Measuring Progress:Indicators for care homes

‘Quality Management by Result-oriented Indicators – Towards Benchmarking in Residential Care for Older People’ is co-financed by the European Commission in the framework of the PROGRESS Programme of DG Employment, Social Affairs and Equal Opportunities

Authors and project partners

European Centre for Social Welfare Policy and Research (Coordinator)

Vienna Austria

Frédérique Hoffmann Flip Maas Ricardo Rodrigues

E-Qalin GmbH Bad Schallerbach Austria

Adelheid Bruckmüller Simon Gross Andreas Kattnigg Kai Leichsenring Wilfried Schlüter Heidemarie Staflinger

Technische Universität Dortmund Forschungsgesellschaft für Gerontologie

Dortmund Germany

Eckart Schnabel

Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen (MDS)

Essen Germany

Uwe Brucker

Ministry of Health, Equalities, Care and Ageing of the State of North Rhine-Westphalia

Düsseldorf Germany

Andreas Burkert Hans Braun Daniela Grobe

City University London United Kingdom

Julienne Meyer

Vilans Knowledge Centre for Long-Term Care

Utrecht Netherlands

Mirella Minkman Ruth Pel Sabina Mak

Layout and copy-editing

European Centre for Social Welfare Policy and Research

Vienna Austria

Katrin Gasior Willem Stamatiou

The explicit purpose of this handbook is to get reproduced and disseminated as widely as possible. Further copies are available through: Willem Stamatiou stamatiou@euro.centre.org

European Centre for Social Welfare Policy and Research Berggasse 17, A-1090 Vienna, Austria

The main target audience of this handbook are the key stakeholders of care homes, which includes its management, staff, clients and relatives, as well as policy decision-makers, regulators and sponsors. The handbook contains a set of 94 selected result-oriented indicators that has been developed on the basis of the exchange of experiences and existing tools in selected EU Member States.

The focus of this set of indicators is directed towards the question how care homes can measure and manage improvements with regard to the quality of life of their clients, and the related issues of quality of care, management, economic performance and relationships with external stakeholders. The description of the indicators therefore also embraces proposals on how to apply them and instruments for their use.

The Handbook is available in three languages: English, German and Dutch. The handbook is one of the outputs of the project ‘Quality Management by Result-oriented Indicators – Towards Benchmarking in Residential Care for Older People’ that has been co-financed by the European Commission, DG Employment, Social Affairs and Equal Opportunities in the framework of the PROGRESS Programme.

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This Handbook is an output of the project entitled ‘Quality management by result‐orientedindicators:Towardsbenchmarkinginresidentialcareforolderpeople’whichisco‐financedbytheEuropeanCommission,DGEmployment,SocialAffairsandEqualOpportunities intheframeworkof the PROGRESS Programme. The projectwas coordinated by the European Centre for SocialWelfarePolicyandResearch(Austria)andcarriedoutwithpartnersfromGermany(theInstituteofGerontologyatTechnischeUniversitätDortmund; theMinistryofHealth,Equalities,CareandAgeing of the State of North Rhine‐Westphalia; and the Medizinischer Dienst desSpitzenverbandes Bund der Krankenkassen –MDS), The Netherlands (Vilans) and England (CityUniversityLondon)aswellaswithE‐QalinLtdrepresentingpartnersfromAustria,Germany,Italy,LuxembourgandSlovenia.

Special thanks go to themore thanhundred experts andprofessionalswhoparticipated in theDelphi Study organised by our project partner Vilans and/or in the validation workshopsorganisedbyE‐Qalin.Theirinputsandcommentsfundamentallyenrichedourknowledgeandthelistofindicators.

The authors are particularly thankful to Susan Blasko (University of Applied Sciences Zwickau,Germany),RehkaElaswarapu(CareQualityCommission,England),SimonGross(RBS–CenterfirAltersfroen,Luxembourg),NadineHastert(Servior,Luxembourg),BerndMarin(EuropeanCentrefor SocialWelfare Policy and Research, Austria), Inge Rasser (Ministry of Health, Welfare andSport, The Netherlands) and Christine Wondrak‐Dreitler (SeneCura Sozialzentrum Purkersdorf,Austria)fortheirinvaluablecommentsandinputtoanearlierversionofthelistofresult‐orientedindicatorsfromwhichwebenefitedgreatly.

Wewouldalso liketothankKatrinGasiorforherpatientsupportthroughoutthepreparationofthe design and layout of the Handbook; Andrea Hovenier for her reliable efficiency whenorganising the various project teammeetings (inVienna,Utrecht,Dortmund and London); andfinally Willem Stamatiou, who scrutinised the final typescript with his usual attentiveness andprofessionalismandwasresponsibleforcopy‐editingofallthreeversionsoftheHandbook.

Vienna,October2010

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• Domain1:Qualityofcare..............................................................30

• Domain2:Qualityoflife................................................................45

• Domain3:Leadership....................................................................69

• Domain4:Economicperformance ................................................79

• Domain5:Context ........................................................................83

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Demographic ageing causes a rising number of persons in need of care, calling for structuralchanges of existing and emerging long‐term care systems in Europe.One strategy to steer theincreasing demand and supply was to turn formerly public systems into quasi‐markets bycomplementing public services with new and additional providers (commercial and non‐profitorganisations).OneambitionofapplyingNewPublicManagement tosocialandhealthserviceswas certainly to increase efficiency and effectiveness with the final aim to reduce costs inincreasingly market‐driven systems. These developments are important drivers to installcompulsory or at least voluntary quality management systems and to enhance measures forexternalcontrol(certification,inspection).

Publicpurchasersneedtoknowwhattheyarepurchasingandwhotheycantrustifnewprovidersappear on the market. Increased transparency, clearly defined descriptions of services andrespective quality assurance mechanisms, at best based on mutually agreed indicators, arebecomingaprecondition for the governanceofquasi‐markets toassess, compare,monitorandsupportthesector’seffortsinproducingmoreadequateoutcomestousers’needs.

Atthe levelofserviceproviders,carehomesneed to improvetransparencynotonlybecauseofthe changing modes of governance (competitive tendering, provider contracts etc.), but alsobecauseofchanging expectationsof residentsand their familiesconcerning thequalityof care.Strategies to overcome existing shortcomings of the sector include attempts to strive towardsfurther orientation towards user needs, to involve the public as well as to improve structural,process and outcome quality in care homes by means of quality management and respectivecriteriaandindicators.Serviceprovidersmayalsoviewqualitymanagementasawaytoachievegreater organisational effectiveness in the delivery of care or in the improvement of the well‐beingoftheirusers.

Quality assurance aswell as developingquality standards in long‐term care has equally gainedincreasing attention at the level of the European Union. In the context of the debate overmodernising social services of general interest, and in the framework of the Open Method ofCoordinationinthefieldofsocialsecurity,thedesireforEUstandardsinassuringqualityofsocialserviceshas recentlybeen gaining ground.Theproject 'QualityManagementbyResult‐orientedIndicators–TowardsBenchmarkinginResidentialCareforOlderPeople'intheframeworkofthePROGRESS programme results partly from this interest of the EU that highlights “the need tosupport the promotion of the quality of social services in a more systematic manner”(Commission,2007:16).

In the last decade, a broad range of measures and initiatives on the part of insurance bodies,services, organisations and researchprojects have focusedon this subject, and effort has beendevoted tofurtheringthedevelopmentofquality.Yetbecauseofthediversityof ideas,culturalandorganisationalapproaches,aswellasconceptsandmodels,ithasnotbeenpossibletocreatea uniform, generally accepted definition of quality that could bring together the variousviewpointsoftheactorstoformaconsensus.Inlightofthissituation,itisnotsurprisingthatthemainemphasisofpracticalactivitiesremainswiththequalityofstructuresandprocesses.Whileitisworthwhiletomonitorandenhancetheframeworkwithinwhichservicesaredeliveredaswellasthefunctionalandprofessionalbasisofdelivery,thequalityofresultsandoutcomesremainsa

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challengingarea.Aswithpersonalservices, it isstilldifficult todisentanglethedifferentaspectsproducingaspecificoutcomeandtomutuallyagreeuponacommonframework.

The project ‘Quality Management by Result‐oriented Indicators – Towards Benchmarking inResidential Care for Older People’ therefore aimed at collecting, sifting and validating result‐orientedquality indicators on theorganisational level of care homes, basedon an exchangeofexperiences inselectedMemberStates.Apartfromthequalityof(nursing)care,aspecialfocuswasgiventothedomain’qualityoflife’.Economicperformance, leadershipissuesandthesocialcontextcomplementedthedomainsusedtodefine,measureandassessthequalityofresults incare homes. Furthermore, one of the objectives was to investigate and gain experience inmethods,howtoworkwith result‐oriented indicatorsandhowto traincarehomemanagers indealingwiththerespectivechallenges.

The project was coordinated by the European Centre for Social Welfare Policy and Research(Austria)andcarriedoutwithpartnersfromGermany(theTechnischeUniversitätDortmund,theMinistry of Health, Equalities, Care andAgeingof the State ofNorth Rhine‐Westphalia and theMedizinischer Dienst des Spitzenverbandes Bund der Krankenkassen – MDS), the Netherlands(Vilans) and England (City University London) aswell aswith E‐Qalin Ltd representing partnersfromAustria,Germany,Italy,LuxembourgandSlovenia.

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Usingexistingqualitymanagementguidelinesandframeworksfromthecountriesrepresentedintheproject(aswellastheMinimumDatasetfromtheUnitedStates),theprojectteamcollectedaninitiallistofperformanceindicatorstakingintoaccountdifferentperspectives,includingthoseof residents, relatives, staff, management, and othersworking in the wider social and politicalcontext(forexample,regulatorsandcommissioners).Thefollowingqualityframeworksareattheheartofthisproject:

• TheGerman(NorthRhine‐Westphalia)"#$#%#&'()*#++(ReferenceModel):The‘ReferenceModelsforthePromotionofQualityDevelopmentinNursingHomes’weredevelopedbythe Institute of Gerontology at the Technical University of Dortmund, the Institute ofNursingCareat theUniversityof Bielefeldand the InstituteofSocialWork inFrankfurt.Themainobjective of this projectwas the specificationof care and social services anddevelopment and evaluationof quality criteria and their implementation into everydaylifeofresidentialcaretoimprovebothqualityofcareandqualityoflifefortheresidents.Thecomponentswereimplementedin20carehomes(referencemodels)inNorth‐RhineWestphalia. For the validationof the implementation and the realisationof the centralconceptualelements,acomprehensiveevaluationwasdeveloped,encompassing,amongothers,structuraldataof thecarehomes,residents’ surveysandfocusgroup interviewswith staff. Improvement of central requests to the quality of services such as, forinstance, the promotion of mobility or higher consideration of psycho‐social problemswere achieved. The main products of the project are a guide for care homes offeringquality criteria for the most relevant services in care homes and a structuredimplementation guide that takes into account different types of organisations ofresidential care facilities. The project results represent a valid basis for the furtherdevelopment, definition and measurement of quality in long‐term care especially withregard to outcome indicators, taking into account user orientation, transparency,transferabilityandresponsivenessofservicesprovided.

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• The Netherlands’ Quality Framework for Responsible Care: This framework and set ofindicatorswasdevelopedbythenationalumbrellaorganisationofcareproviders,usersoflong‐term care, professionals, health care providers and the national health careinspectors. Itwaspartlybasedon theConsumerQuality Index (CQ Index)whichwas inturnbasedontheAmericanConsumerAssessmentofHealthcareProvidersandSystemsindicators(CAHPS).Moreover,asetofinternationallyfrequentlyusedobjectiveoutcomeindicatorswas incorporated.Thesetof indicators is currentlybeingimplemented in theentirelong‐termcaresector.Thefirstmeasurementhasbeencarriedoutamongallcarehomes. The findingswerepublished in July 2008on a national website for consumers.Moreover, they were incorporated in the annual compulsory report on SocialAccountabilityinSeptember2008.Thisset isthebasisformonitoringbythehealthcareinspection, for commissioning by health care insurance companies and for qualityimprovement by internal quality management teams in dialogue with service usersand/or their representatives. Furthermore, the Framework offers a basis forbenchmarkingand consumer choice.Alongside this Frameworkanational improvementprogramme and supportive network is focusing on improving outcomes. Theimprovement programme is based on the collaborative principle. Until now, some 350care‐providing organisations have participated in this programme and significantimprovementshavebeenachieved(30to50%reductionofnegativeoutcomes). In2010theFrameworkwasrevised.

• The E‐Qalin quality management system is the result of a successful EuropeanCommission‐funded Leonardo da Vinci project (2004‐2007) with partners from Austria,Germany, Italy, Luxembourg and Slovenia. It is based on training of E‐Qalin processmanagersandaself‐assessmentprocessduringwhich66criteriaintheareaof‘structures& processes’, and 25 foci in the area of ‘results’ are assessed. As usual in qualitymanagement, the E‐Qalin self‐assessment builds on the PDCA‐management cycle (,+-&.!/).!01#23.!425)butpaysparticularattentiontotheassessmentofrelevantstakeholders’involvement in planning, implementing, monitoring and improving processes andstructures. Thus it takes notice of the specific character of Social Services of GeneralInterest(SSGI) inwhichusersarealwaysco‐producersofservices.Intheareaof‘results’theE‐Qalinmodelincludesa listofexamplesforkeyperformanceindicatorsfromwhichcare homes may choose, unless they have identified more appropriate indicatorselsewhere. Each keyperformance indicator thatwas selectedunder the 25 foci is thenanalysedfollowingasystematicassessmentscheme:Haveactualvaluesbeencollected?Havetargetvaluesbeendefinedand,ifyes,weretargetvaluesachieved?Whattrendcanbe read fromtheactual values (ifat least twoactualvalueshavebeen reported)?Howshouldtheresultsbeinterpreted?Whichfactorsinfluencetheresults?Which‘structures&processes’hadanimpactonresults?Whichsteeringmeasuresshouldbeenvisagedtoattainthehitherto(un)achievedtargetvalues?Which‘structures&processes’havetobechanged or improved to realise further improvements? What are the critical successfactors for improvements? By involving all stakeholders in the self‐assessment and thecontinuous improvement of quality, E‐Qalin strives to strengthen the individualresponsibility of staff and their ability to cooperate across professional andhierarchicalboundaries.Ongoingattemptstodevelopandincludetheassessmentofresult‐orientedkeydataandtoputthemintopracticeinmorethan100carehomesintheparticipatingcountries have shown that furtherwork is needed to elaborate on the description anddefinitionofresultsinlong‐termcare.

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• NationalMinimumStandardsandKeyLinesofRegulatoryAssessment(KLORA) inEngland:The Commission for Social Care Inspection (CSCI) is an independent body, set up byGovernment topromote improvements in social careand to inspectand reviewall socialcareservices(includingcarehomes)inthepublic,privateandvoluntarysectorsinEngland.It developed a framework for regulation (KLORA) based on the Department of HealthNational Minimum Standards for Care Homes. KLORA serves to assess residential carefacilities inrelationto7outcomegroupswhichhavebeendevelopedbytheGovernmentdepartment of health in consultation with older people and the residential care sector.Under eachoutcome group there are a rangeof standards that residential care facilitiesshould meet. In addition to the KLORA, most inspectors make use of a tool called SOFI(Short Observational Tool for Inspection) which helps assess the outcomes for thoseresidentswithdementia.In2008,CSCIintroducednewqualityratingsforallcareproviders,ranging fromno stars (‘poor’) to three stars (‘excellent’).Despite being overwhelmedbynumerous top‐down initiatives fromGovernment, this systemhas largelybeenwelcomedbytheresidentialcaresector;althoughthereissomeconcernthatthemovetowardslessfrequent inspectionand ‘self‐regulation’mightpotentially lead topoorpracticenotbeingpickedup and actedon quickly enough. From April 2009, theHealth and Social CareBillestablished theCareQualityCommission(CQC),whichtookoverthefunctionsfromCSCI,the Healthcare Commission and the Mental Health Act Commission (MHAC). The newCommissiondevelopedon itsmethodologyandcriteria forassessingcompliancewith therequirementsandestablishedanewregistrationsystemfromApril2010.WhilstCSCI(nowCQC)focusesonEngland,thereareongoingchangesinregulationacrosstheUK.

• The67HomeLife(MHL)programmeintheUK:InresponsetoarecentconsultationontheFramework for Registrationof Health and Adult Social Care Providers, the67 Home Life(MHL) programme (www.myhomelife.org.uk) argued for an outcome‐focused andevidence‐based regulation for residential care facilities based on 8 evidence‐based,relationship‐centred themesidentifiedinavisionforbestpracticethat issupportedbyallthekeyumbrellaorganisationsrepresentingcarehomesacrosstheUK.ThesethemeslinkcloselywithKLORAandarehighlyrelevanttocurrentdiscussionsaboutthepersonalisationofresidentialcarepracticeandtheworkondignityincare.The67HomeLifeprogrammeisaUK‐widecollaborativeinitiative,ledbyHelptheAgedincollaborationwiththeNationalCare Forum (represents not‐for‐profit residential care facilities across the UK) and CityUniversity, which brings together residential care providers, voluntary organisations,statutoryagenciesandcarehomeresidentsandtheirrelativestopromotequalityoflifeincare homes.MHL is acknowledgedby CSCI (nowCareQuality Commission) as a valuableprogramme with an important evidence‐based, relationship‐centred vision. It also haspotential influence with the other regulatory bodies across the UK. For instance, inScotland, the equivalent regulatory organisation (Care Commission) has integrated theprinciples and themes of My Home Life into its own quality framework and similardiscussions are ongoing in Wales and Northern Ireland. My Home Life offers a newevidence‐based, relationship‐centred vision which is owned and driven forward by theresidentialcaresector–animportantfactorwhendealingwithasectorthatfeels‘doneto’ratherthaninvolved.

• Theintroductionofthelong‐termcareinsuranceinGermanyhasgivenqualityassuranceofprofessionalnursingservicesandnursingfacilitiesmuchmoreprominence. Inthiscontextquality assurance is based on the principles and standards of quality that were agreedbetween the long‐term care insurance as a regulator and the federations of providers of

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care homes. Internal quality assurance in residential care facilities is complemented byinspections carried out by the Medical Advisory Service (Medizinischer Dienst derKrankenkassen–MDK).Untillate2009,theMDKperformedmorethan50,000inspectionsin care homes and community care services. These inspections focus primarily onprofessionalaspectsofcarequality intermsofprocessandoutcomequality.However,byassessingrespectiveconditionsofresidentsimportantdeterminantsofprocessqualitywithdirect influence on outcome quality could be identified. These determinants have beenincreasinglydevelopedoverthepastfewyearstowardsacomprehensive listofoutcome‐orientedqualityindicators.

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Startingfromthetraditionalseparationofstructural,processandoutcomequality,theselectedindicators cut across both the ‘process’ and ‘outcome’. It is therefore useful to distinguishbetweenthesetwo(Zimmermanetal.,1995):

• “Processindicatorsrepresentthecontent,actions,andproceduresinvokedbytheproviderin response to the assessed condition of the resident. Process quality includes thoseactivitiesthatgoonwithinandbetweenhealthprofessionalsandresidents.”

• “Outcomemeasuresrepresenttheresultsoftheappliedprocesses.”

While Zimmerman et al. (1995) and others before (Donabedian, 1980) focused their outcomemeasures on changes of the health status, the concept used in this project is broader. Theselectedindicatorsareconceivedasmeasurementcategoriesthatareabletoverifythedegreetowhichresultsinvariousqualitydomainsofacarehomehavebeenachieved.Apartfromastrongfocus on quality of life, quality of care and quality of leadership, the list of indicators alsoconsidersthedifferentperspectivesofresidents,staff,managementaswellasthesocialcontext(purchasers, family members, other external stakeholders). The selected indicators are notdefiningstandards.Theyshould,inthefirstplace,supportthedifferentstakeholdersdealingwiththemtostartworkingwithdatathatmaketheireffortsmoretransparenttothemandtoothersinordertomakesuccess/failurevisible,toreflectuponopportunitiesandtoproactivelydevelopmeasuresforimprovement.

Result‐oriented indicators aim to define objectives and standards at the level of the individualcarehomeoragroupofcarehomes,eitherinaregionalcontextoratthenationallevel.Forthisreasonwedidnotdefinestandardsforeachindividualindicator–onlybyanalysingthedegreetowhichobjectiveshavebeenreached,stakeholdersareincitedtothinkabouttheircorrelationwithstructuresandprocesses,respective improvementmeasuresandtheimplementationoftangiblemeasuresthatimpactdirectlyorindirectlyontheresultsoftheindividualindicator.

Fortheselectionofeachresult‐orientedindicator itwasthusagreedthatitwillhavetofulfilthefollowingconditions:

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• Ability to steer change: The set of indicators should be able to constitute a tool thatstakeholders working, visiting and living in care homes can use to bring aboutimprovements.Indicatorsarerelevanttosteerchange,iftheyallowverificationastohowfartherespectiveorganisationhascomeonitswaytoreachadefinedgoal.

• Reliability/Validity/Soundness: The indicators should be based on a body of evidencestrong enough as to preclude doubts towards their impact on the quality of life ofresidents.

• Feasibility: Attention should be paid to the resources needed to collect the necessaryinformationtobuildtheindicator,astime,financialresourcesandethicalconsiderationsallimposeconditionsontheinformationthatisavailable.

• Generalusability:Atbest,result‐oriented indicatorsshouldbeapplicable inallEuropeancare homes. This condition could not be maintained for all Member States due topolitical, cultural and structural differences both between and even within countries –respective choiceswill have to bemadeon the level of individual countries, regions orcarehomes.

• Quantifiable:Evenifbasedonqualitative information,theindicatorsmustbeabletobequantifiedsoastofacilitatetheprocessofbenchmarkingandofevaluatingprogress.

Oncetheinitiallistofindicatorshadbeenselectedaccordingtothecriteriadescribedabove,thesecondphaseoftheproject(September2009toApril2010)wasdedicatedtotheapplicationandvalidation of these indicators. This was achieved, on the one hand, by means of consensusbuildingwith experts in the field (Delphimethod) and, on theother hand, bymanagers of andpractitionersincarehomes:

• To carry out the Delphi study, ten experts of each participating country (N=70) wereinvited to participate. These were policy‐makers, inspectors, commissioners, serviceproviders and representatives of user organisations as well as researchers in sevenMember States (Austria, Germany, Italy, Luxembourg, The Netherlands, the UnitedKingdom,Slovenia),selectedonasetofcriteria,suchasfocusonresearchandpracticalexperience with the national frameworks. During three anonymous rounds the expertswere asked to reflect on both the overall framework and on each individual indicator.Experts reflected on the importance of the indicator, its feasibility, and put forwardsuggestions for further refinement and/or additional indicators. The project teamanalysed the results of each round andprepared the input for thenext round. Aweb‐basedinstrumentwasdevelopedforthestudytofacilitate thistaskfortheparticipants.TheDutchpartnerVilansorganisedthesurveyandanalyseditsresults.

