How does health regulation affect patient care?

Introduction of selected quality indicators in the Styrian nursing home control protocols to measure the quality of nursing outcomes


1 Master's thesis Introduction of selected quality indicators in the Styrian nursing home control protocols for measuring the quality of nursing outcomes submitted by Antonios Angelakis, BSc to obtain the academic degree Master of Science (MSc) at the Medical University of Graz, carried out at the Institute for Nursing Science under the guidance of FH Prof. Mag . Dr. Gerhard Pöttler MBA Graz am

2 Affidavit I declare on my honor that I wrote the present work independently and without outside help, that I have not used any sources other than those given and that I have identified the passages taken verbatim or with regard to content as such from the sources used. Graz, at Antonios Angelakis eh. I

3 Acknowledgments A big thank you goes first and foremost to the FH Prof. Mag. Gerhard Pöttler MBA, who gave me the opportunity to write this thesis at all and for his dedicated support. I would also like to thank the employees in Department 8 Science and Health of the Office of the Styrian Provincial Government and especially Mr. Christian Schwarz, representative of the Department of Health and Care Management, which is subordinate to her. They made it possible for me to do an instructive internship and provided me with comprehensive support and advice in preparing this master’s thesis. My thanks also go in large measure to Mag. Dipl.-HTL-Ing. Gerd Hartinger MPH and the staff of the Geriatric Health Centers of the City of Graz, for the permanent advice and support during the preparation of my master's thesis. Of course, we are very grateful to all the experts who participated in the survey. Last but not least, special thanks also go to my parents, who made my studies possible in the first place. I would also like to take this opportunity to express my thanks again to my Alexandra. Thank you for your decision to come to Graz, you are just something very special! ii

4 Table of Contents Affidavit ... i Acknowledgments ... ii List of Abbreviations ... v List of Figures ... vii List of Tables ... vii Summary ... viii Abstract ... ix 1. Introduction Relevance Objective and Research Questions Method Systematic literature search Delphi method Design data analysis Participation in the expert survey The nursing home control protocols Elements of the nursing home control protocols Nursing Basics of quality work Definition of quality Quality concept Quality management Quality assurance Guidelines Standards and criteria Scales and indicators Benchmarking audit Dimensions of quality Structural quality Process quality iii

5 4.2.3 Outcome quality Nursing quality Nursing outcome quality Assessment / measurement of care Outcome quality Indicators Types and functions of quality indicators Assessment instruments Quality indicators from international literature Pressure ulcers Malnutrition Fall incontinence (urinary stool) Urinary incontinence Faecal incontinence experts Survey of overall results Discussion Limitations Limitations Conclusion Bibliography ... Sources of law ... xx APPENDIX ... xxi iv

6 List of Abbreviations AI Assessment Instruments A-IQI Austrian Inpatient Quality Indicators AQM Australian Quality Matrix ASV Official Experts B VG Federal Constitutional Law BIQG Federal Institute for Quality in Health Care or CHRSA Center for Health Systems Research and Analysis CMS Centers for Maidicare and Madicaid programs DIN EN ISO German Institute for Standardization - European Norm- International Organization for Standardization DKG Deutsche Kontinenz Gesellschaft DNQP German Network for Quality Development in Nursing EBN Evidence Based Nursing EPUAP European Pressure Ulcer Advisory Panel et al. et alia EuroQUAN European Network for Quality Development in Nursing GGZ Geriatric Health Centers of the City GMDS German Society for Medical Informatics, Biometrics and Epidemiology GÖG Gesundheit Österreich GmbH GQG Health Quality Act GuKG Federal Act on Health and Nursing Professions as amended. in the current version ISO International Organization for v

7 KAKuG Standardization of Hospitals and Health Resorts Act LEVO Performance and Remuneration Ordinance MDS Minimum Data Set MIF Mobility Interaction Case Chart MKÖ Medical Continence Society Austria MNA Mini Nutritional Assessment MNA-SF Mini Nutritional Assessment- Short Form MUST Malnutrition Universal Screening Tool Lower Austria Lower Austria NPO Non Private Organization NPUAP National Pressure Ulcer Advisory Panel NRS Nutritional Risk Screening p., Pp. Page, page range PAV Personnel Equipment Ordinance PAVK Peripheral Arterial Occlusive Disease PEG Percutaneous Endoscopic Gastrostomy PHG Nursing Home Act POL Problem Oriented Learning QI Quality Indicator QM Quality Management QS-VO Quality Assurance Ordinance, RAI Resident Assessment Instrument RUMBA Unambiguous , Measurable, Observable and Appropriate SHG Social Welfare Act STAT Statistics Austria StPHG Styrian Nursing Home Act STRATIFY St. Thomas Risk Assessment Tool in Falling elderly inpatients St SBBG Social Care Professions Act vi

8 SWWT USA etc. WHO BMI e.g. Stops Walking When Talking United States of America and so on World Health Organization Body Mass Index for example list of figures Figure 1.1: Population pyramid 2013, 2030 and Figure 6.1.1: Indicators fall, consensus achievement Figure 6.1.2: Pressure ulcer indicators no consensus achievement Figure 6.1.3: Indicators malnutrition consensus achievement Figure 6.1.4: Indicators malnutrition no consensus achievement Figure 6.1.5: Indicators fall consensus achievement Figure 6.1.6: Indicators fall no consensus achievement Figure 6.1.7: Indicators incontinence consensus achievement Figure 6.1.8: Indicators incontinence no consensus achievement List of tables Table 2.1. 1: PubMed Table 2.1.2: CINAHL ... 8 Table 2.1.3: PubMed Table 5.1: Breakdown of the indicator categories into main categories vii

9 Summary The state of Styria is responsible for inspecting the public nursing homes twice a year without prior notice. As part of these controls, among other things, official experts for health and nursing check the quality of the care results using the care home control protocols. These protocols are important quality assurance instruments for public nursing homes in the Province of Styria. The aim of this work is accordingly to increase the potential of the Styrian nursing home protocols for measuring the quality of nursing outcomes. In order to achieve this, firstly, relevant care-sensitive quality indicators from various areas are identified through an extensive systematic literature search in the international databases. Acquired indicators from literature research were sorted according to the area and frequency of their occurrence. Due to the large number of quality indicators found, not every single one of the identified indicator categories could be processed within the scope of this work. Instead, the principles of time management are used and the Pareto principle or otherwise the 80/20 rule is applied. Thus, indicators in the areas of pressure ulcers, malnutrition, falls and incontinence are analyzed further, but also frequently used survey assessment instruments relevant to these categories. The indicators determined from the literature research were then summarized in an evaluation sheet and evaluated by a panel of experts using the modified Delphi method with regard to their suitability for measuring the quality of care outcomes in nursing homes. The Delphi survey was successfully completed in two rounds. The quality indicators on which consensus was reached among the experts are finally proposed as a conclusion of this work, for the introduction in the Styrian nursing home protocols. viii

