approaches ( k = 12). Intrarater reliability in a subsample of 66 registered nurses revealed good test-retest results (overall intraclass correlation coefficients [ICC] = 0.78). The CES-LTC appears to be a valid and reliable measure of staff perceptions of the care environment and may be used to actively engage staff in QAPI endeavors including root cause analyses and improvement activity.

 

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Research Practice and Methodology

Perspectives on involvement in the peer-review process: surveys of patient and public reviewers at two journals.
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S. Schroter, A. Price, E. Flemyng, et al.
BMJ Open 2018 Sep 5;8(9):e023357-2018-023357
In 2014/2015, The BMJ and Research Involvement and Engagement (RIE) became the first journals to routinely include patients and the public in the peer review process of journal articles. This survey explores the perspectives and early experiences of these reviewers. DESIGN: A cross-sectional survey. SETTING AND PARTICIPANTS: Patient and public reviewers for The BMJ and RIE who have been invited to review. RESULTS: The response rate was 69% (157/227) for those who had previously reviewed and 31% (67/217) for those who had not yet reviewed. Reviewers described being motivated to review by the opportunity to include the patient voice in the research process, influence the quality of the biomedical literature and ensure it meets the needs of patients. Of the 157 who had reviewed, 127 (81%) would recommend being a reviewer to other patients and carers. 144 (92%) thought more journals should adopt patient and public review. Few reviewers (16/224, 7%) reported concerns about doing open review. Annual acknowledgement on the journals’ websites was welcomed as was free access to journal information. Participants were keen to have access to more online resources and training to improve their reviewing skills. Suggestions on how to improve the reviewing experience included: allowing more time to review; better and more frequent communication; a more user-friendly process; improving guidance on how to review including videos; improving the matching of papers to reviewers’ experience; providing more varied sample reviews and brief feedback on the usefulness of reviews; developing a sense of community among reviewers; and publicising of the contribution that patient and public review brings. CONCLUSIONS: Patient and public reviewers shared practical ideas to improve the reviewing experience and these will be reviewed to enhance the guidance and support given to them.

Data Sanity: A Quantum Leap to Unprecedented Results
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Balestracci, Davis.
Englewood, CO: Medical Group Management Association, Second edition.
Forget everything you’ve learned in any “statistics” courses you’ve ever attended. If you are involved in quality in any of the healthcare fields, the second edition of Data Sanity is a must-read, and should be well-tabbed and dog-eared in a prominent place in your reference library. From the forward (written by no less a healthcare quality luminary than Dr. Donald Berwick) to the appendices, the work is packed with knowledge gleaned from Davis’ long experience in the healthcare field and includes many examples from that field that help drive the concepts home. If you are new to quality in the healthcare field, this book should be on your shelf as a go-to reference for any of the concepts you will be learning

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Aging

Agitation and Aggression Are 2 Different Syndromes in Persons With Dementia.
Non UofA Access

L. Volicer and E. Galik.
J Am Med Dir Assoc 2018 Sep 6.
Behavioral and psychological symptoms of dementia are very common, and a recent study found that they occur in up to 90% of people living in residential care facilities. These symptoms are often more disturbing than cognitive impairment and are associated with increased healthcare use, earlier institutionalization, excess morbidity and mortality, and greater caregiver distress and depression.3 Development of strategies for the effective management of this problem is hindered by confusing terminology.

Voluntary stopping of eating and drinking (VSED) as an unknown challenge in a long-term care institution: an embedded single case study.
Non UofA Access

N. Saladin, W. Schnepp and A. Fringer.
BMC Nurs 2018 Sep 1;17:39-018-0309-8. eCollection 2018
Chronically ill persons experience conditions of life that can become unbearable, resulting in the wish to end their life prematurely. Relatives confronted with this wish experience ambivalence between loyalty to the person’s desire to die and the fear of losing this person. Caring for a person during the premature dying process can be morally challenging for nurses. One way to end one’s life prematurely is Voluntary Stopping of Eating and Drinking (VSED). Methods: This embedded single case study explored the experiences of registered nurses (embedded units of analysis: ward manager, nursing manager, nursing expert) and relatives who accompanied a 49-year-old woman suffering from multiple sclerosis during VSED in a Swiss long-term care institution (main unit of analysis). By means of a within-analysis, we performed an in-depth analysis of every embedded unit of analysis and elaborated a central phenomenon for each unit. Afterwards, we searched for common patterns in a cross-analysis of the embedded units of analysis in order to develop a central model. Results: The following central concept emerged from cross-analysis of the embedded units of analysis: As a way of ending one’s life prematurely, VSED represents an unfamiliar challenge to nurses and relatives in the field of tension between one’s personal attitude and the agents’ concerns, fears and uncertainties. Particularly significant is the personal attitude, influenced on the one hand by one’s own experiences, prior knowledge, role and faith, on the other hand by the VSED-performing person’s age, disease and deliberate communication of the decision. Depending on the intention of VSED as either suicide or natural dying, an accepting or dismissing attitude evolves on an institutional and personal level. Conclusions: To deal professionally with VSED in an institution, it is necessary to develop an attitude on the institutional and personal level. Educational measures and quality controls are required to ensure that VSED systematically becomes an option to hasten death. As VSED is a complex phenomenon, it is necessary to include palliative care in practice development early on and comprehensively. There is a high need of further research on this topic. Particularly, qualitative studies and hypothesis-testing approaches are required.

