Consistency of priorities for quality improvement for nursing homes in Italy and Canada: A comparison of optimization models of resident satisfaction

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HealthPolicy121(2017)862–869

ContentslistsavailableatScienceDirect

Health

Policy

jo u rn al h om ep a ge :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Consistency

of

priorities

for

quality

improvement

for

nursing

homes

in

Italy

and

Canada:

A

comparison

of

optimization

models

of

resident

satisfaction

Sara

Barsanti

a,∗

_,

_Kevin

_Walker

b

_,

_Chiara

_Seghieri

a

_,

_Antonella

_Rosa

a

_,

_Walter

_P.

_Wodchis

c

a_Laboratorio_Management_e_Sanità,_Institute_of_Management,_Scuola_Sant’Anna_di_Pisa,_Italy b_Institute_of_Health_Policy,_Management_&_Evaluation,_University_of_Toronto,_Canada

c_Institute_of_Health_Policy,_Management_&_Evaluation,_University_of_Toronto,_Institute_of_Clinical_Evaluative_Sciences,_Toronto_{Rehabilitation}_Institute,

Canada

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received4October2016

Receivedinrevisedform19May2017 Accepted14June2017 Keywords: Qualityimprovement Processes Willingnesstorecommend Nursinghomes Long-termcare Patientexperience Optimizationtechnique

a

b

s

t

r

a

c

t

Thepaperseekstoidentifyaspectsofcarethatmaybeeasilymodifiedtoyieldadesiredlevelof improve-mentinresidents’overallsatisfactionwithnursinghomes,comparingdataacrossCanadaandItaly.Using astructuredquestionnaire,681and1116nursinghomeresidentsweresurveyedinOntarioin2009and inTuscanyin2012,respectively.Fourteenitemswerecommontothesurveys,includingwillingness torecommend(WTR),whichwasusedasthedependentvariableandmeasureofglobalsatisfaction. Theotheranalogousitemswereenteredascovariatesinordinallogisticregressionmodelspredicting residents’WTRineachjurisdictionseparately.Regressioncoefficientswerethenincorporatedintoa con-strainednonlinearoptimizationproblemselectingthemostefficientcombinationofpredictorsnecessary toincreaseWTRbyasmuchas15%.Staff-relatedaspectsofcarewereselectedfirstintheoptimization modelsofeachjurisdiction.InOntario,toimproveWTRtheprimaryfocusshouldbeonstaffrelationships withresidents,whileinTuscanyitwasthetechnicalskillandknowledgeofstaffthatwasselectedfirst bytheoptimizationmodel.Differentoptimizationsolutionsmightmeanthatthestrategiesrequiredto improveglobalsatisfactioninonejurisdictioncouldbedifferentthanthosefortheotherjurisdictions. Theoptimizationmodelemployedprovidesanovelsolutionforprioritizingareasoffocusforquality improvementfornursinghomes.

1. Introduction

Measuringthe quality of nursing homes (NHs) has become a generally accepted practice, to varying degrees of formality, in many developed nations [1]. In someOECD countries, such asAustralia,England,Finland,theNetherlands,Canada,andthe UnitedStates,NHqualitymeasurementisunderstoodtoinclude subjectiveresidentperceptionsofquality,suchasresidents’ sat-isfaction,whicharecomplementarytothemoreobjectiveclinical indicatorsofquality,suchastheincidenceofpressureulcersor pain,availablefromresidentfunctionalassessmentdata[2,3].The extenttowhich subjectivemeasuresare includedin systematic qualitymeasurement,however,hasbeenlimited[1].

Surveys to measure perceptions and experience typically includevariousitemsrelatingtodifferentdomains(as

combina-∗ Correspondingauthorat:LaboratorioManagementeSanità,Instituteof Man-agement,ScuolaSant’AnnadiPisa,PiazzaMartiridellaLibertà27,56125,Italy.

E-mailaddress:s.barsanti@sssup.it(S.Barsanti).

tionsofitems)suchascomfort,safety,dignity,andinvolvement incareamongothers.Subjectiveresidentperceptionsofquality mayincludeoverallratingsofcareorexperienceor“willingnessto recommend”(WTR).Examiningtherelationshipsbetween over-allratingsandspeciﬁcitemsordomainscanprovidepolicymakers andproviderswithguidanceonwhichdomainsaremostimportant to NH residents and might be prioritizedfor quality improve-ment.Onesuchanalysisfoundthatbeingtreatedwithdignityand staff-residentrelationshipswerethetwodomainsmoststrongly associatedresidents’overallratingsofqualityinOntario,Canada [4].Similarly,of11 domainstested,Buracketal.[5]foundthat beingtreatedwithdignityhadthestrongestassociationwith resi-dent’soverallsatisfactionwithNHsinNewYorkState,concluding thatthisdomainshouldbeastartingpointforNHimprovement. Inmakingthisconclusion,Buracketal.[5]failedtoconsiderhow wellNHswerealreadyperformingoneachofthedomainstested. Infact,beingtreatedwithdignitywastheirhighestrateddomain and,therefore,hadtheleastroomforimprovement.