10 Abstract The province of Styria is responsible for the unannounced control of the public nursing homes twice annually. Part of the assessment from the nursing expert representative of the public health office, is among others, the control of the nursing outcome quality, using the nursing home inspection protocols. These protocols are important quality assurance tools for the public nursing homes of Styria. Therefore the aim of this thesis is to increase the ability of the Styrian nursing home inspection protocols for measuring the nursing outcome quality. In order to achieve this goal, relevant nursing sensitive indicators from different fields are firstly identified, through a comprehensive systematic literature research in international databases. The acquired indicators were sorted depending on their domain and the frequency of their occurrence. Due to the large amount of indicators, every identified category could not be analyzed in this paper. Instead, based on the principles of time management, the Pareto Principle or otherwise the 80/20 rule was applied. Thus the indicator categories pressure ulcers, malnourishment / weight loss, if and incontinence were further analyzed as well as commonly used assessment instruments relevant to these categories. The specified indicators, from the literature review, were then summarized in an evaluation sheet and rated by a panel of experts using the modified Delphi method, regarding to their suitability for the measurement of the nursing outcome quality in nursing homes. The Delphi survey was successfully completed in two rounds. The quality indicators for which consensus among the experts was reached, are finally being proposed to be introduced in the styrian nursing home inspection protocols, as an end result of this work. ix

11 1. Introduction In 2012 Austria had a population of 8.43 million. The current forecasts show that the population of Austria will continue to grow in the future and that 99 million people will populate Austria per year. The population will rise to 9.37 million by 2060 (Statistics Austria [STAT] 2012, p. 15). Simultaneously with the increase in the Austrian population, the age structure will also change, especially for older people (STAT 2012). Currently, the proportion of the population aged 65 and older is 17.9% or 1.51 million. The number of this age group will increase to 1.71 million (+ 13%) by 2020 and to 2.16 million (+ 43%) by 2030. After all, by 2060 the population of over 65-year-olds will be 2.70 million (+ 79%) (STAT 2012, p. 44). The forecasts for the development of the Austrian population show that for the years 2030/2060, simultaneously with the increase in the population aged 65 and over, the working population aged 20 to under 65 will steadily decrease (STAT 2012, pp ). In all federal states of Austria, the population will therefore get older in the future. In Styria, the increase (+ 64%) in the population over 65 years of age by 2060 will be one of the lowest compared to the other eastern and southern federal states, but it will still be significant. In Styria, as in all other federal states except Vienna, a decline in the proportion of the working population is to be expected in the long term (STAT 2012, p. 51). 1

12 Figure 1.1: Population pyramid 2013, 2030 and 2060 (STAT 2014) Internationally, a rapid increase in the proportion of older people in the population has also been observed. According to forecasts, the proportion of people over 60 should double by 2050. Since Europe has the highest life expectancy, it is named as the aging continent (Federal Ministry of Labor, Social Affairs and Consumer Protection [BAKS] 2013). For a long time now, all European countries have been confronted with the trends of demographic change. The increasing proportion of people over 65 years of age gives new importance to age and its quality. This trend of aging of the population, which is strengthened by medical progress and the prognoses for life expectancy and mortality, fertility development, birth development, number of children, marriages and divorces, household types and migration, puts massive pressure on the social security systems with regard to their sustainability (Deutmeyer & Thiekötter 2009, pp). The increasing number of elderly people is causing an increase in the proportion of people in need of care and thus in the overall need for care (BAKS 2013). 2

13 As part of these developments, care facilities must simultaneously increase their efficiency, improve their quality and develop offers in order to remain competitive (Bock von Wülfingen, Model & Polz 2009, p. 240). In addition to all other care facilities, these developments also affect care homes. Renate Stemmer defines the target group of care in homes ,,, old and especially very old people, for whom preventive, activating, compensatory or palliative care interventions are required. The increase in the number of this group due to the already mentioned demographic development places high demands on medicine, nursing and care (Stemmer 2009, p. 59). These elderly people, who are predominantly dependent and in need of help, have the right to be cared for in accordance with the latest findings in nursing science (Stemmer 2009, pp). Accordingly, Hermann Brandenburg and Claudia Calero have dealt with questions of care quality in inpatient care for the elderly in Germany. They justify the importance of focusing on the quality of care in order to distinguish it from other aspects such as quality of life, well-being or safeguarding participation on the one hand because securing the quality of care in the sense of good care forms the prerequisite for the implementation of further requirements and perspectives such as e.g. the increase in residents' participation (Stemmer 2009, p. 57). They also report on a nebulous theoretical and empirical debate that prevails in the identification of relevant indicators for measuring the quality of care, which is the reason for the fruitless discussion of the topic and continues to make improvements in the direction of quality assurance more difficult. However, you describe the development of inpatient care for the elderly as a success story, at least for the providers of facilities due to the demographically influencing increase in the number of inpatients (Stemmer 2009, p. 57). In addition to the US region, where the discussion of quality indicators for different areas, occupational groups and for different dimensions of the quality of the health care system has been taking place for decades, initiatives in this direction have also been carried out in the European region in recent years, such as the EU project Progress . As part of the project, various partners and experts from different EU countries, against the background of increasing interest in the EU, have come to 3

14 issues of quality development and quality assurance in the field of long-term care were dealt with and experiences about applied methods were exchanged with the aim of systematically supporting measures to promote the quality of services in the social field. Accordingly, the project focused on result-oriented quality indicators and, in addition to the quality of care, also examined indicators in relation to the areas of quality of life, economic efficiency, leadership and social context (Hoffmann, Maas & Rodrigues 2010, pp. 3-4). In Austria, nursing-relevant indicators are already used to collect the quality of the nursing care services offered by various individual hospitals, associations and nursing homes. However, these indicators vary with one another and are difficult to compare due to the heterogeneous patient and resident groups, the different objectives of the actors and institutions with regard to external or internal quality assurance, as well as the different survey instruments used (Stewig et al. 2013, p.1). Up to the present time, experiences in the area of ​​the application of quality indicators have also been made throughout Austria through various projects, such as the quality register managed by Gesundheit Österreich GmbH / BIQG (GÖG / BIQG) division or the A-IQI project of the Lower Austria Regional Clinics Holding. However, these are based exclusively on medical outcome indicators (Stewig et al. 2013, p. 1). Through the methodical investigation and understanding of the literature, the present work aims to identify relevant quality indicators for measuring the quality of care outcomes, which could be important for the measurement of results in the context of the official control of the Styrian nursing homes by means of the nursing home control protocols. The nursing home control protocols are used by Department 8 Science and Health of the Office of the Styrian Provincial Government and the department of Health and Nursing Management, which is subordinate to it, to check the quality of care of the public nursing homes twice a year without prior notice. Accordingly, the international literature is examined to identify key indicators that are relevant for measuring the quality of care outcomes. Possible relevant assessment instruments in connection with the selected indicator categories are also discussed. The most suitable 4