An Old Challenge with New Promises: A Systematic Review on Comprehensive Geriatric Assessment in Long-Term Care Facilities.
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F. Panza, V. Solfrizzi, M. Lozupone, et al.
Rejuvenation Res 2018 Feb;21(1):3-14
Comprehensive geriatric assessment (CGA) is a multidimensional and multidisciplinary diagnostic process focused on determining the clinical profile, pathological risk, residual skills, short- and long-term prognosis, and personalized therapeutic and care plan of the functionally compromised and frail older subjects. Previous evidence suggested that the effectiveness of CGA programs may be influenced by settings where the CGA is performed [i.e., hospital, posthospital discharge/long-term care facilities (LTCFs), or community/home] as well as the specific clinical conditions of older frail individuals. In this scenario, CGA and quality of care in LTCFs have been a challenge for decades. In the present article, we systematically reviewed evidence from the last three decades of clinical research devoted to systematic implementation of CGA programs in LTCFs, that is, nursing homes, care homes, residential homes, and rehabilitation facilities. In the United States, all LTC residents must undergo a CGA on a regular basis on admission to a facility, prompting the development of the Resident Assessment Instrument (RAI) Minimum Data Set, a specific CGA-based assessment tool in this population. In the LTCF setting, the present reviewed evidence suggested that most complex older subjects may benefit from a CGA in terms of improved quality of care and reduced hospitalization events and that CGA must be standardized across healthcare settings to promote greater health system integration and coordination. In the LTCF setting, particularly in nursing homes, other new and promising CGA programs have also been proposed to develop rapid screening CGA-based tools to enhance in the future the ability of primary care physicians to recognize and treat geriatric syndromes in this setting. However, at present, the interRAI suite of instruments represented an integrated health information system that has the potential to provide person-centered information transcending healthcare settings.

A Dementia Café as a Bridgehead for Community-Inclusive Care: Qualitative Analysis of Observations by On-the-Job Training Participants in a Dementia Café.
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H. Takechi, Y. Sugihara, H. Matsumoto and H. Yamada.
Dement Geriatr Cogn Disord 2018 Sep 4;46(3-4):128-139
Dementia cafes are becoming widespread as a new approach to dementia care, but their operational procedures and significance have not been adequately studied. METHODS: On-the-job training (OJT) for professionals planning to operate a dementia cafe in the future was conducted in a pioneering dementia cafe in Japan. The reports of OJT trainees’ observations and learning were analyzed qualitatively. RESULTS: Reports could be summarized in up to 9 themes: 2 related to the atmosphere and significance of the cafe, 3 related to the guests, such as people with dementia and their families, and 4 related to the cafe staff. DISCUSSION: The results of the present study identified the elements that make up dementia cafes and their significance and suggest that dementia cafes could be a new type of community resource for dementia care in the future.

They are still the same – family members’ stories about their relatives with dementia disorders as residents in a nursing home.
Non UofA Access