MoredetailedstudieshaveassessedbothNHperformanceon speciﬁcitemsordomainsalongsideapproachestoidentifying pri-http://dx.doi.org/10.1016/j.healthpol.2017.06.004

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oritiesforimprovement.OnestudyconductedintheNetherlands prioritizeditemsforNH improvementbased onboth their cur-rentratingsandrespondentratingsoftheimportanceofeachitem [7].Theyidentifiedworkingwithacareplanandshareddecision makingasprioritiesforqualityimprovement.Inastudyfromthe UnitedStates,Becker&Kaldenbergidentifiedprioritiesby com-bining(low)performanceand(high)correlationswithwillingness torecommend theNH [6].Althoughbeingtreatedwithdignity, nurses’skillandnurses’friendlinessweremoststronglycorrelated withwillingnesstorecommend,theyidentifiedservicesprovided byaides(itemsincludedinformation provision,assistance with meals,responsetothecallbuttonandresponsivenesstoideas)as thedomainthatshouldbethetoppriorityforqualityimprovement becauseofitshighcorrelationwithwillingnesstorecommendand itslowrating.

Implementation of user-oriented care (stressing personal autonomy, dignity,respect,quality oflife,etc.)is stillan ongo-ingchallengeforelderlycare[8].Asjurisdictionsseektoimprove NHquality,ifthere islimitedlocaldata,policymakersand NH providers may look elsewhere, particularly to territories with broadly similar structural characteristics, for change ideas and opportunities.Theabovecitedstudiessuggestservicesprovided byaidesandcareplanningshouldbeprioritized.However,these prioritiesareonlyvalidif:1)theselecteddomainshavethesame importanceineachjurisdiction,and2)currentperformancelevels onthesedomainsarethesameineachjurisdiction.Itisnotclear whetherthedistinctprioritiesacrosscountries,asidentiﬁedabove, reﬂectdifferencesinthevalueplacedonparticulardomainsin dif-ferentcountriesordifferencesinperformanceofNHsindifferent countries.Tothebestofourknowledge,nostudyhascompared whichdomainsofNHsareassociatedwithoverallmeasuresof sat-isfactionandshouldbeprioritizedforqualityimprovementacross multiplejurisdictions.

Thepurposeofthispaperistoaddressthisgapinknowledge.We proposethatoptimizationtechniques[9–11],thatidentifydomains withlowcurrentperformance,butstrongrelationshipswith over-allperformance ratings,can beappliedtoresident surveydata fromOntario,Canada,andTuscany,Italy, separately,toidentify prioritiesforimprovementinNHs.Weexplorewhethertheitems selectedbyoptimizationmodels,and,therefore,thosedomainson whichhealthcaremanagersandprofessionalsshouldfocustheir improvementstrategies,arethesameinthetwojurisdictions.Such informationcanbetakenintoaccounttoimproveserviceby target-ingandprioritizingthoseimportant,butlowperforming,domains [12].

2. Methods

2.1. Studysetting

Tuscany(Italy)andOntario(Canada)wereselectedasthe set-tingsforthisstudybecauseNHsinthesejurisdictionshavemany similaritiesandbecausetheybothhaveastronginterestinhealth carequalitymeasurement.Withrespecttotheﬁrstreason, regula-tionandqualityassuranceforNHsisthepurviewofthecentralized government (national and provincial governments in Italy and Ontario,respectively),butotheractivities,includingdistributing fundingandaccesstoNHs,havebeenregionalizedinbothItalyand Ontario.NHsreceivepublicfundingfornursingandpersonalcare, butresidentsarerequiredtocontributeaco-payment,theamount ofwhichisconditionalontheresident’s,and,inTuscany,alsotheir family’sabilitytopay,andissubsidizedbythegovernment.While NHsarepubliclyfunded inbothTuscanyandOntario,thereare bothprivatelyandpubliclyownedfacilities.Inbothjurisdictions, admissiontoNHsisneeds-based(individualsrequiringfrequent

assistancewithpersonal careandonsite 24-hnursingcareand supervision),butonceeligibilityhasbeendeterminedbyregional authorities,residentsmayselectwhichhomestoapplyto.Amore detaileddescriptionofLTCinOntarioandinTuscanyisreportedin theappendixofthismanuscript.

Regardingthesecondreasonforthestudysetting,Tuscanyand Ontarioaretwojurisdictionswithstronginterestinhealthcare per-formancemeasurementandmanagement[13–15]andbothareat formativestagesinthedevelopmentoftheirperformance mea-surementandmanagement forLTC[16–18].Moreover,Tuscany andOntariobothhaveaparticularinterestonpatientandresident satisfaction[19–21],whichislesscommonly,includedin perfor-mancemeasurementsystemsforLTC[4,18].Attheprovincial-level, Ontarioreliesmostlyonobjectivemeasuresofqualityfrom admin-istrativedatasets andhashad littlesystematic measurementof user-reported indicators. In Italy, quality measures have been mostlylimitedtomeasuresofservicecoverageforolderpeople [22];however,qualitymeasuresinsomeregions,suchasTuscany, includepatientreportedindicators[18].

2.2. Datacollection 2.2.1. Ontario

Structuredinterviewswithresidentsfrom30NHsinOntario wereconductedfromNovember2008toFebruary2009usinga modiﬁedversionoftheSmallerWorldSurveyofResident Satisfac-tion[23].Thissurveyincluded66itemsonavarietyofdomains including(thenumberofquestionspertainingtoeachdomainis showninparentheses):comfort(7),privacy(2),spiritual(1), secu-rity(5),food(7),activity(9),staff(3),dignity(8),autonomy(10), relationships(4),clinicalcare(5)andglobalsatisfaction(5).Most itemsusedathreepointscale(Yes,Sometimes,No)withnot appli-cableanddonotknowoptions.