15 indicators for measuring the quality of care outcomes selected using an expert survey or a modified Delphi survey. These indicators could make an important contribution to the further development of the Styrian control protocols with regard to the measurement of the quality of care results. 1.1 Relevance In 2011 there were 844 nursing homes in Austria, whereas in Styria there were a total of 287 inpatient facilities in 2013. Of these, 215 are nursing homes that can also be referred to as old people's homes, geriatric centers, nursing centers, senior centers, residences or homes. There are both public nursing homes belonging to the state, municipalities and social welfare associations, but also nursing homes run by charities / NPOs and private nursing homes. Of these nursing homes, 32 are publicly run and 183 privately run (Department of Health and Nursing Management: Department Nursing Management 2013b). In 2009 there were more than 1,000 care places available throughout Austria. As of December 31, there were approved inpatient beds in nursing homes and nursing homes in Styria. The proportion of beds made available by the public sector in 2012 was. If the number of inpatient beds is related to the number of residents aged 75 and over, this results in around 125 beds per person in old age in Styria 75 years and older are available. The average age of the nursing home residents in 2013 was 83.01 and the average care level in 2013 in the nursing homes was 4.1 (Department of Health and Nursing Management: Referat Pflegemanagement 2013b). In Austria, the care allowance has existed since 1993 to provide financial support for people in need of care, which is granted in seven stages depending on the care needs. As of the reference date, there were care allowance recipients in Austria. The number of people who received federal care allowance and the proportion of state care allowance recipients (Bachner et al. 2012, p. 33). Overall, at the end of 2013, there were people in Styria who received care allowance from the federal and state governments, spread across all 7 care levels. Of these, there were federal long-term care allowance recipients and state care allowance recipients (Department of Health and Care Management: Department of Care Management 2013a). The proportion of the 5th

16 nursing home residents who received money was (specialist department health and nursing management: Department nursing management 2013b). In order to ensure the quality of care in the Styrian care homes, in the background of demographic developments and the financial pressure on the social security systems, it is important that the control instruments, namely the control protocols of the state, in addition to the structural and process quality, also care - Comprehensively assess the quality of the results. A detailed survey and a corresponding evaluation by experts of the aspects or quality indicators that are suitable for measuring the quality of care outcomes can provide incentives to submit the care home control protocols with some of the proposed quality indicators and thus to discover potential for improvement or weaknesses in the care homes. 1.2 Aim and research questions The aim of the present work is to increase the potential of the Styrian nursing home control protocols for measuring the quality of nursing outcomes by supplementing them with the proposed quality indicators from an expert survey based on the current state of scientific knowledge. This is why the following research questions are asked: 1) What quality indicators can be used to measure the quality of the care outcomes in the care homes? 2) Which survey assessment instruments are used to measure results based on the selected indicator categories? 3) Which quality indicators are suitable for measuring the quality of care outcomes in nursing homes, from the perspective of the experts? 2. Method In this work, the data required to answer the research questions from a comprehensive literature search in care-relevant databases, the Internet and an expert survey are used. Experts from different institutions in the health care system are selected for the survey. Accordingly, a modified Delphi method is attempted, 6

17 To achieve consensus between the experts with regard to the suitability of the quality indicators for measuring the quality of care outcomes in the nursing homes. The application of the modified version of the Delphi method is selected after basic information on the subject of the survey is already available. Accordingly, in the first round of the survey, a structured questionnaire based on the literature research that has already been carried out is used and sent to the experts by (Hsu & Sandford 2007, p. 2). This includes several quality indicators from different care-relevant areas. 2.1 Systematic literature search The starting point for this work is a systematic literature search in international databases. To this end, the PubMed and CINACHL databases were searched for relevant articles in December 2014. The aim of the search was to show which indicators for measuring the quality of care outcomes in nursing homes can be found in the international literature. The key words care quality, care homes, quality indicator, care-sensitive, result, which are necessary for the systematic literature search, result from the research questions. Their English translation and the corresponding synonyms were entered into the respective database and linked with one another using the Boolean operator (AND). The keywords chosen are nursing quality care, nursing home, quality indicator, outcome, nurse sensitive. The following graphic shows the procedure and the logical connection of the search terms when searching in the databases: PubMed 1 Search terms nursing quality care nursing home quality indicator nursing outcome (nursing quality care) AND nursing home (nursing quality care) AND quality indicator 3089 ( nursing quality care) AND nursing 7039 hit 7

18 outcome (nursing home) AND quality indicator 1045 (nursing home) AND nursing outcome 6707 (quality indicator) AND nursing outcome 1053 ((nursing quality care) AND quality 1014 indicator) AND nursing outcome ((nursing quality care) AND nursing home) 996 AND quality indicator ((nursing quality care) AND nursing home) 1828 AND nursing outcome ((nursing home) AND quality indicator) 296 AND nursing outcome (((nursing quality care) AND nursing home) 282 AND nursing outcome) AND quality indicator Table 2.1.1: PubMed 1 CINAHL search terms nursing quality care nursing home quality indicator 1820 nursing outcome 9168 nursing quality care AND nursing home 5454 nursing quality care AND quality indicator 372 nursing quality care AND nursing outcome 2191 nursing home AND quality indicator 91 nursing home AND nursing outcome 2018 quality indicator AND nursing outcome 74 nursing quality care AND quality indicator 64 AND nursing outcome nursing quality care AND nursing home 83 AND quality indicato r nursing quality care AND nursing home 561 hits 8

19 AND nursing outcome nursing home AND quality indicator AND 19 nursing outcome nursing quality care AND nursing home 18 AND quality indicator AND nursing outcome Table 2.1.2: CINAHL A separate literature search was carried out to identify studies relating to the Delphi method. The keywords Modified Delphi, Delphi technique, Delphi Method, nursing were used and entered in the PubMed database. PubMed 2 search terms (Delphi technique) OR Delphi method 4955 ((Delphi technique) OR Delphi method) 885 AND nursing ((Delphi technique) OR Delphi method) 337 AND quality indicators (((Delphi technique) OR Delphi method) 58 AND nursing) AND quality indicators Table 2.1.3: PubMed 2 hits A total of 318 articles could be found in the databases. In the next step, they were individually checked for relevance to the research questions posed in the present work. Each title and the corresponding abstract were checked very carefully. What remained were those articles which examined or analyzed nursing homes in the context of the research questions mentioned above. Studies whose topic does not deal with the quality of care outcomes or the quality in nursing homes focused on specific quality aspects such as Quality of End of Life or Quality of Life that are not written in English or German were excluded. 9

20 On the basis of this examination, only 16 articles could be classified as relevant to the research questions of the present work. In addition, research using the Internet search engine Google and Google Scholar led to 9 further usable publications. A further 7 relevant publications were identified by searching the source references of the literature found. Regarding the Delphi Method, 7 other relevant articles could be identified. The credibility of the data collected from the internet could potentially be desperate from a scientific point of view. However, all information used in this work comes from state or non-state websites, world-famous institutes in the field of health promotion, health regulation, monitoring and / or inspection in the USA and Europe. Thus, the information derived from these sources is considered credible. 2.2 The Delphi Method The Delphi Method is a survey of experts in a specific area in several rounds / repetitions, using questionnaires, until a consensus on the topic is reached. In the first phase, the process includes the issuing of a questionnaire to a panel of experts in order to obtain their opinion or judgment on the subject under investigation. In the second phase, new questionnaires are designed based on the combined answers from the original questionnaires. The new questionnaires are then returned to the participants and contain the answers of the entire group and the answers given by the respective participants from the original questionnaire. The experts are then asked to reconsider their original responses in light of the responses from the entire group. This process is repeated until consensus is reached (Keeney, Hasson & McKenna 2006, p. 206). At the beginning of the Classical Delphi Method, a qualitative approach is usually used so that a wide range of participants' opinions can be identified, which will be used as the basis for developing the next questionnaire (Keeney, Hasson & McKenna 2006, p. 206). Within the scope of this thesis, the quantitative approach was carried out using the modified process of the Delphi method. In practical terms, this means that a structured questionnaire based on the literature research carried out was set up. This questionnaire was aimed at the evaluation of the 10