• In order to facilitate a complementary validation process, representatives of about 25care homes from three countries (Austria, Germany, Luxembourg) were involved inworkshops(2times2days)thatweredesignedonpurposetoelaborateonmethodstoworkwith indicatorsand to validate theirapplicability incarehomes.TheseworkshopswereorganisedbyE‐QalinLtdandtheirpartnersfromAustria,GermanyandLuxembourg.The reasons for inviting mainly professionals that are applying the E‐Qalin qualitymanagement system in their care homes to these workshops were threefold. Firstly,

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E‐QalinLtd.asaprojectpartnerwasreadytoorganisetheworkshopsandtodevelopanappropriate workshop design; secondly, managers and staff in these care homes havestarted to work with result‐oriented indicators over the past few years so that it waspossible to work with them without starting from scratch, even though, thirdly, it hasbecome evident during this period that there is a great need for further training andadditionalreflectionontheworkwithresultindicatorsincarehomes.

Indicators for which no consensus was reached neither during the three rounds of the Delphiprocess, nor during the E‐Qalin workshops in Austria, Germany and Luxembourg were laterdiscussedinaprojectmeetinginvolvingDelphiexperts,participantsoftheE‐Qalinworkshopsandtheprojectteam.Indicatorsforwhichnoconsensushadbeenreachedinthevalidationphaseaswellasthe‘new’indicatorssuggestedduringthisphasewerefinallyincluded/excludedduringthemeeting.

ThepresentHandbooknowcontainsavalidatedlistof94result‐orientedqualityindicators(Section4).Italsocontainshintsandencouragementsonhowtousetheindicatorsinpractice(Section2),inparticularonhowtoapplythemwithafocusonimprovingthequalityoflifeofresidentsandotherstakeholdersincarehomes(Section3).TheHandbookisthusdirectedatallrelevantstakeholderswholive,visitandworkinandwithcarehomes:management,staff,residentsandtheirrelatives,butalsopublicauthorities,inspectionagenciesandpolicy‐makers.

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Performanceindicatorsareconcurrentlybeingoverratedandundervalued.Theyareoverratedbythosewhobelievethattheymayexpressquality incarehomesbymeansofsimplifiedrankingsandgradesonly.At thesame time, theyareundervaluedbymanymanagersandstaff in socialand care services who feel they should escape from competition, transparent service delivery,qualitymanagementandcomparisonofperformance.

Bothmotivationsarecallingforperformanceindicators.Whilebenchmarkingandgradeshavetobebasedondefinedmethods,validormutuallyagreedindicatorsandadecentlyorganiseddatacollection,managersandstaffofcarehomeshavetoshowtopublicpurchasers,residentsandanincreasinglycriticalpublichowtheyareusingpublicmoney,whytheircarehomeispreferabletoothers and how reliable their services are. Public authorities and other regulators are movingtowards a role as purchasers of services. This role necessitates clear descriptions of terms andproducts. Respective indicators and standards thus have to be collected and presented byproviderorganisations,butmanycarehomemanagersareaccomplishingthistaskoftenmainlytosatisfythefundingbodyratherthantoimproveperformance.Moreover,legallydefinedminimumstandardsandaccreditationcriteriaareprimarilyfocusingonstructuralquality(staffratio,surfaceperresidentetc.),sometimesonprocessquality(availabilityofacomplaintsprocedure,individualcare planning in place etc.), but rarely on the quality of results or outcomes. It is thus alwaysquestionable,whether suchminimumstandardsareappropriate todo justice toacontinuouslyalteringsocialandeconomiccontext,shiftingexpectationsof(potential)residents,relativesandmajor transformations of labourmarkets.Nevertheless legally prescribed (minimum) standardswillalwaysdefinethebottom‐lineofqualityincarehomes.

Still, we can also observe different trends: many providers have started to adapt qualitymanagementsystemsthatwereoriginallydevelopedinthemanufacturingindustrytothehealthandsocialcaresector(Eversetal.,1997)and tosearchforappropriate instrumentstomeasurethequalityofresults.Furthermore,publicadministrationsarecommissioningprojectstodevelopresultindicatorsforthesocialcaresector,andtheEUCommissionispromotingqualityguidelinesintheareaofsocialservicesofgeneralinterest.

Result‐orientedperformanceindicatorspersegiveonlylimitedtestimonyofthequalityofacarehome. They may point at specific strengths and weaknesses of a care home or at potentialproblemareasthatneedfurtherreviewandexploration.Notmore,butalsonot less(cf.Bullen,1991).

The collectionofdata fora specificperformance indicator is thestartingpoint for steeringandimprovement processes by all relevant stakeholders who are involved in the processes andaspectsconnected toservicedelivery(Eisenreichetal.,2004).Oneofthekeycriteriaforsiftingandvalidatingthepresent listofresult‐orientedperformance indicatorswas theirpertinence tosteerquality incarehomes.Aperformanceindicator isdefinedaspertinenttosteerquality if it

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helps to assess how far an organisation has got on its way to achieve an objective that wasdefinedbythemanagement.Thismeansthatwearepromotinganorganisationaldevelopmentperspective on quality improvement, rather than a perspective of standard‐setting and/or anapproachtomeasuretheperformanceofentirelong‐termcaresystems(seeChallisetal.,2006).

Working with performance indicators at an organisational level is thus inevitably linked tocontrolling, i.e. the management function that provides instruments/methods and theinformation that supports decision‐makers to accomplish planning and control processes moreefficiently.Workingwithperformance indicators incarehomes,however, goesbeyond classicaleconomicdefinitionsandfunctionsofcontrolling.Thecomplexityofcarehomescallsforsteeringin relation to the quality of care, the organisational culture and networking as well as theresidents’,relatives’andstaff’squalityoflife.

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Work with performance indicators may be planned during strategy development processes orduring the introduction of a quality management system. In any case it is important to clearlydefineobjectives,tochooseappropriateindicatorsandtodefinetargetvalues.Atthispointitwillalsobeusefultocheck,whether theorganisationisactually ‘fit forcontrolling’(seeBox)and toimplementperformanceindicators.

Thedefinedindicatorsandrespectivetargetvalueswillhithertorepresenttheframeandbasisforfuture management decisions. It should therefore be assured that they are quantitative(numeric), pertinent for steering, valid as well as feasible in the current context of theorganisation.

Result‐orientedperformanceindicatorsaremarkersfortheperformanceofacarehome,buttheywill never be able to display all accomplishments and qualities of an organisation. On the onehand,itbecomesrelativelyfutiletocollectdataforhundredsofindicators(e.g.forallindicatorspresented in this Handbook), as they cannot be controlled and steered simultaneously. Anyflexibilitywouldgoastrayandstaffwouldbecomeoverwhelmedduetoexcessivedatagathering.On theotherhand, too few indicatorswould representan insufficient framework for triggeringimprovementprocesses.Forinstance,tobeginwith,acarehomemightconsiderusingabout10‐15keyperformanceindicatorsforcontinuouscontrolofkeyareastobemonitoredandsteered.Additionalindicatorsmightthenbeappliedatthedepartmentleveland/orforpurposesoflegallyprescribedorvoluntaryannualreporting.Furthermore,theremightbesupplementary indicatorsthatwillnotbeassessedonamonthlyorquarterlybasis,e.g.thosebasedonsurveysthatwillbeperformedonlyonceayearorwithevenlongertimeintervals(see ‘qualityof life’).However, itshouldbenotedthatthereisnoevidencebasetoprescribehowbesttousetheindicatorsinthisproject.

Other planning issues pertain to the distribution of responsibilities for data collection,documentation,analysisaswellasreporting.Forinstance,itisimportanttoconsiderwhetherthedesign and realisation of surveys and their analysis should better be outsourced to externalpersonsororganisations.

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P7."4':"$'&.:'))7&,Q"Controllingwillonlytakeeffectifitsfunctionisacceptedandusedbymanagement.Thiscanonlybe accomplished if there is a shared idea within the organisation about the potentials ofcontrollinganditsfunctioning.Thisgeneralsituationcanbeassessedbymeansofachecklisttocriticallyscrutinisethefollowingissues:

• 0)&*829:#!$%-(#;)%3!2)&*959)&<=Havemanagementandleadershipprinciplesbeenmutuallyagreedandhavetheybeencommunicatedwithintheorganisation?Areplanningandcontrolfunctionsbeingrealisedbymanagersintheirrespectiveroles?

• /#$9&#*!9*#&5957=!Dostaffmembershaveageneralimageaboutwhatcontrollingcanbringaboutandhowitworks?

• >5-&*-%*9<#*!<5##%9&?!@%)2#<<#<=Havesystematicandstandardisedprocessesforplanningandcontrollingbeendefinedandarethesebeingimplementedinpractice?

• 4@@%)@%9-5#!9&<5%8(#&5<=Aremethodsandinstrumentsofcontrollingandworkwithindicatorseasytohandleandcompatiblewithotherinstruments?Havestaffbeentrainedappropriatelytoworkwiththeseinstruments?

• 6-&-?#(#&5!-&*!51#9%!@)5#&59-+=!Ismanagementstaffable,allowedandwillingtoworkwithcontrollinginstruments?

• A8&259)&-+!@%)$9+#<=Isthedesignatedcontrollersufficientlyqualifiedandaccepted?Arethereclearresponsibilitiesastowhowillrealisethecontrollingtasks(ifnofull‐timecontrollerisemployed)?

• B%?-&9<-59)&-+!#(C#**9&?=Isthereaclearplaceforcontrollingintheorganisationalchart?

Source:Theentirechecklistcanbeobtainedatwww.bvmba.net.

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Planningwithoutcontrolismeaningless.Onlybymeansofcontrollingcanthefollowingfunctionsofworkwithindicatorsbeensured:

• Tomakeobjectives(targetvalues)tangibleandworkable,

• Todocumentperformancebymeansofnumericvalues,

• To follow the degree to which defined objectives have been achieved by means of acomparisonbetweentargetvaluesandresults(actualvalues),

• To realise transparency towards residents, families/friends, staff as well as towardsexternalstakeholders(purchasers,deliverers,public),

• Toinstallasystemofearlywarningbycontinuousmonitoringofselectedvalues,

• Toidentifyopportunitiesforimprovementbyrealisinginternalcomparisonsoftargetandactualvaluesovertimebothinternallyandeventuallywithothercarehomes.

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Systematiccontrollinghas thus todecideandassesswhich indicators shouldbe chosenand forwhat reason (clear definitions). Furthermore, it has to be formally decided who will beresponsible for data gathering (contact person, administrative support), how the data will becollected(schedules,IT),whenandhowfrequentlyaswellastowhomtheyhavetobereported.Also,itisessentialtobeclearaboutthegroupofpeoplewithwhomanappraisaldiscussionwillbe carried out, e.g. an ‘indicator task force’. In general, particular attention should be paid toavoidfrustrationofstaffthat,for instance,couldarisefromhavingtocollectdatatwiceorfromimprecise communication about which decisions and tangible interventions were derived fromresults.

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Result‐oriented performance indicators are only a small part of quality management that isgeared at describing, assessing and improving results of services in a care home. Data as suchrarelyspeakforthemselves.Thisiswhythenextstepsareoffundamentalvalue:

• Adetailedanalysistodiscusstrendsanddiscrepanciesbetweentargetandactualvalues.Suchadiscussionpreferablyrequiresanatmosphereoftrustandadialoguethatdoesnotaimatpersonalattackandrespectivejustification.Thiskindofappraisaldiscussionshouldtakeplaceinatimelymannerwithinthe‘indicatortaskforce’orinaface‐to‐facemeetingbetween the manager and a selected staff member responsible for the respectiveindicator.Theaim is to identify structuresandprocesses (critical success factors) in thecarehomethatmighthaveinfluencedthe(un)achievedresult.

• Apartfromidentifyingimpedimentstotargetachievement,itisthennecessarytoaddresswhat kind of steering activities could be developed to trigger a further step forimprovementor,atleast,toavoidfurthernon‐compliancewithdefinedstandards.

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The systematic embedding of result‐oriented performance indicators as part of managementtasks in care homes has only just begun. Planning and steering are, at best, based on costaccounting. Surveys and the analysis of qualitative indicators from a resident and/or relative’sperspective(qualityofcareandassistance,qualityof life)orinrelationtothequalityofworkingconditions still represent new frontiers. This is particularly true when it comes to derivedstrategiesandrespectiveimprovementprocesses.

One reason for laggingbehind in thisapproach is certainly the fact thatpersonal social serviceshave for a long time been oriented exclusively at professional ethics and the quality ofrelationships, rather than at economic efficiency and the quality of results. In a context ofdiminishingsocialcarebudgets,growingmarketorientation(keyword:NewPublicManagement)andhigherexpectationsofusers,asof thisdateprovidersandpurchasersof social servicesareconfrontedwithnewchallengescallingforcontrolling,efficiencyandevidence‐based indicators.However, social careprovidersaresolicitednot to ‘throwout thebabywith thebathwater’bynow focusing all their energy on economic criteria and forgetting about the characteristics ofpersonalsocialservices.Thesespecificitieshavetobecomepartandparcelofrespectivequalitymanagement systemswhile, at the same time, beingunderpinnedby facts and figures, amongothers by result‐orientedperformance indicators.Only on thisbasiswill itbepossible to frame

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negotiationswithpurchasersonprices-&*quality,andperhapstomovetowardstransparentand‘quality‐based’paymentschemes.

Beforegettingthere,alotofflip‐chartpaperwillbefilledwithgraphsandkeywords,butvariousapproacheshavealreadybeenstartedindifferentMemberStates,callingfornetworkingandanexchange of experiences. The project ‘Quality management by result‐oriented performanceindicators’ responded to this demand in multiple ways. One of them was the organisation ofvalidationworkshopswithcarehomeandqualitymanagersinAustria,GermanyandLuxembourg.These workshops had two main aims: first of all, to encourage and realise national andtransnational exchange about practical, missing and new issues in working with performanceindicators. Secondly, the involvement of participants in the validationof thepreliminary list ofindicatorsaimedatapracticalexchangewithaEuropeanperspective.

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S3T*$.7R*/"• Todefineandreflectuponresult‐orientedperformanceindicators:whichindicatorsare

pertinenttosteerqualitydevelopmentincarehomes?

• Toidentifyrelevantsteeringtasksincarehomes:howfarcanindicatorssupportimprovedsteering?

• Toexchangeexperienceswithkeyperformanceindicators.

• Togetacquaintedwithnewinternationallyappliedindicators:whatistheirrelevanceforcarehomesinmycountry?

• Todevelopcriteriaforvalidatingindicatorsdependingonthevariouscontextualconditions.

12:,*.",:';?"Care home managers and management staff with experience of working with result‐orientedperformanceindicators,inparticularthosewithcontrollingknowledge.

K*.='+/"Interactiveworkshop,facilitation,workinggroups,validationtools.

<':%/='?"!"U0"+2C/V"• Presentationoftheprojectandinformationabouttasks;expectationsofparticipants

• Definitions:keyresult‐orientedperformanceindicators,quality,steering,workingwithindicators,controllingandindicators,leadingwithindicators

• Identificationofsteeringtasksincarehomesandrelevantindicators

• Exchangeofexperiencesfromworkwithkeyperformanceindicators

• Presentationofadditionalindicatorsbasedoninternationalexperiences

• Tasksandcriteriaforvalidatingindicatorsbetweenthetwoworkshops

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<':%/='?"0"U0"+2C/V"• Feedbackofparticipantsontherelevanceofpresentedindicators

• Reflectionaboutcriteriaandtheirrelevanceindifferentcontextualconditions

• Choiceofthe10‐15mostrelevantindicatorsforindividualcarehomes(dependingoncontext)andelaborationofaplan,howtoworkwiththeseindicatorsthatwillbeimplementedintherespectivecarehome

A first finding of the workshops was that, in daily practice, systematic controlling with keyperformance indicators is taking place at best in a rudimentary manner: data collection andsatisfaction surveys are rare, while resistance of staffwho fear losing autonomyand control iswidespread, as well as a general apprehension of comparisons and transparency. Monitoringquality of results andquality assurance in the context of yearly inspections aremainly used tosatisfy the regulator, but the implementation of quality management systems has started toincreaseawareness forqualitydevelopment,alsobymeansof strategicplanning incarehomes(seeTable1).

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Systematiccontrollingindailypractice

Monitoringqualityofresultsandqualityassurance

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10‐15keyperformanceindicators

20‐25performanceindicators,respectivelythoseforeseenbytherespectivequalitymanagementframework

Revisionandselectionofappropriateperformanceindicatorsforsteeringandcontrolling

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Continuousdocumentation;datacollectiononpurpose

Continuousdocumentation,specialsurveys,externalauditorinspection

Evaluationofworkwithindicators;revisionofcontrollinginstruments

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Yearly(every2years) Every3‐4years

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Participants of validation workshops were mainly chief executives of care home groups, carehomemanagers,headnurses,qualitymanagement officersand controllers fromprivate,quasi‐public and private non‐profit organisations. They identified a variety of hitherto neglected orbarely tapped potential of working with performance indicators. Such instances includedfollowingtrendsoverlongerperiodsoftime,comparisonswithinagroupofcarehomesbutalsowithotherprovidersaswellasfirststepstowardsbenchmarkinginaregionalenvironment.

Aspecific,mostlyunsolvedchallenge for themanagementstaff seems to consistof fear tonotpickthe‘correct’keyperformanceindicator–andthustheyoftenprefernottochooseany.Itwas

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thus important to discuss the relevance of indicators in different contexts, in particular whengoingbeyondpurebusinessdata.During the firstworkshopparticipantsalready foundout thatindicatorsarenot‘good’or ‘bad’assuch,buttheyservetoanalysepotentialproblemsandhelpsteer improvement measures. Working with indicators means goals must be set that aremeasurable and traceable – be it in the area of nursing care, in supporting quality of life ofresidentsandstaff, leadershiporeconomicperformance,and in relationwith families,partnersandsuppliers.Onlyifdataonthe“percentageofresidentswithpressureulcersthatstartedinthecarehome”havebeencollectedandonlyiftargetvalueshavebeendefined,canonecontrolovertimewhethertargetvalueshaveactuallybeenachieved.Onlyifperiodicsatisfactionsurveyswithresidents, families and staff are accomplished, may one reflect upon results and designcorrections.Onlythroughadecentanalysisonwhytargetswere(not)achievedcanimprovementmeasuresbedevelopedandimplemented.

By focusing on 10‐15 3#7 performance indicators, as well as the systematic controlling and adialogue about related issues in daily practice, a continuous improvement process in the carehomecanbesetinmotion.Oncestaffandmanagementhavestartedtoimplementthisapproachitwillbeeasiertochooseappropriate3#7performance indicatorsandtodistinguish themfromotherperformanceandresultindicatorsthathavetobemonitored.

Atthebeginningofthesecondworkshopparticipantsprovidedfeedbackonthepreliminarylistofindicatorsbymeansofatraffic‐lightsystem(usefulforall,usefulunderspecificconditions,notatall useful). Furtheron theyalso ranked indicators to endupwithabout 15 indicators that theyconsidered the most relevant or useful among the indicators. Related planning and first stepstowards implementationwereat the centreof thesecondday,with respectiveworking groupselaboratingontwoindicators.

Altogether,participantscameoutwithalotofenthusiasmfromtheseworkshopsaswellaswithsuggestionsfortheirdailypractice,methodsandinstrumentstoworkwiththe indicators.Apartfrom choosing indicators and getting to grips with their operationalisation in terms of cleardefinitions,thenextchallengeformanagers isnowtoidentifycriticalsuccessfactorsandto linkanalysis and steering processes in their daily practice. The workshops have in any casecontributed to reducing fears about bureaucratic control and punishment when working withperformanceindicators.

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The validation workshops of key performance indicators have resulted in the identification offundamentalaspectsatdifferentlevelsinrelationtoworkingwithindicatorsincarehomes:

• Thereisastronginterestinresult‐orientedperformanceindicators iftransparencyisnotbeingapproachedandexperiencedasamereexternalobligation.TheGermanMDSalsoreportsthatinspectionsbymeansofindicatorsareusuallyperceivedbymanagementandstaffasencouragementandrecognitionoftheirperformance.

• Resultandperformance indicatorsarenotan end in itself,butan instrument to triggerreflection and dialogue within the organisation about the causes and potentialconsequencesofinterventions.

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• Working with indicators can facilitate quality improvement in the care homeindependently from the quality management system that is being applied. However,living‐up to the intentions of quality management by involving front‐line staff, forgingpartnerships with other stakeholders and linking performance measures to strategicmanagementdecisionswillenhanceitsimpact.

• Systematiccontrollingandtheidentificationofcriticalsuccessfactorsinconnectionwithachievementsreflectedinperformanceandresult indicatorshavetobeunderpinnedbyenablingmechanismssuchasappropriatetrainingandthepreparationofstaff(seeBox).

• The evidence base for choosing and analysing appropriate result‐oriented performanceindicatorsandrespectivestandardsforcarehomesisrelativelyscarceandcallsforfurtherinvestigation.

To conclude, an important step to further disseminate and promote workwith result‐orientedperformanceindicatorsincarehomeswouldcertainlyconsist inestablishingadialoguebetweenproviders and purchasers – respectively inspection units and organisations representing(potential) residents. The aim would be to mutually agree upon the scope and meaning ofperformanceindicators,theirchoiceandthedegreeoftransparencythatwouldbefeltconduciveandacceptablebyallstakeholders.

G'.*&.72)" $'&.*&." '4" .:27&7&,/" '&" :*/;).>':7*&.*+" ?*:4':-2&$*" 7&+7$2.':/""7&"$2:*"='-*/"• Definitions:performanceindicators,result‐orientedperformanceindicators,steeringquality,

workingwithindicators,controllingandresult‐orientedindicators,leadershipandindicators

• Identificationofsteeringtasksincarehomesandrelevantresult‐orientedperformanceindicators

• Exchangeofexperienceswithindicatorsindailypractice

• Developmentofownindicators,e.g.basedonthosepresentedinthishandbook

• Presentationofresult‐orientedperformanceindicators(seeSection4)

• Reflectiononcriteriaabouttherelevanceofindicatorsindifferentcontextualcircumstances:differentiationbetweenperformanceindicators,resultindicators,keyperformanceindicatorsandkeyresultindicators

• Selectionof10‐153#7performanceindicatorsforparticipants’ownorganisationstostarttheimplementationofsystematiccontrollingindailypractice

• Planningtheimplementationofresult‐orientedcontrollingincarehomes:conduciveframeworkconditions,planning,responsibilities,systematicsteering

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Themainfocusofqualityinitiativesisoftenplacedonthequalityofstructuresandprocesses.Thisisdueinthefirst instancetotheprofessionalizationoflong‐termcare,withaparticularlystrongfocusonthequalificationrequirementsofstaff inthepastandwithanemphasisonraisingthequality of care processes. The second point is that the change to a user‐oriented, user‐participation perspective required for stronger outcome orientation is taking time to evolve inEurope,particularlywherequalityoflifeaspectsareinvolved.Butstillitisoftenoverlookedinthecourse of practical work, although it recently has been receiving a lot more attention fromspecialists inthefield. Inaddition,thereisnoagreementontheweightthatshouldbeattachedtothevariousaspectsofapotentialoutcome.Thisisparticularlyevidentinthedebateonqualityoflife,whichplaysmoreofatokenroleinmanyconceptsthanthatofaconceptuallysound,fullyoperationalised construct being implemented in everyday practice. The outcomes of careinterventions frequently lacksatisfactoryevidenceand reliable indicators,but this is evenmorethecasewhenappliedtoqualityoflife,particularlyinitsevaluationfromtheperspectiveofusersandcarerecipients.