Thesampleof30NHswasselectedfroma groupof72 NHs, whichhadpreviouslyparticipatedinseniormanagementandstaff surveysconductedbythestudyteam.AllNHsinOntariowerefirst invitedtoparticipateintheseniormanagementsurvey.Ofthe353 NHsthatparticipatedinthissurvey,100wererandomlyselected, stratifiedbyprofit-status,andinvitedtoparticipateinthestaff sur-vey.Inadditiontoparticipatinginthesesurveys,tobeeligiblefor theresidentsurvey,NHshadtohaveatleast80English-speaking residents,haveadoptedtheMinimumDataSetResident Assess-mentInstrument,andbelocatedwithina2-hdrivefromOttawa or Toronto, Ontario. Ofthe72 homes that participated in both theseniormanagementandstaffsurveys,40metthesecriteria. 30homeswererandomlyselectedtoparticipateintheresident survey;6homesrefusedandwerereplacedfromtheremaining 10homes usingrandomselection.Residentswerepre-screened byNHstaffforinclusioninthestudy.Exclusioncriteriaincluded severecognitiveimpairmentmeasuredusingtheMinimumData SetCognitivePerformanceScore(CPS5and6)andnon-English speaking.Homeadministratorscompiledalistofeligibleresidents and provided theirnames, birthdatesand lengthof stay tothe studyteam,whichwasusedtorandomlyselectatargetof30 res-identsperhome.Trainedinterviewersapproachedtheseresidents toseektheirparticipation.Agreeableresidentswerebroughttoa privatelocationwithinthehomewhereconsentwastakenand thestructuredinterviewstookplace.Ifresidentswereunwillingto beapproachedbystudyinterviewerstoexplainthestudyorwere unabletoprovideinformedconsent,theywerereplacedusing ran-domsubstitution.Datacollectionfollowedtheprotocolapproved bytheUniversityofTorontoHealthSciencesResearchEthicsBoard. 2.2.2. Tuscany

In2011,all298NHsinTuscanywereﬁrstinvitedbytheRegional Authorities toparticipatein thedevelopmentofa performance

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864 S.Barsantietal./HealthPolicy121(2017)862–869

evaluationsystem(PES)[18].NinetyNHsparticipatedinthe devel-opmentofthePESfromwhichasampleof60NHswereselected forthisstudy.NHswererandomlyselected,stratiﬁedby geogra-phy,sothatthesampleincludedatleastoneNHsfromeachofthe 34localhealthdistrict.In2012,face-to-faceinterviewswere con-ducted,usingastructuredquestionnaire,withresidentsfromthe 60NHsinTuscany.Thenumberofresidentsapproachedineach homewasafunctionofitssize.Residentswerepre-screenedby NHstaffforinclusioninthestudyusingthePfeifferTest,withthe exclusionofresidentswith7ormoreerrorstothetest.Ona prede-termineddayfortheinterviews,homeadministratorscompileda listofpresentresidentsandprovidedtheirdetailstothestudyteam, whichwasusedtorandomlyselectatargetgroupofresidentsin eachNH.Trainedinterviewersapproachedresidentsseekingtheir participation.Ifresidentswereunwillingtobeapproachedby inter-viewerstoexplainthestudyorwereunabletoprovideinformed consentortoreplytothethreeﬁrstquestionofthePfeiffertestat thetimeoftheinterview,theywerereplacedusingrandom substi-tution.QuestionsfromtheOntariosurveywereincorporatedinto theTuscansurvey.Thequestionnaire,whichwaspre-testedinaNH notparticipatinginthisstudy,included57closed-endedquestions coveringthefollowingninedomains(thenumberofquestions per-tainingtoeachdomainisshowninparentheses):1.Receptionand orientation(3);2.Environmentandcomfort(7);3.Services(8); 4.Leisureactivities(9);5.Externalrelationships(4);6.Assistance andcare(12);7.Staff(9);8.Privacy(3);and9.Overallquality(2). Inaddition,thequestionnaireincludedquestionsaboutresidents’ socioeconomicstatusandothergeneralinformation(e.g.whether s/heisinawheelchair,whethers/heisblindordeaf,whethers/he hasrelatives,themunicipalityofresidencepriortoadmissiontothe NH,thelengthofstayintheNH,whethers/hesuffersfromachronic illness).Mostquestionsuseda“Yes,always”,“Yes,sometimes”and “No,never”ratingscale.

2.2.3. Selectionofcommonitems

ThesurveysusedinOntarioandItalywerecomparedfor anal-ogousitems.14items,includingwillingnesstorecommend(WTR) theNH,wereidentiﬁedasbeingconceptuallyequivalent,though thereweredifferencesinsyntax,mostlyattributabletothe lan-guageinwhichthesurveywasconducted.The14itemsaskedabout thepredominantdomainshighlightedin theliterature[24–26]. QuestionsarereportedinTable1.Theitemsrefertosecurity (ques-tionQ1),comfort(questionsQ2-Q4),autonomy(questionsQ7-Q9), staff(questionsQ10-Q13),servicesandfacilities(questionsQ5-Q6), whichareallmodiﬁable.