21 by the participants without asking them to propose further indicators. Although there are no strict guidelines governing the number of rounds / repetitions of the Delphi survey, a number of two rounds / repetitions is considered necessary to ensure feedback and the opportunity to revise previous answers (Keeney, Hasson & McKenna 2006, p. 207). Studies that use the Delphi method and evaluate a large number of items require the investment of large blocks of time. In addition, there is a risk that some of the panel members will lose their focus on the study and subsequently drop out of the study (attrition bias) (Custer, Scarcella, & Stewart 1999, p. 2 of 3). In addition, a response to exhaustion and tiredness of the participants is observed in several survey rounds in the literature (Keeney, Hasson & McKenna 2006, p. 207; Keeney, Hasson & McKenna 2001, p. 198). Although most Delphi studies use a number of participants, given the total number of Delphi studies published, a diverse number of panel members are observed. There are neither generally valid selection criteria nor instructions about the number of experts who should take part in the Delphi survey (Keeney, Hasson & McKenna 2006, p. 208). That is why the main criterion for the selection of experts in this work is the many years of experience and examination of quality indicators for nursing homes. Finally, before carrying out the Delphi survey, it is necessary to determine what percentage of the experts' agreement on the indicator assessment is accepted as reaching the consensus. In studies with the applied Delphi method, a variety of percentages for reaching consensus is observed (50%, 75%, 80%), which are justified with various arguments (Keeney, Hasson & McKenna 2006, p. 210). As a result, there is a high degree of flexibility in designing the Delphi method, which often depends on the goals of the respective study (Keeney, Hasson & McKenna 2006, p. 208). One of the main advantages of the Delphi method is the guarantee of anonymity, which can subsequently reduce the effect of dominant people on the group. This is a common problem in group-based processes in which information is collected and synthesized (Hsu & Sandform 2007, p. 2). 11

22 Further advantages of the method are the reduction of consumption effects due to group interaction and the guarantee of controlled feedback to the participants (Custer, Sardelle, & Stewart 1999, p.2 of 3). 2.3 Design The research questions asked in this thesis or research question three require a panel design to answer them, a kind of long-cut design after the necessary data are collected in several points in time with the same method or by means of the modified Delphi method and in the same sample. The results from the expert survey are evaluated and described with the help of descriptive statistics. 2.4 Data analysis The Delphi method often collects qualitative and quantitative data. Nevertheless, there are very few instructions in the literature relating to the equilibrium and management of the generated data (Keeney, Hasson & McKenna 2001, p. 198). In this survey, due to the use of the modified Delphi method, only quantitative data are generated and analyzed. These quantitative data from the expert survey are analyzed using descriptive statistics or by analyzing the frequency distributions in the Microsoft Office Excel program. The data analysis in each round / repetition aims to determine the percentage of consensus achievement for each indicator. A consensus achievement of 50% or more for an indicator with regard to the fulfillment of the criteria for measuring the quality of care outcomes was found to be satisfactory and sufficient before the Delphi survey was carried out. 2.5 Participation in the expert survey In this survey, experts from Department 8 Science and Health of the Office of the Styrian Provincial Government and the Department of Health and Care Management, which is subordinate to it, took part. Other valued experts who were involved in the survey came from the Geriatric Health Centers of the City of Graz, Volkshilfe and Kages. A total of 13 experts with a background in nursing and with a master's degree or other awards took part in the survey for their scientific expertise 12

23 can prove. These experts were selected based on their knowledge of the nursing home setting and their experience with quality indicators. 3. The nursing home control protocols According to the provisions of 13 and 14 of the Styrian Nursing Home Act 2003, State Law Gazette No. 77/2003, under the term `` control '' ,,, either the ongoing control or a structured on-site procedure in the premises and in the outdoor facilities of the checked care facility (these are care homes and care places) (Bezirkshauptmannschaft Deutschlandsberg 2008, p. 1). According to 14 pcs. The Nursing Home Act 2003 is the responsibility of the licensing authorities to monitor the care facilities. The district authorities are responsible for inspecting private nursing homes and the state of Styria for public nursing homes. The latter are checked twice a year without prior notice (Bezirkshauptmannschaft Deutschlandsberg 2008, pp.3-4). As part of the control, the structural operating conditions, the processes and the quality of the results in the care are checked (Bezirkshauptmannschaft Deutschlandsberg 2008, p.1). In addition to the routine checks, the reason for a control can be either a complaint or a presumption of defects or a correction of defects (Bezirkshauptmannschaft Deutschlandsberg 2008, p.4). If deficiencies are identified during the inspection, the operator will be commissioned by the authority to remedy these deficiencies within a reasonable period of time. If the care and support is marked as seriously inadequate in a control, the authority must take all necessary measures to protect the residents, which could also include the closure of the facility (Bezirkshauptmannschaft Deutschlandsberg 2008, p.1). The control is carried out by at least one official expert. The ASV person is optimally accompanied by the negotiator, who is responsible for leading the control procedure as well as for checking compliance with all legal bases of the company and its sponsorship (Bezirkshauptmannschaft Deutschlandsberg 2008, p.1, p. 4).The control of nursing and care is the responsibility of either the official expert for health and nursing of the 13th

24 District Authority or the Office of the Styrian Provincial Government (District Authority Deutschlandsberg 2008, p. 4). After the official control contributes to quality assurance in the nursing homes, the nursing home control protocols within the framework of this procedure form quality assurance instruments which, among other things, secure the interests, needs and human dignity of the home residents (Bezirkshauptmannschaft Deutschlandsberg 2008, p. 1). The legal assessment bases which are contained in the nursing home control protocols of the state of Styria and which have had a very strong influence on the structure and structure of the protocols are the Styrian Nursing Home Act (StPHG) 2003 as amended, the SHG Performance and Remuneration Regulation (LEVO-SHG) 2007 as amended. , the Personalausstattungsverordnung (StPHG) 2009 as amended, the Health and Nursing Act (GuKG) 1997 as amended. and the Styrian Social Care Professions Act (StSBBG) 2007 as amended. 3.1 Elements of the care home control protocols The main part of the care home control protocols is divided into 16 points: Personnel, duty rosters, hand signal list, duty of confidentiality, services in the context of catering, medication management, care documentation, care, support, resident areas, medical care, care support point, care bathroom, hygiene, quality assurance, Care measures in the last phase of life. The aspects that are examined under the point of care serve to check the quality of the results in care and therefore the focus of this master's thesis is on the further development and supplementation of this unit of the care home control protocols with some of the proposed QI, after completion of the expert survey Pflege Das The knowledge acquired by the author of this work from participating in the official control as part of his internship at the Health and Care Management Department of the State of Styria was used for the content analysis of this unit. On the one hand, with the consent of the residents and in the presence of the responsible nurse, random nursing visits are carried out by the ASV person on 14