For research on quality of life, no uniform tradition of research exists. Therefore it is notsurprising that the terms ‘quality of life’, ‘satisfaction’ or ‘well‐being’ which are used in thisconnection have been taken up by various branches of research, butwithout being integratedintoanoverall conceptualunderstandingofwhat olderpeoplewant fromqualityof life incarehomes.Theterm‘qualityoflife’iscloselyconnectedwith‘welfare’.Accordingly,qualityoflifeisacomplex, multi‐dimensional concept simultaneously comprising both tangible and intangible,objective and subjective, individual and collective aspects of welfare, with the emphasis on‘better’ratherthan‘more’.Sincethe1970s,welfareresearchhasalso increasinglybeenfocusedon thepartial aspect of the subjective dimension, knownas ‘subjectivewell‐being’. Apart fromthis branchof research, psychologically orientedwell‐being and health research (Abele/Becker,1991;Mayring,1987)alsoattributesgreatsignificancetothesubjectiveaspectsofqualityoflife.Althoughithassofarbeenunabletoestablishauniformconceptualunderstandingofqualityoflife inoldage,ageingsciencehas identified ‘well‐being’and ‘satisfaction’askey indicatorsofasuccessful ageing process. Concerning research with older people, it should be noted that inrecentyearsprogresshasbeenmadetomeasurethesubjectiveandobjectivequalityoflifewithregard to the areas of health‐related quality of life, home environment and aspects ofparticipation and social support. However, research on the quality of life for older people inhealthservicesand long‐term care institutions is still inneedof furtherdevelopment. Researchconcerning the quality of life at a very advanced age which also includes older people withdementia,iscurrentlystillveryrudimentary.

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Accordingly, quality of life essentially comprises two dimensions, a subjective as well as anobjective dimension. The objective dimension can be measured with the help of suitable‘objective’ indicators of the individual’s situation in life. Here, relevant aspects are the socio‐economicstatus,thehomeanditsenvironment,socialrelationshipsandsocialsupportaswellasthe degree of participation in public life. However, this presupposes that these are importantfeaturesforthatparticularindividual,unlesstheyhavebeenidentifiedasbeingimportantbytheindividual.The focusof the individual componenthere ismoreon the individualassessmentoftheir situation, that is their perception of the quality of life in these and other areas, whichincludescognitiveandemotionalaswellasbehaviouralaspects. Inthiscontextitisimportanttonote that individually perceived quality of life not only includes relevant areas of life, but alsointangible and collective values such as ‘freedom’, ‘justice’ or the degree of ‘autonomy’ asexperiencedby the individual. This is of special importance for thequality of life of care homeresidentswhosescopefordeterminingandinfluencingtheirownobjectivelivingenvironmentislimited and also highlights the significance of other intangible components such as ‘dignity’,‘privacy’or‘safety’.

In positive cases, the agreement between both perspectives (‘good’ objective conditions andsubjective assessments) can be taken as an indicator of a highor goodquality of life, while innegativecases(‘poor’objectiveconditionsandsubjectiveassessments)thequalityof lifecanberegarded as low or ‘poor’. But often the connection between subjective quality of life andobjective criteria is only meagre (inter alia Kane, 2003), a phenomenon also known as the‘paradoxof ageing’, with research results indicating that especially older peoplewith decliningobjective resources show a high level of satisfaction (Mayring, 1987; Smith et al., 1996;Staudinger, 2000). However, not all quality of life researchers regard this empirically verifiablephenomenonasaparadox,butsometimesalsointerpretitasaneffectoftheplasticityofoldage(Lehr,1997)and/orasuccessfulcopingstrategy.Basically,thesefindingsalsoinvariablyraisethequestionofvalidation(validity)oftheanswersfromresidents.Kane(2003)describesvalidationofthesubjectivephenomenaasoneofthefundamentalchallengesinresearchaboutqualityoflife,eventhoughthereisnoconclusiveanswertothisquestion.

However, the consequenceof restricting investigations exclusively to examineobjective criteriafor the quality of life would lead to the exclusion of an essential aspect, since particularly thefindings from health‐related research about quality of life (inter alia Idler, 1993; Filipp/Mayer,2002;Lehr,1997;Lehr/Thomae,1987;Mossey/Shapiro,1982)overwhelminglydemonstrate thesignificanceofthesubjectiveaspect.

There is more or less universal agreement concerning this general conceptualisation and thedistinction between subjective and objective components. With regard to measuring thesubjective quality of life, however, different views exist about approaches and methods. Forinstance, a distinction ismadeherebetween the cognitive component of ‘satisfaction’ and theemotional component of ‘happiness’. Another approach to conceptualisation following Lawton(Lawton,1984)distinguishesfouraspectsofsubjectivequalityoflife:

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• anegativeemotionalfactor,

• apositiveemotionalfactor,

• happinessastheconvictionthatthepositiveemotionsexistonalong‐termbasis,and

• goalcongruence,i.e.theconvictionofhavingreachedone’spersonalgoals.

Here,happinessrepresentsanimportantfactorofwell‐being,comprisingcurrent(astate)aswellashabitualwell‐being(atrait).Currentwell‐beingincludesaperson’spresentexperience,positiveemotions,moodsandphysicalfeelingsaswellastheabsenceofdiscomfort(Abele/Becker,1991:13).Habitualwell‐beingcovers“statementsaboutthewell‐beingthatistypicalfortheindividual,i.e. assessments of aggregated emotional experiences”. It should benoted that the term ‘well‐being’inthiscontextistobeunderstoodnormatively(positively).

Oftendiscussed is theconnectionbetween thequalityof long‐termcareand thequalityof life.Empiricalresearchprovidesnouniformanswertothequestionof1);51#!F8-+957!)$!2-%#G?9:9&?!-&*! 51#!F8-+957! )$! +9$#!-%#! 9&5#%%#+-5#*. In everyday theory, it isassumedthat there isapositivecorrelationbetweentheresident‘squalityoflifeandthequalityofcare‐giving.Accordingtosuchassumptions,qualityoflifecouldserveasanindicatorforthequalityofcare‐giving.Theavailableresearchresultsonthistopicareonlyscanty,andtheypresentaninconsistentpicture,dependingon which aspects of the quality of life and care‐giving have been investigated. However, thestudiescarriedout so faroftenshowno connectionbetween thequalityof care‐givingand thequalityoflife(Challingeretal.,1996;Rubinstein,2000;Sowarka,2000).

Therelationshipbetweenqualityofcare‐givingandqualityoflifeislinkedtothequestionofhowquality of life is understood and defined. If quality of life is understood as synonymous withconditions(oflife),itamountstoaninputanalysis(Veenhoven,1997;Filipp/Mayer,2002).Inthatcase,thequalityof life isseenasaconditiondependingon thequalityofcare‐giving. If,on theotherhand,qualityof life isdefinedasaperson’ssubjective, individualview(Veenhoven,1997;Filipp/Mayer,2002),aconnectionbetweenthequalityofcare‐givingandthequalityof lifedoesnotnecessarilyexist.

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Researchonthequalityoflifeincarehomesformanyyearshadaratherlowpriority,whichwasdue to a strong focus on the investigation of ‘traditional’ quality of care topics aswell as to acertainamountofaversionagainstscienceandmeasurementsbythosewhoareresponsibleforimprovingthequalityoflifeinpractice(Kane,2003).

Qualityof lifedimensionstobedescribedbymeansofobjective indicatorscannotbeapplied inthesamewaytoeveryage.Thisisparticularlytrueforcarehomeresidents.Inaddition,differentconceptualisations of quality of life appear in the literature. For our work, we selected thefollowing concepts, which, on theonehand, represent different approaches to conceptualizingquality of life in nursing homes and on the other hand, have overlapping themes, aspects andperspectives.

Asarepresentativeofastrongempiricalapproach,Kane(2003)defines thefollowingfactorsasimportant aspects of quality of life for older people in care homes, derived from extensiveresearchontheuserperspective.

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• physicalabilities

• self‐care(autonomy)

• dailyactivities

• socialfunctions

• sexualityandintimacy

• psychologicalwell‐beingandgrief

• cognitiveabilities

• pain/discomfort

• energy,fatigue

• self‐respect

• senseofmastery

• subjectivehealth

• satisfactionwithlife

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Kanepointsoutthatmanycarehomesfocusonthequalityofcareandondisease‐specificaspectsanddonottakeenoughintoaccountqualityoflifeaspects.Shepleadsfordirectandsystematicinquiriesandseesthemainchallengeinanecessaryculturechangeinnursinghomes.

AnotherapproachfromtheUKthathaswidelyinfluencedthedevelopmentofaUK‐wideinitiativeto improvequality of life in care homes for older people (67 Home Life programme; formoredetailsseehttp://www.myhomelife.org.uk)focusesmoreondifferentperspectivesandtakesintoaccounttheviewofresidents,staffandrelatives(NCHR&DForum,2007).

This reviewof the literature updated a previous reviewbyDavies (2001) on the care needs ofolderpeopleandfamilycare‐givers incontinuingcaresettings.Forthepurposesofthisproject,items for the reviewwere identified from the fields of nursing, health,medicine, allied health,socialgerontology,socialworkandpsychology.Synthesisof thisdiverse literaturefocuseduponthe experiences of residents, family care‐givers and staff in order to identify strategies whichpractitioners could use to enhance the quality of life of residents of care homes, while alsosupportingcare‐givers inthemostappropriateway.Anappreciative inquiryapproachwastaken(Cooperrider et al., 2003) to focus on positive messages, rather than poor practice. Wherepossible, reviewers were asked to word their messages positively, identify examples of goodpracticeandensuretheolderperson’svoiceremainedcentraltothework.

Eight evidence‐based, relationship‐centred themes underpin the 67 Home Life (MHL)programme. Threeof the themes are about the approach to care (Personalisation) and include‘6-9&5-9&9&?! 9*#&5957LM! N>1-%9&?! *#29<9)&G(-39&?L.! and ‘0%#-59&?! 2)((8&957LO! Another threethemes (Navigation) are focused on what staff need to do to support residents and relativesthroughthejourneyofcareandinclude‘6-&-?9&?!5%-&<959)&<LM!NP(@%):9&?!1#-+51!-&*!1#-+512-%#L!and‘>8@@)%59&?!?))*!#&*!)$!+9$#LO!Theremainingtwothemesareabout‘Transformation’andareconcerned with whatmanagers need to do to help support their staff to put the previous sixthemesintopractice(‘H##@9&?!;)%3$)%2#!$95!$)%!@8%@)<#Land‘,%)()59&?!@)<959:#!28+58%#<LQ. !Seethefollowingtableforafullerexplanationofeachoftheeightthemes.

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123)*"A8"" !5*]'-*"E74*8"1=*-*/"4':"?:'-'.7&,"B;2)7.C"'4")74*"7&"$2:*"='-*/"U^5]F_["P':;-`"0NNJV

K27&.27&7&,"O+*&.7.C"U+"&$,(#6'$#1',(V Workingcreativelywithresidentstomaintaintheirsenseofpersonalidentityandengageinmeaningfulactivity.

5:*2.7&,"5'--;&7.C*7+"&$,(#6'$#1',(8" Optimisingrelationshipsbetweenandacrossstaff,residents,family,friendsandthewiderlocalcommunity.Encouragingasenseofsecurity,continuity,belonging,purpose,achievementandsignificanceforall.

6=2:7&,"[*$7/7'&>-2%7&)*7+"&$,(#6'$#1',(8" Facilitatinginformedrisk‐takingandtheinvolvementofresidents,relativesandstaffinshareddecision‐makinginallaspectsofhomelife.

K2&2,7&,"1:2&/7.7'&/*79#:')#1',(8* Supportingpeoplebothtomanagethelossandupheavalassociatedwithgoingintoahomeandtomoveforward.

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Ensuringadequateaccesstohealthcareservicesandpromotinghealthtooptimiseresidentqualityoflife.

6;??':.7&,"a''+"X&+"'4"E74**79#:')#1',(8" Valuingthe‘living’and‘dying’incarehomesandhelpingresidentstopreparefora‘gooddeath’withthesupportoftheirfamilies.

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Identifyingandmeetingever‐changingtrainingneedswithinthecarehomeworkforce.

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Developingleadership,managementandexpertisetodeliveracultureofcarewherecarehomesareseenasapositiveoption.

!67!Home Lifeprovidesaconceptual framework for promotingqualityof life incarehomes forolderpeopleand isunderpinnedbyrelationship‐centredcare(Tresloniand thePew‐FetzerTaskForce,1994)andtheSensesFramework(Nolanetal.,2006).Basedonempiricalresearchincarehomes askingolder residents, relatives and staffwhat is important to them,Nolan et al. (ibid.)suggest that the fulfilment of six senses (security, belonging, continuity, purpose, achievementandsignificance)iskeytogoodrelationshipsinthiscontext(seeTable4forafullerexplanationofeachofthesixsenses).

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6*&/*"'4"/*$;:7.C" • tofeelsafe

6*&/*"'4"3*)'&,7&," • tofeelpartofthings

6*&/*/"'4"$'&.7&;7.C" • toexperiencelinksandconnections

6*&/*"'4"?;:?'/*" • tohaveagoaltoaspireto

6*&/*"'4"2$=7*R*-*&." • tomakeprogresstowardsthesegoals

6*&/*"'4"/7,&747$2&$*" • tofeelthatyoumatterasaperson

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Based on Nolan’s research, attempts have been made to construct tools (CARE profiles) tomeasurequalityof lifefromtheperspectiveofolder residents,relativesandstaff incarehomes(Faulkner et al., 2006). The CARE profiles were developed and tested and an Event FrequencyApproach was adopted to create three questionnaires (residents, relatives and staff), eachcontaining 30 consensually valid positive events. The thematic content of these events wasbalanced for each questionnaire using the Senses Framework as a theoretical model. Oncecompleted, the CARE profiles were tested in four care homes. Although the CARE profiles arehelpful inmeasuringqualityoflifeincarehomes,notonlyfromtheperspectiveofresidentsbutalso from those of relatives and staff. Further development of the profiles is needed if theexperiencesofcognitivelyimpairedresidentsaretobeincludedintheassessmentprocess.

Indifferentmeta‐analyses,Schalock(Schalock,2006)identifiedeightcorequalityoflifedomainsandthethreemostcommonindicatorsforeachofthecoreQoLdomains.Thisconceptualisationcanhelp tooperationalise thegeneraldomainsand formulatespecificquestions on theQoLofresidents.

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X-'.7'&2)"(*))>3*7&," • Contentment(satisfaction,moods,enjoyment)

• Self‐concept(identity,self‐worth,self‐esteem)

• Lackofstress(predictabilityandcontrol)

O&.*:?*:/'&2)":*)2.7'&/" • Interactions(socialnetworks,socialcontacts)

• Relationships(family,friends,peers)

• Supports(emotional,physical,financial,feedback)

K2.*:72)"(*))>3*7&," • Financialstatus(income,benefits)

• Housing(typeofresidence,ownership)

G=C/7$2)"(*))>3*7&," • Health(functioning,symptoms,fitness,nutrition)

• Activitiesofdailyliving(self‐careskills,mobility)

• Leisure(recreation,hobbies)

G*:/'&2)"[*R*)'?-*&." • Personalcompetence(cognitive,social,practical)

• Performance(success,achievement,productivity)

6*)4>+*.*:-7&2.7'&" • Autonomy/personalcontrol(independence)

• Goalsandpersonalvalues(desires,expectations)

• Choices(opportunities,options,preferences)

6'$72)"7&$);/7'&" • Communityintegrationandparticipation

• Socialsupports(supportnetwork,services)

F7,=./" • Human(respect,dignity,equality)

• Legal(citizenship,access,dueprocess)

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Quality of life researchwith older people and care home residents has brought about, amongotheraspects,thefollowingkeyissues(Schönberg,2006):

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The results of the welfare survey, for example, show age‐specific degrees of significance indifferent areas of life. The areas of ‘health’, ‘religious faith’ and ‘protection from crime’ are ofgreatersignificanceforolderpeoplethanforyoungeragegroups.

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Objectiveconditionsoflifemainlyhaveanindirecteffectonsubjectivewell‐beingbutthereisnota direct connection between both. The concept of QoL always requires a value judgementconcerningthequestion“Whatisagoodlife?”,whichinthecontextofourworkmainlyrequiresasubjectiveapproach.Forexample,independentlyfromanobjectivehealthassessment,subjectivehealthinparticularisavitalfactorinqualityoflifeandcanevenserveasapredictorformortality(Idler,1993;Mossey/Shapiro,1982).

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Thisresultwasprovedempiricallyby theextensiveBASEstudy.Concerning thequalityof lifeofcare home residents, this group was shown to represent “an identifiable sub‐group of olderpeople with a higher risk of impaired well‐being” (Smith et al., 1996: 511). “(However)...it isextremelyimportanttopointoutthatthisnegativedifferencecouldalreadyhaveexistedpriortomovingintoahome”(Smithetal.,1996:512).

These results point to various facets of further research needs on the quality of life of olderpeople living in care homes. For example, thequestion arises how residents “(...) arrange theirownhierarchyofvalueswhentheirlivingspacebecomesincreasinglyrestricted”(Sowarka,2000:79).

Lastbutnot least, findingson thequalityof lifeof residents suffering fromdementiahaveonlyappearedduringrecentyearsandwillneedmoreinvestigation.Ithasbeenshown,however,thattoacertaindegreepersonswithdementiaarealsoable toprovidepersonal informationabouttheirqualityoflife(Kane,2003).

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Asshown,theassessmentofQoLisakeycategory,especiallyforthoseinneedoflong‐termcare.Accordingly, besides quality of care, an assessment of quality of life is an essential part of anycompletesetofindicators.

A number of requirements need to be fulfilled should the future development of indicators bebacked by a reliable knowledge base, if transparency and comparison are to be facilitated toguaranteesatisfactoryserviceprovisionforpeoplewithlong‐termcareneeds:

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• Qualitycriteriaandqualityindicatorsneedtobedevelopedbasedonevidence, i.e.onthe“conscientious,explicitandreasonableuseofthecurrentlybestexternalscientificevidenceto back decisions made in the medical service provision to individual patients” (GermanNetworkforEvidence‐basedMedicine,2008).Therespectiveprinciplesarealsorelevantforlong‐term care: what demonstrable benefit is associated with specific interventions andhowshoulditbemeasured?

• Thedevelopmentof indicators shouldbeconductedonan interdisciplinarybasis.Expertsfromcarescience,gerontology,medicineandsocialworkshouldbebrought inalongwithlong‐term care practitioners to ensure that the focus is not restricted to the classicalnursingcareareasandinvolvesthequalityof lifeperspectivetoobtainapicturethatisasbroadaspossible.

• Inordertoimprovelong‐termcareprovision,thedevelopmentofQoLindicatorsshouldbelinked to theorganisationaldevelopmentof services and institutions. References to long‐termcareandqualityof lifeaspectsmentionedcouldbeused in initiating reorganisationmeasuresthattakeintoconsiderationtheconcernsofresidents,relativesandstaff.

• Indicatorsmustcorrespondwithscientificqualitycriteria:objectivity,reliabilityandvalidity.Reliability is used to describe the degree of accuracywith which the assessed feature ismeasured. There are various statistical procedures, which can be used here: both thecalculationof9&5#%&-+!2)&<9<5#&27(Cronbach’sAlpha)and,inparticular,the%#5#<5G%#+9-C9+957!areofimportance.Thelattertellsusiftheresultsobtainedontwooccasionsfromoneandthe same person co‐relate. The validity of a measure reveals how well an instrumentmeasures what it is supposed to measure. In this context the validity of content andconcurrenceareparticularlyimportantastheyallowdrawingconclusionsaboutthequalityoftheinstrumentandwhetherallrelevantaspectsofoutcomequalityhavebeencovered.Otherestablishedproceduresusedtomeasureconcurrentvaliditymeasuresimilar,butnotidenticalcharacteristics.

• Theriskadjustment(alsoriskelimination)ofindicatorsisofspecificsignificancewithregardto the comparisonof services and institutions. Risk adjustmentmeans to exclude factorsthatarenotdependentontheserviceperformedbytheinstitutionbutwhichneverthelessinfluencethemeasurementoftheindicator(e.g.age,previousillnesses,andprofileofthecare need). The “neutralisation” effect of risk adjustment can avoid, for instance, thatinstitutionswithamajorityofresidentswithhigh‐level careneedsorothercircumstances(e.g. a high percentage of people with severe dementia) show worse results than thosewith residents needing less care and support. Risk adjustment will be an even moreimportantchallengeforthefuturedevelopmentofQoLindicatorsbecausethedefinitionofrisksintherelevantdomainsseemstobeanevenmorecomplextaskthaninthe‘qualityofcare’domain.

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There is a special need to ensure that QoL indicators and instruments to measure QoL aretransparent,canbeunderstoodeasilyandareuser‐friendly,bothforstaffandespeciallyforcarerecipientsandtheirfamiliestogivethemtheopportunitytoexpresstheirneeds,andtosupportthemintheirsearchforsuitableoptions.

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Inresearchonthequalityof life incarehomes,variousmethodsofempiricalsocialresearchareapplied,suchas

• directinterviewingofresidents,

• representativeinterviewingofcloserelativesand/ornursingstaff,

• observationofthebehaviourofresidents,

• collectingobjectiveinformationaboutphysical,socialandenvironmentalaspects.

Each of thesemethods has its advantages and disadvantages.When residents are intervieweddirectly, the“witnessproblem”occurs, that is, subjectiveassessmentsdonotallowconclusionsconcerning objective facts. Interviews with representatives about the resident’s quality of lifehave shown that their assessment often deviates from the assessment of the residentsthemselves(‘representativeproblem’–Cohn/Sugar,1991;Lavizzo‐Moureyetal.,1992).

