Part 5: Connecting clinical and audit information to continuously improve the quality of care provided in rest homes

Effectiveness of arrangements to check the standard of rest home services: Follow-up report.

5.1
In this Part, we discuss two initiatives that the Ministry is implementing to improve the quality of audit and clinical information, namely:

the Provider Regulation and Monitoring System (PRMS); and
the international resident assessment instrument (interRAI).

5.2
We also discuss the opportunity that the PRMS and interRAI present for the Ministry to consider how it might bring together and use clinical and audit information to encourage continuous improvement in the quality of care for rest home residents.

Our overall findings

5.3
The Ministry expects the PRMS to improve the quality and use of data from certification and monitoring audits, including identifying areas where auditor education needs to improve. The Ministry expects the first phase of the PRMS to be complete by April 2013.

5.4
The clinical data from interRAI should allow better assessment of rest home residents and show quality of care. The Ministry anticipates that interRAI will be phased into rest homes over the next three years. The Ministry told us that the current focus is on uptake of interRAI across the residential care sector by 2015.

5.5
During our audit, we were not able to establish how the audit data that the Ministry currently collects from its existing information technology (IT) systems feeds into monitoring of the actual quality of care delivered to rest home residents. We consider that the introduction of the PRMS and interRAI over the next two to three years provides an opportunity for the Ministry to consider how it might bring together and use clinical and audit information to continuously improve the quality of care provided in rest homes by:

better understanding the quality of care being provided to rest home residents;
making ongoing improvements to the Standards that rest homes must meet in order to provide residential care services for older people; and
continuing to enhance the effectiveness and efficiency of auditing in providing assurance that the Standards are being met.

The Provider Regulation and Monitoring System should further improve the effectiveness and efficiency of auditing

The Ministry expects that the PRMS will enable better use of data from certification and monitoring audits to continuously improve the effectiveness and efficiency of auditing. The Ministry expects that the first release of the PRMS will be complete by April 2013.

5.6
The Provider Regulation Group (PRG) in the Clinical Leadership, Protection and Regulation section of the Ministry regulates 2400 providers of health care services. As the Group's functions have grown during the last 10 years, it has inherited the computer systems from each new function it has acquired. The Ministry describes this as a "patchwork of systems". The PRMS is an IT system that is designed to bring together existing IT systems into one new system and strengthen HealthCERT's ability to monitor the health care sector, including DAAs.

5.7
The PRMS was identified as a priority in PRG's business plan and approved in 2009/10. It was further considered in December 2010 and in November 2011. A further business case was provided in January 2012, after the Request for Proposal process.

5.8
Subject to contract negotiations, the Ministry expects the first phase of the PRMS to be complete by April 2013. The Ministry expects that the PRMS will:

help get better data directly from DAA auditors;
deploy business intelligence tools that can work out statistical distributions and trends;
provide better information to support decisions about the performance of DAAs;
result in better ability to use audit data to identify cross-sector areas of concern;
support the direction of the reduced criteria project (see paragraphs 3.67 to 3.70) by focusing on particular and relevant audit criteria based on a risk analysis, as opposed to the current focus on all criteria; and
improve communications to the health care sector, such as providing better information to DHBs and more information online.

The international resident assessment instrument should improve assessment of quality of care but will not be fully implemented in rest homes until 2015

interRAI is being phased into rest homes over the next three years. The clinical data from this computer-based system should allow better clinical assessment of rest home residents and show the quality of rest home care. Uptake of interRAI throughout the entire residential care sector is expected by 2015.

5.9
In October 2009, the Minister of Health directed the newly formed National Health IT Board to create the first National Health IT Plan for the overall health sector.

5.10
The National Health IT Plan was written in 2010. It aimed to establish an integrated health care model during the next five years, so that:

New Zealanders will have a core set of personal health information available electronically to them and their treatment providers regardless of the setting as they access health services.