B. S. Cronfalk, A. Norberg and B. M. Ternestedt.
Scand J Caring Sci 2018 Mar;32(1):168-176
In order to better understand the context of suffering from dementia disorders, greater efforts should be made to understand and identify what persons with such disorders experience when living in a nursing home. The aim of this qualitative study was to gain further understanding of how persons with dementia disorders experienced and coped with their changed life situation after being relocated to a nursing home as described by their family members’ perceptions. Qualitative data were collected from ten interviews with family members and evaluated using content analysis. The main findings suggest that residents with dementia disorders largely maintained their personality intact throughout the trajectory of illness as they were able to keep their habits and interests. The local environment of the nursing home and the residents’ relationships to staff were important in order to feel accepted. Four categories were discerned during the analysis: living in limbo; coming to peace; keeping old habits and relationships; and thoughts about impending death. It is reasonable to believe that old habits and interests may be preserved as the embodiment of such habits are deeply rooted and connected to a person’s identity even when going through various changes and transitions in life. Therefore, to be accepted as the person you are requires care and services to specific needs, i.e. person-centeredness. Lack of understanding from staff may therefore have an adverse effect on a person’s self-respect and identity. For that reason, staff needs to reflect on their attitudes and relationships as well as extending their knowledge about how to address sensitive topics such as the residents’ impending death. To achieve this support from managers is pivotal. Future research should focus on support to nursing staff to further knowledge and understanding about the individual changes resident go through near the end of life.

Signs of Dehydration in Nursing Home Residents
Non UofA Access

P. Johnson and R. G. Hahn.
J Am Med Dir Assoc 2018 Sep 15
Although dehydration can affect mental and physical health, there is no clear, consistent, and reproducible diagnostic tool for this condition in older people. We applied multiple methods to detect dehydration with the aim of assessing the value of using urine analysis for this purpose. DESIGN: Nonrandomized cohort study. SETTING AND PARTICIPANTS: Sixty nursing home residents, aged 64-103 (mean 84) years. METHODS: Sampling of morning urine, blood analyses, and clinical examination. A previously validated algorithm summarized the urine specific gravity, osmolality, creatinine, and color to a Fluid Retention Index (FRI). RESULTS: The cut-off for renal fluid conservation consistent with dehydration (FRI >/= 4.0) was reached by 51% of the cohort. No statistically significant linear correlation was found between FRI and serum osmolality (mean 307.5 mOsmol/kg) or plasma sodium (mean 139 mmol/L), but the subjects reported less thirst with increasing FRI scores (linear correlation r = -0.35; P < .03). Clinical examinations of mucous membranes and tongue furrows did not correlate with other markers of dehydration. Subjects with sunken eyes had higher C-reactive protein (P < .02) and lower albumin (P < .002) concentrations in plasma than the others, while impaired skin turgor only correlated with age (P < .04). CONCLUSIONS/IMPLICATIONS: Renal fluid conservation consistent with dehydration was found in half of the nursing home residents, which could partially be accounted for by decreased thirst. Clinical examinations probably reflected the physical status and age more than dehydration. The lack of correlation between the serum osmolality and the FRI, both of which are purported to be gold standards for dehydration, raises questions about whether a gold standard exists.

How Can Autonomy Be Maintained and Informal Care Improved for People With Dementia Living in Residential Care Facilities: A Systematic Literature Review
Non UofA Access

Jogé Boumans, Leonieke van Boekel C., Caroline A. Baan and Katrien G. Luijkx.
Gerontologist 2018 09/15:gny096-gny096
For people with dementia living in residential care facilities, maintaining autonomy and receiving informal care are important. The objective of this review is to understand how caregiving approaches and physical environment, including technologies contribute to the maintenance of autonomy and informal care provision for this population.Research Design and MethodsA literature review of peer-reviewed articles published between January 1995 and July 2017 was performed. Realist logic of analysis was used, involving context, mechanism and outcome configurations.ResultsForty-nine articles were included. The improvement of the relationship between residents and formal/informal caregivers is important. This increases the knowledge (sharing) about the resident and contributes to their autonomy. A social, flexible, and welcoming attitude of the formal caregiver improves the provision of informal care. Specially designed spaces, for instance, therapeutic gardens, create activities for residents that remind them of themselves and contribute to their autonomy. Use of technologies reduces caregiver’s time for primary tasks and therefore enables secondary tasks such as interaction with the residents.Discussion and ImplicationsThe results revealed how residential care facilities could maintain autonomy of their residents and improve informal care delivery using caregiving approaches and the physical environment including technologies. The results are supporting toward each other in maintaining autonomy and also helped in enhancing informal care provision. For residential care facilities that want to maintain the autonomy of their residents and improve informal care delivery, it is important to pay attention to all aspects of living in a residential care facility.

 

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Events

Engagement, Evaluation and Beyond Citation: A fireside chat with NIHR’s Simon Denegri, OBE

Tuesday 2 October 16:00-17:00 MT
Presenter: Simon Denegri
Join Simon and a panel of Can-SOLVE CKD Network members for this exciting event. We will be sharing stories of our experiences with patient-oriented research and discussing topics such as:
-Democratizing health research through patient engagement
-Evaluating patient engagement (why is it important and who is it really for?)
-How can we meaningfully share our research discoveries beyond the covers of traditional research journals?