The collection of objective facts in quality of care is often the preferred method for creatingindicators.However,onthebasisofsuchdataitisverydifficulttomakeanystatementsabouttheindividualqualityoflife,despiteitsimportanceasalreadymentioned.

Personaloutcomescanbeanalysedattheleveloftheindividual,aggregatedattheorganisationor systems level,andcomplementedbyotherperformancemeasuressuchashealthandsafetyindicators, client movement patterns, staff turnover and unit costs (Gardner/Carran, 2005;HumanServicesResearchInstituteandNationalAssociationofStateDirectorsofDevelopmentalDisabilitiesServices,2003).

Itcanalsobesuitabletouseashorterquestionnairethatfocusesononeortwoissuesinsteadoftrying to implementan instrument thatmayoverburden the institution. Both the interviewsaswellasthecollectionofdatashouldbedoneexternally(Schalocketal.,2008)asstaffgenerallydonotliketoworkwithsuchdata,arenottrainedindataanalysesand/orareafraidofdataduetoitsfrequentnegativeassociationwithevaluationand itspotentialconsequenceswithregardstolicensing,fundingcertificationorinvestigation.

Data management has frequently not been handled well in the past, which impacts how theorganisation accepts information and its willingness to act on it. Certain ways to improve thiscouldbeto(Schalocketal.,2008):

• Help the personnel understand the contextual factors affecting the obtained results andsupportadequateinterpretation,

• Provide personnel with specific suggestions as to how the data can be used to enhancepersonaloutcomesorotherperformanceindicators,

• StressthattheprimarypurposeofdatacollectionandanalysisisforQIpurposesandnottoevaluatethegoodness/badnessoftheprogramme/servicesprovided,

• EmphasisethatanyevaluationrepresentsonlyapointintimeandthatusingdataforQIisacontinuousprocessthatrequiresalong‐termcommitment.

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As shown, themeasurement of outcome‐orientated quality indicators for care homes requiresboththeperspectiveonqualityofcareandqualityoflife.Withviewtothis,somegeneralissueson the possibilities and limits have to be taken into account when it comes to implementingappropriate procedures andusing the results for further ameliorationof processes (Schönberg,2006):

• S1#%#! 9<! &)! N?+)C-+! 9&*92-5)%L! $8&259)&9&?! -<! -! N?#&#%-+! <9?&-++#%L! $)%! 51#! F8-+957! )$!9&<595859)&<=!Apartfromthelackofcausalitybetweenvariousdimensionsofoutcome,thereisalsonodirectconnectionbetweendifferentaspectsofthequalityofresults.Goodresultsinrespectofoneindicator(suchasdecubitusulcers)donotnecessarilyimplygoodresultsinotherareas.ThisisalsotrueforQoLindicators.

• "#<9*#&5<!-%#!E)9&5+7!%#<@)&<9C+#!$)%!51#!F8-+957!)852)(#<=!Thequalityofsubject‐to‐subjectrelationships (between care‐giver and care recipient) influences the outcome(Bond/Thomas,1991).Inthissense,carerecipientsare‘co‐producers’ofcare‐giving.

• 4! ?#&#%-+! -<<#<<(#&5! )$! F8-+957! <5-&*-%*<! C7!(#-&<! )$! 9&*92-5)%<! 9<! &)5! @)<<9C+#=! In theprocess of quality development andquality assurance, indicators are regarded as signals,but a general quality assessment for a given institution by means of indicators is notpossible (Faust, 2003; Gebert/Kneubühler, 2003; Halfon et al., 2000). However,measurementbymeansofqualityindicatorscanbeastartingpointforanextensivequalityassessment, for example, where an indicator points to a deficit. In this sense, indicatorsfunctionas‘sentinelevents’(Höwer,2002:19),whoseoccurrencemustbeexplainedbytheinstitutions.!

• B852)(#<! C-<#*! )&! 9&*92-5)%<! -%#! 9&! &##*! )$! 9&5#%@%#5-59)&=! Outcomes of indicatormeasurementsneedtobeinterpreted(Donabedian,1992,Faust,2003,Höwer,2002).Theproblem is that suchoutcomes“tempt” researchers todrawconclusions thatareentirelyunadmissibleonthebasisofthesemeasurements.Thusalargenumberofdecubitusulcersinaninstitutionmayleadtotheconclusionthatamorein‐depthanalysisofthecare‐givingperformanceneedstobeconsideredand/oranexplanationrequestedfromtheinstitution.Howeveritisnotpossibletodrawadirectconclusionfromthenumberofdecubitusulcersabouttheoverallqualitystandardofcare‐givingintheinstitution.“Outcomesasindicatorsof quality care are (…) open tomisrepresentation andmisunderstanding by the public ifmultiplecausationisnotunderstood”(Donabedian,1992:359).

• S#21&92-+! +9(95<! )$! @)<<9C+#! 2)++#259)&! )$! 9&*92-5)%<! 9&! 2-%#! 1)(#<=! Summarised dataindicators require the collection of individual data from care recipients, which are thenaggregatedattheinstitutional level.This, inturn,requiresaroutineofdatacollectionandappropriatetechnicalequipment,aswellasananalysisandinterpretationexpertise.

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Thediscussionaboutmeasurableoutcomesand relevant indicators inhealthcareand long‐termcareservicesalsoembracesthequalityoflifeperspectivetoanincreasingextent.Thisreflectsageneral trend that not only aims to study the structural and process attributes of nursing andlong‐term care andmake them an issue for quality development, but also recognises the useraspectasanindispensablecomponentofqualitydevelopment.

It must also be pointed out, however, that indicators are essential but only a part of acomprehensivequalityassessment–thisisacruciallimit imposedonthecollectionofindicatorsand the expectations associatedwith them. Instead, they point to relevant areas and problemaspects thatneed to receive furtherattention in the courseofqualitydevelopmentandqualitymanagement. Even if there is no mono‐causal correlation between the quality of structure,processes and outcomes, so that indicators of quality in outcome do not permit conclusionsconcerning thequality levels of structure andprocesses, theydoprovide relevant information.Furthermore, the residents themselves are partly responsible for the quality of care‐givingoutcomes, so that indicatorsmay be used to measure outcomes for institutions for which theinstitutionsthemselvesareonlypartlyresponsible.

Howeveron theotherhand, theuseof indicatorsoffersanumberofopportunities thatcanbesummarisedintermsof

• establishingtransparency,

• establishingabasisforscientificresearchonlong‐termcare,

• apossibilityforinstitutionalbenchmarking,

• apossibilityfordrivingqualitydevelopmentininstitutions.

EveniftheinterestinusingindicatorstomeasureandexaminethequalityofoutcomeshasrisensharplyinEuropeancountrieslatelyinparticularforin‐patienthealthcareincomparisonwiththeUnitedStates,thedebateonempiricallysound,reliablequality indicatorsreachedEuropelate inthedayand,asshownbythefocusofthemainquality initiatives,seemstobestillofsecondaryimportance. The search for and exploration of indicators for the quality of outcomes in carehomesisatopicthathasbynomeansreceivedtheattentionitdeserves,lastbutnotleastfromtheperspective of users and in the interest of ensuring long‐term care that is compatiblewithhuman dignity. Yet indicators are an important way of measuring quality from the userperspectiveandmakingitavailableforthequalitydevelopmentofservicesandinstitutions.Alonethey cannot guarantee quality but are part of an overarching context of effectiveness andefficiencyofservicesinlong‐termcare.

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Theselectionofresult‐orientedperformanceindicatorsfocusesonfivedomainsthatarerelevantfor care homes. Reflecting upon results requires consideration for thedifferent perspectives ofstakeholdersinvolved:residents,familyandfriends,staff,management,fundersaswellasothersocialgroupsandthelegislator.

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1 Qualityofcare Residents,staff 1‐24

2 Qualityoflife Residents,family,friends,staff 25‐70

3 Leadership Management,staff 71‐87

4 Economicperformance Management,funder 88‐91

5 Context Funder,legislator,suppliers,generalpublic

92‐94

Each indicator will be presented following a common terminology and based on the followingscheme:

[*47&7.7'&" Definitionoftheindicator

S?*:2.7'&2)7/2.7'&" Practicalissuesconcerningtheapplicationorthetypeofdatacollectionneeded

52)$;)2.7'&d"P':-;)2"

Measures,definitionofvaluesinthenumeratorandthedenominatoroftheindicator

e/*dG;:?'/*" Useandrationaleoftheindicatorinmeasuring,assessingandimprovingthequalityofresultsincarehomes.Generalcommentsconcerningnationalcontext,ifappropriate.

G*:/?*$.7R*" Fromwhichstakeholderperspectiveistheindicatorparticularlyrelevant?

1=*-*"" Whichthemesandissuespertinenttocarehomesareaddressedbytheindicator?

6';:$*" Source,qualityframeworkorcontextinwhichtheindicatorisalreadyusedorfromwhichtheindicatorwasinspired.

*

1 Generally speaking quality improvements should always target the residents of care homes; however, some

indicatorsareaddressingotherstakeholdergroups,e.g.stafformanagement,inthefirstplace.

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The indicators in this first domain are concerned with the quality of care, this being the mostimportant aspect to all concerned. Older people move to a care home because of healthproblems, care needs or personal circumstances, and/or when there are no more options toremainlivingathome.Oftentheseresidentsaredependentfortheirphysicalcareoncarerseveryday.

Carersincarehomeshavetheprimarytasktocareforexistinghealthproblemsaswellaspossibleandtopreventimpairmentandothercomplications.

The key focus in this domain is on the quality and safety of care. Understanding care needs,complications and adverse events is an essential part of managing the quality of care. Theregistration of for example decubitus ulcers, medication errors or fall incidents must beintegrated in the resident’s registration documentation, such as the resident record or thepersonal care plan. Only then can care providers and carers assess their results and steer onimprovement of quality. The indicators can also be used to monitor the success of theirimprovementprogrammesandtoestablishprioritiesforfurtheraction.

The indicators in thedomain ‘Qualityofcare’aremostlydescribed fromtheperspectiveof theresidents. When using the indicators one should therefore use the information from theresident’s recordor personal care plan. Often a choice canbemadewhether tomeasureon adefinedday (e.g. point prevalencemeasurement) or tomaintain a continuous registration. Theindicator on decubitus ulcersmight bemore suitable for a prevalencemeasurementwhile theindicatoronfallregistrationismoresuitableforcontinuousregistration.

Most indicators in this domain emerged from existing quality management systems from theproject’s participating countries, but also from quality management systems from the UnitedStates.Noindicatorwithinthisdomaincamefromanon‐participatingcountry.Astheseindicatorswereconsideredtobecritical inseveralofthecountriesrepresentedinthisproject,somewerepresentinmorethanonequalitymanagementsystemorguideline.

Indicators 19‐24 did not emerge from existing quality management systems but from theinternationalexpertsintheDelphipanelorintheE‐Qalinvalidationworkshops.InaworkshopinwhichrepresentativesofDelphiandE‐QalinexpertsaswellasthePROGRESSteamtookpart,allproposed new indicators were discussed and those finally selectedwere added to the existingindicatorsinthedomain‘Qualityofcare’.

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[*47&7.7'&" Percentageofresidentswhosufferfromdecubitusulcersstage2‐4thatbeganinthecarehome

S?*:2.7'&2)7/2.7'&" Tomeasurethisindicatoraninitialassessmentofthedecubitusstatusisneededatthepointofadmission.Pressureulcersstage1areexcludedduetomeasuringdifficultiescausingunreliability.Thisindicatorismeasuredonadefineddayonceayearasaprevalencemeasure.Alternatively,itcanbebasedoncontinuouscaredocumentation.

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Numerator:Numberofresidentswithdecubitusulcersstage2‐4

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristoimprovestrategiestopreventdecubitusulcers,mainlybyregularlychangingresidents’positionsintheirbedstorelievepressureonthesameskinareas.Decubitusulcersarenotonlypainfulanddebilitating,butcanhaveadevastatinglong‐termimpactonthehealthandqualityoflifeofresidents.

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" Inspiredby:KVZ‐VVT,2007;KVZ‐VVT,2010;E‐Qalin,2009;MDS,2009;USDHHS,2008;CSCI,2008

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[*47&7.7'&" Percentageofresidentswhosufferfromintertrigo

S?*:2.7'&2)7/2.7'&" Intertrigoisaskindisease(especiallyinskinfolds)withlocalrednessandpain.Intertrigoiscommonforpeoplewithobesity.Itisoftenseenunderthebreasts,inanalcleftsandinthegroinsoftheresidents.Thisindicatorismeasuredforadefineddayonceayearasaprevalencemeasure.Alternatively,itcanbebasedoncontinuouscaredocumentation.

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Numerator:Numberofresidentswhosufferfromintertrigo

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristodetecttheskinfoldsandtopreventthem.Carefulconsiderationofskin‐foldcausationhelpsinpreventingtheproblem.Theeffectivetreatmentand/ormanagementofunderlyingfactors,suchasincontinence,shouldalsohelppreventskinfoldulcers.

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" Inspiredby:KVZ‐VVT,2007;KVZ‐VVT,2010;LPZ,2009andMDS,2009

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[*47&7.7'&" Percentageofresidentsforwhommedicationerrorshavebeenreportedoverthepast30days

S?*:2.7'&2)7/2.7'&" Multiplesourcescanbeusedtomeasurethisindicator:theresident’sfile,thememoryofthestaffmembers/residentsandformalincidenceregistrations,suchasintheDutchsystem.

Medicationmismanagementincludesthefollowingincidences:

• Aprescribedmedicinehasnotbeengiven,

• Thewrongdosagewasadministered,

• Medicationwasgivenatthewrongtime,

• Theresidentsdidnottakethemedicine,

• Thewrongmedicinehasbeengiven,

• Inappropriatecombinationofmedications.

Donotmeasurewithresidentswhotaketheirmedicineontheirown(measureonlywithresidentswhogettheirmedicinedistributedbyothers).

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Numerator:Numberofresidentsforwhommedicationerrorshavebeenreportedinthepast30days

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristopreventmedicationerrors.Forexample,over‐dosagecanresultinharmtotheresidentprescribedthemedication,andanunder‐dosagecanresultinlessthandesirabletreatmentoutcomes.Theindicatorisalsousefultogetinsightintotheleadershipcultureofcarehomes:ifreportsofmedicationerrorsareonlyusedtoblameandpunish,staffwillbereluctanttoreportincidentsinthefuture,ratherthanusingthemasastartingpointforimprovingproceduresandcarestructures.

G*:/?*$.7R*" Staffandresidents

1=*-*"" Qualityandsafetyofcare,qualityofstaff

6';:$*" Inspiredby:KVZ‐VVT,2007;KVZ‐VVT,2010;USDHHS,2008andCSCI,2008

"

"

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

AA" "

O&+7$2.':"^'"D"

[*47&7.7'&" Percentageofresidentswhohavehadahealthcheckbyaspecialist(ophthalmologist/dentist/chiropodist/hearingspecialist)periodically

S?*:2.7'&2)7/2.7'&" Thisindicatorisusuallybasedoncontinuouscaredocumentation.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhohavehadahealthcheckbyaspecialistatleastonceortwiceayear

Denominator:Numberofresidents

e/*dG;:?'/*" Evenif,inanumberofcountries,healthchecksorvisitsatspecialistscannotbeinfluencedbycarehomestaffitisimportanttofacilitateandcontrolresidents’accesstothehealthsystem:Olderpeoplewholiveincarehomesshouldnotbediscriminatedagainstintermsofaccesstospecialisthealthservices(cf.DoH,2001).

G*:/?*$.7R*" Residents

1=*-*"" Physicalhealthandwell‐being

6';:$*" Inspiredby:E‐Qalin,2009;CSCI,2008;MDS,2009;DoH,2001

O&+7$2.':"^'"H"

[*47&7.7'&" Percentageofresidentswhohadarelativeweightlossinthelastmonththatwasunintendedandwasnotagreedinthetreatmentplanoftheresident

S?*:2.7'&2)7/2.7'&" Thisindicatorismeasuredwiththeweightoftheresident.Weightlossofmorethan3kgofthetotalbodyweightinthelastmonthormorethan6kginthelastsixmonths.

Donotmeasurewithresidentswho:

• receiveterminalcareorwhoareterminallyill,

• donotwanttobechecked.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhohadarelativeweightlossinthelastmonththatwasunintendedandwasnotagreedinthetreatmentplanoftheresident.

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristopreventunintentionalweightloss.Olderresidentswithunintentionalweightlossareatahigherriskofinfection,depressionanddeath.

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare(riskmanagement)

6';:$*" Inspiredby:KVZ‐VVT,2007;KVZ‐VVT,2010;USDHHS,2008;MDS,2009

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

AD" "

O&+7$2.':"^'"I"

[*47&7.7'&" Percentageofresidentswithdehydrationsymptoms

S?*:2.7'&2)7/2.7'&" Aresidentisdehydratedifthereisanacuteweightlossofmorethan3%ofthetotalbodyweight,oracuteweightlossofmorethan1kgaday.Othersymptoms,suchastheconditionoftheskin,drymucousmembranesanddrytongueareindications,butcanalsobecausedbyotherfactorssuchasmedicationuse.

Thisindicatorisusuallybasedoncontinuouscaredocumentation.

Donotmeasurewithresidentswho:

• receiveterminalcareorwhoareterminallyill,

• donotwanttobechecked.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswithdehydrationsymptoms

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Dehydrationisconsideredtobeasentinelhealthevent.Itleadstoanumberofcomplications,e.g.disorientation,lossofappetite,lossofenergyandgeneraladynamia.Inpersonssufferingfromdementia,dehydrationisoneofthemaincausesofdeath,apartfrommalnutritionandpneumonia.

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare(riskmanagement)

6';:$*" Inspiredby:KVZ‐VVT,2007;USDHHS,2008;Scholsetal.,2009;MDS,2009

O&+7$2.':"^'"J"

[*47&7.7'&" Percentageofresidentswhohadafallincidentinthepast30days

S?*:2.7'&2)7/2.7'&" Multiplesourcescanbeusedtomeasurethisindicator:theresident’sfile(caredocumentation),thememoryofthestaffmembers/residentsandtheincidencereportingsystems/registrations.Self‐reportedfallsmustbeincluded.Itistoberecommendedtoalsoregistertheplaceofthefallincidentanditsconsequencesfortheresident.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhohadafallincidentinthepast30days.

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristoseehowmanyfallincidentsoccurinthecarehomeandtopreventfallincidents.Fallsareamajorcauseofmorbidityandmortalityamongolderpeople.!

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" Inspiredby:KVZ‐VVT,2007;KVZ‐VVT,2010;USDHHS,2008;CMS–RAI,2002;E‐Qalin,2009;MDS,2009

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

AH" "

O&+7$2.':"^'"L"

[*47&7.7'&" Percentageofresidentswhohavedisplayedsignsofchallengingbehaviourtowardsstaffmembersand/orotherresidentsduringthepastsevendays*

S?*:2.7'&2)7/2.7'&" Thefollowingbehaviouralsymptomsarebeingmeasured:

• Verballychallengingbehaviour:residentthreatens,yellsorcursesatotherpeople.

• Physicallychallengingbehaviour:residenthits,pushes,scratchesorintimidatesotherpeople.

• Sociallyunacceptablebehaviour:residentmakesdisturbingnoises,isnoisy,screams,maltreatshim/herself,presentssexualorexhibitionisticbehaviour,spreadshimselfwithfoodorfaeces,hoardsupornosesaboutothers’possessions.

• Refusingcare:residentrefusestotakemedicationorinjections,refusesfoodandparticipationinactivities.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhohavedisplayedsignsofchallengingbehaviourtowardsstaffmembersand/orotherresidentsduringthepastsevendays*

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristoseehowoftenresidentsdisplayproblembehaviourandtomonitorhowstaffareabletorespondtothischallenge.Ifatendencyofincreasingproblembehaviourhasbeenassessed,managementandstaffmightthinkaboutadditionaltrainingonhowtocopewiththeseresidents."

G*:/?*$.7R*" Staffandresidents

1=*-*"" Qualityandsafetyofcare,qualityofstaff

6';:$*" Inspiredby:KVZ‐VVT,2007;KVZ‐VVT;2010;USDHHS,2008;CMS‐RAI,2002

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

AI" "

O&+7$2.':"^'"M"

[*47&7.7'&" Percentageofresidentswhowerephysicallyrestrainedduringthelastsevendays

S?*:2.7'&2)7/2.7'&" Restrainingislimitedto:theSwedishbelt(thewaistrestraintbeltwithkeylock),adeepchairfromwhichonecannoteasilystanduporatabletopthatisfixedontothechairinfrontofapersontopreventsomeonestandingup.

Youcanmeasurethisbyobservationanditshouldbereportedintheresident’sfile.Inmostcountriesajudicial/medicalauthorisationforrestraintsisneeded,sotheindicatorcanbebasedontherespectivedocumentation.Theuseofrestraints(theexamplesgivenabovearenotacomprehensiveenumerationoftherestrainingmeasuresusedincarehomes)mustbeminimisedasmuchaspossiblesincetherearemanynon‐restrainingalternativesavailableinlong‐termcare.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhowerephysicallyrestrainedduringthelastsevendays

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristoseehowmanyresidentswererestrained.Ifthispercentageisveryhigh,maybetheresidentsarebeingrestrainedtoosoon.Restraintscanaddtotheriskoffalling.Tryingtofreethemselvesfromrestraints,residentsendupinjuringthemselvesmorethaniftheyhadbeenfreeoftherestraint.Theirinjuriesarealsomoreseverethaniftheyhadnotbeenrestrainedinthefirstplace.

Staffarestimulatedtothinkaboutalternativemeasurestoguaranteethesafetyofresidents.

G*:/?*$.7R*" Residents,Staff

1=*-*"" Qualityandsafetyofcare,qualityofstaff

6';:$*" Inspiredby:KVZ‐VVT,2007;KVZ‐VVT,2010;USDHHS,2008;MDS,2009

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

AJ" "

O&+7$2.':"^'"!N"

[*47&7.7'&" Percentageofresidentswhoareincontinentofurineatleastonceaweek

S?*:2.7'&2)7/2.7'&" Urineincontinencemeans:everytypeofunintentionalurineloss.Urineretentionisnotincontinence.Thisindicatorismeasuredforadefineddayonceayearasaprevalencemeasure.Alternatively,itcanbebasedoncontinuouscaredocumentation.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhoareincontinentofurineatleastonceaweek*************************

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristoseehowmanyresidentsinthecarehomeareincontinentandtopreventincontinence.Incontinencecanbeasymptomofurinarytractinfection.Incontinencecancauseshameandcandeclinethequalityoflife.IntheNetherlands,75%ofresidentswithurinaryincontinencedonotknowwhichtypeofthedisordertheyactuallyhaveasithasneverbeendiagnosed.Bypayingmoreattentiontodiagnosis,morepatientscanbecured–oratleastfindtheirinconveniencereduced(LPZ,2008)."