5.11
The National Health IT Plan does not explicitly describe comprehensive clinical assessment or interRAI by name. However, the plan discusses patient-based information that sets out the plan for the patient's course of care and that helps in a multidisciplinary approach to support patient care.

5.12
In the National Health IT Board's priority programmes list for 2011/12, interRAI for aged care was one of the IT Board's five "National Solutions". interRAI was developed in the United States and is now used in more than 30 countries.

How the data from interRAI can be used

5.13
The latest version of interRAI includes the assessment, care planning, and reporting of changes in resident well-being and the resources needed to care for rest home residents. The assessment covers 19 domains, including cognition, functional status, health conditions, and activity pursuits. Twenty-four quality indicators are then used to assess the rest home's performance against the domains. The indicators include accidents, clinical management, infection control, nutrition and eating, and skin care.

5.14
The data from the interRAI system can be used to monitor the quality of care provided to rest home residents at the following levels:

"resident over time" – an individual resident's health status can be monitored over time to find out whether it is improving or deteriorating and how it is being managed;
"rest home over time" – the quality indicators of care in the rest home can be monitored from quarter to quarter or from year to year to establish any positive or adverse trends; and
against other rest homes – the quality indicators can be compared to other care homes in the local area or nationwide.

5.15
Therefore, the data could be used to monitor and assess the quality of care provided in rest homes.

5.16
In December 2010, the chief executives of all DHBs endorsed a business case recommending a phased roll-out to all aged care providers in New Zealand by 2015. All DHBs use interRAI when assessing older people for home-based care.

5.17
The current focus is on uptake of interRAI across the residential care sector by 2015. By June 2012 there were 82 rest homes whose staff had attended interRAI training and 50 of those had nurses who were competently using the interRAI system to help them work out their residents' care plans.

5.18
The national roll-out of interRAI follows a successful pilot in the Canterbury and Bay of Plenty DHBs. The project has the support of the Ministry, the DHBs, the New Zealand Aged Care Association, and a number of rest homes. Representatives from these organisations form the project steering group. During 2012, the Ministry expects 110 rest homes to implement the system. In each rest home or group of rest homes,²² there will be a lead practitioner who will teach the registered nurses how to use the tool in a consistent manner. HealthCERT advisors have done interRAI training and a HealthCERT advisor will be a member of an interRAI user support group.

5.19
At the time of our fieldwork, there was not yet a structured plan for rolling out interRAI throughout rest homes and the wider health and disability sector because the focus had been on ensuring that implementation of interRAI for home-based care was completed by 30 June 2012. The Ministry has also told us that interRAI is going to be voluntary.

An opportunity to bring together audit and clinical information to encourage continuous improvement in the quality of care for rest home residents

In our view, the Ministry should take the opportunity to consider how it brings together and uses data from the PRMS and the clinical data collected through interRAI to continuously improve the Standards that rest homes must meet and the quality of care that rest homes provide.

5.20
Under the current auditing and certification arrangements, the Ministry audits rest homes to ensure that they have the capability and capacity to meet the Standards and provide safe, quality care to their residents. The rest homes' ongoing ability to do this is checked through the audit and certification process. The introduction of the PRMS will allow the data collected from the audit process to be analysed to better monitor and assess rest homes and continuously identify where audit effectiveness and efficiency can be improved.

5.21
We noted that the Ministry monitors the quality of care provided in rest homes by measuring the number of complaints, setting the time that rest homes are certified for, and assessing the number of and type of audit findings. We do not consider this is enough to measure the quality of care provided to residents, particularly clinical care. We support the introduction of the PRMS and interRAI to improve the quality and use of data from certification and monitoring audits to improve the quality of rest home care.

5.22
In our view, the Ministry should take the opportunity presented by the introduction of these new systems to consider how it brings together and uses data to encourage continuous improvement in the quality of care for rest home residents.

22: When referring to a group of rest homes, we mean a rest home provider that has more than one rest home. For example, Ryman Healthcare, Oceania Group, and Presbyterian Support.

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