25 residents. As part of these visits, the nursing process is subjected to an in-depth analysis and control, taking into account the nursing documentation. On the other hand, there are also surveys of residents, but also, under certain circumstances, surveys of relatives (Bezirkshauptmannschaft Deutschlandsberg 2008, p. 1). The care visit is divided into the following points: communication, orientation, mobility, skin status / dental status, washing / dressing, nutrition, vital functions, elimination, social care, prophylaxis, measures that restrict freedom. Subsequently, the number of residents under 65 is recorded with certain characteristics or with a psychiatric diagnosis, mental disability or physical disability, according to the Styria. Children and Youth Welfare Act (see Appendix 4). The number of residents assessed as having an increased nursing risk is also recorded and, depending on the characteristics of their state of health that justify this risk (depending on the risk factor), they are listed in the following groups: residents with PEG tubes, indwelling urinary catheters, tracheostoma, ventilated residents, Mostly in a wheelchair, - get walking training, Bew. with predominant support in eating, residents with restricted freedom, wound dressings Finally, 2 categories of residents with increased risk are dealt with in detail, namely those with wound dressings and with PEG tubes. In the case of wound dressings, the name of the residents is listed in a table, as well as the type and location of the wound (decubitus, leg ulcer), the underlying disease (e.g. PAD, diabetes) and whether photographic documentation is available. In the case of the PEG tubes, the name of the resident is given, as well as a description or note in connection with the tubes or gastrotube puncture sites (e.g. Bland), their type of supply (e.g. dry) and whether special food has been prescribed by a doctor. The name of the responsible wound manager in the facility is ultimately also documented. 4. Basics of quality work Internationally, the demand for quality has largely been established in almost all areas of business, technology and research. Measures to secure the 15th

26 Quality of health services are constantly being introduced and thus the area of ​​health care is also included in this development. According to the Council of Europe in 1997, quality is seen as an essential and indispensable part of health care and a regular characteristic of any care measure. Every citizen is granted the right to access good quality health care (Schiemann & Moers 2011, p. 617). The basics of quality work in the field of health and care are anchored in law. The most important legal provisions are the following: Federal Law on the Quality of Health Services (Health Quality Law) Hospitals and Health Resorts Act (KAKuG), Federal Law on Health and Nursing Professions (GuKG), Quality Assurance Ordinance 2012 (QS-VO 2012), agreement according to 15a B VG on the organization and Financing in the health system Health Quality Act GQG Occupation-specific laws Council of Europe 1997 WHO Health for All 2000 European Network for Quality Development in Nursing (EuroQUAN) 1992 (Federal Ministry for Health 2014, p. 9) 4.1 Definition of quality Quality is a complex variable which is made up of a different number is composed of properties or features of a qualitative or comparative kind (Görres 1999, p. 51). Quality is not a one-dimensional quantity, but a bundle of characteristics that are partly dependent on one another (Görres 1999, p. 51). There are many different definitions of quality. The following paragraph tries to get an overview of the assumptions about this term. 16

27 4.1.1 Quality concept The Federal Law on the Quality of Health Services ([GQG] 2004, p. 1) of the Austrian Federal Republic, Article 2 2 defines quality as follows: “Degree of fulfillment of the characteristics of patient-oriented, more transparent, more effective and more efficient Provision of health care. The main concerns in this context are the optimization of structural quality, process quality and result quality. DIN EN ISO 9000: 2005 defines quality as the “degree to which a set of inherent characteristics meets requirements (Kussmaul 2011, p. 14). The definition of the working group `` Quality Assurance in Medicine '' of the German Society for Medical Informatics, Biometry and Epidemiology (GMDS) is based heavily on the definition of the International Organization for Standardization (ISO): "Quality is the totality of the characteristics of a unit with regard to the fulfillment of the requirements specified and stipulated for health care (Geraedts & Selbmann 2011, pp). The concept of quality in health care, which probably best reflects the current state of discussion, comes from Charles Cangialose 1997: "Quality of Care is the degree to which health services for individuals and populations are consistent with current professional knowledge and reflect the preferences of well-informed consumers with." regard to the trade-off between increasing desired health outcomes and reducing other consumption alternatives (Geraedts & Selbmann 2011, p. 600) Quality Management Internationally, the ISO 9000 ff. family of standards is used as the basis for all industry-specific quality management standards for quality management systems. An earlier version of the ISO 9000 standard defines QM as, ... all activities of the overall management that define the quality policy, the goals and responsibilities within the framework of the QM system as well as these through means such as quality planning, control, assurance, presentation and Realize improvement (Wernisch & Hartl 2011, p. 17). Quality management in the definition of DIN: ISO 9000: 2000 means: 17

28 ,, Coordinated activities for managing and directing an organization with regard to quality, e.g. Quality policy, quality assurance, quality planning, quality improvement (Menche 2011, p. 66). The decisive factor when applying the various approaches to quality management with regard to the contribution made to improving the quality of care is to what extent a practiced quality management system leads to real changes within the facility (Stemmer 2009, p. 64). A practiced quality management means the involvement of employees and residents, networks with partner organizations and a connection to strategic management (Hoffmann, Maas & Rodrigues 2010, p. 16) Quality assurance The aim of quality assurance in nursing at the beginning of the 1990s was, in principle, a minimum level to determine the quality of care for the individual care processes and to fulfill this, in principle through the evaluation and control of the results. Today quality assurance is characterized by a comprehensive and constant quality development of all work steps (Conzen 2009, p. 245). Quality assurance is an instrument of quality management and is defined according to DIN ISO 9000: 2008 as, ... ,, part of quality management, which is aimed at generating trust that quality requirements are met. These requirements are defined both internally and externally (Kussmaul 2011, p. 17) Guidelines A guideline is an evidence-based instrument that provides help and orientation for the practitioner or patient in order to decide which measures or treatments are related to a specific one clinical problem promise the most success. These measures are based on the current state of scientific knowledge and their effectiveness has been proven. A typical example is the guideline on pressure ulcer prophylaxis and treatment. Although guidelines are highly binding on professionals, the recommendations need not be followed in all circumstances. The acceptance of the recommendations of a guideline by the respective nurse depends on the individual situation of the patient as well as the available resources. 18th