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" Inspiredby:KVZ‐VVT,2007;KVZ‐VVT,2010;USDHHS,2008

O&+7$2.':"^'"!!"

[*47&7.7'&" Percentageofresidentswithalong‐termcatheter,insertedmorethan14daysago

S?*:2.7'&2)7/2.7'&" Donotmeasurewithresidentswhoalreadyhadalong‐termcatheteratthetimetheymovedtothecarehome.Thechoicefora14‐dayperiodistomakeadifferencebetweenacuteandchroniccatheteruse.Acutecatheteruseisforexampleindicatedforresidentswhoreceivepalliativecareorsufferfromacutepainfromahipfracture(notyetoperated).

Thisindicatorisusuallybasedoncontinuouscaredocumentation.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswithalong‐termcatheter,insertedmorethan14daysago

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristoseehowmanyresidentsinthecarehomehavealong‐termcatheter.Ifthispercentageisveryhigh,maybethecathetersareinsertedtoosoon.Problemsrelatingtotheuseofurinarycathetersincludeinfection,obstructionandleakage."

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" Inspiredby:KVZ‐VVT,2007;USDHHS,2008

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

AL" "

O&+7$2.':"^'"!0"

[*47&7.7'&" Percentageofresidentssufferingfrompaininthelast30days

S?*:2.7'&2)7/2.7'&" Themeasurementofpainincarehomesisaspecificchallenge,thoughseveraloptionsforpainmeasurement(scales)areoffered(forinstance,VanHerketal.,2009a;Clossetal.,2004;www.schmerzskala.de).

Thereisalargegroupofresidentsforwhompainmeasurementwithusualmethodsisimpossibleduetocommunicationproblemsorcognitivedecline.Insuchcases,e.g.forpeoplesufferingfromdementia,theMOBIDpainobservationscaleissuggested(Huseboetal.,2007).Askingrelativestoestimatethepainoftheirfamilymembers,however,isnotindicated(VanHerketal.,2009b).

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentssufferingfrompaininthelast30days

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Oneofthemaincausesofinsufficientpainmanagementisthelackofsystematicregistrationofpain.Incarehomespainregistrationexists,forexamplewithaneasymeasurementinstrumentsuchasanumericalpainscalebutitisnotbroadlyimplemented.Researchshowsthat66%ofnursinghomeresidentsexperiencepain(Boerlageetal.,2007).

Thepercentageofresidentswithsubstantialpaininthelastweek(score>4ona0‐10scale)isevenhigher:>75%.Morethan25%oftheresidentsfromthisgroupdoNOTreceivepainmedication.Morethan50%ofthemreceiveonlymedicationfromstep1oftheWHOanalgesicscheme(paracetamol,NSAIDs).Innursinghomeswherealargeamountoftheresidentsexperiencepain,painisoftennotorrarelyregistered.Forresidentswithcommunicationproblemsthisisevenworse."

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" Inspiredby:CSCI,2008;USDHHS,2008.

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

AM" "

O&+7$2.':"^'"!A"

[*47&7.7'&" Percentageofresidentswhouseanti‐psychoticmedication

S?*:2.7'&2)7/2.7'&" Donotmeasurewithresidentswhotaketheirmedicineontheirown.Whentheresidentremainsresponsibleforhisorhermedicationandkeepsitinpossession,itmeansthestaffmembersdonotknowwhethertheresidenttakesthemedicationasprescribed.

ThisindicatorshouldbeseeninconjunctionwithInd.No9onrestraints.

Thefrequencyoftheprevalencemeasurementcanvary.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhouseanti‐psychoticmedication

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristoseeifthepercentageofresidentsusingantipsychoticmedicationatarandompointistoohigh.

Theotherpurposeofthisindicatoristoseeifthenumberofresidentswithadiagnosedmentalillnessisequaltotheresidentswhousepsycho‐pharmaceuticaldrugs."

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" Inspiredby:KVZ‐VVT,2007;KVZ‐VVT2010;USDHHS,2008

O&+7$2.':"^'"!D"

[*47&7.7'&" Percentageofresidentssufferingfromdementiawhouseneuroleptics

S?*:2.7'&2)7/2.7'&" Percentageofresidentssufferingfromdementiawhohavebeengivenneurolepticsduringthepastweek.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentssufferingfromdementiawhohavebeengivenneurolepticsduringthepastweek.

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Therearemanyissuesraisedbytheuseofmultiplemedicationsforpeoplesufferingfromdementia.TheGermanCommitteeofexpertsfortheassessmentofhealthcaredevelopmenthaslatelypointedatthehighrisksconnectedtotheuseofneurolepticswhich,inparticularincombinationwithsedatives(benzodiazipines),mayfurtherreducecognitiveabilities:“Thereforethebluntprescriptionofsedativesforolderpeoplecannotbeanacceptablestrategytocompensateforthelackofhealthandsocialcarestaff(...)Inparticulartheprescriptionofneurolepticsistobeconsideredcriticallyasmortalityisincreased(...)ashort‐termapplicationisacceptableinexceptionalcasesifotherrisksforthepatientorhis/hersurroundingsmayoccur”(arznei‐telegramm,2008,cit.Sachverständigenrat,2009:471).

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" Sachverständigenrat,2009

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

DN" "

O&+7$2.':"^'"!H"

[*47&7.7'&" Percentageofresidentswhouseanti‐depressants

S?*:2.7'&2)7/2.7'&" Donotmeasurewithresidentswhotaketheirmedicineontheirown.Whentheresidentremainsresponsibleforhisorhermedicationandkeepsitinpossession,itmeansthestaffmembersdonotknowwhethertheresidenttakesthemedicationasprescribed.

Theuseofantidepressantswillbeconsideredinrelationtotheprevalenceofdepressionamongresidents.

Thefrequencyoftheprevalencemeasurementcanvary.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhouseanti‐depressants

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristoseeifthenumberofresidentswithadiagnosisofdepressionisequaltotheresidentswhouseantidepressants.

Thisindicatorreflectshowstaffcopewithdepressedresidentsorresidentswithanothermentalillness."

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" KVZ‐VVT,2007

O&+7$2.':"^'"!I"

[*47&7.7'&" Percentageofresidentsdiagnosedwithdepressivesymptomsatonepointintime

S?*:2.7'&2)7/2.7'&" BasedontheGDS(GeriatricDepressionScale)weproposetoasktheresidenthowhe/shehasbeenfeelingduringthepastweekincludingtoday.TheGDSwasfirstdevelopedin1982byJ.A.Yesavageandothers(Brink/Yesavage,1982;Yesavageetal.,1982).Asavalidatedinstrumentithasbecomeagoldenstandardworldwide:http://www.stanford.edu/~yesavage/GDS.html(GDSinalllanguages)orhttp://www.stanford.edu/~yesavage/Testing.htm(shortversioninEnglish,withscoring).TheGDSisonetechnique;however,theremaybeotherswhichcanbeusedinthecarehome.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsdiagnosedwithdepressivesymptomsatonepointintime

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristoseehowmanyresidentsshowsignsofadepression.Itisveryimportanttodetectthesignsofadepression,diagnoseadepressionandstartatherapy."

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" Inspiredby:KVZ‐VVT,2007&2010;USDHHS,2008;CMS‐RAI,2002

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

D!" "

O&+7$2.':"^'"!J"

[*47&7.7'&" Percentageofresidentswithdeficitsintheirmouthandteethstatus

S?*:2.7'&2)7/2.7'&" Examinationofmouthproblems(oralmucosa,teethanddenture).

Residentswithareducedself‐carecapacityoftenhavemutationsintheiroralcavity.Thoseatriskare:

• Residentswhohavedysfunctionsinchewingorswallowing:theirintakeofcertaindrugs(e.g.antidepressives,antihypertonika)thatreducesalivawillalsohaveaneffectontheiroralmicro‐flora(antibiotics,corticoids);

• Residentsregularlyundertheadministrationofoxygenorresidentswhocanonlybreathethroughtheirmouthand

• Residentswithareducednutritionalstateanddehydration.

Thisindicatorismeasuredforadefineddayonceayearasaprevalencemeasure.Alternatively,itcanbebasedoncontinuouscaredocumentation.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswithdeficitsintheirmouthandteethstatus

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristosteerthequalityofcareforthosewithmouthproblems.Mouthanddentalcareisoftennotgivenenoughattentionandhasagreatinfluenceontheresident’swell‐being.

G*:/?*$.7R*" Residents

1=*-*"" Physicalhealthandwell‐being

6';:$*" MDS,2009

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

D0" "

O&+7$2.':"^'"!L"

[*47&7.7'&" Percentageofresidentswithdiagnosedcareneedsduetogeronto‐psychiatricdisorders**

S?*:2.7'&2)7/2.7'&" DiagnosisofaGPorspecialist;recordingsinthecaredocumentationsuchasbiography,contactwithfamilymembers,individualisedday‐timeactivitiesetc.;care‐assessmentsandtests.Thefrequencyoftheprevalencemeasurementcanvary.!

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswithrecordedcareneedsduetogeronto‐psychiatricdisorders

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Residentssufferingfromcognitiveimpairments(especiallyfromdementia)needaspecifickindofcareandattention.Hencethestaffmustbequalifiedindifferentskills.Thecareofcognitivelyimpairedresidentsleadstochangesatdifferentlevelsofacarehome:

• Care‐concept.

• Qualificationofstaff.

• Organisationandmanagementofcare(dayandnight).

• Architecturalimpacts(insideandoutsidethebuildings).

G*:/?*$.7R*" Residents

1=*-*"" Qualityandsafetyofcare

6';:$*" MDS,2009

O&+7$2.':"^'"!M"

[*47&7.7'&" Percentageofresidentswhoaresatisfiedwiththeirpersonalcare

S?*:2.7'&2)7/2.7'&" Satisfactionsurveyswithresidentsand/ortheirrepresentatives.*

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Percentageofresidentswhostatethattheyaresatisfiedwiththeirpersonalcare

Denominator:Numberofresidentswhohavebeensurveyed

e/*dG;:?'/*" Thepurposeofthisindicatoristoevaluatewhethertheopinionoftheresidentsaboutthegivenpersonalcarecorrespondswiththeresultsoftheotherqualityofcareindicators.Bycombiningthe‘objective’withthe‘subjective’viewsamoreholisticpicturecanbedrawnandpotentialneedsforimprovementmightbedetected.

G*:/?*$.7R*" Residents*

1=*-*"" Physicalhealthandwell‐being*

6';:$*" PROGRESS,2010

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

DA" "

O&+7$2.':"^'"0N"

[*47&7.7'&" Percentageofresidentssufferingfromthromboses

S?*:2.7'&2)7/2.7'&" Thisindicatorismeasuredonadefineddayonceayearasaprevalencemeasure.Alternatively,itcanbebasedoncontinuouscaredocumentation.*

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentssufferingfromthromboses

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristosteeronthepreventionofthromboses

G*:/?*$.7R*" Residents*

1=*-*"" Qualityandsafetyofcare

6';:$*" PROGRESS,2010

O&+7$2.':"^'"0!"

[*47&7.7'&" Percentageofresidentswithcontractures

S?*:2.7'&2)7/2.7'&" Thisindicatorismeasuredonadefineddayonceayearasaprevalencemeasure.Alternatively,itcanbebasedoncontinuouscaredocumentation.*

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswithcontractures

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristosteerthepreventionofcontractures.

G*:/?*$.7R*" Residents*

1=*-*"" Qualityandsafetyofcare*

6';:$*" PROGRESS,2010

O&+7$2.':"^'"00"

[*47&7.7'&" Percentageofpermanentlybed‐riddenresidents

S?*:2.7'&2)7/2.7'&" Thisindicatorismeasuredonadefineddayonceayearasaprevalencemeasure.Alternatively,itcanbebasedoncontinuouscaredocumentation.*

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhoarebed‐ridden

Denominator:Numberofresidentswhohavebeenassessed

e/*dG;:?'/*" Thepurposeofthisindicatoristoestablishhowmanypeoplearebed‐riddenandtoimprovestrategiestopreventunnecessaryimmobility.Immobilityleadstovarioushealthproblemssuchaslossofmusclemass,constipation,incontinence,decubitusulcersandcognitiveregression.

G*:/?*$.7R*" Residents*

1=*-*"" Qualityandsafetyofcare*

6';:$*" PROGRESS,2010

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

DD" "

O&+7$2.':"^'"0A"

[*47&7.7'&" Percentageofresidentswithenteraltubefeeding(PEG‐tube)

S?*:2.7'&2)7/2.7'&" Thisindicatorismeasuredonadefineddayonceayearasaprevalencemeasure.Alternatively,itcanbebasedoncontinuouscaredocumentation.*

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswithenteraltubefeeding(PEG‐tube)

Denominator:Numberofresidents

e/*dG;:?'/*" Manyresidentswithadvancedstagesofcognitivedeclineand/orswallowingproblemsareatriskofmalnutrition.Theymaybenefitinsuchcasesfromtubefeeding.Inprolongedsituationsenteraltubefeedingisinmanycasesapreferredchoicecomparedtotubefeedingbythenose.Forresidentsenteraltubefeedingislessburdensomeandtheriskofcomplicationsislower.Ontheotherhand,thisindicatorcanbeusedtocheckwhethertubefeeding(incaseofanincreasingtrend)isusedtoooftenandtooquicklyinordertosaveworkingtime(tubefeedingisfasterthanhand‐feedingaresidentindividually).

G*:/?*$.7R*" Residents*

1=*-*"" Qualityandsafetyofcare*

6';:$*" PROGRESS,2010

O&+7$2.':"^'"0D"

[*47&7.7'&" Percentageofresidentswithanassessmentofabilitiestoeatindependentlyand/orrelatedrisks

S?*:2.7'&2)7/2.7'&" Thisindicatorismeasuredonadefineddayonceayearasaprevalencemeasure.Alternatively,itcanbebasedoncontinuouscaredocumentation.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhoareassessed

Denominator:Numberofresidents

e/*dG;:?'/*" Itisimportanttocheckeveryresidentifhe/sheisabletofeedhimselfalone;ifnotthenthisindicatorshouldleadtomeasuresinthecarehometoensuretheyareproperlyfed,e.g.byaPEG‐tube.

G*:/?*$.7R*" Residents*

1=*-*"" Qualityandsafetyofcare*

6';:$*" PROGRESS,2010

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

DH" "

['-27&"08"\;2)7.C"'4")74*"

Qualityoflifeisfrequentlyconfusedwithqualityofcare.Whilstthetwoareofteninterconnectedtheyshouldnotbeseenasthesame.Qualityoflifemaybehighwhilequalityofcareislow:thatis,peoplemayfeelwell,satisfiedwithlifeorhappyevenifthecaretheygetispoor.Conversely,people may have a high quality of care, in that itmeets a number of standards, but have lowqualityoflife.Qualityoflifeisdifficulttodefineasitisdeterminedbyindividualpreferencesandthesemayincludephysical,socialorpsychologicalaspects.Universalmodelsofqualityoflifemaybeeasiertouseinpractice,butnotreflectindividualdifferences.Itisalsoimportanttorecognisethatthereisnoevidencethatqualityoflifeforcarehomeresidentsisfundamentallydifferenttoanyone else’s quality of life (Gerritsen et al., 2004: 612). Nonetheless, it is important that ifuniversalmodelsaretobeusedthattheyareconstructedwiththeparticipation,wherepossible,ofthosetheyareseekingtorepresent.Interestingly,onlyveryfewofthefollowingqualityoflifeindicators emerged from existing quality and inspection frameworks that are generally morefocusedonqualityofcare.

Evidence‐basedqualityof life indicatorsweretherefore takenfromanothersource,whichwereuniversal indicators from research based on what residents, relatives and staff had said wasimportanttothemintermsofqualityoflifeincarehomes.Theindicatorsemanatingfromthesesourceswerewritteninsuchawaythatthefindingsfromthemwouldbebasedonthesubjectiveexperienceof individuals(surveys).Twoof themainsources that inspiredtheseindicatorswerethe literature review underpinning the 67 Home Life programme (NCHR&D, 2007;www.myhomelife.org.uk) and the combined assessment of residential environments (CARE)profiles(Faulkneretal.,2006).67HomeLife isaUK‐wideinitiativetopromotequalityof life incare homes for older people,whichhas the support of theRelatives andResidentsAssociationand all the provider organisations that represent care homes across the UK as well as of twoprestigious charities interested in care for older people (Age UK and the Joseph RowntreeFoundation). The evidence base for67 Home Life was collaboratively developed by over 60academicresearchersfromuniversitiesacrosstheUK,whobelongedtotheNationalCareHomeResearchandDevelopmentForum.

MyHomeLife(MHL) isstructuredaroundeightthemes,twoofwhichareaimedatmanagerstohelpthemsupporttheirstaffputtheothersixthemesintopractice.ThesetwothemesareaboutTransformation and include Keepingworkforce fit for purpose andPromotingpositive cultures.Three of the six themes aimed at staff are about the approach to care (Personalisation) andincludeMaintaining identity; Sharing decision‐making, and Creating community. The remainingthreethemes(Navigation)arefocusedonwhatstaffneedtodotosupportresidentsandrelativesthrough thejourneyofcareand includeManaging transitions; Improvinghealthandhealthcare;and Supporting good end of life. My Home Life is underpinned by Relationship‐centred Care(Tresloniand the Pew‐FetzerTaskForce,1994)and theSensesFramework (Nolan etal.,2006),whichhighlights the importanceof relationships between residents, relatives and staff and theneedtoconsiderwhatgiveseachasenseofsecurity,belonging,continuity,purpose,achievementand significance. 24 indicators were constructed from theMHL literature review, one for eachthemefromtheperspectiveofresidents,relativesandstaff.

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

DI" "

O&+7$2.':"^'"0H"

[*47&7.7'&" Percentageofresidentswhofeelemotionallysupportedinmanagingtheirsenseofloss

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedfromanitemconstructedforitspurposeonannualsatisfactionsurveysorqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingemotionallysupported

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Anumberofsourcesoflosscanoccurforresidentsincarehomesincludingmovingfromone’shome,reducingsocialnetworks,increasingfrailty,andapproachingendoflife.Residentscanbesupportedtomanagethesetransitionswhentheyhaveaccesstoinformationregardingtheircareandareencouragedtomaintainownershipovercaredecisions.Whenresidentsareemotionallysupportedsothattheycaneffectivelymanageepisodesofloss,animprovedqualityoflifecanresult.Thisindicatorallowsmonitoringofemotionalsupport.Effortshouldbemadetoaskallresidentsadaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Managingloss

6';:$*" InspiredbyNCHR&DForum,2007

"

O&+7$2.':"^'"0I"

[*47&7.7'&" Percentageofrelatives/friendswhofeelemotionallysupported

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitemconstructedforitspurposeonannualsatisfactionsurveysorqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingemotionallysupported

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Inadditiontoresidents,itisimportantthatrelatives/friendshaveafeelingofemotionalsupportfromcarehomestaff.Relatives/friendsoftendealwiththeirownsenseoflossforthemselves,andonbehalfoftheirlovedone.Relatives/friendscanoftenfeelguiltyforplacingtheirlovedoneinacarehome.Emotionalsupportcanhelpeasetheburdenonrelatives/friendsandimprovefamilyinvolvementincaredelivery.Thisindicatorcangiveinformationregardingwhetherstaffareeffectivelysupportingrelatives/friends.

G*:/?*$.7R*" Relatives/friends

1=*-*"" Qualityoflife,Managingloss

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

DJ" "

O&+7$2.':"^'"0J"

[*47&7.7'&" Percentageofstaffwhofeelemotionallysupportedindealingwithconstantlossandbereavementatwork

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitemconstructedforitspurposeonannualsatisfactionsurveysorqualitativeinterviewswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstafffeelingemotionallysupported

Denominator:Totalnumberofstaffsurveyed

e/*dG;:?'/*" Staffcanexperiencelossandbereavementduringemployment,particularlywhenfacedwithresidentdeath.Staffrequiresupporttodealwithfeelingsoflossandbereavement.Thissupportcanhelpimprovethequalityoflifeforstaffandkeeptheworkforcefitforpurpose.Thisindicatorwillassistingauginghoweffectivelystaffaresupportedtodealwithloss.

G*:/?*$.7R*" Staff

1=*-*"" Qualityoflife,Managingloss

6';:$*" NCHR&DForum,2007

O&+7$2.':"^'"0L"

[*47&7.7'&" Percentageofresidentswhofeelstaffintheirunitknowtheirlifestory

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitemconstructedforitspurposeonannualsatisfactionsurveysorqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingstaffknowtheirlifestory

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Thecapacitytogettoknowresidentlifestoriesisenhancedbyconsistentassignmentofstafftoresidents.Havingstaffknowandunderstandresidents’lifestoriesiscriticalformaintainingresidentidentity.Residentswhoareabletomaintaintheiridentityhavemorepositiveexperiencesthatcanimprovequalityoflife.Effortshouldbemadetoaskallresidentsadaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Resident

1=*-*"" Qualityoflife,Maintainingidentity

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

DL" "

O&+7$2.':"^'"0M"

[*47&7.7'&" Percentageofrelatives/friendswhofeelstaffknowwhotheyare

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedfromanitemconstructedforitspurposeonannualsatisfactionsurveysorqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingstaffknowwhotheyare

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Relatives/friendswhofeelstaffknowwhotheyareasapersonexperienceanimprovedsenseofcommunityinthecarehome.Thissenseofcommunityensuresrelatives/friendsfeelthattheywillbetrustedasvaluablesourcesofinformationabouttheirlovedone.Feelinglikepartofacommunityresultsinsharedunderstandingsthatcanreducenegativefeelingsbetweenstaffandrelatives/friendsaboutcare.Thisindicatormonitorshowwellstaffknowrelatives/friendsaspersons.

G*:/?*$.7R*" Relatives/friends

1=*-*"" Qualityoflife,Creatingcommunity

6';:$*" NCHR&DForum,2007

O&+7$2.':"^'"AN"

[*47&7.7'&" Percentageofstaffwhofeeltheirpersonalskillsandabilitiesarerecognisedbycolleagues

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstafffeelingliketheirskillsandabilitiesarerecognised

Denominator:Totalnumberofstaffsurveyed

e/*dG;:?'/*" Staffwhoarerecognisedfortheirskillsandabilitiestoprovidecare,canexperienceasenseofempowermentandvalue.Careworkerdutiesareoftendifficult,yetcareworkerscontinuetodotheirjobsbecausetheyhaveadeepsenseofcommitmenttohelpingothers.Whenstaffarerecognisedforwhattheyhavedone,itvalidatestheirhardworkandcankeeptheworkforcefitforpurposeleadingstafftohavestrongerdesiretostayintheirposition.Thisindicatormonitorsstaffrecognition.