Table1Items,domains,questionsanddescriptivestatisticsfor thecomparisoninTuscanyandOntario

2.3. Analysis

Dataanalysisforthisstudyfollowedtheapproachdescribedin Brownetal.,Sandovaletal.andSeghierietal.[9–11].Foreach coun-try,the13itemsthatwerecomparableacrossthetwosurveyswere firstenteredascovariatesinanordinallogisticregressionmodelto predictresidents’overallWTRtheirNH.Thetwoordinalregression models(separately,oneforCanadaandtheotherforTuscany)were usedtoobtainestimatesofthecoefficientsofthepredictorsthat arethenincorporatedintotheoptimizationmodel.Inthissense, theadjustmentforsex,ageorotherindividualfactorsisnot neces-saryfortheregressionmodel.Inotherstudies[5–7]onlyvariables relatedtoexperience/satisfactionareusedintheregressionmodel. Furthermore,theaimofthestudyisnottomakepredictionsfor thedependentvariableortocomparetheperformancebetween thetwocountries.Regressioncoefficientsofthepredictorsfrom thelogisticmodelwereincorporatedintotheoptimizationmodel toselectthemostefficientcombinationofpredictors necessary

toincreasetheoverallWTRmeasurebyupto15%.The optimiza-tiontechniquewasaconstrainednonlinearoptimizationproblem selectingthecombinationofitemsrequiringthelowesttotal rel-ativeimprovementtoachievepre-setincreasesinthedependent variable[9].Theoptimizationmodelcombinedinformationfrom theaveragevaluesofthepredictorsandtheregressionestimates inordertoidentifythepredictors(items)thatweremoststrongly relatedtothedependentvariable(WTR)(i.e.thosepredictorswith largeregressioncoefficients) andthat had arelatively low cur-rentperformance(averagevalueinthepopulation).Restrictions imposedontheoptimizationmodelincluded:1)predictorscould notimprovebymorethan15%beyondtheircurrentperformance (e.g.apredictorwithacurrentvalueof2ona3pointscale,where1 isthebestpossiblerating,couldonlybeimprovedto1.7);and2)the improvementinthedependentvariable,WTR,wascappedat15%. Todeterminewhichitemswereselectedfirstbytheoptimization models,thelevelofimprovementinWTRwasfirstpre-setat1%and then,subsequently,increasedbyincrementsof1percentagepoint, untileitherthemaximum15%improvementinWTRwasachieved orthenumberofpredictorsrequiredtoachieveanadditionalone percentagepointimprovementinWTRbecameimpracticable.

Beforerunningtheregressionandoptimizationmodels, miss-ingvaluesandanswersof“don’tknow”and“notapplicable”were replacedusingthemultipleimputationbychainedequations algo-rithm[27].Missingdatafortheselectedquestionsrangedfrom3% to16%.DataanalysiswasperformedusingSAS9.3software.Values ofp≤0.05wereconsideredstatisticallysigniﬁcantinallanalyses.

3. Results

3.1. Descriptivestatistics

Face-to-faceinterviewswereconducted,usingstructured ques-tionnaires,with1116residentsfrom60NHsinTuscanyand681 residentsfrom30NHsinOntario.Table2presentsdemographics characteristicsforresidentssurveyedin eachjurisdiction.There werenostatisticallysignificantdifferencesbetweenjurisdictions withrespecttosex,ageandperceivedhealthstatusatthe5%level ofsignificance.Thegroupsweresimilarinagedistribution,witha majority,asexpected,ofpatientsineachcountryaged>65years. Approximately70%oftheresidentssurveyedwerewomeninboth TuscanyandOntario.Almosthalfofallresidentsinterviewedrated theirhealthstatusasverygoodorexcellent,whereas13%ofthe samplefrombothregionsreportedpoorhealthstatus.Lengthof staywasslightly,butstatisticallysignificantly,longerinOntario with75%ofresidentsreportingastayofoneyearormoreversus 70%oftheirTuscancounterparts.

Meansandstandarddeviationsofthe13comparableitemsfrom thetworegionsareshowninTable1.Allitemswereansweredon a3-pointscale.Forpositivelywordeditems,thescalewascodedas Yes=1,Sometimes=2andNo=3.Scalesofnegativelyworded ques-tionswerecodedinreverse(Yes=3,Sometimes=2andNo=1),so thatforallitems,valuescloserto1indicateamorepositiveresult. Inbothregions,theworst-rateditemwasbeingabletochooseto haveashowerorbathwhentheywantedto.Theaverageratingof thisitemwasslightlyhigher(i.e.worse)inTuscanycomparedto Ontario(2.55versus2.08).Asforthemostpositivelyrateditem, NHresidentsinOntarioandTuscanywerebothmostsatisﬁedwith beingcalledbynamebythestaff.NHenvironmentandcomfort (room,smellandstateofrepairofthehome),andstaffskillsand knowledgeandrelationshipswithstaffwerealsoratedpositivelyin bothjurisdictions.NHresidentperceptionsofstaffcontinuitywere, however,onaverage,worseinTuscanythaninOntario,thoughthis wasoneoftheworstrateditemsinbothregions.Additionally, res-identsinOntarioNHsreportedgreaterfreedomtoleavetheNH iftheywished,moreﬂexibilityintheireatingscheduleandfelt

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S. Barsanti et al. / Health Policy 121 (2017) 862–869 865

Items,domains,questionsanddescriptivestatisticsforthecomparisoninTuscanyandOntario.

CodeandItem Domain TuscanyQuestion TuscanyMean(SD) OntarioQuestion OntarioMean(SD) p-value

Q1SafePlace Security Isthereasafeplaceinyourroomwhere youcankeepyourbelongings?

1.348(0.313) Doyoufeelyourpossessions aresafeatthishome?

1.342(0.503) 0.8468

Q2Room Comfort Doyoulikeyourroom? 1.911(0.625) Isyourroomhowyouwould

likeittobe?

1.348(0.476) 0.0000 Q3Renovation* Comfort DoyouthinkthatthisHomeneeds

renovation(e.g.reparations,e.g. painting...)?

1.477(0.454) Doesthisplaceneedﬁxingup (forexample,repairs, decorating,orpainting)?