29 After guidelines are drawn up by experts and scientific societies / institutions, guidelines are primarily valid through the recognition of the professional authorization and competence of these experts and institutions by the professional group or their representatives (Bölicke 2007, pp) Standards and criteria If If you deal more closely with the topic of standard in nursing, it quickly becomes apparent from the literature that there is no simple or unambiguous definition of the term `` standard '' in technical terminology (Bölicke 2007, p. 1). Most authors use the definition of the World Health Organization: “Standards correspond to an achievable and professionally coordinated level of performance and reflect a specified target for the quality of care against which the actual performance is measured (Bölicke 2007, p. 2). The members of the German Network for Quality Development in Nursing (DNQP) define nursing standards as, ... ,, professionally coordinated performance level that is adapted to the needs of the population addressed. Care standards should also contain criteria for monitoring the success of care (Bölicke 2007, p. 2). There are different standards of care with different names. In the context of this paragraph, a standard in care is regarded as a quality standard that determines a corresponding quality level and includes criteria that describe this quality level. The criteria form the measurable factors of a standard and can make statements about the degree of fulfillment of the standard. According to the RUMBA rule, they should be relevant, unambiguous, measurable, observable and appropriate (Bölicke 2007, p. 22). The criteria must then contain certain questions or items in order to check the quality level you have achieved (Baartmanns & Geng 2005, p. 24). The criteria are often subdivided into the dimensions structure, process and result (Bölicke 2007, p. 22) and summarized at a higher level in the form of indicators (Baartmanns & Geng 2005, p. 24). 19th

30 4.1.6 Standards and indicators Quality standards identify aspects of care where there is definitely a problem. Quality standards do not require any further examinations in order to make judgments about the quality of care (Zimmerman 2003, p. 254). In contrast to the quality standard, the quality indicator gives information about possible quality problems and therefore requires a careful examination by qualified clinical experts in order to determine whether a quality problem actually exists in the respective examination area (Zimmerman 2003, p. 254) Benchmarking The German Benchmarking Center defines benchmarking as, ... ,, a methodical comparison of processes and products using reference points from comparison partners, which are found on the basis of similarities in their own or in other organizations. Benchmarking aims to decisively improve one's own processes and products using the example of the comparison partner. Benchmarking as a quality management tool is used more and more to improve quality in the healthcare system (Menche 2011, p. 70) Audit The DIN EN ISO 9000: 2005 standard defines audit as follows: systematic, independent and documented process for obtaining audit evidence and for their objective evaluation in order to determine the extent to which audit criteria are met (Masing 2007, p. 333). For nursing, this means that audits are an instrument for the systematic assessment of the quality of the nursing and organizational work of a facility. The empirical knowledge and the implementation of the processes in the own system are checked on the basis of defined criteria and thus the standards used can also be checked. The audit report summarizes the resulting results and forms the basis for the creation of a project plan in which the period and the steps to improve the processes and results of the facility are determined. (Ritter 2007, pp) The auditors should not belong to the audited area and should be independent his (Masing 2007, p. 332). 20th

31 4.2 Dimensions of quality work Avedis Donabedian is considered the founder of modern quality research in the healthcare sector. For clinical-technical quality, he was the first to introduce the term process quality, which he differentiated from structural quality and the quality of results (Geraedts & Selbmann 2011, pp) Structural quality The Federal Act on the Quality of Health Services (GQG 2004, 2) relates to structural quality, ... ,, the sum of material and personnel resources in quantitative and qualitative terms. According to Donabedian, the concept of structural quality describes the framework conditions under which the care services are provided. This means: Material resources such as infrastructure or equipment and space available Personnel resources such as personnel key, skills and training of staff Organizational characteristics of the provision of medical and nursing health services such as type of facility, team structures, available materials and financing options (Görres 1999, p. 180) . The structural quality can be evaluated using structural criteria (Giebing et al. 1999, p. 18). For the fair application of structural criteria, they should be justified by scientific and professional knowledge. They correspond to the RUMBA rules minus the aspect of observability (Baartmans & Geng 2005, p. 74) Process quality Process quality is understood to mean ... ,, work processes and procedures that are systematized according to comprehensible and verifiable rules and correspond to the state of professional knowledge , regularly evaluated and continuously improved (GQG 2004, 2). The process quality relates to diagnostic, therapeutic and nursing interventions within the framework of the treatment process and includes all activities or interactions of a nurse with the facility, the staff and the patient (Görres 1999, p. 181). 21

Process quality can be evaluated using process criteria (Giebing et al. 1999, p. 19) Process criteria relate to the execution of the actions (Baartmans & Geng 2005, p. 74) Result quality Result quality is defined as measurable changes in what is professionally assessed Health status, quality of life and satisfaction of a patient or a population group as a result of certain framework conditions and measures (GQG 2004, 2). Donadedian understands the term as a measurable change in the patient's state of health, which can be attributed to previous treatment or medical, nursing and therapeutic action. The term result includes the following points in connection with the current or future health of the patient: The change in the state of health The change in the state of satisfaction The change in the health knowledge of the patient The change in the health behavior of the patient (Görres 1999, p. 183). The quality of results depends on the structure and process quality (Menche 2011, p.66) The division of quality aspects into structure-process-result is not always clear, but this classification scheme is helpful (Geraedts & Selbmann 2011, p. 600). The quality of results can be assessed using result criteria (Giebing 1999, p. 19). These criteria are often the reason for quality assurance and promotion programs (Baartmans & Geng 2005, p. 73). 4.3 Quality of care Avedis Donabedian defines quality of care as, ... the degree of correspondence between the goals of the health care system and the care actually provided (Weidlich 2011, p. 65). The care actually provided should match the previously formulated criteria (Korečić 2012, p. 38). 22nd

33 As part of a problem-oriented session (POL) of the Nursing Quality Outcome Seminar module at the Medical University of Graz, the team tried to find its own definition of care quality: Care quality is the sum of the characteristics of nursing activities that result from the use of resources and the consistency of the Fulfillment of expectations of care is characterized and its focus varies depending on the perspective (Eichhorn-Kissel 2013, p. 2). Care quality can only be experienced through the cooperation of all persons involved (service providers, service providers, people in need of care and relatives) in this ongoing process (Conzen 2009, p. 245). Nursing quality is a continuous process that occurs through the interaction within the framework of the relationship between care and always in the context of the entire organization. Accordingly, care should be assessed in connection with the entire organization. This is an important point that should not be ignored when assessing the quality of care (Menche 2011, p. 66). 4.4 Quality of Nursing Outcomes Results from patients or residents are very often subject to multidisciplinary influences in the health sector. This makes it difficult to attribute responsibility for an outcome to a particular professional group. Of course, this also applies to care. A result can therefore be described as a care-sensitive result only if a care intervention leads to a measurable change in the state of health or the emotional state of the patient or the residents. Decisive for the care sensitivity of the results are not the measurable or observable changes or the measurement method itself but the nursing intervention carried out (Stemmer 2009, pp; Stewig et al. 2013, p. 4). Accordingly, the quality of care outcomes is expressed as the measurable changes in the professionally assessed state of health, the quality of life and the satisfaction of a patient or a population group as a result of framework conditions and measures of nursing care (Stewig et al. 2013, p. 4) . 23