G*:/?*$.7R*" Staff

1=*-*"" Qualityoflife,Recognisingworkercontribution

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

DM" "

O&+7$2.':"^'"A!"

[*47&7.7'&" Percentageofrelatives/friendswhofeelwelcomedinthecarehome

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithrelatives/friends

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingwelcomed

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Developmentofrelationshipsiscriticaltoensuringcreationofcommunityinthecarehome.Asenseofcommunitycanbringaboutsharedunderstandingsandfeelingsofvalue.Feelingwelcomeinacarehomecanbesupportedbytheenvironmentwherespacesfacilitateasenseofbelonging.Thissensecanimproverelative/friendsatisfactionwithcare.Thisindicatormonitorshowwellcommunityhasbeencreated.

G*:/?*$.7R*" Relatives/friends

1=*-*"" Qualityoflife,Creatingcommunity

6';:$*" NCHR&DForum,2007

O&+7$2.':"^'"A0"

[*47&7.7'&" Percentageofresidents,relativesandstaffwhofeelthecarehomeispartoftheirlocalcommunity

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveyswithresidents,relatives/friends,andstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidents,relatives/friends,orstafffeelingpartoflocalcommunity

Denominator:Totalnumberofresidents,relatives/friends,orstaffsurveyed

e/*dG;:?'/*" Carehomesthatareapartofalargercommunityhaveaccesstoresourcesthatcanimprovecare.Furthermore,thislargercommunitycanallowresidentstoremainconnectedtotheirpriorrelationshipsandactivitiestherebyimprovingfeelingsoflossresidentsandrelatives/friendsmayhavewhenplacementinacarehomeoccurs.Thisindicatormonitorsthesenseofconnectiontothelocalcommunity.

G*:/?*$.7R*" Residents,relatives/friendsandstaff

1=*-*"" Qualityoflife,Creatingcommunity

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

HN" "

O&+7$2.':"^'"AA"

[*47&7.7'&" Thepercentageofdecisionsimplementedbytheleadershipofthecarehomebasedondecisionsmadebytheresidents’council

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedbycarefulreviewofresidentcouncilandotherfacilitydocumentsthatdescribeleadershipdecisions.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentcouncilsuggestionsimplemented

Denominator:Totalnumberofresidentcouncilsuggestionsforfacilitychange

e/*dG;:?'/*" Participationindecisionswhichconcernthearrangementoflivingconditionsincarehomesincentralaspects(e.g.housing,recreationalactivities,orderofthecarehomes)ispartofequitableparticipationinsociallife.Generalconditionsofdemocraticparticipationandco‐determinationofresidentsareaddressedbythisindicator.Thefacilitywillhavetoagreeonhowtodefinewhetheradecisionhasbeenmadebasedonresidentcouncilinput.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Participation

6';:$*" InspiredbyCSCI,2008;NRWActofhousingandparticipation(WTG);BMFSFJ,2009(GermanCharterofRightsforpeopleinneedofcare)

O&+7$2.':"^'"AD"

[*47&7.7'&" Percentageofresidentswhofeeltheirownrightsareacknowledgedandactedon

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingtheirrightsareacknowledged

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Sharingdecision‐makingiskeytoqualityoflifeincarehomesandisaddressedwiththisindicator.Residents,includingthosewithcognitiveimpairment,canbeincludedinaspectsofdailycaredecisionsthroughaprocessofnegotiationwhichbalancesresidentrightsandrisks.Includingresidentsindecision‐makingenhancesthesenseofcontrolresidentshaveoverdailylife,therebyimprovingtheirqualityoflife.Effortshouldbemadetoaskallresidentsadaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Shareddecision‐making

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

H!" "

O&+7$2.':"^'"AH"

[*47&7.7'&" Percentageofrelatives/friendswhofeelinvolvedindecision‐makingabouttheirresident’scare

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithrelatives/friends

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelinginvolved

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Relatives/friendshaverepeatedlyidentifiedtheneedtosharedecision‐makingbyparticipatinginresidentcaredecisions.Thisinvolvementmayimproveresident‐relative‐staffcommunicationandinteractiontherebyenhancingresidentqualityoflife.Thisindicatormonitorsrelative/friendinvolvement.

G*:/?*$.7R*" Relatives/Friends

1=*-*"" Qualityoflife,Sharingdecision‐making,Senseofpurpose

6';:$*" Faulkneretal.2006

O&+7$2.':"^'"AI"

[*47&7.7'&" Percentageofstaffwhofeelthattheycantakeinformedrisksincaringforresidents

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstafffeelingtheycantakeinformedrisks

Denominator:Totalnumberofstaffsurveyed

e/*dG;:?'/*" Staffwhowishtobeinnovativeandcreativeinmeetingresidentneedsandpreferences,requiretheabilitytotakeinformedriskswhiledeliveringcare.Theresultantfeelingofempowermentoverworkdecisionscanimprovestaffmoraleandlowerturnover,keepingworkforcefitforpurpose.Thisindicatormonitorsstaffcapacitytomakedecisionsaboutworkandcare.

G*:/?*$.7R*" Staff

1=*-*"" Qualityoflife,Shareddecision‐making

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

H0" "

O&+7$2.':"^'"AJ"

[*47&7.7'&" Percentageofresidentswhofeeltheirhealthispromotedtooptimisetheirqualityoflife

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingtheirhealthisoptimised

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Thisindicatorhighlightstheimportanceofensuringadequateaccesstohealthcareservices–boththosegeneralinnatureandspecialistservicesasrequired–andpromotinghealthtooptimiseresidentqualityoflife.Healthcanbepromotedwhentheresidentisengagedinmeaningfulactivitiessuchassocialisingandlearning.Healthisfundamentaltoqualityoflifeand,withouthealth,qualityoflifeisunlikelytobeachieved.Effortshouldbemadetoaskallresidentsadaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Healthpromotion

6';:$*" NCHR&DForum,2007

O&+7$2.':"^'"AL"

[*47&7.7'&" Percentageofrelatives/friendswhofeeltheirresidenthasadequateaccesstohealthcareservices

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingtheirresidenthasaccesstohealthcare

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Thisindicatorgivesanalternativeperspectiveontheabilityofresidentstoreceivenecessaryhealthcareservicesthatcanimproveoverallfunctioningandhealthultimatelyenhancingqualityoflife.

G*:/?*$.7R*" Relatives/friends

1=*-*"" Qualityoflife,Healthpromotion

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

HA" "

O&+7$2.':"^'"AM"

[*47&7.7'&" Percentageofstaffwhofeeltheirownhealth(physicalhealthandwell‐being)isvaluedatwork

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstafffeelingtheirownhealthisvalued

Denominator:Totalnumberofstaffsurveyed

e/*dG;:?'/*" Attentiontostaffphysicalandmentalwell‐beingcanenhancestaff’sfeelingofimportanceandvalue.Supportforthesocialneedsofstaffatworksuchastherelationshipsstaffformwitheachother,andwiththeirsupervisorinparticular,hasbeenrepeatedlyidentifiedascriticalinstaffsatisfactionwiththeirjobs.Thismayhelpreduceturnoverofstaffandkeepworkforcefitforpurpose.Thisindicatormonitorsstaffhealthandwell‐being.

G*:/?*$.7R*" Staff

1=*-*"" Qualityoflife,Healthpromotion

6';:$*" NCHR&DForum,2007

O&+7$2.':"^'"DN"

[*47&7.7'&" Percentageofresidentswhofeelabletotalkaboutdeathanddyingwithstaff,whentheywishso

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingtheycantalkaboutdeathanddying

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Carehomesarecomplexsystemswherepeoplearebothlivinganddying.Thereisaneedtodevelopacultureofcarewhichequallyvaluesolderpeople’sdyingaswellastheirliving.Relationship‐centredcare,withtheemphasisonpersonalneedanddignity,canprovideafoundationthroughwhichresidentsaresupportedindiscussingdeathanddying.Thesediscussionscanimprovethelikelihoodthatresidentsexperiencetheirdeathaccordingtotheirwishes.Thisindicatormonitorsresidentcomfortwithdiscussionofdeathanddying.Effortshouldbemadetoaskallresidentsadaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Dyingandend‐of‐lifecare

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

HD" "

O&+7$2.':"^'"D!"

[*47&7.7'&" Percentageofrelatives/friendswhohavediscussedwithstaffend‐of‐lifecareplansfortheirresident

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendswhohavediscussedend‐of‐lifewithstaff

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Includingrelatives/friendsindiscussionsaboutresidentdeathisimportanttoencouragecommonunderstandingofbothrelatives/friendsandresidentwishesandpreferencesregardingdeathanddying.Sharedunderstandingcanimprovetheexperienceofdyinganddeathforrelatives/friendsinwaysthatcanprovideclosureandfeelingsofacceptance.Thisindicatoraddressesinclusionofrelatives/friendsindiscussionsofend‐of‐life.

G*:/?*$.7R*" Relatives/friends

1=*-*"" Qualityoflife,End‐of‐lifecare

6';:$*" NCHR&DForum,2007

O&+7$2.':"^'"D0"

[*47&7.7'&" Percentageofstaffwhofeelemotionallysupportedwhenresidentsdie

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstafffeelingemotionallysupportedwhenresidentsdie

Denominator:Totalnumberofstaffsurveyed

e/*dG;:?'/*" Inadditiontorelatives/friends,thestaffoftenfeelasenseofdeeplosswhenresidentsdiebecauseoftheclosenatureoftheworkstaffengageinwithresidents,aswellastherelationshipstheyformwithresidents.Itiscommonforstafftorequiresupportafteradeath,forexampleinformsofopendiscussion,funeralattendance,ormemorialservices.Supportduringthegrievingprocesscanenhancestaff’sabilitytoreachacceptanceandclosure.Thisindicatormonitorsemotionalsupportofstaff.

G*:/?*$.7R*" Staff

1=*-*"" Qualityoflife,End‐of‐life

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

HH" "

O&+7$2.':"^'"DA"

[*47&7.7'&" Percentageofresidentswhofeeltherearenotenoughstaffavailabletomeettheirneeds

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithresidentsand/ortheirrepresentatives

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingthattherearenotenoughstaffavailable

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Thisindicatoraddresseshavingadequate,properlytrainedstafftomeetresidentneeds.Afeelingthatthereisinsufficientstaffavailablecanoccurasaresultofinsufficientnumbersofstaffaswellasinsufficienteducationortraining,particularlyinunderstandingandmeetingneedsofresidents.Staffwhohavetraininginrelationship‐centredcareandareconsistentlyassignedtothesameresidents,forexample,maybeabletoadequatelyaddressresidentneedsbecausestaffwillhavecrucialknowledgeofresidentwishesandroutines.Afeelingthatthereisenoughstaffcanfacilitateresidentfeelingsofworthandimportanceasindividualsandimprovequalityoflife.Effortshouldbemadetosurveyallresidentsadaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife

6';:$*" NCHR&DForum,2007

O&+7$2.':"^'"DD"

[*47&7.7'&" Percentageofrelatives/friendswhofeelstaffarecompetenttocarefortheirresident

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingstaffarecompetent

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Relatives/friendsoftendesiretomaintainsomecare‐takingdutieswhenresidentsareplacedinnursinghomes.Relatives/friendsareoftenunsurewhattheirroleincaringforresidentscanbeafterplacement.Negotiationsofcaretasksamongstaffandrelatives/friendsareimportantforrelative/friendsatisfactionwithcareplacementandongoingcare.Thismayrequireeducationortrainingnotjustforstaff,butforrelatives/friendsaswell.

G*:/?*$.7R*" Relatives/friends

1=*-*"" Qualityoflife,Relative/friendinvolvementincare

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

HI" "

O&+7$2.':"^'"DH"

[*47&7.7'&" Percentageofstaffwhofeeltheirtrainingneedsaremettocareforresidents

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstafffeelingtheirtrainingneedsaremet

Denominator:Totalnumberofstaffsurveyed

e/*dG;:?'/*" Careforolderadultsandpersonswithdementiacanrequirespecialisedknowledge.Manycarehomeworkersarelackingineducationandtrainingtomeettheneedsofanincreasinglycomplexpopulationofindividualsincarehomes.Education,accompaniedbypracticalguidanceandsupportintransferringknowledgeiscriticalforensuringdesirablestaffpractices.Thisindicatorcanhelpgaugewhetherstafffeeltheyareadequatelypreparedfortheirduties.

G*:/?*$.7R*" Staff

1=*-*"" Qualityoflife,Staffeducation&training

6';:$*" NCHR&DForum,2007

O&+7$2.':"^'"DI"

[*47&7.7'&" Percentageofresidentswhofeelthereisapositiveatmosphereinthecarehome

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingthereisapositiveatmosphere

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Apositiveatmosphereinthecarehomecanbefacilitatedbystrongleadershipandmanagementandisanatmospherewhereinstaff,residents,andrelatives/friendsarecontinuallyabletoadapttomeetchangingneedsandimprovecarepractices.Apositiveatmospherefosterspositiveexperiencesforresidentsthatcontributetoenhancedqualityoflife.Thisindicatormonitorshowresidentsfeelaboutthecarehomeatmosphere.Effortshouldbemadetosurveyallresidentsadaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Organisationalatmosphere

6';:$*" NCHR&DForum,2007

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

HJ" "

O&+7$2.':"^'"DJ"

[*47&7.7'&" Percentageofrelatives/friendswhofeeltheirsuggestionsforimprovementarewelcomedbystaff

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingtheirsuggestionsarewelcomed

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Inapositiveatmosphere,theknowledgeofeveryindividualisvalued.Relatives/friendsareconsideredpartofthe‘team’forqualityimprovement.Relatives/friendsoftenhavevaluableinsightsintocaredeliveryandcanoffercreativesolutionstoconcernsaboutcaredelivery.Welcomingrelative/friendsuggestionscancreateasenseofpartnershipandsharedmeaningregardingcarehomepracticeswhichwillfacilitatefeelingsofsatisfactionwithcareandqualityoflife.Thisindicatormonitorsinclusionofrelatives/friendsintheteam.

G*:/?*$.7R*" Relatives/friends

1=*-*"" Qualityoflife,Relatives’andfriends’involvementincare

6';:$*" NCHR&DForum,2007

O&+7$2.':"^'"DL"

[*47&7.7'&" Percentageofresidentswhofeelsafe,protectedandsecureinthecarehome

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#1),orqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingsafeandsecure

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Feelingsafe,protected,andsecurehasbeenidentifiedasapositiveeventbyresidentsincarehomes.Feelingsafecanleadtoasenseofsecurity,whichcanimprovequalityoflifeforresidents.Thisindicatormonitorsthissense.Effortshouldbemadetosurveyallresidents,adaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Senseofsecurity

6';:$*" Faulkneretal.,2006

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

HL" "

O&+7$2.':"^'"DM"

[*47&7.7'&" Percentageofresidentswhofeelstaffarefriendlytothem

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#3),orqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingstaffarefriendly

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Feelingstaffarefriendlytoresidentshasbeenidentifiedasapositiveeventbyresidentsincarehomes.Beingreceivedbystaffinafriendlymannercanleadtoasenseofbelonging,whichcanimprovequalityoflifeforresidents.Thisindicatormonitorsthissense.Effortshouldbemadetosurveyallresidents,adaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Senseofbelonging

6';:$*" Faulkneretal.,2006

O&+7$2.':"^'"HN"

[*47&7.7'&" Percentageofresidentswhofeeltheycanhavevisitorswhenevertheylike

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#5),orqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingtheycanhavevisitors

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Feelingtheycanhavevisitorswhenevertheylikehasbeenidentifiedasapositiveeventbyresidentsincarehomes.Havingvisitorscanleadtoasenseofcontinuity,whichcanimprovequalityoflifeforresidents.Thisindicatormonitorsthissense.Effortshouldbemadetosurveyallresidents,adaptingquestionsforindividualswithcognitiveimpairment.

Thisindicatormightnotberelevantincarehomeswherevisitorscanenterthecarehomeatanytime.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Senseofcontinuity

6';:$*" Faulkneretal.,2006

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

HM" "

O&+7$2.':"^'"H!"

[*47&7.7'&" Percentageofresidentswhofeelstaffencouragethemtohelpthemselves

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#25),orqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingstaffencouragethem

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Encouragingresidentstohelpthemselvesallowsresidentstomaintainabilitiesandhaveasenseofpurposeinlifebyreducingtherelianceonstaffforallaspectsofcare.Asenseofpurposecanbringmeaningtolifeinthecarehomeandimprovequalityoflife.Thisindicatormonitorsthissense.Effortshouldbemadetosurveyallresidents,adaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Senseofpurpose

6';:$*" Faulkneretal.,2006

O&+7$2.':"^'"H0"

[*47&7.7'&" Percentageofresidentswhofeelstaffgivethemtimetodothingsontheirown

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#18),orqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingstaffgivethemtime

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Feelingstaffgivethemtimetodothingsontheirownhasbeenidentifiedasapositiveeventbyresidentsincarehomes.Residentswhoaregiventhetimeandopportunitytodothingsontheirownhaveasenseofachievementwhichcangivemeaningtolifeandimproveitsquality.Thisindicatormonitorsthissense.Effortshouldbemadetosurveyallresidents,adaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Senseofachievement

6';:$*" Faulkneretal.,2006

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

IN" "

O&+7$2.':"^'"HA"

[*47&7.7'&" Percentageofresidentswhofeelstaffrespecttheirpersonalbelongings

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#20),orqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingstaffrespecttheirbelongings

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Respectforpersonalbelongingshasbeenidentifiedbyresidentsasapositiveevent.Thisrespectcangiveresidentsasenseofsignificanceasaperson.Whenresidentsfeelthatthey,andbyextension,theirbelongingshavesignificance,theyhaveanenhancedqualityoflife.Thisindicatormonitorsthissense.Effortshouldbemadetosurveyallresidents,adaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Senseofsignificance

6';:$*" Faulkneretal.,2006

O&+7$2.':"^'"HD"

[*47&7.7'&" Percentageofstaffwhofeelresidents’familiesappeartotrustthem.

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstafffeelingfamiliestrustthem

Denominator:Totalnumberofstaffsurveyed

e/*dG;:?'/*" Staffthatfeelfamilytruststhemandtheircapacitytocareforresidentshaveasenseofachievementthatmayimprovetheirsatisfactionwithwork.Thisindicatormonitorsthissense.

G*:/?*$.7R*" Staff

1=*-*"" Qualityoflife,Senseofachievement

6';:$*" Faulkneretal.,2006

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

I!" "

O&+7$2.':"^'"HH"

[*47&7.7'&" Percentageofrelatives/friendswhofeelstaffrespondquicklywhentheirrelativeasksforhelp.

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#19)orqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingstaffrespondquickly

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Feelingstaffrespondquicklyhasbeenidentifiedasapositiveeventbyrelatives/friendsincarehomes.Aquickresponseforhelpcanhelprelatives/friendshaveasenseofsecuritywhichiskeytorelative/friendqualityoflifeincarehomes.Thisindicatormonitorsthissense.

G*:/?*$.7R*" Relatives/Friends

1=*-*"" Qualityoflife,Senseofsecurity

6';:$*" Faulkneretal.,2006

O&+7$2.':"^'"HI"

[*47&7.7'&" Percentageofrelatives/friendswhofeeltheirresidentseemshappyinthehome

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#7),orqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingtheirresidentishappy

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Feelingtheirresidentseemshappyinthecarehomehasbeenidentifiedasapositiveeventbyrelatives/friendsincarehomes.Whentheirresidentseemshappy,relatives/friendshaveasenseofbelongingthatiskeytotheirqualityoflifeincarehomes.Thisindicatormonitorsthissense

G*:/?*$.7R*" Relatives/Friends

1=*-*"" Qualityoflife,Senseofbelonging

6';:$*" Faulkneretal.,2006

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

I0" "

O&+7$2.':"^'"HJ"

[*47&7.7'&" Percentageofrelatives/friendswhofeelthehomesmellspleasant

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#1),orqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelthehomesmellspleasant

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Feelinglikethehomesmellspleasanthasbeenendorsedbyrelatives/friendsasanitemofparticularimportancethatreflectsapositiveeventinthecarehomeandmaybeabletoimprovetheirsatisfactionwithcare.Thisindicatormonitorsrelative/friendsatisfactionwiththephysicalenvironmentofthecarehome.

G*:/?*$.7R*" Relatives/Friends

1=*-*"" Qualityoflife,Satisfactionwithcare

6';:$*" Faulkneretal.,2006

O&+7$2.':"^'"HL"

[*47&7.7'&" Percentageofrelatives/friendswhofeeltheyareinvolvedindecisionsabouttheirresident’scare

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#2),orqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingtheyareinvolved

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Relatives/friendshaveidentifiedbeinginvolvedincaredecisionsasapositiveeventthatcanimprovesatisfactionandenjoymentwithcare.Beinginvolvedcanalsofosterasenseofpurposeforrelatives/friends.Thisindicatormonitorsthissense.

G*:/?*$.7R*" Relatives/Friends

1=*-*"" Qualityoflife,Relatives’andfriends’involvementincare

6';:$*" Faulkneretal.,2006

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

IA" "

O&+7$2.':"^'"HM"

[*47&7.7'&" Percentageofrelatives/friendswhofeelstaffappreciatetheirinputtotheirresident’scare

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#16),orqualitativeinterviewswithrelatives/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingstaffappreciatetheirinput

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Havingafeelingthatstaffappreciatetheinputfromrelatives/friendsincarehomesisapositiveeventthatcanimprovesatisfactionandenjoymentwithcare.Havinginputcanalsogiverelatives/friendsameaningfulsenseofachievement.Thisindicatormonitorsrelative/friendsenseofachievement.

G*:/?*$.7R*" Relatives/Friends

1=*-*"" Qualityoflife,Senseofachievement

6';:$*" InspiredbyFaulkneretal.,2006

O&+7$2.':"^'"IN"

[*47&7.7'&" Percentageofrelatives/friendswhofeeltheyarekeptup‐to‐datewithchangesaffectingtheirresident.

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveys,CAREprofiles(item#15),orqualitativeinterviewswithrelatives/friends

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofrelatives/friendsfeelingtheyarekeptup‐to‐date

Denominator:Totalnumberofrelatives/friendssurveyed

e/*dG;:?'/*" Feelingkeptup‐to‐dateregardingchangesaffectingrelative/friendresidentsisapositiveeventthatcaninfluencesatisfactionandenjoymentwithcare.Beingkeptup‐to‐datecanalsogiverelatives/friendsasenseofsignificance.Thisindicatormonitorsrelative/friendsenseofsignificance.

G*:/?*$.7R*" Relatives/Friends

1=*-*"" Qualityoflife,Senseofsignificance

6';:$*" InspiredbyFaulkneretal.,2006

"

"

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

ID" "

O&+7$2.':"^'"I!"