1.418(0.621) 0.1800

Q4Smells* Comfort Arethereanyunpleasantsmellsinthe roomsandhalls(bedrooms,livingrooms, toilets,diningroom,hallways...)ofthis Home?

1.231(0.219) Doesthesmellaroundhere botheryou?

1.239(0.303) 0.7458

Q5Food Services Areyouallowedtohaveasnackifyouare hungryduringtheday?

2.150(0.599) Whenyouarehungryisfood available?

1.331(0.494) 0.0000 Q6Laundry* Services Haveyourclotheseverbeendamagedor

lostinthelaundry?

1.357(0.335) Doyourclothesgetlostor damagedinthelaundry?

1.683(0.710) 0.0000 Q7Activities Autonomy Duringtheday,areyouallowedtodo

otheractivitiesyoulike(reading,watching TV,knitting...)?

1.241(0.234) Doyoudecidewhatyouare goingtodoeachday?

1.492(0.661) 0.0000

Q8Comeandgo Autonomy Duringtheday,areyouallowedtoleave theHomeifyouwish(goingtoMass,toa bar,downtown,meetingfriends, graveyard...)?

2.267(0.613) Areyoufreetocomeandgoas youplease?

1.316(0.485) 0.0000

Q9BathandShower Autonomy Areyouallowedtohaveabathorashower whenyouwantto?

2.554(0.507) Canyouchoosewhentohave yourbathorshower?

2.076(0.945) 0.0000 Q10Skilledstaff Staff Arethestaffcapable?(Doestheresident

feelthestaffmembersareprofessionally capable?)

1.202(0.180) Arethestaffskilledand knowledgeable?

1.257(0.303) 0.0233

Q11Relationshipwiththestaff Staff Dothestaffaskyouhowyoufeel? 1.322(0.348) Dothestafftrytounderstand whatyou’refeeling?

1.460(0.531) 0.0002 Q12Callbynamebythestaff Staff Whenthestaffaretalkingtoyou,dothey

callyoubyyourname(eitherﬁrstorlast name)?

1.066(0.073) Dothestaffcallyoubyname? 1.132(0.172) 0.0001

Q13Staffchangetoooften Staff Dothestaffwhocareforyouchangeoften? 2.251(0.443) Dothestaffwhocareforyou changetoooften?

1.845(0.852) 0.0000 WTR Willingnesstorecommend WouldyourecommendthisHometo

friendsandrelatives?

1.497(0.488) WouldyouRecommendthis Home?

1.286(0.383) 0.0000

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Table2

SampleDemographicCharacteristicsinTuscanyandOntarioandwillingnesstorecommend.

Tuscany Ontario X2

Frequency Percentage Frequency Percentage p-value

Age 18–45 2 0.20% 5 0.80% 0.09 46–65 95 8.70% 55 8.81% 66–85 569 52.40% 299 47.92% Over85 420 38.70% 265 42.47% Sex Male 359 32.20% 205 30.42 0.44 Female 757 67.80% 469 69.58

Self-PerceivedHealthStatus

VeryBadorBad 146 13.20% 69 12.38% 0.64

Satisfactory 432 39.10% 231 41.47%

VeryGoodorExcellent 527 47.70% 257 46.14%

LengthofStay

Lessthan6months 174 17.10% 66 11.54% 0.01

6monthstoalmostayear 131 12.90% 76 13.29%

Oneyearormore 709 70% 430 75.17%

Willingnesstorecommend

Yes,always 615 61.25% 445 81.05%

Yes,sometimes 264 26.29% 58 10.56%

No,never 125 12.45% 46 8.37%

thattheirbelongingsweresaferthandidtheirTuscancounterparts. Bycontrast,TuscanNHresidentsreportedslightlygreater auton-omytochoosewhattodoeachdayandwerelesslikelytoreport thattheirclothesweredamaged orlostinthelaundry.Overall, OntarioNHresidentshadbetterWTRscores(1.29)comparedto NHresidentsinTuscany(1.50).

3.2. Ordinallogisticregression

Table 3 shows the regression results for WTR for Tuscany and Ontario expressed in terms of standardized coefficients in order to make comparisons between the two regions. In both regressionmodelstheassumptionofproportionaloddswastested through the Brant test [28]. For both countries we obtained a non-significantteststatisticprovidingevidencethatthe propor-tionaloddsassumptionwasnotviolated(p-value=0.20forTuscany regionand 0.46 forOntario). Additionally, diagnosticsfor pres-enceofmulticollinearityandoutlierswereperformedandresults showedneithermulticollinearitynoroutlierobservations.Positive predictorsofWTRinbothjurisdictionsincludedlivinginrooms matchingtheresident’spreferences,theNHnotneedinga renova-tion,staffaskingtheresidenthowtheyfeel,andbeingallowedto dotheactivitiestheylike.InOntario,staffmembers’attemptsto understandwhattheresidentwasfeelingwasthestrongest pos-itive predictorof WTR, butwas thefifthstrongest predictor in Tuscany.Bycontrast,beingabletocomeandgoastheyplease, havingstaffthedon’tchangetoooftenandbeingallowedtotakea bathorshowerwhentheychoosewerenotstatisticallysignificant positivepredictorsofWTRineitherOntarioorTuscany.

Therewereanumberofpredictorsthatwereonlystatistically significantinoneofthetwojurisdictions.InTuscany,residentswho perceivedstaffasbeingtechnicallyskilledwasoneofthestrongest predictors.Inaddition,WTRwassignificantlyassociatedwithbeing allowedtohaveasnackwhenhungry,thesmellaroundtheNHand beingcalledbyname.InOntario,nothavingclothesdamagedorlost inthelaundryandhavingasafeplaceintheirroomtokeeptheir belongingshadsignificantlypositiverelationshipswithWTR.