Documenting Sexually Responsive Behavior: Language has Meaning

Tuesday October 16 10:00-11:00
Presenter: Lori Schindel Martin
This webinar will provide an overview of changes in language used to document staff observations of sexually responsive behaviour. Best practice expectations require descriptive accounts of behavioural episodes as well as a record of observations to determine frequency, duration, risk and patterns of sexual expression. Yet there is no consensus regarding the definition of sexually responsive behaviour, or what distinguishes normal expression from pathology. The webinar will discuss descriptive language that can capture behaviour in a respectful, professional fashion, at the same time providing accurate and detailed information useful for health care teams to interpret behaviour, determine risk levels and develop a care plan. An outline of important behavioural descriptors will be discussed. Participants will have an opportunity to provide important feedback and input into editing responsive behaviour descriptions.

KT Canada: Honouring Practice, Dialogue, and Difference: Taking a Hermeneutic Approach to Knowledge Translation

Thursday 11 October 10:00-11:00 MT
Presenter: Dr. Martha MacLeod
KT Canada has developed and hosted the first, expert-led seminar series dedicated to current and emerging topics in KT. Each session includes a question and answer period (15 minutes per 1 hour session). Sessions are held via WEBEX. To register as an individual or a site, please contact us: StoreyM@smh.ca

 

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Courses

Alzheimer Society: U-First! Training program

1–21 October & 5-25 November
U-First! online is a certificate training program that helps frontline health care professionals to develop a common knowledge base, language, values and approach to caring for people with Alzheimer’s disease and other dementias. Through blended learning, participants will increase their understanding of persons living with dementia and its associated behaviour changes, and enhance their work as a member of the care team in developing individualized support strategies.

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Resources

High-quality care transitions: New guide available for improving continuity of care

The framework for High-Quality Care Transitions is adapted from Burke and colleagues’ work on Ideal Transitions in Care and lists eight factors that contribute to reducing our reliance on hospital care:
Medication safety
Advanced care planning
Self management and health promotion
Coordinated transition planning
Post transition monitoring, management and support
Social and community support
Information completeness, continuity and timeliness
Functional decline prevention
To help individuals and teams in Saskatchewan, we have pulled together a short guide on the best evidence around each domain, related tools and resources, and identified some examples and case studies to provide inspiration for action.

RAND: Improving Patient Safety in Long-Term Care Facilities Module 1: Detecting Change in a Resident’s Condition

This 27-page workbook helps staff learn how to detect changes and identify whether changes in a resident’s condition are important.

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News

Creating a culture where quality improvement is a way of life

Canadian health care lacks culture of innovation

Sharing your research with the public can change minds

Jelly treats for people with dementia

It’s Hard for Doctors to Unlearn Things. That’s Costly for All of Us.

Half of Europe’s clinical trials fail to report results despite EU rule

We like to talk about “a good death.” But how often does this really happen?

Ottawa Public Health preparing for a more diverse senior population

Has ‘Write Daily’ Become Dogma?

New person-centred service being developed by Alzheimer’s Society UK

The challenges of revision

Review on support for early career researchers recommends the development of independence (UK)

Canadian company creates ‘dementia-friendly’ picture books

Westview Care Community: Enhancing experiences in long-term care

What not to do when applying for an academic job

Where should Ontario’s 30,000 new long-term beds go?

Writing a PhD in your second language: seven reasons you’re doing great and five ways to do even better

Getting more health from healthcare: quality improvement must acknowledge patient coproduction—an essay by Paul Batalden

An explosion of openness is about to hit scientific publishing

Almost all Canadians would benefit from palliative care. Only one in seven can actually access it at end-of-life

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Opportunities

Saskatchewan Health Quality Council Chief Executive Officer

Saskatoon SK
DEADLINE: 28 September
HQC’s Chief Executive Officer plays a critical leadership role in the Saskatchewan health care system. Accountable to the HQC Board of Directors, the CEO is responsible for providing leadership, direction, and day-to-day management of the Council’s 43-member team. The CEO supports the Board in shaping the priorities for the organization and is accountable for leading the successful implementation of HQC’s strategic plan. A key role will be ensuring the health system workforce continues to grow in its ability to make and sustain improvements in quality and safety. This will require forging strong relationships, collaborating effectively with key stakeholders, and applying leading practices in the science of quality improvement.

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