[*47&7.7'&" Numberofjointinitiativesthatengagepositivelyresidents,relativesandstaffwiththeexternalcommunityinthelastyear

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedthroughtrackingofattendanceofevents/initiatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numberofjointinitiativesinthelastyear

e/*dG;:?'/*" Thisisanindicatorofsupportprovidedtoassistresidentstodevelopandmaintainrelationshipswithpeopleoutsidethecarehome.Maintainingrelationshipswithfamilyandfriendsfacilitatesasenseofbelongingandsignificanceforresidents.Linkswith,andengagementincommunityeventscanpromoteasenseofpurpose.

G*:/?*$.7R*" Resident,relative/friend,staff

1=*-*"" Qualityoflife,Communityconnections

6';:$*" InspiredbyCSCI,2008;E‐Qalin,2009;MAGSNRW,2006

O&+7$2.':"^'"I0"

[*47&7.7'&" Percentageofresidentvoluntaryparticipationinorganisedsocialactivitiesduringachosenperiod

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedthroughtrackingrecordsofattendanceofevents/initiatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberoftimesresidentsparticipateinsocialactivities

Denominator:Totalnumberofactivitiesoffered/organized

e/*dG;:?'/*" Thisisanindicatorofsupportprovidedtoassistresidentstodevelopandmaintainrelationshipswithpeoplewithinthecarehome.Creatingrelationshipswithinthecarehomecanfacilitateasenseofbelongingandsignificanceforresidents.Linkswith,andengagementinevents,canalsopromoteasenseofpurpose.Thisindicatormonitorsresidentsocialinvolvement.

G*:/?*$.7R*" Resident

1=*-*"" Qualityoflife,Socialactivities

6';:$*" InspiredbyCSCI,2008;E‐Qalin,2009

"

"

"

"

"

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

IH" "

O&+7$2.':"^'"IA"

[*47&7.7'&" Percentageofresidentswhofeeltheirprivacyisadequatelyprotected

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingtheirprivacyisprotected

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Studiesofconsumerpreferencehaveshownthatthepossibilitiesanddegreeofexperiencingprivacyandintimacyareveryimportantfortheindividualperceptionofautonomyandqualityoflife.Theindividualcontroloverprivateinteractionplaysasignificantroleinthiscontext.Thisindicatormonitorsresidentcomfortwithprivacylevels.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife

6';:$*" InspiredbyE‐Qalin,2009;Kane,2003;CSCI,2008

O&+7$2.':"^'"ID"

[*47&7.7'&" Percentageofrelativeswithwhomatleasttwomeetingstoreviewcarewerecarriedoutperyear

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedthroughtrackingofthenumberofappraisalinterviewsforeachresidentwithatleastonerelativeoranadvocate.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswhosecarehasbeenreviewedatleasttwiceperyearbymeansofanappraisalinterviewwitharelativeoradvocate

Denominator:Numberofresidentswithatleastonerelativeoradvocate

e/*dG;:?'/*" Meetingswithrelativestoreviewcare(appraisalinterviews)shouldaddressissuesconcerningthepastperiodsuchassatisfactionoffamilymembers,theirperceptionofcare,thedevelopmentoftheirrelativelivinginthefacility,backgroundinformationorbiography,complaintsetc.Secondly,proposalsandplansfortheupcomingperiodshouldcoverspecialneedsthatshouldbesatisfiedincludingbothqualityofcareandqualityoflife,plansandintentionsofstaffetc.Residentswithoutrelativesshouldbeallocatedanadvocate.Thisindicatormonitorsamountofresidentcarereview.

G*:/?*$.7R*" Relatives/friends,Residents

1=*-*"" Qualityoflife,Involvementofrelatives/friendsincare

6';:$*" InspiredbyE‐Qalin,2009;CSCI,2008

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

II" "

O&+7$2.':"^'"IH"

[*47&7.7'&" Percentageofresidents(andtheirrelatives)withadefinedkeyworker

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedbycarefulreviewofthecareplandocumentationand/oranitem,constructedforitspurpose,onannualsatisfactionsurveyswithresidentsandrelatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswithadefinedkeyworker

Denominator:Numberofresidents

e/*dG;:?'/*" Positiveexperiencehasbeenreportedwithdefinedkeyworkerswhoserveasareferenceforresidents,inparticularthosesufferingfromdementiaandcognitiveimpairment,andtheirrelatives.Ifassignedtoactasadefinedcontactpersontoanumberofresidents,healthandsocialcarestaffareenabledtobuildabetterrelationshipwithresidents,toincreaseknowledgeontheirbiographicalbackgroundandtodeveloprespectiveinterventions.Thisindicatorassessesthedegreeofkeyworkerassignmentwhich,insomecountries,hasbecomeamandatorystandard.

G*:/?*$.7R*" Residents,staff

1=*-*"" Qualityofcare,Qualityoflife

6';:$*" Mageeetal.,2008;Lind,2000

O&+7$2.':"^'"II"

[*47&7.7'&" Percentageofresidentswhoreceivedprofessionalend‐of‐lifecareinthelastyear

S?*:2.7'&2)7/2.7'&" Thisindicatorisproducedthroughcarefulreviewofcaredocumentation.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsreceivingprofessionalend‐of‐lifecare

Denominator:Numberofresidents

e/*dG;:?'/*" Anadequateend‐of‐lifecarebelongstothemostimportanttasksincarehomesandfacilitieshavetoofferanadequateframeworkfortheorganisationofthedyingprocess,includingthesupportofrelatives.Thepurposeoftheindicatoristomonitortheprocessofdyingwithafocusontheresidents,relativesandincludingreligious,culturalandmedicalneeds,suchasadequatepalliativecare.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife

6';:$*" InspiredbyReferenceModels3,QualityStandardsforResidentialCare,V1.0andtheCSCI,2008

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

IJ" "

O&+7$2.':"^'"IJ"

[*47&7.7'&" Percentageofresidentswhoseculturalneedsandpreferencesaremet

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitemonannualsatisfactionsurveyswithresidentsand/orresidentrecordsincludingdietaryrequirements.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentshavingtheirculturalpreferencesmet

Denominator:Numberofresidents

e/*dG;:?'/*" Thisindicatoraddresseswhetherstaffhavebeenadequatelypreparedtomeetthereligious,spiritualanddietaryneedsofdifferentethnicgroupsanddetermineswhetherresidentsandfamilieshavetheopportunitytoparticipatefullyintheassessmentprocessanddevelopmentofcareplans.Theindicatormightbemorepertinentinsomecountriesthaninothers.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife,Socialactivities

6';:$*" InspiredbyCSCI,2008

O&+7$2.':"^'"IL"

[*47&7.7'&" Percentageofresidentswhohaveanup‐to‐dateend‐of‐lifecareplanthatisconsistentwiththeirpreferences

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedbycollectionofdatafromcaredocumentation,whichshouldincludeAdvanceCarePlanningdirectivesfromtheresidentaswellaschoiceofplaceofdeath.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswithanup‐to‐datecareplan

Denominator:Numberofresidents

e/*dG;:?'/*" Theindicatorhelpstomonitorthedegreeofindividualisationofferedbythecarehome.Managementandstaffarerequiredtodefineobjectives,tocomparethesewithactualresults,toreflectonthegeneraltendencyandtoelaborateonchangetoreachdefinedobjectives.

G*:/?*$.7R*" Residents

1=*-*"" Qualityoflife

6';:$*" InspiredbyE‐Qalin,2009;CSCI,2008;MDS,2009;DoH,2008

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

IL" "

O&+7$2.':"^'"IM"

[*47&7.7'&" Percentageofresidentswhoaresatisfiedaboutthetasteandqualityofthemeals

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentssatisfiedwithmeals

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Mealsareanimportantsocialevent.Mealsrepresentvaluesandculturethatwereengagedinwithrelatives/friendsbeforecarehomeplacement.Enjoyingthetasteandqualityofmealscanimprovequalityoflife.Thisindicatormonitorsresidentsatisfactionwithmeals.Effortshouldbemadetosurveyallresidents,adaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Resident

1=*-*"" Qualityoflife,Food

6';:$*" InspiredbyKane,2003

O&+7$2.':"^'"JN"

[*47&7.7'&" Percentageofresidentswhofeeltheyhavesufficientcontrolovertheirdailyliving

S?*:2.7'&2)7/2.7'&" Thisindicatorisgeneratedasanitem,constructedforitspurpose,onannualsatisfactionsurveysorqualitativeinterviewswithresidentsand/ortheirrepresentatives.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentsfeelingtheyhavecontrol

Denominator:Totalnumberofresidentssurveyed

e/*dG;:?'/*" Havingcontroloverdailylifecanenhanceresidentqualityoflife.Waysresidentsmayhavecontrolovertheirdailylifeincludeareasofcaresurroundingwake/sleepcycles,dining,bathing,etc.Thisindicatormonitorsresidentaccesstocontrol.Effortshouldbemadetosurveyallresidents,adaptingquestionsforindividualswithcognitiveimpairment.

G*:/?*$.7R*" Resident

1=*-*"" Qualityoflife,Autonomy

6';:$*" InspiredbyKane,2003

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

IM" "

Domain 3: Leadership

Managingcarehomesisacomplextaskthat,inthecontextofsocialandhealthcarepolicies,callsfor skills that reach on a general level from partnership working, effective contracting,engagement with communities, users and carers and a continued focus on performance andoutcomes to innovation and enthusiasm for service delivery. These demands suggest a moveawayfromtraditionalhierarchicalleadershiptonetworkingapproachesandparticipativewaysofsteering and controlling. On a personal and organisational level, such approaches have to becomplementedbyaninternaldialogue,team‐working,empowermentandemployeewell‐being.

Care homes are characterisedbymanagement, staff, residents andother stakeholdersworkingandlivingtogether24hoursaday,7daysaweekand365daysperyear.Thisspecificitycallsforaparticipative organisational culture that works for, with and towards the well‐being of theresidents,while taking intoaccount theneedsand expectationsof staff, familiesand friendsaswellaspublicpurchasersorsuppliers.

The indicators gathered in the domain ‘leadership’ are therefore, on the one hand, combiningresults from satisfaction surveys with staff, families, friends and/or advocates of residents tomonitor ‘subjective’ views in relation to the organisational ‘climate’ and the satisfaction offamilieswiththeresultsofcare.Ontheotherhand,quantitativeandmore‘objective’ indicatorswereidentifiedtocontrol:

• for the degree of compliance tomutually agreed or externally defined standards, e.g. inrelationtodefinedindividualcareplans;

• forbottlenecksandpotential strainsonstaff,e.g.by overtimeworkorextendedabsenceduetosickness;and

• forpreventingshortcomings,e.g.bycombiningtheneedsstructureofresidentswithactualdataonfurthertrainingondealingwithresidentssufferingfromdementia.

Choosingkey indicators toassess,discussand improveresultsofmanagementperformance isamanagement task that requires openness and transparency towards collaborators and externalpartners.Itisuptothemanagementtodecideonthescopeoftransparency,buttheirchoiceandtheir extent itself will always be an indicator for the typeof leadership to be encountered in aspecificcarehome,fortheorganisational‘climate’inthatcarehomeaswellasforthecredibilityandreputationofitsmanagers.

""

"""

"

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

JN" "

O&+7$2.':"^'"J!"

[*47&7.7'&" Percentageofcomplaintsbystakeholdersthathavebeenadequatelyaddressedintheframeworkofacomplaintsmanagementsystem

S?*:2.7'&2)7/2.7'&" Forthisindicatoritismostimportanttoagreeuponadefinitionof‘adequatelyaddressed’withinthecomplaintsmanagementprocedure.Furthermore,amemberofthemanagementstaffshouldbespecifiedasresponsibletogatherindividualcomplaints,toinitiaterespectivemeasuresandtodocumentthem.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofadequatelyaddressedcomplaints

Denominator:Numberofallcomplaints

e/*dG;:?'/*" Thisindicatorhasadoublevalueasitmaybeinterpretedbothfromaresident’sandfromamanagementperspective.Discussionofresidents’problemshelpscarehomesidentifyandunderstandproblemsandwaystoimprovetheirquality,byprovidinginformationabouttheexperienceofthevariousstakeholders(residents,staff,andrelatives).

G*:/?*$.7R*" Management,Residents

1=*-*"" Complaintsmanagement,improvement

6';:$*" E‐Qalin,2009;NRWActofhousingandparticipation(§8WTG)

O&+7$2.':"^'"J0"

[*47&7.7'&" Percentageofresidentswhohavehaddefinedcareplansthatareregularlyupdatedandevaluatedwithspecificmeasuresaccordingtotheirindividualneeds

S?*:2.7'&2)7/2.7'&" Datagatheredincaredocumentation.Regardingtheassessmentofcareneeds,thisshouldalsobecheckedforupdatesanditshouldbedefinedwithinwhichperiodoftimethecareplanhastobedefinedfollowingadmissionandwithinwhichperiodupdatesaredue.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidentswithdefinedcareplansaccordingtotheirneeds

Denominator:Numberofallresidents

e/*dG;:?'/*" Thisindicatormightnotbeusefulincountrieswherelegalstandardsprescribethatindividualcareplanshavetobedefinedandregularlyupdated.However,eveniftheindicatorhasalwaystobeat100%,itmightbehelpfultomonitorthedegreeofindividualisationofferedbythecarehome.Managementandstaffarerequiredtodefineobjectives,tocomparethesewithactualresults,toreflectonthegeneraltendencyandtoelaborateonimprovementstoreachdefinedobjectivesduringthenextyear,e.g.“focusonmoreindividualisedcareplansbyinvolvingspecialisedtherapistsandgeriatricians”.

G*:/?*$.7R*" Residents

1=*-*"" Careprocess,Individualisedcare

6';:$*" E‐Qalin,2009;MDS,2009

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

J!" "

O&+7$2.':"^'"JA"

[*47&7.7'&" Ratingsoffamilymembers/closefriends/advocateswithrespecttotheirsatisfactionwithcarequality

S?*:2.7'&2)7/2.7'&" Surveyandratingsaccordingtonationalcultures.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Averageratingaccordingtothedefinedscale(couldbeanalysedbytargetgroup,bydepartmentetc.)

e/*dG;:?'/*" Asalldataonusersatisfaction,thisindicatoralsohastobeassessedandinterpretedwithcare.Managementandstaffareinvitedtocarryoutatleastonesurveyperyear,tosetobjectives(ratingtobeachieved),tocomparedefinedandactualratings,toreflectonthegeneraltendencyandtoelaborateonmeasurestoreachdefinedobjectivesduringthefollowingperiod,e.g.moreinvolvementoffamilymembers,betterinformationetc.

G*:/?*$.7R*" Familymembers,friends,advocates

1=*-*"" Satisfactionoffamilymembers

6';:$*" E‐Qalin,2009

O&+7$2.':"^'"JD"

[*47&7.7'&" Averagepercentageofovertimework(includingnon‐paidhours)

S?*:2.7'&2)7/2.7'&" HRMrecords–averageovertimehoursworkedbydifferentdepartments(professions)asapercentageoftotalregularworkingtime.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Sumoftheindividualpercentageofovertimeworkofeachstaffmember(seebelow)

Denominator:Numberofstaffmembers

Individualpercentageofovertimework:

• Numerator:Totalhoursofovertimeworkinayear(includingnon‐paidhours)forstaffmemberx

• Denominator:Totalhoursofworkinayearforstaffmemberx

e/*dG;:?'/*" Thisindicatormustbeanalysedfrombothastaffandamanagementperspective.Overtimeworkmaycontributetohigherstaffsatisfaction(increasedincome)aswellasindicatingstressduetoanintenseworkload.Managementandstaffareinvitedtosetgoals,tocomparedefinedandactualdata,toreflectonthegeneraltendencyandtoelaborateonimprovementstoreachdefinedobjectivesduringthefollowingperiod,inparticularbycombiningrespectivedatawithstaffsatisfactiondata,sickleaveorstaffturnoverrates.

G*:/?*$.7R*" Staff,management

1=*-*"" Staffsatisfaction,humanrelations,workclimate

6';:$*" E‐Qalin,2009

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

J0" "

O&+7$2.':"^'"JH"

[*47&7.7'&" Averagepercentageofworkingtimelostduetosicknessofstaff

S?*:2.7'&2)7/2.7'&" RecordsofHRdepartment.Itshouldbecalculatedasapercentageoftotalworkingtimeperyear.Itcouldalsobecalculatedonaquarterlybasis.Disaggregationbyprofessionwouldbeofaddedvalue.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Sumoftheindividualpercentageofworkingtimelossduetosicknessofeachstaffmember(seebelow)

Denominator:Numberofstaffmembers

Individualpercentageofovertimework:

• Numerator:Totalhoursofworklostduetosicknessofstaffmemberxduringtheyear

• Denominator:Totalhoursofworkofstaffmemberxduringtheyear

Workingtimelosttosicknessshouldalsoincludehours/daysnotcoveredbysocialsecuritysicknessbenefits.Forinstance,ifthereisawaitingperiodbeforebenefitsaregiven,resultsmaybebrokendownby‘short‐termsickness’(waitingperiod)andlong‐termabsenceduetosickness.

e/*dG;:?'/*" ThisisanotherclassicalHRMindicatorfocusingonstaffsatisfaction,thoughinterpretationsshouldalwaysreflectonthegeneralcontextandculturalspecificities,i.e.datashouldbecomparedwithgeneralstatistics(e.g.regional,national,bysector).

Managementandstaffareinvitedtosetgoals,tocomparedefinedandactualdata,toreflectonthegeneraltendencyandtoelaborateonimprovementstoreachdefinedobjectivesduringthefollowingperiod.Theindicatorshouldbecombinedwithotherssuchas,forinstance,staffsatisfactiondata,staffturnoverrates(seeabove)ordataonparticipationinpreventativeorhealth‐promotingactivities.

G*:/?*$.7R*" Staff,management

1=*-*"" Qualityofworkingconditions,Health/sickness

6';:$*" E‐Qalin,2009

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

JA" "

O&+7$2.':"^'"JI"

[*47&7.7'&" Averagedirectfinancialresourcesavailableforhealthpromotion‐relatedtraining,meetingsandinfrastructureperstaffmember

S?*:2.7'&2)7/2.7'&" Financialdata,accountingsystem.Itshouldbecalculatedperyearinreferencetofull‐timeequivalents,oralternativelytoaveragedirectfinancialresources.Itcanbecalculatedasapercentageofthetotaloperatingbudgetperyear.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Sumoffinancialresourcesspentonhealthpromotion‐relatedtraining,meetingsandinfrastructureduringtheyear

Denominator:Totaloperatingbudgetintheyear

e/*dG;:?'/*" Severalinitiativeshaveaddressedissuesofhealthpromotioninhospitalsoverthepastfewyears.Financialbackingofhealthpromotionisanimportantpreconditionforadevelopmenttowards‘health‐promotingcarehomes’.Managementandstaffareinvitedtoassessbaselinedata,setobjectivesandmonitorresultsinordertodevelopimprovements.

G*:/?*$.7R*" Staff,management

1=*-*"" Qualityofworkingconditions,health/sickness

6';:$*" WHO,2004;EUPIDH,2001

O&+7$2.':"^'"JJ"

[*47&7.7'&" Percentageofstaffwithadvancedtrainingindealingwithdementiaandcognitivedecline

S?*:2.7'&2)7/2.7'&" Records.Staffwhohavereceivedspecifictrainingorqualification.Theadvancetrainingismeanttoalsoincluderecognitionofdementiainresidents.Shouldonlybeappliedtonursesandsocialworkers.Couldalsobeexpressedinhoursoftrainingorasapercentageoftheworkingtimeofcarestaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstaffmembers(onlycarestaffandsocialworkers)withadvancetrainingondementia

Denominator:Numberofstaffmembers(onlycarestaffandsocialworkers)

e/*dG;:?'/*" Staffprovidinghealthcaretoolderadultsareoftensofocusedonacutemedicalproblemsthattheymaymisssymptomsofcognitiveimpairment.Initsannualreportfor2006,AlzheimerEuropepointstothelikelyunderestimationofthenumberofpeoplewithdementiaduetodifficultiesinidentifyingthecondition.Asthepercentageofresidentswithdementiaincarehomesissignificantlyhigh,propertrainingtorecogniseandmanagethesecaseswilllikelybecomeapressingissue.

G*:/?*$.7R*" Staff,management

1=*-*"" Mentalcondition,qualityoflife,stafftraining/qualification

6';:$*" InspiredbyE‐Qalin,2009;ActofhousingandparticipationNRW(§12WTG);CSCI,2008

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

JD" "

O&+7$2.':"^'"JL"

[*47&7.7'&" Averagenumberofhoursinformaltrainingperstaffmemberbyprofession

S?*:2.7'&2)7/2.7'&" Records;datashouldbeabletobedisaggregatedbygender,professionand/orhierarchicallevel.Furthermore,theindicatorcouldberefinedanddisaggregatedbytypeandcontentsoftraining.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofhoursinformaltrainingperstaffmemberinayear(byprofession)

Denominator:Numberofstaffmembers(byprofession)

e/*dG;:?'/*" Theindicatorshowstowhichdegreethecarehomeisabletoofferfurthertraining.Managementandstaffareinvitedtoidentifybaselinedata,tosetobjectives,tocomparedefinedandactualdata,toreflectonthegeneraltendencyandtoelaborateonmeasurestoreachdefinedobjectivesduringthefollowingperiod.Maybecombinedwithretentionrate,numberofapplicantsforemployment,andstaffsatisfaction.

G*:/?*$.7R*" Management

1=*-*"" Development,furthereducationandtraining

6';:$*" InspiredbyE‐QalinManual,2009;CSCI,2008

O&+7$2.':"^'"JM"

[*47&7.7'&" Percentageofstaffwhoagreewiththestatementthathighstandardsofmovingandhandlingarepracticedintheircarehome

S?*:2.7'&2)7/2.7'&" Satisfactionsurveyswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstaffmembersthatagreewiththestatement

Denominator:Numberofstaffmemberswhorepliedtothesurvey

Alternative:averagerating(ifascaleisusedinthesurvey)

e/*dG;:?'/*" Havingasenseof‘security’iskeytoqualityoflifeincarehomes.Staffhaveidentifiedthisindicatorasoneofthemostimportantfactorsforthemfeelingasenseofsecurityinthecarehomesetting.Theindicatorprovidesinsightintotheorganisationalandteamclimateinthecarehomeandresultsmightimplyfocusedactivitiesforimprovingteamworkandmutualtrust.