34 4.4.1 Assessment / measurement of the quality of care results The increasing importance of the quality of care services makes the measurement of care-sensitive results and thus the quality of care results one of the most important tasks of nursing research. The increasing awareness of problematic events such as falls and decubitus ulcers or the increasing cost pressure on healthcare facilities are some of the reasons for the importance of measuring care-sensitive results and the quality of care results. (Stemmer 2009, p. 84) In addition, from a time perspective, nurses represent the highest proportion of care that is provided in all facilities. Accordingly, the quality of nursing services must be evaluated through the documentation, identification and application of nursing-sensitive results (Moorhead 2012, p. 63). The provision of relevant data with regard to the quality of results of nursing services serves as a decision-making aid for technical or strategic planning in the context of quality management in which each professional group is evaluated according to the effects and the value of their services (Stemmer 2009, p. 79). It is important to understand what evaluation of the results and thus also the quality of results means in the context of the maintenance process. The quality of the preliminary last step in the nursing process, the evaluation, depends on the quality or the correctness of the previous steps in the nursing process (assessment, diagnosis, intervention) (Leoni-Scheiber 2004, p. 138; Wilkinson 2012, p. 439) . The evaluation or assessment means the control of the success, the effect and the quality of the care. This includes, on the one hand, the assessment of the client's degree of target achievement with regard to the state of health (results) and, on the other hand, checking all previous steps of the nursing process with regard to their correctness and appropriateness (Leoni-Scheiber 2004, pp; Wilkinson 2012, pp). It is important to emphasize that the client or patient, together with the caregiver, determines the quality of the results (Wilkinson 2012, p. 438). The assessment of the quality of the results is therefore included in the maintenance process. Results that can be influenced by care or care-sensitive results can be classified in different levels depending on the degree of abstraction. It can be about results that are generally influenceable result range of the nursing, about nursing results per se or about concrete formulations of indicators for each outcome (Moorhead 2012, pp). 24

35 The more abstract the results are, the more difficult it is to determine the influence of a certain professional group on the result. By identifying and documenting specific indicators of outcomes that can be traced back to certain nursing interventions, nurses can be held accountable for the work they have done (Moorhead 2012, p. 104). The measurement of the results of the care and thus also the care result quality can take place in 3 levels. Macro level: Measurement of results at the national level. Meso level: Measurement of results in a system or institution that are important for internal quality management. Micro level: Measurement of results related to the individual situation of the patient in the context of the nursing process (Stemmer 2009, p. 89). The author of this thesis considers it sensible not to interpret the results according to the classic assumption of the linear connection between structure-process results in Donabedian's model or that only good structures lead to good processes and, in turn, good processes lead to good results. Instead, this assumption is expanded by taking into account the reciprocal effects of various influences, including patient characteristics, when interpreting the results. This approach based on the Quality of Outcomes Model developed by the American Academy of Nursing seems suitable to justify quality work in the field of nursing (Stemmer 2009, pp). Indicators and standardized assessment instruments are used to assess the results (outcome) of care and thus the quality of the results. These means, which are part of the investigations in this thesis, are presented in the following paragraphs is very good (Baartmanns & Geng 2005, p. 23). Subsequently, actions can be used to stabilize or improve the quality of care (Baartmanns & Geng 2005, p. 23). 25th

36 The quality indicators (e.g. urinary infection rate) can also monitor the success of actions taken to improve quality in combination with defined criteria (e.g. techniques for inserting a catheter). Indicators and criteria are closely related and are, unfortunately, often used synonymously. In order to grasp their meaning, they have to be assessed in the context of the respective projects and made explicit (Baartmanns & Geng 2005, p. 23). The development and application of quality indicators in nursing is not random in Austria, but is also legally supported. According to Section 5, Paragraph 4 of the Health Quality Act (2004, p. 3), indicators and reference values ​​are to be developed, among other things, with regard to the quality of results, as part of Austrian quality reporting, and reporting obligations are to be established. Based on this provision from the GQG (2004) and the concept of reference values, the terms associated with this must be made explicit here. An important term here is the reference range, which determines the limits in which a quality indicator is rated as good or normal, whereby the reference value represents a numerical value in which the lower and upper limits match (Jäckel 2009, p. 2). Optimally, a reference range is determined that has high sensitivity and specificity or a reference range in which as many quality problems as possible are identified and not many false alarms are signaled (Jäckel 2009, pp.2-3). According to 2 paragraph 15 of the GQG, the quality indicator is defined as a measurable variable that is suitable for observing, comparing and evaluating the quality of health care (GQG 2004, p. 2). Result-oriented indicators create transparency in connection with activities and success or failure. Therefore, they form the occasion for the consideration or definition of goals and the implementation of improvement measures at various levels (home, supporting organization, regional, country) (Hoffmann, Maas & Rodrigues 2010, p. 7). Accordingly, it is important to emphasize that the control in the areas of quality assurance and quality development on the basis of quality indicators, advantages for the public payers as well as for the operator and your customers. or residents or relatives. On the one hand, the public payers can find out which services they are financing and, on the other hand, 26

37 The operators of nursing homes for the elderly can prove the quality of their facility and, as a result, negotiate better with payers, but also meet the requirements of residents or relatives for more control, assessment, comparison and improvement of quality. (Hoffmann, Maas & Rodrigues 2010, p. 3, pp). However, the use of indicators is often criticized. Result-oriented quality indicators or key figures in themselves only say something about the quality of an old people's and nursing home to a limited extent. As measured variables, they indicate possible weaknesses and strengths or problem areas that need to be further investigated and discussed. No more, but also no less (Hoffmann, Maas & Rodrigues 2010, p. 9). Individual indicators only relate to a partial aspect of quality (Jäckel 2009, p. 2) Types and functions of quality indicators Quality indicators can be categorized on the basis of various characteristics. Accordingly, in addition to the classic classification according to Donabedian's quality dimensions (structure-process-result), QI can be categorized according to the scope (generic or disease-specific indicators) and subsequently according to the care area, the function or type of intervention (Jäckel 2009 , p. 3). QI can be differentiated independently of the characteristics mentioned above with regard to their frequency measures. In addition, QI can be assigned either as aggregated data or as individual events. The frequency of the occurrences is decisive for the delimitation of the two categories. Aggregated data refer to desirable or adverse events that occur with a certain frequency after treatment. Individual events refer to very seldom degenerate events and require further investigation in each particular individual case in order to identify factors that could prevent them. On the contrary, aggregated data give rise to the use of an intervention if a defined limit value is exceeded. Aggregated data can subsequently represent either continuous (mean values ​​for target populations) or discrete variables (proportions or ratios) (Jäckel 2009, pp. 3-4). 27