3.3. Optimizationmodels

TheoptimizationmodelssetouttoimproveWTRbyupto15%, but it wasnot practical toimprove WTRby morethan 10% in TuscanyNHsand7%inOntario,becausebeyondthis,the num-berofpredictorsneededincreasedsubstantially.Thetotalnumber ofitemsidentiﬁedbytheoptimizationmodelrequiredtoincrease WTRinTuscany’sandOntario’sNHsby10%and7%,respectivelyis reportedinTable2oftheAppendixofthismanuscript.

Table4 shows theimprovements required toincrease WTR by up to 10% in Tuscany and 7% in Ontario. For example, to increase“willingnesstorecommend’by8%,meaningthatthe cur-rentperformanceoftheWTR,whichwas1.497,wouldimprove to1.377(0.92*1.497),nursinghomeswouldneedtoimproveQ1 “roomcomfort” by15%, which meansthat witha current per-formance of 1.348onQ1, Q1 would need toimprove to1.146 (0.85*1.348).

InTuscany,theﬁrstitemselectedbytheoptimizationmodel wasstaffknowledgeandskill,which,byitself,couldleadtoa4% improvementinWTR.Toachieve this4%increaseinWTR, resi-dentratingsofstaffknowledgeandskillwouldhavetoincreaseby 14%.Basedontheoptimizationmodel,themostefﬁcientwayto increaseWTRby5%wouldbetofocusonimprovingboththe capa-bilityofNHstaff,whichwouldrequireanimprovementof15%,and onthecomfortoftheresident’sroom,whichwouldalsoneedtobe improvedby4%.ToincreaseWTRbyafurther5%,theoptimization modelselected3additionalpredictors.Thesewerethe availabil-ityoffood,whichwouldneedtobeimprovedby15%,residents’ autonomytodecidewhattodoeachdayandthestaffcallingthe residentsbyname,whichwouldneedtobeimprovedby2%and 6%,respectively.Inaddition,toachievethe10%increaseinWTR, residentratingsofthecapabilityofstaffandthecomfortoftheir roomswouldeachneedtoimprovebyatotal15%.

InOntario,theﬁrstitemselectedbytheoptimizationmodel wasthewillingnessofstafftotrytounderstandwhatresidents werefeeling.Alone,a13%improvementinthisitemcouldresult ina2%improvementinWTR.ToincreaseWTRby5%,according totheoptimizationmodel,QIeffortsinOntarioshouldfocuson improving4items.Thesewerethecomfortoftheresident’sroom, whichwouldneedtobeimprovedby6%,andstaffwillingnessto

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Table3

OrdinalLogisticRegressionforwillingnesstorecommendforTuscanyRegionandOntario.

IndependentVariables Item(Domain) Tuscany Ontario

Std.Coefﬁcients p-value Std.Coefﬁcients p-value

Q1 SafePlace(Security) 0.250* _0.000 _0.242* _0.003

Q2 Room(Comfort) 0.063 0.319 0.223* _0.006 Q3 Renovation(Comfort) 0.131* _0.019 _0.227* _0.020 Q4 Smells(Comfort) 0.098* _0.004 _0.014 _0.823 Q5 Food(Services) 0.202* _0.001 _0.059 _0.463 Q6 Laundry(Services) 0.065 0.200 0.307* _0.017 Q7 Activities(Autonomy) 0.117* _0.002 _0.301* _0.005

Q8 Comeandgo(Autonomy) 0.106 0.097 0.037 0.652

Q9 BathandShower(Autonomy) −0.040 0.490 −0.369* _0.006

Q10 Skilledstaff(Staff) 0.216* _0.000 _0.059 _0.385

Q11 Relationshipwiththestaff(Staff) 0.121* _0.008 _0.426* _0.000

Q12 Callbynamebythestaff(Staff) 0.059* _0.002 _−0.031 _0.524

Q13 Staffchangetoooften(Staff) −0.036 0.479 −0.160 0.237

*_p-value_<_0.05.

Table4

TuscanandOntariooptimizationmodelresults.

IndependentVariables Item(Domain) Region Improvementsrequired

1% 2% 3% 4% 5% 6% 7% 8% 9% 10%

Q1 SafePlace(Security) Tuscany

Ontario 8% 15% \ \ \

Q2 Room(Comfort) Tuscany 4% 9% 14% 15% 15% 15%

Ontario 6% 15% 15% \ \ \

Q3 Renovation(Comfort) Tuscany

Ontario 14% \ \ \

Q4 Smells(Comfort) Tuscany

Ontario

Q5 Food(Services) Tuscany 6% 15%

Ontario

Q6 Laundry(Services) Tuscany

Ontario 8% 15% 15% 15% 15% \ \ \

Q7 Activities(Autonomy) Tuscany 2%

Ontario 6% 15% 15% 15% \ \ \

Q8 Comeandgo(Autonomy) Tuscany

Ontario

Q9 BathandShower(Autonomy) Tuscany Ontario

Q10 Skilledstaff(Staff) Tuscany 3% 7% 10% 14% 15% 15% 15% 15% 15% 15%

Ontario

Q11 Relationshipwiththestaff(Staff) Tuscany

Ontario 6% 13% 15% 15% 15% 15% 15% \ \ \

Q12 Callbynamebythestaff(Staff) Tuscany 6% 6% 6%

Ontario

Q13 Staffchangetoooften(Staff) Tuscany Ontario

trytounderstandwhatresidentswerefeeling,thelaundryservice (clothesnotgettinglostordamagedinthelaundry)and,finally, residentautonomytodecidewhattodoeachday,whichwould eachneedtoimproveby15%.Toachievea7%improvementinWTR, twoadditionalpredictorswereselectedbythemodel.Thefirstwas relatedtosecurityoftheresident’spossessions,and,thesecond,to whethertheNHneedsfixingup.