G*:/?*$.7R*" Staffandmanagement

1=*-*"" Qualityofcare,qualityoflife,teamclimate

6';:$*" Faulkneretal.,2006

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

JH" "

O&+7$2.':"^'"LN"

[*47&7.7'&" Percentageofstaffwhoagreewiththestatementthatcolleaguesworkwiththemaspartofateam

S?*:2.7'&2)7/2.7'&" Satisfactionsurveyswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstaffmemberswhoagreewiththestatement

Denominator:Numberofstaffmemberswhorepliedtothesurvey

Alternative:averagerating(ifascaleisusedinthesurvey)

e/*dG;:?'/*" Despitethewell‐knownbenefitsofpositiveeventsforsubjectivewell‐being,littleisknownaboutthenatureofpositiveeventsexperiencedbyresidents,relativesandstaffincarehomes.Thisindicatorisavaliditemtocheckstaff’sfeelingsforthesenseof‘belonging’toateamandtothecarehomeasawhole.Resultswillimplyreflectionsaboutpotentialmeasurestoimprovethissenseofbelongingandteamworkingeneral.

G*:/?*$.7R*" Staffandmanagement

1=*-*"" Qualityoflife,teamwork

6';:$*" Faulkneretal.,2006

O&+7$2.':"^'"L!"

[*47&7.7'&" Percentageofstaffwhoagreewiththestatementthatrecordsarekeptup‐to‐dateintheircarehome

S?*:2.7'&2)7/2.7'&" Satisfactionsurveyswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstaffmembersthatagreewiththestatement

Denominator:Numberofstaffmemberswhorepliedtothesurvey

Alternative:averagerating(ifascaleisusedinthesurvey)

e/*dG;:?'/*" Havingasenseof‘continuity’iskeytoqualityoflifeincarehomes.Staffhaveidentifiedthisindicatorasoneofthemostimportantfactorsinthecarehomesetting.Ifrecordsarenotkeptup‐to‐datethismightbeathreattothecontinuityofcare.However,reflectionontheresultsofthisitemhastofocusonpotentialimprovementsandfactorsthatmightenablestafftocomplywithwhatshouldbeageneralprofessionalstandard,ratherthanblamingindividualstaffmembersandcreatingaclimateofbureaucraticcontrol.

G*:/?*$.7R*" Staffandmanagement

1=*-*"" Qualityofcare,Qualityoflife

6';:$*" Faulkneretal.,2006

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

JI" "

O&+7$2.':"^'"L0"

[*47&7.7'&" Percentageofstaffwhoagreewiththestatementthattheircarehomehasthegoaltodeliverhighstandardsofcare

S?*:2.7'&2)7/2.7'&" Satisfactionsurveyswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstaffmembersthatagreewiththestatement

Denominator:Numberofstaffmemberswhorepliedtothesurvey

Alternative:averagerating(ifascaleisusedinthesurvey)

e/*dG;:?'/*" Staffhaveidentifiedthisindicatorasoneofthemostimportantfactorsforthemfeelingasenseofpurposeinthecarehomesetting.Reflectingonresultsofthisitem,managementandstaffmightwanttofocusonpotentialfactorsthatinfluencethedeliveryofhighstandardsofcare,andhowthesefactorscanbeimproved.

G*:/?*$.7R*" Staffandmanagement

1=*-*"" Qualityofcare,Qualityoflife

6';:$*" Faulkneretal.,2006

O&+7$2.':"^'"LA"

[*47&7.7'&" Percentageofstaffwhoagreewiththestatementthatallgradesofstaffarebeingequallyvaluedintheirrole

S?*:2.7'&2)7/2.7'&" Satisfactionsurveyswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstaffmembersthatagreewiththestatement

Denominator:Numberofstaffmemberswhorepliedtothesurvey

Alternative:averagerating(ifascaleisusedinthesurvey)

e/*dG;:?'/*" Thisindicatoris,similarlytotheabove,focusingontheindividualstaffmember’ssenseofpurposeinthecarehomesetting.Itshowsthedegreetowhichstaffarefeelingequallyvaluedwithintheorganisationandmighthintatpotentialshortcomingsinrelationtomutualrespectandthegeneralworkingclimate.Incombinationwithdataonfluctuationratesorabsenceduetoillness,managementandstaffmightwanttoreflectuponmeasurestopositivelyinfluenceresultsinordertopreventdeterioration.

G*:/?*$.7R*" Staffandmanagement

1=*-*"" Qualityofcare,qualityoflife

6';:$*" Faulkneretal.,2006

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

JJ" "

O&+7$2.':"^'"LD"

[*47&7.7'&" Percentageofresidents/family/friendswhoagreewiththestatementthattheyhadbeenprovidedrelevantinformationbyadmissionintothecarehome

S?*:2.7'&2)7/2.7'&" Satisfactionsurveyswithresidents/family/friends.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofresidents/family/friendswhoagreewiththestatement

Denominator:Numberofresidents/family/friendswhoansweredthesurvey

Alternative:averagerating(ifascaleisusedinthesurvey)

e/*dG;:?'/*" Admissionintoacarehomeisacrucialphaseforresidents,theirfamilyandfriends.Decentinformationduringthisphaseisthusimportanttosupportchoicesandexpectationsofallinvolvedpersonsduringthistransition?.Managementandstaffareinvitedtoreflectuponfactorsthatcanbeinfluencedtoimproveinformationprocesses.

G*:/?*$.7R*" Residents/family/friends,leadership

1=*-*"" Satisfactionofresidents/family/friends

6';:$*" PROGRESS,2010

O&+7$2.':"^'"LH"

[*47&7.7'&" Percentageofstaffwhoagreewiththestatementthatthedecisionsintheircarehomearemadebasedonthequalityofcareratherthanpurelyonfinancialresources

S?*:2.7'&2)7/2.7'&" Satisfactionsurveyswithstaff.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofstaffwhoagreewiththestatement

Denominator:Numberofstaffmemberswhorepliedtothesurvey

Alternative:averagerating(ifascaleisusedinthesurvey)

e/*dG;:?'/*" Thisindicatorcanhelpspecifythedegreetowhichstaffareconvincedthatqualityisanimportantdriverofdecisionsinthecarehome.If,onthecontrary,staffpointoutthatdecisionsarerathermadefromafinancialperspective,managementandstaffmightreflectontheconsequencesofthistendencyanddevelopmeasuresforimprovement,ifnecessary.

G*:/?*$.7R*" Staffandmanagement

1=*-*"" Satisfactionofstaff

6';:$*" PROGRESS,2010

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

JL" "

O&+7$2.':"^'"LI"

[*47&7.7'&" Percentageofabsencetimes(sickness,vacation,other)andauxiliarytimes(meetings,training,etc.)asashareofthetotalworkingtime

S?*:2.7'&2)7/2.7'&" HRMdata;itisindispensabletoexactlydefinethecategoriesofabsencetimestobeincludedinthenumerator,forinstancebyreflectinguponthedegreetowhichthetypeofabsencetimecan/shouldbeinfluencedbystaffandmanagement.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Totalnumberofabsencetimes(bycategory:sickness,vacation,meetings,trainings,other)peryearDenominator:Totalworkingtime(basedonexistingcontracts)peryear

e/*dG;:?'/*" Theresultsofthisindicatorcanprovideinterestinginsightintimeuseandlossofworkingtimeduetovariousabsenceandauxiliarytimes.However,whilesomecategoriesofabsencetimesmaybeclearlyinterpretedasdetrimentaltothegeneralperformanceofacarehome(e.g.sickness),otherabsenceandauxiliarytimesmightbeunderstoodasgeneratingwell‐being(e.g.ifvacationisusedonaregularbasis)orimprovedservice(e.g.training,coordinationmeetings).Tooextendedabsencetimes,ontheotherhand,mighthavenegativeconsequencesonperson‐centredcareandresidents’satisfaction.Managementandstaffareinvitedtoreflectupontheimpactofrising/fallingabsencetimesbycategoryandrelatedatatootherindicatorssuchasresultsfromresidents’orstaffsatisfactionsurveys.

G*:/?*$.7R*" Staffandmanagement

1=*-*"" Sustainability,staffsatisfaction,residents’satisfaction

6';:$*" PROGRESS,2010

O&+7$2.':"^'"LJ"

[*47&7.7'&" Percentageofstaffbyagegroups(professionalgroups)

S?*:2.7'&2)7/2.7'&" HRMdata;thesamedatacanalsobeusedtoidentifythepercentageofstaffbyprofessionalgroupsinordertomonitorexternally(legal)orinternallydefinedstaffingstandards.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Staffperagegroup(e.g.16‐19,20‐29,30‐40etc.)Denominator:Totalnumberofstaff

e/*dG;:?'/*" Thoughitcanbequestionedwhetherthisindicatorisresult‐oriented,ratherthanreflectingthestructureofstaff,itisimportanttomonitortheaverageage(alsobyprofessionalgroup)inordertoavoidstaffshortageandtosteera‘generationalmix’ofstaffwithinthecarehome.Managementandstaffareinvitedtoreflectuponthe‘ideal’structureofstaffandtomonitorwhether,forinstance,itislikelythatahighpercentageofnursingcarestaffarereachingpensionageduringthenext5years.Correspondingmeasuresmightthusbetakentofindsolutionsinapreventiveandtimelymanner.

G*:/?*$.7R*" Staffandmanagement

1=*-*"" Sustainability,compliancewithlegalstandards

6';:$*" PROGRESS,2010

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

JM" "

['-27&"D8"X$'&'-7$"?*:4':-2&$*""

The indicators presentedunder this domain reflect a broader notionof quality in care servicesthat includes the concept of ‘sustainability’, which is at the centre of the EUOpenMethod ofCoordinationregardinglong‐termcare.Asteadycontinuumintheprovisionofcareservicesmustbe guaranteed over time, which means that the management of financial resources mustguarantee the viability of the care homeover the long‐term. Failure to do sowould negativelyimpactonthequalityofcarebyleadingto,forinstance,increasedstaffturnoverorreducingstaffbelow optimal levels. Ultimately, the closure of a care home and the ensuing need fordisplacementoftheresidentwouldmostprobablyresultinanadverseoutcomefortheresidents.

Furthermore, given that available resources are scarce, the provision of care services must beorganised in an efficient way to produce the best outcome for residents with the availableresources. It is important to stress though, that cost‐containment is not the focus or aim ofeconomic performance as measured by the indicators presented here. The aim is rather toachieveabetteruseofavailableresourcesby improvingtheratioofoutcomesasagainstmeansappliedandbyensuringthecontinuityofcareoverthelongterm.

Including economic performance within the list of key indicators also addresses the quest formoreefficiencyandeffectivenessinthedeliveryofsocialandhealthservicesthathasbeenoneofthe characteristics of the ongoing modernisation process, including the introduction of NewPublicManagement ideasalsointheareaoflong‐termcare(Huberetal.,2008).Inthistraditionandbyputtinganemphasisonperformancemeasurement,theeconomicperformanceindicatorspresentedherewillallowcarehomestoworktowardscomparisonsovertimeand,inamid‐termperspective,betweenindividualorganisationsorgroupsofcarehomes.

Despite the renewed emphasis on efficiency and effectiveness of care services, economicperformance indicators were for the most part absent from the various national qualityframeworks that formed the basis of the indicators for this project. Most of the indicatorspresented here were in fact inspired by existing indicators belonging to the E‐Qalin qualitymanagement system or were created in the framework of the several E‐Qalin validationworkshopsduringthisproject.

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

LN" "

O&+7$2.':"^'"LL"

[*47&7.7'&" Overallcostperresidentforthecarehome,peryear

S?*:2.7'&2)7/2.7'&" Thisindicatorisbasedonexistingfinancialdataintheaccountingsystem(indicateifdepreciationofcapitalisaccountedfor).

Theaveragenumberofresidentsiscalculatedasthemonthlyaveragetoaccountforthepossiblevariationinthenumberofresidentsthroughouttheyear.

Disaggregationofcosts(staffcosts,costsperlivingunitetc.)wouldbeofaddedvalue.

Accountforthelevelofcareneedsofresidents,whichshouldbemeasuredaccordingtothelocalassessmentscale.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Overallcostofrunningthecarehome

Denominator:Numberofresidents(monthlyaverage)

e/*dG;:?'/*" Economicevaluationtakesintoaccountthecostsandbenefitsofmeasuresorpolicies,recognisingthatavailableresourcesarelimitedandthussheddinglightonthemostcost‐effectivewaytoachievedefinedaims.Thisindicatorwouldhelptoplacenursinghomesalongtheproductioncurve,allowingfortheanalysisofcostsandeconomicsustainabilityofprocessesovertimeandwithinthecarehome.

G*:/?*$.7R*" Management,policy‐makers(purchasers)

1=*-*"" Economicsustainability

6';:$*" E‐Qalin,2009;Sefton,2000;Drummondetal.,2005

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

L!" "

O&+7$2.':"^'"LM"

[*47&7.7'&" Staffcostpercaredays

S?*:2.7'&2)7/2.7'&" Financialdata,accountingsystem.

Acaredayiscalculatedbythetotalnumberofcarehoursofallresidentsdividedby24.

Theindicatorcouldalsobecombinedwiththeutilisationratetoaccountforunoccupiedplacesinthecarehome.Accountforthelevelofcareneedsofresidents,whichshouldbemeasuredaccordingtothelocalassessmentscale.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Overallstaffcosts

Denominator:Numberofcaredays

e/*dG;:?'/*" Economicevaluationtakesintoaccountthecostsandbenefitsofmeasuresorpolicies,recognisingthatavailableresourcesarelimitedandthusshowingthemostcost‐effectivewaytoachievecertainaims.

Thiskeyresultindicatorallowsforthequantificationofcostswithpersonnelpercaredayprovided.Thisindicatorbecomesusefulonlyifappliedregularlyandwhencomparedwiththeevolutionofcareneedsofresidents.Itcanalsoindicatetheimportanceofoverheadcosts.

G*:/?*$.7R*" Management,policy‐makers

1=*-*"" Economicsustainability

6';:$*" E‐Qalin,2009;Eisenreichetal.,2004:59

O&+7$2.':"^'"MN"

[*47&7.7'&" Averagetimefordirectcareprovidedperdayperresident

S?*:2.7'&2)7/2.7'&" Surveyormonitoronlydirect‘hands‐on‐care’providedinanindividualwayoveroneweek.Disaggregationperprofessionandday/nightwouldbeanaddedvalue.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofhoursofdirectcareprovidedbyprofessionalstoeachresident(bytypeofprofession)

Denominator:Numberofresidentsduringtheweekofsurvey

e/*dG;:?'/*" Thepurposeofthisindicatoristoassesstimespentbypersonnelindirectcontactwithresidentstoprovidepersonalcareandassistance.Thistimemayalsobeputinrelationtototalworkingtime.Resultsmayberelatedtoresidents’satisfactionsurveysandsteeringmeasuresmightfocusonsettinggoalsforan‘optimal’amountofdirectcareandrespectiveprocessestoenablestafftoincreasetheaveragetimefordirectcare.Thisimpliesareflectiononcareprocessesandotherprocessesandtaskstobefulfilledbycarestaff.

G*:/?*$.7R*" Staffandleadership

1=*-*"" Careprocess

6';:$*" InspiredbyMAGS,2006

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

L0" "

O&+7$2.':"^'"M!"

[*47&7.7'&" Degreeofcapacityutilisation

S?*:2.7'&2)7/2.7'&" Thisindicatorisbasedontheexistingdataofresidentsinagivenmonth.Itmaybesupplementedbyinformationaboutthecase‐mixofresidents.

Capacityisdefinedasthetotalnumberofplacesforwhichthecarehomeislicensedtooperate.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofbillabledaysforresidentshostedinthepreviousmonth(byindividuallevelofcareaccordingtothenational/regionaldefinitions)

Denominator:Totalnumberofplacesforwhichthecarehomeislicensedtooperatemultipliedbynumberofdaysintherespectivemonth

e/*dG;:?'/*" Thisindicatorshowstheextentofunusedcapacity,thussignallingunderusedcapacitythatcouldpotentiallybedetrimentalforthemediumtolong‐termsustainabilityofthecarehome.Unusedcapacitymayflagapotentiallybadimageofthecarehome,butitmightalsobeasignforovercapacitiesofcarehomeplacesintherespectiveregion.Aggregateddataofcarehomescouldthusbecomeanimportanttoolforpolicy‐makerstomanageregionalorlocalcarepolicies.Fortheindividualcarehomemanageritwillbeimportanttodefinerealisticandfeasibletargetsandtodevelopstrategiesforreducingunusedcapacity.

G*:/?*$.7R*" Management,policy‐makers

1=*-*"" Economicsustainability

6';:$*" PROGRESS,2010

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

LA" "

['-27&"H8"5'&.*W."

One of the difficulties of comparisons within this sector, not to speak of ‘benchmarking’, iscertainly that the performance of a care home is deeply influenced by the context in which itoperates. This includes for example the legal framework, the labour market regulations andeconomic situation as well as the prevailing cultural values. As care homes exist within a setcommunityfromwhichtheresourcesaredrawn,itisimportanttomeasuretheperformanceofacare home in relation to themeans available in their community, particularly human resources(staffandvolunteers)thatcarehomesmustattractinordertoensurecontinuityintheirprovisionofcare.

As the keyperformance indicatorswereselectedon thebasis of their capacity tosteerchangewithin thecarehome,therewereveryfewselectedindicatorsforthisdomainasthe legislationframeworks governing the functioningof thecarehomearesetatnational leveland thereforenotsubjecttochangeatmicrolevel.Indeedalthoughthecarehomemightfinditdifficulttofindand retain qualified staff, it nevertheless cannot influence the quota of qualified nursing staffwhichthecarehomeneedstohaveaccordingtothelegislationitisboundto.

Evenso, theremaybe instanceswhere the resultsofa ‘context’keyperformance indicatorcanlead to change and improvement of certain processes within the care home. For instance,although staff turnover (due to the nature of the job as a low pay, low status profession) is asystemicchallengeacross Europeand elsewhere, theremayneverthelessbeadditional reasonsforthehighturnoverwhichareduetocertainspecificfailingsinthecarehome(forexamplelackof disciplinary action when staff are faced with abusive behaviour, although again the legalframeworkmaydifferfromcountrytocountry).Steeringmeasurestoreducehighturnovermightincluderegularappraisalinterviewswithallstaffmembers,burnoutpreventionorexitinterviewstobetterunderstandthereasonsforleavingthecarehome.

Furthermore,itisanimportanttaskofmanagementtocontributetoapositiveimageofthecarehomeand tosteer relationshipswithexternalpartners, suppliersandcommunitynetworks.Forinstance,theembeddingofacarehomeinalocalcommunitymightbeshownbythenumberofvolunteersthatthecarehomeisabletoattract.Steeringmeasuresmayincludeactivitiesthatareaddressing the neighbourhood of the care home including a proactive search for volunteers.Opening the care home to thepublic, e.g. by renting the assembly hall to local associations orinstallingapubliccaféwithlecturesandpossibilitiestomeetwithresidentsandfamilies,mightbeanadditionalwaytoimproveacceptanceandinvolvementofthelocalpublic.

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

LD" "

O&+7$2.':"^'"M0"

[*47&7.7'&" Averagenumberofhoursprovidedbyvolunteerstothecarehome(peryearandperresident)

S?*:2.7'&2)7/2.7'&" Astaffmember(inmanycarehomesthiswillbethe‘VolunteerCo‐ordinator’)willberesponsibleforkeepingrecordsandaskingvolunteerstosigninandsignoutatthebeginningandtheendoftheiractivities.

Itshouldbeagreedupon,whethertoincludeorexcludehoursofvolunteerworkprovidedbyrelativesexclusivelytotheirfamilymemberlivinginthecarehome.

Itcanalsobecalculatedasapercentageofthenumberoftotalworkinghoursofstaff(thedenominatorwouldthenbecome“Numberofworkinghoursprovidedbystaff”–seemeasurement/calculationformulabelow).

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Numberofhoursprovidedbyvolunteers

Denominator:Numberofresidents(monthlyaverage)

e/*dG;:?'/*" Theindicatorshowstowhichdegreethecarehomeisabletoinvolveexternalstakeholdersasvolunteerstocomplementprofessionalservices.Italsoindicatestowhatextentthecarehomeisabletocreatelinkstotheexternalcommunityandtoprovideresidentswithopportunitiestokeepsocialrelationswithpeopleoutsidethecarehome.

G*:/?*$.7R*" Leadership

1=*-*"" Development,networking

6';:$*" E‐Qalin,2009

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

LH" "

O&+7$2.':"^'"MA"

[*47&7.7'&" Averagelengthofemploymentperstaffmemberinthecarehomeatonepointintheyear(e.g.31stDecember)

S?*:2.7'&2)7/2.7'&" HRMrecords.Averagelengthofemploymentreferstothecarehomeonly,nottopreviousemployersorpreviouscarehomes.Allinformationshouldbedisaggregatedbyprofession.

Besidesaveragelengthofemployment,thestandarddeviationshouldalsobecalculated,asitindicatestowhatextentthelengthofemploymentofthestaffmemberstendstobeveryclosetothesamevalue(mean)ormoredispersed.

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Sumoftheindividuallengthsofemployment(numberofmonths)ofeachstaffmemberon31stofDecember

Denominator:Numberofstaffmembersonthe31stofDecember.

Themeasureforthestandarddeviationis:

WhereNisthenumberofemployees,xiisthelengthofemploymentofemployeeI,µisthemeanoraveragelengthofemploymentofallemployeesand∑representsthesum.

e/*dG;:?'/*" Theindicatorshowstowhichdegreethecarehomeisabletoinvolveexternalstakeholdersasvolunteerstocomplementprofessionalservices.Italsoindicatestowhatextentthecarehomeisabletocreatelinkstotheexternalcommunityandtoprovideresidentswithopportunitiestomaintainsocialrelationswithpeopleoutsidethecarehome.

G*:/?*$.7R*" Management,staff

1=*-*"" Development,networking

6';:$*" E‐Qalin,2009

O&+7$2.':"^'"MD"

[*47&7.7'&" Averagelengthoftime(days)neededtofillastaffvacancywiththesamelevelofqualification

S?*:2.7'&2)7/2.7'&" HRMrecords.Refertoallthevacanciesinthepastyeartimespan(measureatafixedpointintime).

K*2/;:*-*&.d"52)$;)2.7'&"P':-;)2"

Numerator:Sumofthenumberofdaysneededtofilleachstaffvacancyinthepastyear

Denominator:Numberofstaffvacanciesinthepastyear

e/*dG;:?'/*" Thisindicatorseekstoquantifypossibledifficultiesinrecruitingstaff,whichcanultimatelyleadtoshortagesofstafformismatchesinthecompositionofcarestaffthuspossiblyimpactingquality.

G*:/?*$.7R*" Leadership,policy‐makers

1=*-*"" Personnel,humanresourcesmanagement

6';:$*" E‐Qalin,2009

!"#$%&'()*+&,)&"$$-*.(/'0#1,&$*2,&*0#&"*3,4"$

LI" "

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