38 In general, QI are used for evaluation (measuring the current degree of target achievement), monitoring (measuring changes in the degree of target achievement) and as an alarm function (Geraedts 2009, p. 5). Quality indicators can have different functions depending on their internal or external use. In the internal area, QI can be used to control the performance of a facility. This can subsequently form the basis for process analyzes and error management. Subsequently, the collected data in the form of QI and the comparison between departments can promote competition within the facility or lead to process standardization in the context of supply (Geraedts 2009, p. 6). The most important function of the QI in external use is to control and monitor the facilities. This means the ascription of the responsibility of the facilities for the quality of care on the one hand by informing the public and on the other hand by punishing with fines or withdrawal of the license if the target values ​​are not achieved. Subsequently, the external use of QI can be used with the aim of comparing service providers, which can lead to internal organizational development, through benchmarking or not. QI are used externally in the context of certifications or quality assessments for awarding quality awards. Finally, externally deployed QI can serve to increase the efficiency of the supply in the context of performance-based remuneration. (Geraedts 2009, pp. 6-7) Assessment instruments In general, the term assessment is understood to be a procedure for a more or less comprehensive, systematic assessment and assessment of a behavior, a condition or a situation (Stewig et al. 2013, p. 6) . According to the stages of the nursing process, assessment instruments can be broken down as follows. Instruments for assessment at first contact (basic assessment and focus assessment) Instruments for measuring changes in the care process (evaluation instruments) 28

39 instruments for determining the nursing outcome at the end of the nursing process (Reuschenbach 2011, p. 35). In this context, it is important to continue describing the assessment. The fundamental differentiation from assessment in the nursing process lies in the time at which the data is collected and the purpose of use. At the beginning of the nursing process, assessment is used to collect information in order to make nursing diagnoses. As part of the evaluation, assessment is used to collect data in order to assess the results of nursing in connection with the nursing diagnoses made previously (Wilkinson 2012, pp). As part of the nursing assessment, in addition to other assessment methods (observation, questioning), the data are collected using structured assessment instruments (scale tests, questionnaires, etc.) (Reuschenbach 2011, p. 28). The overriding goal of the assessment instruments is to assess specific nursing phenomena and nursing concepts (Reuschenbach 2011, p. 30). Assessment instruments serve both to support nursing diagnostics but also to assess risks or the need for care (Reuschenbach 2011, p. 32, p. 36; Wingenfeld & Büscher 2011, p. 191). Another function is the recording of the result quality, which you should ideally improve (Reuschenbach 2011, p. 50, p.55). Standardized AI must meet classic quality criteria such as variability and reliability. The fulfillment of secondary quality criteria such as Relevance should not be underestimated in practical application (Reuschenbach 2011, p). The use of AI is influenced by various factors that relate to the patient, carer or to the specific situation or organization (Reuschenbach 2011, pp). In the 1980s, the USA led the way in implementing AI at health policy level, where the Resident Assessment Instrument (RAI) is now mandatory for the inpatient area and the Outcome and Assessment Information Set (OASIS) for the outpatient area. The collected data are used as QI in addition to other functions. Assessment instruments are used by the Medical Service of the Health Insurance (MDK) in German-speaking countries. Accordingly, it is important to emphasize the influence of the DNQP through the publication of expert standards for the promotion of the scientific discussion of AI (Reuschenbach 2011, p. 48). The use of assessment instruments therefore serves for quality control and quality assurance (Reuschenbach 2011, p. 48) AI drown out economic evaluations 29

40 to determine the cost-benefit effects (Reuschenbach 2011, p. 75). In the background of the scarcity of resources and the effectiveness of the application of AI compared to other measures, these are very important for QM (Reuschenbach 2011, p. 51). 5. Quality indicators from the international literature In order to find out which quality indicators exist for measuring the quality of care outcomes and possibly to supplement the nursing home control protocols with some of them, a comprehensive literature search was necessary as a first step. There are numerous studies in the literature which examine relevant indicators in the structure-process-result levels, in connection with different factors (e.g. nursing staff) and in different settings (e.g. acute or intensive care or long-term care). Studies that focus on nursing homes can only be found to a limited extent in the literature compared to other institutions (e.g. hospitals).Since the majority of the studies acquired from the databases come from the US and a simple transfer of the care-sensitive result indicators to the nursing home control protocols according to Delnoij & Westert (2012, p. 452) is not scientifically permissible, current projects and studies from the German-speaking region have become included who deal with the topic. Depending on their use, the indicators found can be broken down and summarized in an initial general classification in the main categories of patient safety, disease-related results, functional status or other, with indicators measuring adverse or undesirable events and thus falling within the area of ​​patient safety, most often in the evaluated literature can be found. Patient safety is a very important aspect in the Austrian health system and is accordingly defined in the GQG (2004, 2, paragraph 4, p. 1). Patient safety Top category Indicators Pressure ulcers Fall Infections Measures restricting freedom Malnutrition Fractures 30

41 Disease-related results Functional status Other contractures Pain management Incontinence (urinary fecal incontinence) Fecal incontinence Mental behavioral problems Depression Dehydration ATL s mobility Activity Cognitive function Bedridden Catheterization, medication Table 5.1: Breakdown of the indicator categories into top categories Occurrence in the literature sorted although they do not completely match. (See Appendix 2) Indicators that did not appear more than twice in the investigating literature were excluded from this classification. Due to limited resources, a much desired workshop in which every single one of the identified indicators is processed and evaluated by the experts on the occasion of its suitability for measuring the quality of care outcomes could not be carried out within the scope of this work. Instead, the principles of time management were used in which the Pareto principle or, in other words, the 80/20 rule was applied (Beyer & Beyer 1995, pp). This principle says that 20 percent of the most important activities bring 80 percent of success. For the present work this means that 20% of the activities (analysis of the indicators and subsequent evaluation by the experts using the Delphi method) bring 80% of the success / target achievement (identification of the indicators which are suitable for measuring the quality of the care outcome ) (Beyer & Beyer 1995, pp). The frequency of their occurrence in the literature was selected as the decisive criterion for determining which activities are important or which activities bring the most success / achievement of goals. The analysis according to the Pareto principle of the 31

The 42 most common indicators in the literature research promise the most success / achievement of goals. These are the indicators of pressure ulcers, malnutrition, falls and incontinence. 5.1 Pressure ulcer A pressure ulcer can generally be defined as a pressure sore, which is characterized by damage to the skin and / or the underlying tissue due to exposure to pressure, shear forces or a combination of these factors (Menche 2011, pp). The current international definition of pressure ulcers used by both the US and the European Advisory Councils for Pressure Ulcers (NPUAP and EPUAP) is as follows in its German translation: A pressure ulcer is locally limited damage to the skin and / or the underlying tissue in which Usually over bony protrusions, as a result of pressure or pressure in combination with shear forces (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel [EPUAP & NPUAP] 2009, p. 7). In addition to these two central causes (pressure and shear forces), a number of other factors are often considered to be decisive for the development of a pressure ulcer, such as incontinence. However, the significance of these risk factors for the direct cause of pressure ulcers has not yet been clearly scientifically proven (Schmidt 2012, p. 16). According to the expert standard for pressure ulcer prophylaxis as well as international evidence-based guidelines, it is recommended that the time of the initial risk assessment take place immediately at the beginning of the nursing assignment or upon admission (Balzer & Mertens 2011, p. 292). If the initial risk assessment by the nurse shows that the resident is at risk of pressure ulcers, a more precise, differentiated risk assessment is carried out. Each facility determines its own evaluation intervals and repeats the risk assessment at individually adjusted intervals. For the nursing home setting, this interval is determined once a month to every 8 weeks, depending on the care status, according to the expert standard for pressure ulcer prophylaxis. A repetition of the 32nd