4. Discussion

Thisstudyusedoptimizationtechniquestopredictthemost efﬁ-cientwaytoimprovetheoverallsatisfactionofNH residentsin Tuscany,Italy,andOntario,Canada.Thesemethodstakeinto con-sideration:(1)therelationshipsbetweenthepredictorsandthe measureofoverallsatisfaction,and(2)thecurrentperformance levelsofeachofthepredictors.Thisallowsresearcherstosuggest areaswhere,ifqualityimprovementactivitieswerefocused,overall satisfactionmightbeimproved.

Rodriguez-Martinetal.[29],throughinterviewswithNH resi-dentsinSpain,identiﬁeddomainsrelatedtothepersonsproviding

careasthe“pillarofquality”.Ourresultsconﬁrmthisassertion; theprimaryfocusforqualityimprovementinbothTuscanyand OntarioshouldbeondomainsrelatedtoNHstaff.Thisresultis alsocongruentwithBecker&Kaldenberg’s[6]studythat recom-mendedthatNHsintheUnitedStatesshouldprioritizeservices provided by aides. It holds face value as well because quality in NH occurs in the interactions between staff and residents [30].

Ourresultsalsohighlightanimportantdistinctioninhow qual-itycareisdefinedindifferentjurisdictions.Anumberofpapers haveconceptualizeddifferentdomainsofqualityofcare.For exam-ple,Rodriguez-Martinetal.[29]divideddomainsrelatedtothe personsprovidingcareintoeitheremotionalcompetencies,such asstaffaffectandqualityofrelationships,ortechnical competen-cies,whichincluded,inpart,technicalskillsandtrainingofstaff. Bowerset al.[24]establishedthreedifferentconceptualizations ofqualityofcare:(1)care-as-service;(2)care-as-relating;and(3) care-as-comfort.Thefirstoftheseconceptualizationsfocuseson thetechnical/instrumentaldomainsofcare,thesecondrelatesto staffaffectandfriendship,andthethirddefinedqualitybasedon

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maintainingresidentphysicalcomfort.ToimproveWTRin Tus-cany,theprimaryfocusshouldbeontheprofessionalcapabilityof NHstaff(theirskillandknowledge),indicatingresidentsinTuscany conformtothecare-as-service/technicalcompetency conceptual-izationofquality.Bycontrast,inOntario,thefocusshouldbeon thewillingnessandability ofNH stafftounderstandwhat res-identsare feeling,which reflects thecare-as-relating/emotional competencydomain.Thisitem wasthemostimportant predic-torofWTRinOntario and wasthe5thworstperforming item, andwas,asaresult,thefirstpredictorselectedinOntario’s opti-mization model. In Tuscany,staff members’ relationshipswith residents(tryingtounderstandhowtheywerefeeling),wasonly the5th mostimportantpredictorofWTRandwasthe5thbest performingitematbaseline,basedontheordinallogistic regres-sion models, and was not selected by Tuscany’s optimization model.Havingskilledstaff,however,wasamongthemost impor-tant predictors of WTRin Tuscany and showed up first in its optimizationresults.InOntario,this itemwasnotastatistically significantpredictorofWTRandwasalreadyamongthebest per-formingitems,sowasnotamongthoseselectedbytheoptimization model.

Rodriguez-Martinetal.[29]discussedthepossibilitythat struc-tural characteristics of theNH industry could lead todifferent conceptualizationsofqualityofcare.Forexample,ifresidentspay forservices,theymayfeelentitledtootherrightsasaclientas comparedtoresidentsinpubliclyfundedNHs.Otherstudieshave stressedtheeffectthatdifferentculturalbeliefsandvaluescanhave ontherelativeimportanceofdifferentdomainsofqualityofcare [31,32].Forexample,inTaiwaneseNHs,ChaoandRoth[31]link theculturalvalueplaced onself-suppressiontoresidentsbeing reluctanttosharetheirpreferenceswithcareproviders.

Ofsecondary importance todomains related to thepersons providingcare,Rodriguez-Martinetal.[29]includedinstitutional domains,whichincludefacilities,cleanlinessandfood.Institutional domainsofquality alsoincludedstandards andrules.Only two ofthepredictorsselectedbyouroptimizationmodelswere com-montobothregions.Thesewereresidentratingsofthecomfortof theirroomandhavingtheautonomytochoosewhatactivitiesthey wouldliketodoeachday.Thelatterofwhichwasthelastpredictor selectedinTuscany’soptimizationmodel,butwasselectedmuch earlierinOntario’s.

Therewassubstantialconsistencyinbothjurisdictionsamong predictorsthatwerenotselectedbytheoptimizationprocessto improveoverallWTR.Notably,staffcontinuity,residentautonomy tochoosewhentohaveabathorshower,residentautonomyto choosewhentocomeandgo,andsmellswithintheNHwerenot selectedineitherjurisdiction.InbothTuscanyandOntario,many residentsreportedthattheyweren’tbotheredbysmellsintheir NH.Therewas,thus,littleroomfor improvementandthis pre-dictorwasnotselectedbyeitheroptimizationmodel,despiteits statisticallysigniﬁcantrelationshiptoWTRinTuscany.Inboth Tus-canyandOntario,WTRwasnotstatisticallysigniﬁcantlypositively relatedtoresidentautonomytochoosewhentohaveabathor shower,residentautonomytochoosewhentocomeandgoorstaff continuity.

Thisstudyonlyincludedonemeasureofoverall satisfaction. Thatwasresident’sWTRthehome.Whilealargeproportionof residentsfrombothregionswerealreadywillingtorecommend theirNH,becauseresidents’WTRwasinitiallyhigherinOntario itmaybemoredifﬁculttoimprovethaninTuscany.Toimprove residentWTRby5%inOntariorequires4predictorstobeimproved by15%andanotherby6%,whereasinTuscany,asimilarlevelof improvementwouldonlyrequireimprovementsto2predictors.In addition,itwasonlypossibletotheincreaseWTRby7%and10%in OntarioandTuscany,respectively,because,asdescribedinSeghieri etal.[10],anyincreaseabovethiswouldrequireimprovementtoan

infeasiblenumberofpredictors.Itispossiblethat,similartostudies inothercaresettings[9,10],othermeasuresofoverallsatisfaction (forexampleoverallratingsofcare)mightnothavesuchhighinitial residentratingsandcouldproduceslightlydifferentoptimization results.

5. Limitationsofthestudy

Ourpaperdescribedsimilaritiesinsomebroadstructural char-acteristicsofNHsinTuscanyandOntario(publicfundingofnursing and personal care, resident co-payment,for-profit and not-for-profitNHownership,etc.).Itispossible,however,thatthereare otherstructural characteristicsand/or socio-culturaldifferences (e.g.continuedroleofthefamilyforemotionalsupportinItaly)that explainwhythewillingnessandabilityofNHstafftounderstand whatresidentswerefeelingwasmostimportantforOntarioNH residents,whereasforNHresidentsinTuscanyitwasstaff mem-bers’professionalcapability(skillandknowledge)thatwasmost important.Alternatively,lengthofstaywasfoundtobelongerin OntarioNHsthaninTuscany,itispossiblethatrelationshipswith staffbecomemoreimportant thelongerresidentsliveina NH, whereasshorterstayindividualsaremoreconcernedwith tech-nicalcompetencesofstaff.Futureresearchmaywishtoconsider ifthequalityimprovementprioritiesvarybyresident character-istics(e.g.lengthofstayorhealthstatus).Oursmallsamplesize, however,limitsourabilitytostratifybasedonresident character-istics(e.g.weonlyhave69residentsthatfeelverybadinOntario). Finally,inbothTuscanyandOntario,theresidentsamplesexcluded individualswithseverecognitiveimpairment.Cognitive impair-ment,however,wasdeterminedusingdifferencescales,Cognitive PerformanceScaleinOntarioandthePfeiffertestinTuscany.This studyisfurtherlimitedbytheinclusionofonlythe13predictors ofoverallNHqualitythatwerecommontothesurveysconducted inTuscanyandOntario.Thesepredictorscoverarangeofquality domainsidentifiedasimportantinpriorliterature,butmaynot beinclusiveofallelementsof NHquality.While thedatawere collectedafewyearsago,theissuesraisedandtheapproachto comparingprioritiesforqualityimprovementarecurrent.Further, therehavebeennomajorsysteminnovationsthatwouldsuggest changesinresidentexperiencebetweenthetimeofdatacollection andtoday.

6. Conclusion

Thepaperprovidesanimportantcontributiontotheliteraturein anumberofways.First,bycomparingoptimizationmodelsof sim-ilarpredictors ofNHqualityinvariousjurisdictions,researchers may attempt to establish whetherthe selected items reflect a sharedqualityphenomenaforNHresidents,orwhether percep-tionsofqualitydifferbasedonthelocalcontext.Thispaperconfirms theimportanceofstaffonresidents’perceptionsofqualityofcare, somethingthatiscommonacrossjurisdictions,buthighlights dif-ferencesinthespecificstaff-relatedaspectsthatareimportantto residentperceptionsofqualityandtargetareasforquality improve-ment.

Second,thepaperdescribesauniquemethodology,the opti-mization model, which had not, to our knowledge, been used previously in studies of NH quality. When selecting areas of focus for quality improvement, it is important that stakehold-ers(managers,policymakers)focusnotonlyonthedomainsof qualitywithinNHsthataremoststronglyassociatedwith over-allperceptionsofquality,butalsothosewiththemostroomfor improvement;theoptimizationmodelprovidesauniquesolution fordoingthis.

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Acknowledgements

Ontariodatacollectionandanalysiswassupportedbygrants to Dr. Wodchis from the Ontario Ministry of Long Term Care (MOHLTC)andfromtheCanadian InstitutesofHealth Research (FRN114113).TuscanyRegiondata collectionandanalysiswas supportedandfundedbyTuscanyRegion,HealthandSocialCare Department(Italy).Theopinions,results,andconclusionsreported inthispaperarethoseoftheauthorsandareindependentfrom allfundingsources.NoendorsementbytheMOHLTCisintended orshouldbeinferred.Theauthorswouldliketothankallnursing homes’professionalsinvolvedintheprojects.Specialthanksgoto Prof.SabinaNutiofScuolaSant’AnnaofPisa,Italy.

AppendixA. Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound, intheonlineversion,athttp://dx.doi.org/10.1016/j.healthpol.2017. 06.004.

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